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PubMed2003

Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome.

OBJECTIVE: To compare the effect of adenotonsillectomy on rapid eye movement (REM)- and non-REM-related respiratory and sleep architecture characteristics in children with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: This prospective study evaluated 36 children (median age, 6.9 years; range, 1.8 to 12.6 years) with OSAS using polysomnography before and a few months after adenotonsillectomy. Primary outcomes included the number of obstructive apnea and hypopnea and arousals per hour of sleep. RESULTS: At 4.6 months (range, 1 to 16 months) after adenotonsillectomy, there was a significant improvement of all respiratory parameters. The median respiratory disturbance index (RDI) decreased from 4.1/h (range, 0 to 85/h) to 0.9/h (range, 0 to 13/h) after adenotonsillectomy (p < 0.0001). The median non-REM RDI decreased from 3.0/h (range, 0 to 89/h) to 0.4/h (range, 0 to 13/h) [p < 0.001] as compared with REM RDI, which decreased from 7.8/h (range, 0 to 69/h) to 2.3/h (range, 0 to 54/h) after adenotonsillectomy (p < 0.01). Median arousal index decreased following adenotonsillectomy from 17.5/h (range, 7 to 57/h) to 14.0/h (range, 6 to 47/h) [p < 0.03]. CONCLUSIONS: Adenotonsillectomy resulted in a greater improvement in non-REM RDI as compared with REM-RDI, and a decrease in the number of arousals.

Adenoidectomy↗
PubMed1996

[Acoustic evoked potentials (AEP) in obstructive sleep apnea syndrome].

Patients with obstructive sleep apnea syndrome (OSAS) present upper airway obstruction during sleep which can be documented by electromyography. The cause of weakness in oropharyngeal muscles is still unknown. Lesions of pons and medulla oblongata have to be expected. Brainstem auditory evoked potentials (BAEP) may indicate pathological changes in these regions. Several studies described normal BAEP in OSAS-patients. Moderate forms of OSAS as well as central sleep apnea syndromes were investigated, however. In our study 20 patients (17 men, 3 women, mean age 53.9 +/- 2.1 ys) with severe OSAS (apnea/hypopnea-index: 34.2 +/- 14.1/h, part of O2-saturation < or = 90% during sleep (SaO2 < or = 90%): 13.5 +/- 4.2%, minimal nocturnal O2-saturation: 78.0 +/- 2.5%) before starting nCPAP-therapy were investigated. BAEP were elicited after applying clicks 70 dB above threshold to each ear. Means of single wave latencies as well as interpeak latencies (I-V, I-III, III-V) were delayed significantly compared to normal controls. Main prolongations were seen regarding wave latency I (p < or = 0.001) and-interpeak latency I-V (p < or = 0.001). Prolongation of interpeak latencies (mean +/- 2.5 SD) of one or two sides could be demonstrated in 12 out of 20 patients. Pontomesencephal lesions (9 patients) dominated. There was no connection with respiratory parameters. As against pathological BAEP changes correlated with the duration of the disease. In conclusion pathological BAEP indicating brainstem lesions were seen in 60% of the examined OSAS-patients. Mesencephal lesions dominated, number of lesions increased with duration of disease. Therefore pathological findings have not to be considered as cause but as a result of hypoxemia in OSAS. Pathological BAEP may reveal a higher risk for cerebrovascular stroke. Therefore these patients should be leaded to further cerebrovascular investigation.

Electromyography↗
PubMed1999

Previously unrecognized obstructive sleep apnea in Chinese subjects with essential hypertension.

Obstructive sleep apnea (OSA) is found to affect 2-4% of the middle-aged population in several Caucasian studies, whereas the prevalence among other ethnic groups have not been clearly documented. It has been reported that OSA and systemic hypertension are highly associated; we therefore conducted a study on Chinese subjects who were receiving treatment for essential hypertension to assess the prevalence of OSA among this group. Ninety-two consecutive patients being followed up at a hypertension clinic were recruited for a questionnaire survey. The entire study group was aged 54.7 +/- 11.7 years, with 40 men. One male subject had a diagnosis of obstructive sleep apnea on nasal continuous positive airway pressure (nCPAP) treatment and 46 subjects agreed to an overnight sleep study. Those who underwent sleep study showed selection bias with a higher body mass index and more symptoms associated with OSA. Of the 46 who underwent sleep study, 16 (34.8%) had an obstructive apnea-hypopnea (AHI) score of >/=5 and excessive daytime sleepiness, with a median score of 26.2 (range, 8.3-64.9). Patients in the group with obstructive sleep apnea syndrome (OSAS) thus defined compared with those without OSAS had more men (64.7 vs 17.20%, p = 0.001) and an excess of smokers (31.5 vs 3.3%. p = 0.01) and had significantly more symptoms of excessive daytime sleepiness (p = 0.001), daytime fatigue (p = 0.007), and witnessed apneas (p = 0.008). Seven patients accepted treatment with nCPAP and reported improvement in symptoms, but there was no detectable change in clinic blood pressure measurements after 3 months of nCPAP treatment. This study demonstrated a high prevalence of previously unidentified OSAS among Chinese patients with essential hypertension. Increased awareness of both doctors and patients toward this potentially treatable problem is warranted.

Adult↗
PubMed1985

Nocturnal oxyhemoglobin desaturation following tracheostomy for obstructive sleep apnea.

Eleven obese men with coexistent obstructive sleep apnea and chronic obstructive pulmonary disease underwent tracheostomy. Nocturnal polysomnography prior to tracheostomy revealed oxyhemoglobin desaturation associated with obstructive apnea. Following surgery, repeated polysomnography was performed to assess the effect of tracheostomy on nocturnal oxygen saturation. Non-apneic desaturation characteristic of that previously described in patients with "type B" chronic obstructive pulmonary disease was noted in six subjects. Oxyhemoglobin saturation in these six fell more than 8 percent below baseline waking and non-rapid-eye-movement (REM) sleep levels. These episodes usually lasted five minutes or longer, occurred almost uniformly during REM sleep, and were acutely ameliorated by low-flow (4 liters per minute) supplemental oxygen. The subjects with REM-associated desaturation did not differ from the subjects without desaturation by preoperative anthropomorphic, blood gas, or pulmonary function criteria. However, subjects with REM-associated desaturation tended to have lower right and left ventricular ejection fractions by pooled gated wall studies. It is concluded that patients with obstructive sleep apnea and chronic obstructive pulmonary disease should be re-evaluated after tracheostomy, since they may be at risk for continued oxyhemoglobin desaturation and progressive right ventricular deterioration despite adequate treatment of their apneic condition.

Humans↗
PubMed1999

[Pharyngeal muscles and sleep obstructive apnea syndrome].

An analysis of the way the pharyngeal musculature modulates the caliber of the pharynx is important to better understand and treat obstructive sleep apnea syndromes. The caliber of the pharynx at the soft palate depends on the action of the tensor veli, the palatoglossus, the palatopharyngeus and the uvula muscles. At the ligual level, the action of the genioglossus and the geniohyoideus predominate. These different muscle groups contract in co-ordination before the diaphragm contracts. Their activity is diminished and disorganized during sleep. These muscles appears to have a histological composition adapted to short-duration intense contractions making them vulnerable to fatigue. In apneic patients, these muscles are solicited constantly. Muscular lesions related to overwork have been suggested. The histological composition of these muscles is modified in apneic patients compared with non-apneic subjects (increased number of type IIa fibres), the expression of an adaptive process. The degree of adaptation varies depending of the pharyngeal level considered. Similar to their reflex stimulation, the response of these pharyngeal muscles to increased resistance is probably greater at the soft palate level. Greater solicitation of palatine muscles associated with their greater vulnerability to fatigue could explain why obstruction is particularly important at this level. A study of the mechanical and histological properties of the pharyngeal musculature is required for a better understanding of the occlusive mechanisms of the upper airways and must be undertaken before initiating therapeutic stimulation of these muscles.

Humans↗
PubMed1999

The use of ENT-prescribed home sleep studies for patients with suspected obstructive sleep apnea.

Sleep disordered breathing, including obstructive sleep apnea, is a common and morbid health problem. Traditionally, sleep disordered breathing is diagnosed by complex sleep studies. However, newer, easy-to-use, highly sensitive, and highly specific home sleep study equipment is now available. The present study was undertaken to determine whether an otolaryngologist could easily and effectively dispense home sleep equipment from the office. We used a portable AutoSet home sleep machine. Our experience with the first 100 consecutively presenting patients was recorded and analyzed under institutional review board approval. Ninety-nine of the 100 tests were completed successfully on the first attempt; the one failure was successful on the second attempt. Our results were consistent with those reported from in-house polysomnogram sleep studies; 71% of our patients had an apnea-hypopnea index (AHI) of 15 or higher, and 93% had an AHI at least 5. We conclude that an otolaryngologist, using state-of-the-art home sleep testing equipment, can accurately and cost-effectively prescribe home sleep studies.

Equipment Design↗
PubMed2002

Relationship between cephalometric characteristics and obstructive sites in obstructive sleep apnea syndrome.

Patients with obstructive sleep apnea syndrome (OSAS) have characteristic dentofacial features, but the sites of obstruction differ greatly. The purpose of this study was to investigate the dentofacial characteristics of patients with OSAS with respect to the obstructive sites. The subjects consisted of 30 Japanese men with OSAS divided into 3 groups of 10 patients each. One group had obstruction at the retropalatal and retroglossal region (Rp + Rg group), a second group had obstruction at the retropalatal region (Rp group), and a third group had obstruction due to tonsillar hypertrophy (tonsillar hypertrophy group). To identify the Rp + Rg and Rp groups, dynamic magnetic resonance imaging (MRI) was used. To identify the tonsillar hypertrophy group, Mackenzie's classification, axial MRI, and the weight of the tonsils were used. A control group was composed of 10 Japanese men showing no symptoms suggestive of OSAS. Lateral cephalometric radiographs were obtained for all of the subjects, and analysis of variance was performed for the 46 cephalometric parameters. Among the many dentofacial characteristics of OSAS patients, the tendencies for retrognathia, micrognathia, and skeletal Class II were strongest in the Rp + Rg group and somewhat strong in the Rp group. The presence of a long soft palate was dominant in the Rp group, whereas the tendency for a long face was dominant in the tonsillar hypertrophy group. All of the groups shared the characteristic of having an inferior position of the hyoid bone. Based on the results of the current study, we conclude that many features of OSAS are specifically related to each obstructive type of OSAS.

Adult↗
PubMed2003

Obstructive sleep apnea syndrome in children.

Obstructive sleep apnea syndrome (OSAS) in children is often caused by obstruction of the upper airway due to hypertrophy of the adenoids and palatine tonsils. Between October 1988 and December 1991, 50 children (34 males, 16 females) visited our department due to attacks of sleep apnea and underwent adenotomy or adeno-tonsillectomy. Respiratory monitoring during sleep was performed before and after operation, and the usefulness of the surgery was evaluated. Before operation, 27/ 50 children (54.0%) were diagnosed as having OSAS. Their age distribution showed peaks at the ages of 4 and 5 years and the male:female ratio was 2:1. Concerning the degree of improvement in clinical symptoms after surgery, marked effects were observed in 40/50 patients (80.0%), moderate effects in 7 (14.0%) and slight effects in 3 (6.0%). Concerning the degree of improvement in the apnea index after surgery in the 27 patients with OSAS, marked effects were observed in 22 patients (81.50%), moderate effects in 2 (7.4%), slight effects in 1 (3.7%) and no change in 2 (7.4%).

Adenoidectomy↗
PubMed1996

Polysomnographic studies in children with adenotonsillar hypertrophy and suspected obstructive sleep apnea.

Upper airway obstruction causes many sleep-related respiratory disorders that can culminate in obstructive sleep apnea syndrome (OSAS). Polysomnography is routinely used to define OSAS in adults, but problems remain in diagnosing children by this method. The current study was designed to analyze the polysomnographic patterns in children with symptomatic adenotonsillar hypertrophy and to determine whether obstructive respiratory events shorter than 10 sec could have pathophysiological significance. Furthermore, we analyzed the correlation between clinical data on children with adenotonsillar hypertrophy and polysomnographic findings. Twelve children (mean age, 4.5 +/- 1.5 years) with airflow obstruction due to adenotonsillar hypertrophy were observed in our Sleep Laboratory. Prior to study, a questionnaire was used to score symptom severity. Overnight polysomnography was then performed to measure total sleep time, sleep efficiency, desaturation index, minimal arterial oxygen saturation (SaO2), apneahypopnea (AH) episodes < or = 5 sec and those > or = 10 sec, and AH index, AH percentage of total test time, and number of spontaneous and respiratory event-associated desaturations were recorded. Respiratory events of 5 sec or longer resulted in increases in the AH index and an increase in the number of oxyhemoglobin desaturations due to respiratory events. A significant relationship was found between the AH index and AH episodes > or = 5 sec and > or = 10 sec. There was, however, no association between polysomnographic parameters and symptom severity scores. An appraisal of AH recordings > or = 10 sec showed that desaturation episodes were more frequent than respiratory events, and the desaturation index was closely related to spontaneous and respiratory event-associated desaturations. When considering all obstructive episodes > or = 5 sec, the number of desaturations did not exceed the number of respiratory events. The correlation between the desaturation index and spontaneous or respiratory event associated desaturations was similar. The occurrence of short AH episodes that lead to hemoglobin desaturation are important in the evaluation of OSAS in children.

Adenoids↗
PubMed2006

Sleepiness and sleep in patients with both systolic heart failure and obstructive sleep apnea.

BACKGROUND: Adverse effects of obstructive sleep apnea (OSA), including sleep deprivation, can contribute to the progression of heart failure. The usual indication to diagnose and treat sleep apnea is subjective sleepiness. Previous studies suggest that patients with both heart failure and obstructive sleep apnea often do not complain of sleepiness, albeit their sleep time may be reduced. Therefore, we tested the hypothesis that patients with heart failure have less sleepiness and sleep less compared with subjects without heart failure for a given severity of OSA. METHODS: Sleepiness assessed with the Epworth Sleepiness Scale and sleep structure measured with polysomnography were compared among 155 consecutive patients with heart failure and from a random community sample (n = 1139) according to categories of the apnea-hypopnea index (<5, no OSA; 5-14, mild OSA; and > or =15, moderate to severe OSA). RESULTS: Compared with the community sample, for any given severity of OSA, patients with heart failure had lower mean +/- SE Epworth Sleepiness Scale scores (7.1 +/- 0.4 vs 8.3 +/- 0.2 [P = .005]; 6.7 +/- 0.7 vs 9.2 +/- 0.3 [P < .001]; and 7.8 +/- 0.7 vs 9.8 +/- 0.4 [P = .01]), indicating less sleepiness despite sleeping less (total sleep time mean +/- SE [in minutes]: 306 +/- 7 vs 384 +/- 2, 295 +/- 19 vs 384 +/- 5, and 285 +/- 13 vs 359 +/- 7 for no, mild, and moderate to severe OSA, respectively; P < .001 for all comparisons). CONCLUSIONS: Patients with heart failure have less subjective daytime sleepiness compared with individuals from a community sample, despite significantly reduced sleep time, whether or not they have OSA. In patients with heart failure, the absence of subjective sleepiness is not a reliable means of ruling out OSA.

Body Mass Index↗
PubMed1994

Obstructive sleep apnea syndrome and acromegaly.

Obstructive sleep apnea syndrome is a complex disorder that has been associated with a variety of abnormalities of the upper airway, including tonsil and adenoid hypertrophy, nasal obstruction, retrognathia, and macroglossia. The cause of the airway obstruction in acromegaly is believed to be related to osseous and soft-tissue changes surrounding the upper airway, which lead to narrowing and subsequent collapse during sleep. We describe the results of treatment in seven patients with both sleep apnea and acromegaly. Four patients were treated by transsphenoidal hypophysectomy alone with a resolution of sleep apnea syndrome. One underwent hypophysectomy followed by postoperative radiation therapy, which reduced his apnea. Three patients underwent unsuccessful uvulopalatopharyngoplasty. Successful treatment of the primary disorder, in this case acromegaly, resulted in improved breathing during sleep in five patients. This series would suggest that acromegalic patients with sleep apnea should be treated for their pituitary tumor to reduce growth hormone before consideration of surgery to enlarge or bypass the upper airway.

Acromegaly↗
PubMed2000

Compensatory head posture changes in patients with obstructive sleep apnea.

The upper airway narrowing and changes in head posture and their relationship with apnea severity in patients with obstructive sleep apnea (OSA) were investigated. In 86 male OSA patients and 37 healthy men, one-night polysomnographic examination was performed and a lateral cephalogram by digital image processing system was taken in each subject. Fifteen variables concerning the upper airway dimensions, area and head postures were measured by using a computer software (NIH Image). The results showed that upper airway dimensions in the OSA group at all levels were significantly smaller than those in the control group and the results hold true when the age and body mass index were well controlled in these two groups. Significant forward inclination of the cervical column was found in the patients with an apnea index (AI) greater than 35 episodes/h. And changes in the head posture variables in the whole study group were significantly correlated with AI and airway dimensions at various levels. It was suggested that there exist significant and extensive upper airway narrowing in OSA patients even in upright position and awake state; And as the apnea severity progresses, patients may assume certain compensatory head postures in an attempt to maintain an adequate airway patency.

Adaptation, Physiological↗
PubMed1995

[Effects of nCPAP therapy on the blood picture in patients with obstructive sleep apnea].

In some patients with obstructive sleep apnea, changes in red blood cell count resembling polycythemia can be observed. If these changes result from the sleep-related breathing disorder, its adequate treatment should in turn induce a decrease of, for instance, hemoglobin concentration. We therefore set out by examining retrospectively the development of hemoglobin concentration under nCPAP in 130 patients with polysomnographically verified obstructive sleep apnea, comparing the values before treatment and after a mean of 12.0 months. During this period, hemoglobin mass concentration dropped from a mean of 153 +/- 13 g/Ls to 148 +/- 11 g/Ls (p < 0.001). Afterwards we prospectively examined in 50 patients the changes in complete blood cell count before and immediately after initiation of nCPAP treatment. It turned out that hemoglobin mass concentration dropped from a mean of 154 +/- 14 g/Ls to 148 +/- 14 g/Ls (p < 0.001), the erythrocyte count from 5.02 +/- 0.42/pl to 4.79 +/- 0.51/pl (p < 0.001), and hematocrit from 45.4 +/- 3.1% to 43.1 +/- 4.3% (p < 0.001) after only one night; no more significant change occurred after that. Increased hemoglobin mass concentrations, erythrocyte counts and hematocrit values can be the result of obstructive sleep apnea. Treatment of this sleep disorder with nCPAP will induce a quick and significant decrease of hemoglobin mass concentration, erythrocyte count, and hematocrit, independent of the initial values. This phenomenon points to the fact that changes in blood cell counts are not caused by a disturbance of erythropoesis but rather by alterations in volume regulation.

Adult↗
PubMed2003

Self-efficacy in sleep apnea: instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure.

STUDY OBJECTIVES: The purpose of this study was to evaluate the Self-Efficacy Measure for Sleep Apnea (SEMSA) designed to assess adherence-related cognitions. DESIGN: Subjects completed the questionnaire prior to the initiation of continuous positive airway pressure (CPAP) treatment. Test-retest reliability of the instrument was evaluated by having a subset of subjects complete the SEMSA a second time at home, 1 week later, returning the questionnaire by mail. PATIENTS: 213 subjects with newly diagnosed obstructive sleep apnea were recruited from the clinic populations of 2 sleep disorders centers. MEASUREMENTS AND RESULTS: Content validity was confirmed by a panel of expert judges. Confirmatory factor analysis validated the 3 a priori sub-scales: risk perception, outcome expectancies, and treatment self-efficacy. The internal consistency of the total instrument was 0.92. Test-retest reliability coefficients (N = 20) were estimated to be 0.68, P = 0.001, for Perceived Risk; 0.77, P more more than 0.0001, for Outcome Expectancies; and 0.71, P = 0.0005, for the Treatment Self-Efficacy subscale. Subject responses indicated that approximately half of the subjects did not perceive problems with concentration, sexual performance, sleepy driving, or an accident as related to sleep apnea. More than 60% of the subjects acknowledged most of the benefits of CPAP presented to them, but only 53% associated CPAP use with enhanced sexual performance. Frequently identified barriers to treatment use were nasal stuffiness, claustrophobia, and disturbing bed partner sleep. CONCLUSION: These findings indicate that the SEMSA has strong psychometric properties and has the potential for identifying patient perceptions that may indicate those most likely to not adhere to treatment.

Adult↗
PubMed1997

The sympathetic nervous system and obstructive sleep apnea: implications for hypertension.

Patients with obstructive sleep apnea experience repetitive apneic events during sleep, with consequent hypoxia and hypercapnia. Hypoxia and hypercapnia, acting via the chemoreflexes, elicit increases in sympathetic nerve activity. The sympathetic responses to hypoxia and hypercapnia are potentiated during apnea, when the sympathetic inhibitory influence of the thoracic afferent nerves is eliminated. As a consequence of the sympathetic vasoconstrictor response to apneic events, patients with obstructive sleep apnea manifest marked increases in blood pressure during sleep, especially evident at the end of the apnea. The increases in sympathetic activity and blood pressure during sleep in these patients appear to carry over into the daytime such that patients with sleep apnea have an increased prevalence of hypertension and high levels of sympathetic nerve activity. Although the mechanism underlying the persistent elevation in sympathetic activity during the daytime is not known, it is likely that the increased sympathetic drive is implicated in the higher daytime blood pressures in these patients. Whereas patients with sleep apnea have an increased prevalence of hypertension, in those patients with sleep apnea who do have hypertension, the sympathetic response to apneic events may be potentiated. This may be secondary to impaired baroreflex sensitivity, since the baroreflexes exert an inhibitory influence on the chemoreflex responses to hypoxia. Treatment with continuous positive airway pressure results in an acute reduction in blood pressure and sympathetic activity during sleep. Prolonged effective treatment of sleep apnea may also reduce daytime blood pressure levels. This review examines the physiology of the chemoreflex responses to hypoxia, hypercapnia and apnea, as well as the physiologic responses to sleep in normal humans. These physiologic responses are compared with the pathophysiologic sympathetic and hemodynamic responses that characterize obstructive sleep apnea. Increases in sympathetic activity and blood pressure in patients with obstructive sleep apnea may play a role in linking sleep apnea to hypertension and cardiac and vascular events.

Baroreflex↗
PubMed2005

The psychosocial aspects of obstructive sleep apnea.

The primary events of obstructed breathing during sleep, snoring and obstruction of the upper airway, cause hypoxemia, sleep fragmentation, and daytime sleepiness. Obstructed breathing during sleep can have negative effects on mental processes, behavior, and interpersonal relations. This article reviews some of the cognitive, emotional, and social aspects of obstructive sleep apnea in adults and children. Apnea is associated with cognitive impairments but these are generally mild. Most studies suggest that these impairments improve with CPAP but evidence suggests that some changes may be permanent. Even mild apnea may worsen depression and quality of life. Apnea may have more profound effects in children but the findings are inconclusive. This may be due to difficulty in recognizing sleep apnea in children, the subtle nature of the disorder, the lack of daytime sleepiness, and the imposition of adult norms on children's sleep studies.

Adult↗