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PubMed2000

Diagnostic Approaches to Childhood Obstructive Sleep Apnea Hypopnea Syndrome.

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common sleep disorder in adults that is increasingly recognized in children, affecting 1 to 3% of children. Children experience a spectrum of severity related to the degree of upper airway obstruction, the duration of the disease, and the presence or absence of hypoxemic episodes. Failure to diagnose and treat OSAHS can result in serious, but generally reversible consequences for the child including impaired growth, neurocognitive and behavioral dysfunction, and cardiorespiratory failure. Even mild OSAHS appears linked to reversible health consequences. Adenotonsillar hypertrophy is the major predisposing factor for OSAHS in childhood. However, enlarged tonsils and adenoids can be a normal finding in young children and are not diagnostic for OSAHS. The identification of children with OSAHS is often difficult because affected children may have no signs or symptoms when awake. Furthermore, clinical assessment cannot reliably distinguish between simple snoring and OSAHS. Adenotonsillectomy is the most common therapy for OSAHS in children, but surprisingly, only a small percentage of children undergo any diagnostic testing prior to surgery. Thus, the challenge is to develop new diagnostic strategies that effectively screen, identify, and treat children most likely to benefit from specific treatment.

Journal Article↗
PubMed1996

[Anamnestic and polygraphic parameters in obstructive sleep apnea syndrome patients with reduced nasal respiration during the day in comparison with obstructive sleep apnea patients with normal nasal respiration].

Nasal obstruction is a predictive factor for snoring and may contribute to the development of an obstructive sleep apnea syndrome (OSAS). The aim of this study was to further evaluate the impact of nasal obstruction in OSAS. Therefore, we investigated 2 groups of OSAS-patients, matched pairs concerning gender, age, and BMI: OSAS-patients with nasal obstruction (N, n = 28), total nasal airflow < 500 ccm/s (referred to 150 pa pressure of difference or unilateral nasal resistance > 1 pa/ccm/s), and 28 OSAS-patients without nasal obstruction (control-group K, total nasal airflow > 700 ccm/s [referred to 150 pa pressure of difference or unilateral nasal resistance > 1 pa/ccm/s]). We performed anterior rhinomanometry, lung-function testing, cardio-respiratory polygraphy, and patients answered a standardized questionnaire. We found the following significant differences: 1) N complained more often (n = 17) about dyspnea at night than K (n = 7, p < 0.05, Chi2-test). 2) N had a higher apnea index (20.4 +/- 19.0/h) than K (9.6 +/- 10.0/h, p < 0.05, Student's t-test). There were, however, no significant differences concerning lung function, number of nocturnal hypopneas, nocturnal SaO2 and heart rate. Our results underline the importance of nasal ventilation in the pathogenesis of OSAS. At least in moderate cases of OSAS a therapy of nasal obstruction might be of success in order to abolish nCPAP-therapy or might reduce nasal problems during nCPAP-therapy and thus ameliorate patient's therapy compliance.

Airway Resistance↗
PubMed1991

Surgical treatment of obstructive sleep apnea syndrome (OSAS)

Obstructive sleep apnea syndrome patients usually present with multiple areas of anatomic disproportions. The site or sites of obstruction must be accurately diagnosed preoperatively by a systematic means of examining the patient. This includes nasopharyngoscopy with Muller maneuver and sometimes cephalometrics. The surgical treatment is individualized to the site or sites of obstruction and can include tracheostomy, septoplasty, UPPP, geniohyoid advancement and suspension of the hyoid. For extreme cases advancement of the maxilla, mandible and hyoid bone are sometimes necessary.

Combined Modality Therapy↗
PubMedDate not supplied

Auditory processing assessment in children with obstructive sleep apnea syndrome.

INTRODUCTION: The obstructive sleep apnea syndrome (OSAS) is a respiratory disorder that occurs during sleep and it is relatively common in children. AIM: The goal of this paper is to verify if there is a relationship between the obstructive sleep apnea syndrome (OSAS) and auditory processing. METHODS: In order to do that, three groups of children ranging in age from 5 to 11 were studied, including a normal group. Twenty subjects who made up the study group were submitted to ear, nose and throat (ENT) exams and to polysomnography (PSG), and were divided in two groups: GROUP I (RO) comprised of 10 children who presented oral breathing and displayed normal PSG, and GROUP II (SAS) comprised of 10 children who presented oral breathing and displayed abnormal PSG. Their performance was compared to the performance of the third group--GROUP III (REN) comprised of 10 children who did not refer ENT difficulties. All the subjects completed a basic audiometric assessment as well as an auditory processing diagnosis. RESULTS: The analyses of the results revealed a statistically significant difference in ENT exams related to the turbinate and the palatine tonsils. Group II presented a higher incidence of turbinate hypertrophy levels II and III (p<0.001) and palatine tonsils hypertrophy grades III and IV (p 0.007). Regarding the auditory processing assessment, a statistically significant difference (p<0.001) was obtained in the dichotic digits test. Group II performed worse than group III. Also, for the non-verbal sequence memory test, Group II obtained a worse result (p<0.022) than Group I. CONCLUSION: Subjects with OSAS obtained worse results in auditory processing tests.

Audiometry↗
PubMed1998

Influence of nasal obstruction on obstructive sleep apnea.

Nasal obstruction, either partial or complete, may cause snoring and/or obstructive sleep apnea (OSA). However, there is no clear answer to the question, in how many cases nasal airway is a main or combined site of obstruction. Fifty-four OSA cases (47 men and 7 women) were examined by measuring the upper airway pressure gradient while they were asleep, using a multi-sensor pressure transducer. Their average apnea + hypopnea index was 35.6/h and body mass index was 26.5 kg/m2. Our hypothesis was that elevation of the inspiratory negative airway pressure at the epipharynx could indicate the influence of nasal obstruction. Seven cases out of 54 proved to have inspiratory negative pressure more than -3 cmH2O at the epipharynx during sleep. Four cases indicated elevated negative pressure in the lateral position, and 3 cases out of 19 CPAP candidates showed the same elevation in the supine position. In all 7 cases, the main obstructive site was either at the soft palate or the base of the tongue. Although nasal airway is the preferred route of respiration during sleep, nasal obstruction itself cannot be a main factor causing OSA, but a co-factor of OSA during sleep.

Adult↗
PubMed2003

Fatigue in obstructive sleep apnea: driven by depressive symptoms instead of apnea severity?

OBJECTIVE: Obstructive sleep apnea is a common and frequently devastating illness that often includes significant fatigue. Fatigue is also a hallmark depressive symptom. The authors wondered if depressive symptoms in patients with obstructive sleep apnea would account for some of the fatigue beyond that explained by obstructive sleep apnea severity. METHOD: Sixty patients with obstructive sleep apnea-i.e., score >/=15 on the respiratory disturbance index (mean score=49; range=15-111)-underwent polysomnography and completed the Center for Epidemiological Studies Depression Scale (CES-D Scale), Profile of Mood States (POMS), and Medical Outcomes Study surveys. Data were analyzed by using hierarchical regression, with POMS fatigue score as the dependent variable (step 1, forced entry of apnea severity variables; step 2, forced entry of CES-D Scale score). RESULTS: Whereas score on the respiratory disturbance index and the percent of time oxygen saturation was <90% together accounted for 4.2% of variance in scores on the POMS fatigue scale, the CES-D Scale score accounted for 10 times the variance (i.e., an additional 42.3%) in POMS fatigue scale score. CONCLUSIONS: After obstructive sleep apnea severity was controlled, higher levels of depressive symptoms were dramatically and independently associated with greater levels of fatigue. Assessment and treatment of mood symptoms-not just treatment of the disordered breathing itself-might reduce the fatigue experienced by patients with obstructive sleep apnea.

Depressive Disorder↗
PubMed2000

Laser partial epiglottidectomy as a treatment for obstructive sleep apnea and laryngomalacia.

Obstructive sleep apnea (OSA) and laryngomalacia are two different entities. Occasionally, they may have a common etiology: an elongated, flaccid, and lax epiglottis that is displaced posteriorly during inspiration causing airway obstruction. Twenty-seven adults with a diagnosis of airway obstruction or OSA of various degrees, and 12 infants with severe stridor associated with frequent apneas due to laryngomalacia, who on fiberoptic examination were found to have a posteriorly displaced epiglottis, underwent partial epiglottidectomy with a CO2 laser. Their postoperative recovery was uneventful. Polysomnographic studies performed after operation in the adult patients demonstrated statistically significant improvement in 85% of the patients. In all the cases of laryngomalacia, stridor ceased permanently after surgery, together with complete cessation of the apneic episodes. This study demonstrates that similar pathophysiological mechanisms may be involved in both laryngomalacia and in OSA. Effective and relatively safe treatment can be achieved by partial resection of the epiglottis with a microlaryngoscopic CO2 laser.

Adult↗
PubMed2001

Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea.

Patients with obstructive sleep apnea/hypopnea syndrome can experience residual daytime sleepiness despite regular use of nasal continuous positive airway pressure therapy. This randomized, double-blind, placebo-controlled, parallel group study assessed the efficacy and safety of modafinil for the treatment of residual daytime sleepiness in such patients. Patients received modafinil (n = 77) (200 mg/d, Week 1; 400 mg/d, Weeks 2 to 4) or matching placebo (n = 80) once daily for 4 wk. Modafinil significantly improved daytime sleepiness, with significantly greater mean changes from baseline in Epworth Sleepiness Scale scores at Weeks 1 and 4 (p < 0.001) and in multiple sleep latency times (MSLT) at Week 4 (p < 0.05). The percentage of patients with normalized daytime sleepiness (Epworth score < 10) was significantly higher with modafinil (51%) than with placebo (27%) (p < 0.01), but not for MSLT (> 10 min; 29% versus 25%). Headache (modafinil, 23%; placebo, 11%; p = 0.044) and nervousness (modafinil, 12%; placebo, 3%; p = 0.024) were the most common adverse events. During modafinil or placebo treatment, the mean duration of nCPAP use was 6.2 h/night, with no significant change from baseline observed between groups. Modafinil may be a useful adjunct treatment for the management of residual daytime sleepiness in patients with obstructive sleep apnea/hypopnea syndrome who are regular users of nasal continuous positive airway pressure therapy.

Adult↗
PubMed2004

Hippocampal area metabolites relate to severity and cognitive function in obstructive sleep apnea.

BACKGROUND AND PURPOSE: Obstructive sleep apnea (OSA) is associated with intermittent hypoxia and cognitive decrements. As the hippocampus is particularly susceptible to hypoxia, we hypothesized that it may show biochemical abnormalities, and they may relate to apnea severity. PATIENTS AND METHODS: Eight males with OSA and five age-matched controls underwent neurocognitive testing before and after polysomnography and proton magnetic resonance spectra were obtained from the left hippocampal area of all subjects. RESULTS: In the left hippocampal area, N-acetyl-containing/creatine-containing compounds was significantly increased in OSA (P=0.04). Inspection of these compounds with respect to the water resonance indicated that this was most likely due to a decrease in creatine-containing compounds rather than any change in N-acetyl-containing compounds. Lower levels of hippocampal creatine-containing compounds were correlated with worse OSA severity and neurocognitive performance. CONCLUSIONS: We suggest the changes in creatine levels in the hippocampal area represent adjustments to brain bioenergetics, similar to those seen in ischemic preconditioning, and may reflect the different susceptibility of these tissues to hypoxic damage in OSA.

Adult↗
PubMedDate not supplied

Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea.

BACKGROUND: Insomnia and obstructive sleep apnea syndrome (OSA) are the two most common sleep disorders. Studies showed that insomnia complaints were prevalent in OSA. Relatively little is known about the causes of insomnia in OSA and whether etiological factors differ for insomnia subtypes. We hypothesized that sleep onset problem was mainly due to hyperarousal and sleep maintenance difficulty was primarily related to sleep-disordered breathing. OBJECTIVES: To determine the prevalence of insomnia subtypes in OSA, compare subjects with sleep onset insomnia, sleep maintenance insomnia and no insomnia symptom, and study the relationship of insomnia subtypes to daytime sleepiness. METHODS: We analyzed intake questionnaires and polysomnography and Multiple Sleep Latency Test results of 157 OSA patients. RESULTS: Forty-two percent of the sample had at least one problematic insomnia symptom. The prevalence of sleep onset insomnia, sleep maintenance insomnia and insomnia with early awakening was 6, 26 and 19%, respectively. Patients with sleep onset insomnia had significantly lower apnea-hypopnea (AHI) and arousal indices. There were significant inverse relationships between sleep onset insomnia and measures of daytime sleepiness. On the contrary, subjects with repeated wakening had more severe subjective sleepiness. Results were similar in patients with AHI >or=5 or >or=15. CONCLUSIONS: Insomnia symptoms were common in OSA patients. Insomnia subtypes related differently to measures of daytime sleepiness. Our findings suggest that OSA patients with sleep onset insomnia may be in a state of hyperarousal. It is clinically relevant to examine insomnia subtypes, which may influence the treatment decision in sleep-disordered breathing.

Adult↗
PubMed2005

Differences between men and women in the clinical presentation of patients diagnosed with obstructive sleep apnea syndrome.

STUDY OBJECTIVES: Obstructive sleep apnea syndrome (OSAS) results from recurrent episodes of breathing cessation during sleep. Epidemiologic studies have shown that OSAS is more prevalent in men than women (4% vs 2%). Previous studies have explored gender-related differences in upper airway anatomy and function, hormone physiology, and polysomnographic findings. The aim of this study is to assess differences in clinical presentation between women and men with OSAS. DESIGN: Retrospective chart review analysis. SETTING: Tertiary university-based medical center PARTICIPANTS: 130 randomly selected women with OSAS matched individually with 130 men with OSAS for age, body mass index, apnea-hypopnea index, and Epworth Sleepiness Scale score. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Data were obtained from questionnaires and in-laboratory polysomnographic studies. There were no differences between the genders for age (48.0 +/- 1.1 years [mean +/- SEM] for women vs 47.6 +/- 1.0 years for men), body mass index (40.4 +/- 0.7 kg/m2 for women vs 40.0 +/- 0.6 kg/m2 for men), apnea-hypopnea index (36.8 +/- 3.3/hour for women vs 36.0 +/- 3.0/hour for men), or Epworth Sleepiness Scale score (12.45 +/- 0.53 for women vs 12.84 +/- 0.47 for men). Although snoring and sleepiness were similarly common in women and men, women more often described their main presenting symptoms as insomnia (odds ratio: 4.20; 95% confidence interval: 1.54-14.26) and were much more likely to have a history of depression (odds ratio: 4.60; 95% confidence interval: 1.71-15.49) and hypothyroid disease (odds ratio: 5.60; 95% confidence interval: 2.14-18.57). Women presented less often with a primary complaint of witnessed apnea (odds ratio: 0.66; 95% confidence interval: 0.38-1.12), consumed less caffeine per day (3.3 cups in women vs 5.2 cups in men; P = .0001), and admitted to less alcohol consumption (odds ratio: 0.36; 95% confidence interval: 0.18-0.70). CONCLUSIONS: At the time of OSAS diagnosis, women with OSAS are more likely to be treated for depression, to have insomnia, and to have hypothyroidism than are men with the same degree of OSAS.

Adult↗
PubMed1996

Blood pressure "dipping" and "non-dipping" in obstructive sleep apnea syndrome patients.

Obstructive sleep apnea syndrome (OSAS) has been associated with a higher than normal cardiovascular morbidity and mortality. Some OSAS patients lack the sleep-related, nocturnal decrease, or "dip," in blood pressure which is seen in normal individuals. These subjects, called "non-dippers," may be at greater risk for cardiovascular problems. We studied 40 OSAS patients (including 3 women) and 6 control subjects, all identified by polysomnography, for nocturnal blood pressure "dipping." We performed a second nocturnal polysomnogram to determine their apnea and hypopnea indices, (A + H)I, and oxygen saturation levels at the beginning of the study and then initiated 48 hours of ambulatory blood pressure monitoring, with data points collected every 30 minutes. Controls, which included one hypertensive subject, were all dippers. Nineteen OSAS subjects (48% of OSAS individuals) were systolic non-dippers and only 9 of them (22.5%) were diastolic non-dippers. We considered the following clinical variables as potential predictors of non-dipping: age, body mass index, respiratory disturbance index, years of reported loud snoring by bed partners, lowest oxygen saturation during nocturnal sleep, and percentage of sleep time spent with oxygen saturation below 90%. Multiple regression analyses indicated respiratory disturbance index as the only significant variable for systolic (p = 0.04) and diastolic (p = 0.03) blood pressure non-dipping. When we forced the following two nonsignificant variables into the model, they showed a very meager impact: number of years with reported loud snoring (p = 0.4 and p = 0.5, respectively for systolic and diastolic blood pressure non-dipping) and age (p = 0.5 and p = 0.6). The calculated model explained only a low percentage of the variance with an r2 of 0.25 and 0.26 for systolic and diastolic blood pressure non-dipping, respectively. Analysis of hypertension/normotension and dipping/non-dipping failed to show a significant relationship in the studied population. Fifty percent of the normotensive OSAS subjects were non-dippers and 43% of the hypertensive OSAS subjects were also non-dippers. We found a relationship between increasing respiratory disturbance index and increasing average 24-hour systolic blood pressure only when OSAS subjects were non-dippers and hypertensive.

Adult↗
PubMed2006

Fat snorers and sleepy-heads: were many distinguished characters of the past affected by the obstructive sleep apnea syndrome?

The obstructive sleep apnea syndrome (OSAS) is a clinical condition characterized by the coexistence of irregular breathing at night with excessive daytime sleepiness, and it represents a major social health issue because of its high prevalence and of the growing public awareness of it. The XIX century description of "Fat Joe", the famous character of Charles Dickens's Pickwick Papers, is often retained the first presentation of a person affected by OSAS, since Joe was an obese individual who fell asleep during daytime while performing even extremely simple tasks. However, apart from the fact that Joe's Picwickian syndrome ("the obesity hypoventilation syndrome") needs to be differentiated from true OSAS, already in the Hippocratic Corpus (V-IV century BC) many clues regarding apnea and sleepiness are present, and in 79 AD the Roman author Pliny the Younger clearly reported the death of a man in whom obesity, sleepiness and snoring were co-present in a unique clinical picture. In this paper, elements suggesting OSAS are traced back and evidenced in the XIX and XX centuries in distinguished figures, including Emperor Napoleon Bonaparte, Queen Victoria and President Franklin D. Roosevelt. A posteriori reconstruction of the health status of characters of the past is difficult, and, to an extent, speculative, but the elements here provided appear relevant, since the possible presence of disabling OSAS in important personages of the past may have negatively influenced not only their health status, but also their social life and their work activity.

Humans↗
PubMed1999

The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) in children is frequently associated with growth interruption. The objective of this study was to evaluate the effect of OSAS and adenotonsillectomy on the insulin-like growth factor-I (IGF-I) axis in children. STUDY DESIGN: Thirteen prepubertal children (mean age, 6.0 +/- 2.8 years) were studied before and after adenotonsillectomy (T&A). Weight, height, overnight polysomnography, and IGF-I and IGF-binding protein-3 levels were evaluated before and 3 to 12 months after T&A. The children's weights and heights were monitored for 18 months. RESULTS: The respiratory disturbance index improved from 7.8 +/- 9.1 events/h to 1.0 +/- 2.1 events/h after T&A (P <.02). Slow-wave sleep increased from 29.1% +/- 7.2% to 34.6% +/- 9.8% after T&A (P <.02). The weight standard deviation score increased from 0.86 +/- 1 to 1. 24 +/- 0.9, 18 months after T&A (P <.01). Serum IGF-I levels increased from 146.3 +/- 76.2 ng/mL before T&A to 210.3 +/- 112.5 ng/mL after surgery (P <.01), but IGF-binding protein-3 levels did not change significantly. CONCLUSION: The respiratory improvement after T&A in children with OSAS is associated with a significant increase in serum IGF-I levels and weight. We conclude that the IGF-I axis is affected in children with OSAS.

Adenoidectomy↗
PubMed2001

Cardiovascular variability characteristics in obstructive sleep apnea.

Patients with obstructive sleep apnea (OSA) are at increased risk for cardiovascular disease. Altered cardiovascular variability is a prognostic indicator for cardiovascular events. This review examines the evidence that OSA is accompanied by alterations in cardiovascular variability. This alteration is evident even in the absence of hypertension, heart failure or other disease states, and may be linked to the severity of OSA. The presence of clear-cut abnormalities in time and frequency-domain measures of blood-pressure and heart-rate variability in normotensive OSA patients provides intriguing evidence for the concept of an etiologic interaction between sleep apnea and cardiovascular disease. Mechanisms that could contribute to altered cardiovascular variability in patients with sleep apnea include abnormalities in chemoreflex, baroreflex and endothelial function.

Blood Pressure↗
PubMed1997

Avoiding the supine position during sleep lowers 24 h blood pressure in obstructive sleep apnea (OSA) patients.

Obstructive sleep apnea (OSA), is a common clinical condition affecting at least 2-4% of the adult population. Hypertension is found in about half of all OSA patients, and about one-third of all patients with essential hypertension have OSA. There is growing evidence that successful treatment of OSA can reduce systemic blood pressure (BP). Body position appears to have an important influence on the incidence and severity of these sleep-related breathing disturbances. We have investigated the effect of avoiding the supine position during sleep for a 1 month period on systemic BP in 13 OSA patients (six hypertensives and seven normotensives) who by polysomnography (PSG) were found to have their sleep-related breathing disturbances mainly in the supine position. BP monitoring was performed by 24-h ambulatory BP measurements before and after a 1 month intervention period. We used a simple, inexpensive method for avoiding the supine posture during sleep, namely the tennis ball technique. Of the 13 patients, all had a reduction in 24-h mean BP (MBP). The mean 24-h systolic/diastolic (SBP/DBP) fell by 6.4/2.9 mm Hg, the mean awake SBP/DBP fell by 6.6/3.3 mm Hg and the mean sleeping SBP/DBP fell by 6.5/2.7 mm Hg, respectively. All these reductions were significant (at least P < 0.05) except for the sleeping DBP. The magnitude of the fall in SBP was significantly greater in the hypertensive than in the normotensive group for the 24 h period and for the awake hours. In addition, a significant reduction in BP variability and load were found. Since the majority of OSA patients have supine-related breathing abnormalities, and since about a third of all hypertensive patients have OSA, avoiding the supine position during sleep, if confirmed by future studies, could become a new non-pharmacological form of treatment for many hypertensive patients.

Adult↗