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Background: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). Methods: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidencebased review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. Results: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. Conclusion:This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Study Objectives: Sleep disturbances are common in United States military personnel. Despite their exposure to combat and trauma, little is known about nightmares in this population. The purpose of this study was to describe the prevalence and associated clinical and polysomnographic characteristics of nightmares in United States military personnel with sleep disturbances. Methods: Retrospective review of 500 active duty United States military personnel who underwent a sleep medicine evaluation and polysomnography at our sleep center. The Pittsburgh Sleep Quality Index and the Pittsburgh Sleep Quality Index-Addendum were used to characterize clinically significant nightmares. Subjective and objective sleep attributes were compared between groups. Results: At least weekly nightmares were present in 31.2%; yet, only 3.9% reported nightmares as a reason for evaluation. Trauma-related nightmares occurred in 60% of those patients with nightmares. Patients with nightmares had increased sleep onset latency (SOL) and rapid eye movement (REM) sleep latency (mean SOL/REM sleep latency 16.6/145 minutes, P = .02 and P = .01 respectively) compared to those without (mean SOL/REM sleep latency 12.5/126 minutes I NTRO DUCTI O NNightmares are defined by repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that cause clinically significant distress or impairment in social, occupational, or other areas of functioning. 1 Occasional nightmares are part of a normal adaptive response to life stressors and are not pathologic, with 85% of adults reporting at least one nightmare per year. 2 The prevalence of clinically significant nightmares, which occur at least once per week, is estimated between 0.9% and 6.8%. [3][4][5][6][7][8][9] In the largest study to date (69,813 adults), the prevalence of nightmares was 3.5% in men and 4.8% in women. 10 Participants from the World War II generation had a significantly higher prevalence of 7.2% in men and 7% in women. Nightmares are more common among patients with sleep disturbances, sleep disorders, depression, anxiety, and posttraumatic stress disorder However, most research evaluating sleep disorders in active duty military personnel has focused on insomnia, obstructive sleep apnea (OSA), and PTSD, noting that a recent study focusing on OSA and PTSD did not evaluate nightmares. [18][19][20] Following traumatic experiences, sleep disturbances are frequently reported, including trauma-related nightmares (TRN). 21 The nightmares of trauma survivors tend to be more severe and distressing than idiopathic nightmares. 1,3 Though not exclusive to PTSD, TRN have been referred to as the "hallmark" of this disorder, with rates as high as 90%. 22,23 Addressing nightmares as a distinct sleep disorder following a BRIEF SUMMARY Current Knowledge/Study Rationale: The spectrum of sleep disorders in military personnel is varied and complicated by the presence of comorbidities and psychological disorders. Currently, little is known regarding nightmares, especially trauma-related nig...

Introduction Excessive daytime sleepiness affects an estimated 20% of the general population. While the prevalence of sleepiness in the military is largely unknown, it is well established that short sleep duration is endemic. The reasons for this include: the demanding nature of their duties, shift work and 24-hour duty periods, deployments and exigencies of military service as well as sleep disorders. The Epworth Sleepiness Scale (ESS) is the most widely used sleep questionnaire and provides a self-assessment of daytime sleepiness. To date the clinical utility of this questionnaire in differentiating sleep disorders in military patients with sleep disorders has never been evaluated. Materials and Methods The primary aim of this manuscript was to assess if Epworth Sleepiness Scale (ESS) scores differed between military personnel with insomnia, obstructive sleep apnea (OSA), comorbid insomnia/obstructive sleep apnea (COMISA), and a group with neither insomnia nor obstructive sleep apnea (NISA). This study assessed the clinical utility of the ESS in differentiating sleep disorders amongst a sample (N = 488) of U.S. military personnel with insomnia (n = 92), OSA (n = 142), COMISA (n = 221), and a NISA group (n = 33) which served as the control population. Results In the present sample, 68.4% of service members reported excessive daytime sleepiness (EDS) with an ESS > 10. ESS scores differed between military personnel with COMISA (13.5 ± 4.83) and those with OSA only (11.5 ± 4.08; p < 0.001) and the NISA group (9.46 ± 4.84; p < 0.001). Also, ESS scores differed between patients with insomnia only (13.0 ± 4.84) and the NISA group (p < 0.01). Conclusions Overall, the ESS had poor ability to differentiate sleep disorders. In military personnel, the ESS appears elevated in the most common sleep disorders, likely due to their insufficient sleep, and does not help to differentiate OSA from insomnia. Further studies are required to validate this questionnaire and determine an appropriate threshold value for abnormal sleepiness in the military population.

This chapter explores the influence of sleep on human performance and well-being. A general discussion of the role of sleep in humans is followed by a description of the functions of various stages of sleep. The authors explore causal factors of insufficient sleep and inventory known effects of sleep restriction on human performance. They then describe the particular challenges of fatigue and sleep deprivation in military operational environments. The efficacy of fatigue countermeasures and alertness aids commonly used in military settings is presented. The chapter concludes with an argument for more deliberately protecting and promoting sleep, particularly in vulnerable populations such as shiftworkers.