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Supplementary Mater ial
Night-to-night variability of respiratory events in obstructive sleep apnoea: a systematic review and meta-analysis
Maurice Roeder MD1, Matteo Bradicich MD1, Thomas Gaisl MD1, Sira Thiel MD1, Esther I. Schwarz MD1,2 ,Ulrike
Held PhD3, Malcolm Kohler MD1,2
These supplementary tables, references, figures, and appendices have been provided by the authors to give readers
additional information about their work.
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) Thorax
doi: 10.1136/thoraxjnl-2020-214544–8.:10 2020;Thorax, et al. Roeder M
Table of Contents
Methods
- Search Terms
- Studies obtained by handsearching
- Studies obtained by https://clinicaltrials.gov/
Study details and patient characteristics
- Study characteristics
- Inclusion criteria
- Exclusion criteria
- Patient characteristics
- Sleep study characteristics
Results
Quality Assessment
Guidelines
- MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies
- Prisma 2009 Checklist
References
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) Thorax
doi: 10.1136/thoraxjnl-2020-214544–8.:10 2020;Thorax, et al. Roeder M
Methods
Search terms
a) The following search terms were employed for PUBMED (https://www.ncbi.nlm.nih.gov/pubmed)
1. apnoea-hypopnoea index* or apnoea-hypopnoea indices or apnea-hypopnea index* or apnea-hypopnea
indices or AHI or oxygen-desaturation index* or oxygen-desaturation indices or ODI or obstructive apnea
index* or obstructive apnea indices or OAI or respiratory disturbance index* or respiratory disturbance
indices or RDI or apnoea index* or apnoea indices or apnea index* or apnea indices
2. “variabilit*”.ti,ab.
3. 1 AND 2
4. (night-to-night or first-night effect* or FNE or second-night effect*).ti,ab
5. 3 or 4
b) The following search terms were employed for Cochrane Library
1. “apnoea-hypopnoea index*" OR "apnoea-hypopnoea indices" OR "apnea-hypopnea index*" OR "apnea-
hypopnea indices" OR AHI OR "oxygen-desaturation index*" OR "oxygen-desaturation indices" OR ODI
OR "obstructive apnoea index*" OR "obstructive apnea indices" OR OAI OR "respiratory disturbance
index*" OR "respiratory disturbance indices" OR RDI OR "apnoea index*" OR "apnoea indices" OR "apnea
index*" OR "apnea
2. variabilit*:kw,ti,ab
3. #1 AND #2
4. ("night-to-night" OR "first-night effect*" OR FNE OR "second-night effect*")kw,ti,ab
5. #3 OR #4
c) The following search terms were employed for Embase
1. 'apnea hypopnea index'/exp OR 'oxygen desaturation index'/exp OR 'respiratory disturbance index'/exp OR
'apnoea-hypopnoea index*':ti,ab OR 'apnoea-hypopnoea indices':ti,ab OR 'apnea-hypopnea index*':ti,ab OR
'apnea-hypopnea indices':ti,ab OR ahi:ti,ab OR 'oxygen-desaturation index*':ti,ab OR 'oxygen-desaturation
indices':ti,ab OR odi:ti,ab OR 'obstructive apnea index*':ti,ab OR 'obstructive apnea indices':ti,ab OR
oai:ti,ab OR 'respiratory disturbance index*':ti,ab OR 'respiratory disturbance indices':ti,ab OR rdi:ti,ab OR
'apnoea index*':ti,ab OR 'apnoea indices':ti,ab OR 'apnea index*':ti,ab OR 'apnea indices':ti,ab
2. variabilit*:ti,ab
3. #1 AND #2
4. 'night-to-night':ti,ab OR 'first-night effect*':ti,ab OR fne:ti,ab OR 'second-night effect*':ti,ab
5. #3 OR #4
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) Thorax
doi: 10.1136/thoraxjnl-2020-214544–8.:10 2020;Thorax, et al. Roeder M
d) The following search terms were employed for ClinicalTrials.gov
1. “OSA” AND “variability”
Languages: English, German, French
Children: Yes, Animals: No, Timeframe: from the 23. January of 2019
Studies obtained by handsearching Author Title Journal Year DOI
Kapur, V. K. Clinical Practice Guideline for Diagnostic
Testing for Adult Obstructive Sleep Apnea: An
American Academy of Sleep Medicine Clinical
Practice Guideline
J Clin Sleep Med
2017
10.5664/jcsm.6506.
Table S 1 Studies obtained by handsearching.
Studies obtained by https://clinicaltrials.gov/ Author Title Year ClinicalTrials.gov Identifier
Kohler, M. Effect of Longitudinal Sleep Monitoring on Diagnosis and
Treatment Decision in Patients With Suspected Obstructive
Sleep Apnea (ELSA)
2018
NCT03819361
Table S 2 Studies obtained by https://clinicaltrials.gov/.
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doi: 10.1136/thoraxjnl-2020-214544–8.:10 2020;Thorax, et al. Roeder M
Study details and patient characteristics
Study characteristics
Authors Study Design Multicentric Participants Analysed
Patients
OSA already
diagnosed Comorbidities
Aarab et al.1 RCT No 17 15 Yes None
Ahmadi et al.2 Retrospective No 193 193 No None
Bittencourt et al.3 Prospective No 20 20 Yes None
Bliwise et al.4 Prospective Yes 71 71 No None
Büttner et al.5 Prospective No 100 100 Yes None
Davidson et al.6 Prospective No 44 44 No None
Fietze et al.7 Prospective No 35 35 No None
Gouveris et al.8 Retrospective No 130 130 No Upper airway
pathology
Joosten et al.9 Prospective No 75 44 No None
Laing et al.10 Prospective No 30 19 No None
Le Bon et al.11 Retrospective Yes 243 169 No None
Levendowski et al.12 RCT Yes 118 20 No None
Mendelson et al.13 Prospective No 50 No None
Meyer et al.14 Prospective No 11 11 No None
Mjid et al.15 Prospective No 20 20 No None
Newell et al.16 Retrospective No 118 44 No None
Prasad et al.17 Prospective No 398 84 Yes None
Quan et al.18 Retrospective Yes 99 91 Yes None
Selwa et al.19 Prospective Yes 43 40 No Epilepsy
Stepnowsky et al.20 Retrospective No 1220 1091 No None
Stöberl et al.21 Retrospective Yes 109 77 Yes None
White et al.22 Prospective No 26 26 Yes None
Wittig et al.23 Retrospective No 50 22 Yes None
Yalciner et al.24 Prospective No 30 30 No None
Table S 3 Characteristics of the studies included in the meta-analysis. RCT: Randomised Controlled Trial.
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Inclusion criteria
Authors Inclusion Criteria
Aarab et al.1 Age > 18, AHI 5-45.
Ahmadi et al.2 2 PSGs with available AHI.
Bittencourt et al.3 Age 30-60, AHI > 10 events, laboratory exams (blood cell count, glycaemia, creatinine, T3, T4, and TSH),
spirometry, thoracic radiography, and ECG within normal values.
Bliwise et al.4 None.
Büttner et al.5 Age 18-80, SDB with AHI >5.
Davidson et al.6 Patients with SDB symptoms (primarily snoring), recommended and approved for sleep testing.
Fietze et al.7 Expected OSA with ESS >10 or other two major OSAS symptoms.
Gouveris et al.8 Patients with suspected OSA with 2 PSGs, with upper airway pathology as the sole possible cause of sleep-
related breathing disorder.
Joosten et al.9
Patients with suspected OSA. Inclusion only if, after PSG:
-OSA (AHI>5/h) on both nights
- ≥30 min supine, ≥20 min non-supine in both nights.
Laing et al.10 ESS>10. Symptoms suggesting OSA (observed sleep aponeas, snoring on a regular basis).
Le Bon et al.11 Patients with suspected sleep apnoea free of psychotropic medications for the two weeks prior to PSG.
Levendowski et al.12 AHI 10-40, BMI <40, no OSA treatment, non-smoker, ESS >10, postmenopausal.
Mendelson et al.13 Patients with suspected sleep apnoea.
Meyer et al.14 Adult patients at increased risk for OSA (one or more of the following: history of witnessed apnoeas; presence
of hypertension (DBP>=95 mmHg or history of treated hypertension); increased BMI (>30)).
Mjid et al.15 Clinical suspect of OSAS.
Newell et al.16 Two sleep studies. AHI>5 in the first sleep study.
Prasad et al.17 Age 35-60, AHI >5 at baseline PSG.
Quan et al.18 Participant in Sleep Heart Health Study, willing to perform two PSGs within 4 months after the first one.
Selwa et al.19 Two or more seizures per month (generalised or partial, auras excluded) in medical history. High suspicion
for OSA.
Stepnowsky et al.20 Patients with suspected sleep apnoea referred for sleep apnoea testing.
Stöberl et al.21 Age 20-75, OSA patients (ODI>10 / ODI>20) and CPAP therapy, recurrence of OSA after 4 days of
withdrawal.
White et al.22 Clinical suspicion of sleep apnoea and OSA confirmed.
Wittig et al.23 At least 2 PSG within 30 days, no weight changes > 10 pounds, no change in medication, and no intervening
treatment.
Yalciner et al.24 Signs and symptoms of SDB.
Table S 4 Inclusion criteria of the studies included in the meta-analysis. AHI: apnoea-hypopnoea index. PSG:
polysomnography. T3: triiodothyronine. T4: thyroxin. TSH: thyroid-stimulating hormone. ECG:
electrocardiogram. SDB: sleep-disordered breathing. OSA(S): obstructive sleep apnoea (syndrome). ESS:
Epworth Sleepiness Scale. DBP: diastolic blood pressure. BMI: body mass index. ODI: oxygen desaturation index.
CPAP: continuous positive airway pressure.
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) Thorax
doi: 10.1136/thoraxjnl-2020-214544–8.:10 2020;Thorax, et al. Roeder M
Exclusion criteria
Authors Exclusion Criteria
Aarab et al.1
Respiratory or sleep disorder other than OSA. BMI >40. Medication usage that could affect respiration or sleep.
Periodic limb movement disorder. Previous treatment with CPAP or MAD. Reversible morphological upper
airway abnormalities. Temporomandibular disorders. Untreated periodontal problems. Dental pain. Lack of
retention possibilities for mandibular advancement device or placebo appliance.
Ahmadi et al.2 NR
Bittencourt et al.3 Diseases that might result in sleep alterations, habits, or occupations that might lead to sleep deprivation or altered
sleep-wake cycle, infection of the upper or lower airways, altered ENT evaluation.
Bliwise et al.4 Alcohol or psychoactive medications.
Büttner et al.5 Other sleep disorders or disorders that might affect either sleep or oxygenation. Psychiatric diseases. Drug abuse.
Sleep therapy within 12 months. Reduced CPAP compliance.
Davidson et al.6 Minors, pregnancy, dementia.
Fietze et al.7 Alcohol consumption.
Gouveris et al.8
Patients suspected of suffering from isolated or concomitant to the upper airway pathology narcolepsy,
hypersomnolence, chronic fatigue syndrome, periodic limb movement disorder, and/or diurnal rhythm disorders
as well as patients with an established diagnosis of a psychiatric or neurologic (peripheral or central) disorder.
Congestive heart failure, COPD or any severe pulmonary disorder requiring standard medication.
Joosten et al.9 No informed consent. Domicile more than 75 km from study centre.
Laing et al.10 COPD (FEV1<70% predicted). Heart failure (Eco EF < 30%). Systemic disease. Malignancy. Neurologic
disorders.
Le Bon et al.11 None.
Levendowski et al.12 NR
Mendelson et al.13 Any medication supressing respiration.
Meyer et al.14 Prior oxygen therapy, CPAP therapy, or other medical therapy for OSA.
Mjid et al.15 Major psychiatric disorders, sleep depriving-activities, lower airways-respiratory infection within 30 days.
Newell et al.16
CPAP trial in the second sleep study. Comorbid affective disorders (anxiety and depression), neurological
disorders, PLMI>=5 for one or both recordings, daily consumption of more than two units of alcohol. Patient
referred for MSLT test.
Prasad et al.17 Diagnosis of another sleep disorder diagnosed either on PSG or by history, previous treatment of OSA, pregnancy.
Quan et al.18 CPAP or mandibular device, oxygen therapy, tracheotomy.
Selwa et al.19 Seizures in at least one of the study nights.
Stepnowsky et al.20 Supplemental oxygen or CPAP.
Stöberl et al.21 Ventilatory failure, Cheyne-Stokes respiration, unstable or untreated cardiovascular disease or uncontrolled
hypertension, and professional drivers or patients with a history of a traffic accident.
White et al.22 OSA treated within the last 3 months, tonsillar hypertrophy, heart failure, stroke, and end-stage renal or liver
disease.
Wittig et al.23 NR
Yalciner et al.24 Severe comorbidities. Upper airway infection in the previous two weeks. Sedative medication use or alcohol
addiction. Previous trial of CPAP or MAD.
Table S 5 Exclusion criteria of the studies included in the meta-analysis. OSA: obstructive sleep apnoea. BMI:
body mass index. CPAP: continuous positive airway pressure. MAD: mandibular advancement device. ENT: ear, nose, and throat. COPD: chronic obstructive pulmonary disease. FEV1: forced expiratory volume in the first
second. EF: ejection fraction. NR: not reported. PLMI: periodic limb movement index. MSLT: multiple sleep
latency test. PSG: polysomnography.
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Patient characteristics
Authors Male Female Average Age Average BMI Average ESS
Aarab et al.1 13 4 50.8 30.1 11.2
Ahmadi et al.2 NR NR NR NR NR
Bittencourt et al.3 14 6 50 30 16
Bliwise et al.4 48 23 74.6 34.92 NR
Büttner et al.5 83 17 53.3 30.9 10.2
Davidson et al.6 NR NR 48 30.1 NR
Fietze et al.7 32 3 58 26 NR
Gouveris et al.8 86.1 13.9 52.6 NR NR
Joosten et al.9 24 20 50.3 30.5 8.3
Laing et al.10 12 7 51.6 29 NR
Le Bon et al.11 113 56 47.2 27.4 NR
Levendowski et al.12 17 3 NR NR NR
Mendelson et al.13 42 8 50.2 NR NR
Meyer et al.14 8 3 44.91 28.85 NR
Mjid et al.15 7 13 50.6 36.3 NR
Newell et al.16 29 15 52.16 30.85 9.77
Prasad et al.17 56 28 47 38.3 12
Quan et al.18 55 44 64.2 28.31 NR
Selwa et al.19 19 21 40.2 32.4 NR
Stepnowsky et al.20 947 144 52.5 33 10.7
Stöberl et al.21 65 12 62.6 33.8 14
White et al.22 16 10 57.2 32.1 NR
Wittig et al.23 22 0 49.7 NR NR
Yalciner et al.24 17 13 42.1 30.2 14
Table S 6 Cohort characteristics of the studies included in the meta-analysis. BMI: body mass index. ESS:
Epworth Sleepiness Scale. NR: not reported.
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Authors Population Information and Study Nation
Aarab et al.1 Netherlands.
Ahmadi et al.2
Inpatients at the Toronto Western
Hospital Sleep and Alertness Clinic over the period of
1 year. Canada.
Bittencourt et al.3 Twenty patients referred from the Respiratory Sleep Disorders outpatient clinic (Respiratory
Division). Brazil.
Bliwise et al.4 Volunteers from a cohort study of sleep and breathing. USA.
Büttner et al.5 Germany.
Davidson et al.6 Patients referred for SDB symptoms (primarily snoring). USA.
Fietze et al.7
All study patients have been referred to the sleep centre with possible OSAHS, and had
experienced either self-reported daytime sleepiness (ESS >10) or two other major symptoms of
OSAHS. Symptomatic mild-to-moderate OSAHS patients. Germany.
Gouveris et al.8 Patients suspected of OSA with upper airway pathology as the sole possible cause of sleep-
related breathing disorder. Germany.
Joosten et al.9 Database of OSA referrals waiting for PSG.
Australia.
Laing et al.10 Germany.
Le Bon et al.11 94% comes from immediate surroundings of Brussels with suspected sleep apnoea. Belgium.
Levendowski et al.12 Australia.
Mendelson et al.13 Self-admitted to the sleep disorders Center of the State University of New York. USA.
Meyer et al.14 USA.
Mjid et al.15 Referral for clinical suspicion of OSAS. Tunisia.
Newell et al.16
Referred to the sleep laboratory and diagnosed for snoring or UARS as well as central, mixed,
and obstructive hypopneas or apnoeas.
All patients were free from neuropsychopharmacological treatment, including hypnotics and
antidepressants, for at least two weeks prior to recording. Daytime napping was not allowed in
the sleep unit. Patients that were addressed for multiple sleep latency tests (MSLT) were
excluded from the study since these daytime assessments can potentially influence the following
night's sleep recording
Prasad et al.17 Referrals for possible OSA. USA.
Quan et al.18 Participant in Sleep Heart Health Study. USA.
Selwa et al.19 High suspicion for OSA and quantifiable seizures. USA.
Stepnowsky et al.20 Referrals for suspected OSA. USA.
Stöberl et al.21 Patients under CPAP withdrawal with OSA recurrence after withdrawal. Switzerland, UK.
White et al.22 Referred to sleep centre for clinical suspicion. Canada.
Wittig et al.23 Adult, male patients. USA.
Yalciner et al.24 Referrals to ENT specialist. Turkey.
Table S 7 Population and geographical information of the studies included in the meta-analysis. SDB: sleep-
disordered breathing. OSA: obstructive sleep apnoea. OSA(H)S: obstructive sleep apnoea(-hypopnoea) syndrome.
ESS: Epworth Sleepiness Scale. PSG: polysomnography. UARS: upper airway resistance syndrome. MSLT:
multiple sleep latency test. ENT: ear, nose, and throat.
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Sleep study characteristics
Authors Sleep study Recording device Montage by Number
of studies
Max days
between
studies
Number of
examiners
Aarab et al.1 Home PSG Monet hardware, Rembrandt software (Medcare
Automation BV). Technician 4 23.1 1
Ahmadi et al.2 In-hospital
PSG NR Technician 2 1 NR
Bittencourt et al.3 In-hospital
PSG
Sleep Analyzer Computer (SAC system 9.3,
Oxford Instruments, Abingdon, UK). Technician 4 1 1
Bliwise et al.4 In-hospital
PSG NR Technician 2 1 1
Büttner et al.5 In-hospital
PSG NR Technician 2 1 NR
Davidson et al.6 HSAT Embletta (AutoSet Portable H Plus). Patient 3 1 0
Fietze et al.7 HSAT MESAM-IV. Technician 7 1 1
Gouveris et al.8 In-hospital
PSG Alice 4. Technician 2 1 2
Joosten et al.9 In-hospital
PSG Compumedics E-Series. Technician 2 4 1
Laing et al.10 HSAT Jaeger Pro, Fa ViaSys, Wuerzburg Patient 3 1 1
Le Bon et al.11 In-hospital
PSG Alice Respironics; Plattsburgh, PA. Technician 2 1 2
Levendowski et al.12 In-hospital
PSG
Alice 4-Respironics Inc. and Compumedics E-
series. Technician 2 40 1
Mendelson et al.13 In-hospital
PSG NR Technician 2 1 NR
Meyer et al.14 In-hospital
PSG NR Technician 2 54.1 NR
Mjid et al.15 In-hospital
RP CIDELEC 102 L. Technician 2 1 NR
Newell et al.16 PSG Alice 5. Technician 2 1 2
Prasad et al.17 HSAT +
Actigraphy
EmblettaTM PDS system (Natus Neurology
Inc., Middleton, WI). Technician 8 1 1
Quan et al.18 Home PSG Compumedics PS-2 series - Compumedics Pty.
Ltd, Abbotsville, AU. Technician 2 77 >1
Selwa et al.19 In-hospital
PSG NR Technician 2 1 2
Stepnowsky et al.20 HSAT NovaSom QSG™ (Sleep Solutions, Inc.). Technician 3 1 0
Stöberl et al.21 Pulse
oximetry
Pulse oximeter (Pulsox-300i, Konica Minolta
Sensing Inc, Osaka, Japan) or ResLink (ResMed
Corp, San Diego, CA, USA).
Patient 13 1 NR
White et al.22 In-hospital
PSG Sandman (Nellcor). Technician 2 18.7 1
Wittig et al.23 In-hospital
PSG NR Technician 2 30 NR
Yalciner et al.24 In-hospital
PSG Philips Respironics. Technician 2 7 NR
Table S 8 Sleep study characteristics. PSG: polysomnography. NR: not reported. HSAT: home sleep apnoea
testing. RP: respiratory polygraphy.
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Results
Figure S1: Sensitivity analysis of mean change in AHI between first and second night, by excluding studies with
high risk of bias. Kendall's tau = -0.2308, p = 0.2792. AHI=apnoea-hypopnoea index, HSAT=home sleep apnoea
testing, N=number of analysed patients, PSG=polysomnography, P=prospective study design, Q=Cochrane’s Q test, R=retrospective study design, RE=random effect model, RP=respiratory polygraphy, Y=year.
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Figure S 2 Forest plot of mean AHI change between the 1st and the 2nd night in in-hospital sleep studies. Kendall's
tau = 0.000, p = 1.000. RE=random effect.
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Figure S 3 Forest plot of mean AHI change between the 1st and the 2nd night in in-home sleep studies. Kendall's
tau = 0.0000, p = 1.0000. RE=random effect.
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Figure S 4 Forest plot of the proportion of patients who changed severity class in one of the sequential
measurement nights. Kendall's tau = 0.067, p = 1.000. HSAT=home sleep apnoea testing N=number of analysed
patients, PSG=polysomnography, P=prospective study design, Q=Cochrane’s Q test, R=retrospective study design,
RE=random effect, RP=respiratory polygraphy, Y=year.
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Figure S 5 a Proportions of patients who have changed into a lighter OSA severity class after the first sleep study. Kendall's tau = 0.143, p = 0.697. HSAT=home sleep apnoea testing, N=number of analysed patients,
PSG=polysomnography, P=prospective study design, Q=Cochrane’s Q test, R=retrospective study design, RE=random effect, RP=respiratory polygraphy, Y=year.
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Figure S5 b Proportions of patients who have changed into a more severe class after the first sleep study.
Kendall's tau = -0.333, p = 0.469. HSAT=home sleep apnoea testing, N=number of analysed patients,
PSG=polysomnography, P=prospective study design, Q=Cochrane’s Q test, R=retrospective study design, RE=random effect, RP=respiratory polygraphy, Y=year.
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Quality Assessment
Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Overall bias
assessment
Aarab et al. Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Low
Ahmadi et al. Yes No Yes Yes No No Yes Yes NR No Yes NR NA No Moderate
Bittencourt et al. Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes No Low
Bliwise et al. Yes Yes Yes Yes No CD Yes Yes Yes Yes No NR Yes No Moderate
Büttner et al. Yes Yes CD Yes No Yes Yes Yes Yes No Yes NR Yes No Low
Davidson et al. Yes No Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Moderate
Fietze et al. Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Low
Gouveris et al. Yes No Yes Yes No No Yes Yes NR Yes Yes NR NA No Moderate
Joosten et al. Yes Yes Yes Yes No Yes Yes Yes Yes No Yes NR Yes Yes Low
Laing et al. Yes Yes CD Yes No Yes Yes Yes** Yes Yes Yes NR Yes Yes Low
Le Bon et al. Yes Yes Yes Yes No No Yes Yes Yes No Yes NR NA Yes Moderate
Levendowski et al. Yes No No Yes No Yes Yes Yes Yes No Yes Yes Yes No High
Mendelson et al. Yes No Yes Yes No Yes Yes Yes Yes No Yes NR Yes No Moderate
Meyer et al. Yes Yes NR Yes No Yes Yes Yes NR No Yes NR Yes No Moderate
Mjid et al. Yes Yes Yes Yes No Yes Yes Yes NR Yes Yes NR Yes Yes Low
Newell et al. Yes Yes No Yes No No Yes Yes Yes No Yes NR NA No High
Prasad et al. Yes Yes No Yes No Yes Yes Yes Yes Yes Yes NR No Yes Moderate
Quan et al. Yes Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Moderate
Selwa et al. Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes No Low
Stepnowsky et al. Yes Yes Yes Yes No No Yes Yes NR No Yes NR NA No Moderate
Stöberl et al. Yes Yes No Yes No No Yes Yes* Yes No Yes Yes NA Yes Moderate
White et al. Yes Yes No Yes No No Yes Yes Yes Yes Yes Yes NA No Moderate
Wittig et al. Yes No No No No No Yes Yes NR No Yes NR NA No High
Yalciner et al. Yes Yes Yes Yes No Yes Yes Yes Yes No Yes NR Yes Yes Low
Table S 9 Risk of bias analysis of the included studies, evaluated using the study assessment tool from NIH “Quality of Observational Cohort and Cross-Sectional Studies”. CD=cannot determine; NR=not reported; NA=not applicable; *:
only data on ODI reported.
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Fourteen items for bias assessment adapted for this meta-analysis.
1. Was the research question or objective in this paper clearly stated?
2. Was the study population clearly specified and defined?
3. Was the participation rate of eligible persons at least 50%?
4. Were all the subjects selected or recruited from the same or similar populations (including the same period of
time)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all
participants?
5. Was a sample size justification, power description, or variance and effect estimates provided? 6. Was the study a prospective study with predefined inclusion criteria?
7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and
outcome if it existed? (i.e. more than 2 nights)
8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related
to the outcome (e.g., did the study also measure ODI or other sleep-related disturbance markers)?
9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented
consistently across all study participants (e.g. did the study use predefined guidelines such as AASM etc.)?
10. Was the outcome assessed in different ways (e.g. did the study also report ODI, SpO2 levels etc.)?
11. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study
participants?
12. Were the outcome assessors blinded to the exposure status of participants? 13. Was loss to follow-up after baseline 20% or less?
14. Were key potential confounding variables measured and statistically adjusted for their impact on the relationship
between outcome(s) (e.g. regression analysis)?
Note: Boxes indicate a “significant” item deemed by the authors, affecting the overall bias assessment.
Overall bias assessment was categorized into three ratings
Low 0-2 items with risk factors & no items deemed “significant” by the authors
Moderate 3-4 items with risk factors & max. 1 item deemed “significant” by the authors High >4 items with risk factors and more than 1 “significant” item deemed by the authors
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Guidelines
MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies*
Topic Availabe in
Section…
Title Identify the study as a meta-analysis (or systematic review) Title
Abstract Use the journal’s structured format Abstract
Introduction Present:
The clinical problem Introduction
The hypothesis Introduction
A statement of objectives that includes the study population, the condition of interest, the exposure or
intervention, and the outcome(s) considered
Introduction
Sources Describe:
Qualifications of searchers (eg, librarians and investigators) Methods
Search strategy, including time period included in the synthesis and keywords Methods
Effort to include all available studies, including contact with authors Methods
Databases and registries searched Methods
Search software used, name and version, including special features used
(e.g. explosion)
Methods
Use of hand searching (e.g, reference lists of obtained articles) Methods
List of citations located and those excluded, including justification Methods
Method of addressing articles published in languages other than English Methods
Method of handling abstracts and unpublished studies Methods
Description of any contact with authors Methods
Study
Selection
Describe
Types of study designs considered Methods
Relevance or appropriateness of studies gathered for assessing the hypothesis to be tested Methods
Rationale for the selection and coding of data (eg, sound clinical principles or convenience) Methods
Documentation of how data were classified and coded (eg, multiple raters, blinding,
and inter-rater reliability)
Methods
Assessment of confounding (e.g. comparability of cases and controls in
studies where appropriate)
NA
Assessment of study quality, including blinding of quality assessors;
stratification or regression on possible predictors of study results
Methods
Assessment of heterogeneity Methods
Statistical methods (eg, complete description of fixed or random effects models, justification of
whether the chosen models account for predictors of study results, dose-response models, or
cumulative meta-analysis) in sufficient detail to be replicated
Methods
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Results Present
A graph summarizing individual study estimates and the overall estimate Results
A table giving descriptive information for each included study Results
Results of sensitivity testing (eg, subgroup analysis) Results
Indication of statistical uncertainty of findings Results
Discussion Discuss
Strengths and weaknesses Discussion
Potential biases in the review process (eg, publication bias) Discussion
Assessment of quality of included studies Results
Consideration of alternative explanations for observed results Discussion
Generalization of the conclusions (ie, appropriate for the data presented and within the domain of the
literature review)
Discussion
Guidelines for future research Discussion
Disclosure of funding source Methods
*Modified from Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of
observational studies in8 epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in
Epidemiology (MOOSE) group. JAMA 2000;283:2008–12. Copyrighted © 2000, American Medical Association.
All rights reserved.
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21
Prisma 2009 Checklist
Section/topic # Checklist item Reported in
section
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. Title
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background;
objectives; data sources; study eligibility criteria, participants, and
interventions; study appraisal and synthesis methods; results;
limitations; conclusions and implications of key findings; systematic
review registration number.
Abstract
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already
known.
Introduction
Objectives 4 Provide an explicit statement of questions being addressed with
reference to participants, interventions, comparisons, outcomes, and
study design (PICOS).
Introduction
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed
(e.g. Web address), and, if available, provide registration information
including registration number.
Methods
Eligibility criteria 6 Specify study characteristics (e.g. PICOS, length, of follow-up) and
report characteristics (e.g. years considered, language, publication
status) used as criteria for eligibility, giving rationale.
Methods
Information sources 7 Describe all information sources (e.g. databases with dates of
coverage, contact with study authors to identify additional studies) in
the search and date last searched.
Methods
Search 8 Present full electronic search strategy for at least one database,
including any limits used, such that it could be repeated.
Appendix
Study selection 9 State the process for selecting studies (i.e. screening, eligibility,
included in systematic review, and, if applicable, included in the
meta-analysis).
Methods
Data collection process 10 Describe method of data extraction from reports (e.g. piloted forms,
independently, in duplicate) and any processes for obtaining and
confirming data from investigators.
Methods
Data items 11 List and define all variables for which data were sought (e.g. PICOS,
funding sources) and any assumptions and simplifications made.
Methods
Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies
(including specification of whether this was done at the study or
outcome level), and how this information is to be used in any data
synthesis.
Methods
Summary measures 13 State the principal summary measures (e.g. risk ratio, difference in
means).
Methods
Synthesis of results 14 Describe the methods of handling data and combining results of
studies, if done, including measures of consistency (e.g. I2 for each
meta-analysis).
Methods
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22
Section/topic # Checklist item Reported in
section
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative
evidence (e.g. publication bias, selective reporting within studies).
Methods
Additional analyses 16 Describe methods of additional analyses (e.g. sensitivity or subgroup
analyses, meta-regression), if done, indicating which were pre-
specified.
Methods
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and
included in the review, with reasons for exclusions at each stage,
ideally with a flow diagram.
Results
Study characteristics 18 For each study, present characteristics for which data were extracted
(e.g. study size, PICOS, follow-up period) and provide the citations.
Appendix
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any
outcome level assessment (see item 12).
Appendix
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each
study: (a) simple summary data for each intervention group (b) effect
estimates and confidence intervals, ideally with a forest plot.
Results, Appendix
Synthesis of results 21 Present results of each meta-analysis done, including confidence
intervals and measures of consistency.
Results, Appendix
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see
Item 15).
Appendix
Additional analysis 23 Give results of additional analyses, if done (e.g. sensitivity or
subgroup analyses, meta-regression [see Item 16]).
Results, Appendix
DISCUSSION
Summary of evidence 24 Summarise the main findings including the strength of evidence for
each main outcome; consider their relevance to key groups (e.g.
healthcare providers, users, and policy makers).
Discussion
Limitations 25 Discuss limitations at study and outcome level (e.g. risk of bias), and
at review level (e.g. incomplete retrieval of identified research,
reporting bias).
Discussion,
Limitations
Conclusions 26 Provide a general interpretation of the results in the context of other
evidence, and implications for future research.
Discussion
FUNDING
Funding 27 Describe sources of funding for the systematic review and other
support (e.g. supply of data) and role of funders for the systematic
review.
Methods
Table S 10 Prisma check list.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for
Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097.
doi:10.1371/journal.pmed1000097
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23
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