STUDY OBJECTIVES: To assess the impact of the non-respiratory arousal burden at baseline polysomnography (PSG) on residual daytime sleepiness in positive airway pressure (PAP)-treated obstructive sleep apnea (OSA). METHODS: We included OSA patients from the European Sleep Apnea Database registry with available arousal data who had at least 2 treatment follow-up visits. The primary outcome was the Epworth Sleepiness Scale (ESS) score under PAP. The non-respiratory arousal ratio (NRAR) was defined as the ratio of non-respiratory to total arousals at baseline PSG. A linear mixed model tested the effect of NRAR tertiles on residual sleepiness. Baseline variables that differed significantly between groups were included as covariates. RESULTS: 800 patients with OSA (69.6 % male, mean age 57.1 ± 12.0 years, mean NRAR 0.22 ± 0.20) were evaluated during three follow up visits at a mean of 197.4, 499.3, and 731.6 days after PAP initiation. The interaction between time and NRAR tertile was statistically significant (F = 4.55, p = 0.001). The lowest NRAR tertile was associated with lower residual sleepiness over time compared to the highest NRAR tertile. The associations were independent of sex, comorbidities, body mass index, blood pressure, baseline apnea-hypopnea index, and baseline ESS score. CONCLUSIONS: NRAR at baseline PSG predicts residual sleepiness in PAP-treated OSA patients. The findings offer new insights into OSA phenotyping and have important implications for patient care.

Bethanien Hospital Clinic of Pneumology and Allergology Center for Sleep Medicine and Respiratory Care Institute of Pneumology at the University of Cologne Solingen Germany

Centre for Research and Innovation in Precision Medicine of Respiratory Diseases Department of Pulmonology Victor Babes University of Medicine and Pharmacy Timisoara Timisoara Romania

Department of Pulmonology Louvain University Center for Sleep and Wake Disorders University Hospitals Leuven Campus Gasthuisberg Leuven Belgium

Department of Sleep Medicine National Institute of Mental Health Klecany Czech Republic

Department of Sleep Medicine Royal Infirmary of Edinburgh Edinburgh United Kingdom

Grenoble Alpes University Inserm U1300 CHU Grenoble Alpes HP2 Grenoble France

Respiratory Failure Unit G Papanikolaou Hospital School of Medicine Aristotle University of Thessaloniki Thessaloniki Greece

Sahlgrenska University Hospital Department of Pulmonary Medicine Center for Sleep and Wake Disorders Gothenburg Sweden

Sleep Disorders Center Reinbek Germany

Sleep Disorders Unit Department of Respiratory Medicine School of Medicine University of Crete Heraklion Greece

Sleep Medicine and Neurostimulation Center Department of Otorhinolaryngology University Medical Center Mainz Germany

Sleep Medicine Unit Institute Clinic Scientific Maugeri IRCCS Scientific Institute of Pavia Pavia Italy

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