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PubMed2000

Pharyngeal suspension suture with repose bone screw for obstructive sleep apnea.

OBJECTIVE: Multilevel surgery for obstructive sleep apnea syndrome (OSA) may improve success. This study's goal is to prospectively evaluate the feasibility and short-term subjective effectiveness of a new tongue-suspension technique. METHODS: A multicenter nonrandomized open enrollment trial used the Repose device to treat tongue obstruction in 39 snoring and OSA patients. Outcomes include 1- and 2-month subjective reports of general health, snoring, and sleep. RESULTS: Twenty-three patients completed 1 month and 19 completed 2 months of follow-up. In OSA patients, activity level, energy/fatigue, and sleepiness improved. Two-month outcomes were less (activity level, energy/fatigue, and sleepiness). Fewer changes were observed in snorers than in OSA patients. There were 6 complications (18%), including sialadenitis (4), gastrointestinal bleeding (1), and dehydration (1) after the procedure. CONCLUSION: A pharyngeal suspension suture changes subjective outcomes. Improvement is incomplete. The procedure is nonexcisional, but significant complications may occur. Further evaluation is required to demonstrate effectiveness.

Adult↗

PubMed1992

Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea.

A retrospective study of pediatric patients with obstructive sleep apnea who underwent adenotonsillectomy between 1987 and 1990 was undertaken to determine the frequency of postoperative respiratory compromise and to determine if risk factors for its development could be identified. Sixty-nine patients less than 18 years old had polysomnographically documented obstructive sleep apnea and were observed postoperatively in the pediatric intensive care unit. Of these, 16 (23%) had severe respiratory compromise, defined as intermittent or continuous oxygen saturation of 70% or less, and/or hypercapnia, requiring intervention. Compared with patients without respiratory compromise, these patients were younger (3.4 +/- 4 vs 6.1 +/- 4 years) and had more obstructive events per hour of sleep on the polysomnogram (49 +/- 41 vs 19 +/- 30). They were more likely to weight less than the fifth percentile for age (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.4 to 18.7), to have an abnormal electrocardiogram and/or echocardiogram (OR, 4.5; 95% CI, 1.3 to 15.1), and to have a craniofacial abnormality (OR, 6.2; 95% CI, 1.5 to 26). Multiple logistic regression analysis revealed the most significant risk factors were age below 3 years and an obstructive event index greater than 10. Children with obstructive sleep apnea are at risk for respiratory compromise following adenotonsillectomy; young age and severe sleep-related upper airway obstruction significantly increase this risk. We recommend in-hospital postoperative monitoring for children undergoing adenotonsillectomy for obstructive sleep apnea.

Adenoidectomy↗

PubMed1994

Clinical diagnosis of pediatric obstructive sleep apnea validated by polysomnography.

The decision to perform tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea syndrome is often made on a clinical basis without formal polysomnography. To examine the accuracy of the clinical diagnosis of pediatric obstructive sleep apnea syndrome, we prospectively evaluated 30 children with obstructive symptoms by a standardized history, physical examination, and review of a tape recording of breathing during sleep. On the basis of this clinical evaluation, patients were divided into three predictive groups: (1) definite obstructive sleep apnea syndrome, (2) possible obstructive sleep apnea syndrome, and (3) unlikely to have obstructive sleep apnea syndrome. Nocturnal polysomnography was used to determine the presence or absence of true sleep apnea. Ten of 18 (55.6%) patients predicted clinically to have definite obstructive sleep apnea syndrome had positive nocturnal polysomnographies. Two of six (33.3%) patients predicted to have possible obstructive sleep apnea syndrome had positive nocturnal polysomnographies. One of six (16.7%) patients predicted to be unlikely to have obstructive sleep apnea syndrome had a positive nocturnal polysomnography. Six nocturnal polysomnographies negative by conventional criteria were suspicious for apnea, but considering these positive for obstructive sleep apnea syndrome did not improve the specificity of the clinical prediction. Our results show that clinical assessment of obstructive sleep apnea syndrome in children is sensitive (92.3%) but not specific (29.4%) for making the diagnosis of obstructive sleep apnea syndrome as compared with nocturnal polysomnography and may contribute to the decision to obtain nocturnal polysomnography in specific circumstances.

Adolescent↗

PubMed1998

Oral appliances in the treatment of obstructive sleep apnea and snoring.

Treatment of snoring and obstructive sleep apnea with oral appliances is a promising alternative to continuous positive airway pressure (CPAP) therapy. Although there is wide variability in appliance design, these devices produce enlargement of the upper airway by advancing the mandible, tongue, or both. Oral appliances effectively reduce snoring in a significant proportion of individuals. In general they are less effective than CPAP in eliminating obstructive sleep apnea, with approximately 50% of individuals experiencing resolution of their obstructive sleep apnea with these devices. Patients with milder disease have greater success with oral appliance therapy than those with more severe disease. A small proportion of patients will experience worsening of their sleep apnea with an oral appliance, and close follow-up after device prescription is mandatory. Patient satisfaction with oral appliances may be better than that with CPAP.

Female↗

PubMed1998

The prevalence of calcified carotid artery atheromas in patients with obstructive sleep apnea syndrome.

PURPOSE: Persons with obstructive sleep apnea syndrome (OSAS) suffer cerebrovascular accidents at three to six times the rate of other Americans. Atherosclerosis of the cervical portion of the carotid artery has been suggested as a possible cause of these strokes. Lateral cephalometric radiographs used to determine the site of upper airway obstruction in sleep apnea patients can also image calcified cervical carotid artery atheromas. However, their prevalence in this group of patients has not been previously reported. PATIENTS AND METHODS: The radiographs of 47 male subjects (mean age 59.2 years, range 45 to 77 years) diagnosed as having OSAS (apnea/hypopnea index [AHI] of > or = 15 and a history of snoring and excessive daytime sleepiness) were assessed for calcified carotid atheromas. Healthy, age-matched (+/-18 months) controls were likewise assessed. RESULTS: The radiographs of the subjects with OSAS showed that 21.3% had calcified atheromas. The radiographs of the controls showed that only 2.5% had calcified atheromas. This finding was statistically significant (P = < .000001). The lesions seen in both populations were similar, and located within the soft tissues of the neck at the level of C3 and C4. The lesions were superimposed over these tissues, the prevertebral fascia, and the pharyngeal airspace. CONCLUSIONS: The results of this study seem to indicate that persons with OSAS have a greater prevalence of calcified carotid artery atheromas than healthy, age-matched persons. These lesions, a possible cause of future stroke, can be detected on lateral cephalometric radiographs.

Aged↗

PubMed2003

[Effect of movement arousal and hypoxia on circardian blood pressure in hypertensive patients with obstructive sleep apnea syndrome].

OBJECTIVE: To investigate whether repeated arousals and hypoxia at the end of apnea contribute to nocturnal and diurnal elevation of blood pressure in obstructive sleep apnea syndrome (OSAS) patients with hypertension. METHODS: 30 OSAS patients with hypertension and 30 OSAS patients without hypertension were studied. Movement arousal index (MAI), cortical arousal index (CAI), length of time during which nocturnal oxygen saturation decreased below 90% (OLT90%), apnea/hypopnea index (AHI), 24 h average systolic and diastolic blood pressure (ASBP and ADBP) were measured. Multiple stepwise regression analysis was performed to find the correlation between 24 h ASBP, ADBP and MAI, CAI, OLT90%, AHI, age, body mass index in OSAS patients with hypertension. RESULTS: MAI made the most significant contribution to 24 h ASBP and ADBP in OSAS patients with hypertension (ASBP: r = 0.485, P < 0.01; ADBP: r = 0.407, P < 0.05). OLT90% was the second most important contributing factor (ASBP: r = 0.382, P < 0.05; ADBP: r = 0.369, P < 0.05). CONCLUSION: Movement arousal and hypoxia may make an important contribution to circardian elevation of blood pressure in OSAS patients with hypertension. Both of them may contribute to the development of nocturnal and diurnal hypertension in patients with OSAS.

Adult↗

PubMed2003

Physical activity and perception of energy and fatigue in obstructive sleep apnea.

PURPOSE: This study was designed to examine the relationship between apnea severity, physical activity level, and psychological well being in patients with obstructive sleep apnea (OSA). METHODS: Participants' sleep, subjective report of psychological well-being, and physical activity level were assessed. Thirty-eight patients with sleep apnea (mean age 49.0 +/- 8.9 yr; mean body mass index (BMI) 30.1 +/- 4.9 (kg x m-2) with respiratory disturbance index [RDI] >or= 10 were admitted to the study. Sleep architecture, subjective well-being, and self-reported habitual physical activity were measured. RESULTS: Sleep apnea severity (determined by RDI) was unrelated to subjective self-report of well-being. On the other hand, regular physical activity was significantly correlated with higher SF-36 vitality (r(s) = 0.54), higher Profile of Mood States vigor (r(s) = 0.41), and less fatigue (r(s) = -0.46). The association between physical activity and subjective well being remained significant even after controlling for RDI or BMI. In this group of subjects with sleep apnea, physical activity level was better than sleep apnea severity (i.e., RDI) in predicting perceptions of energy and fatigue. CONCLUSION: The clinical significance of promoting regular physical activity or exercise training as an adjuvant treatment for OSA needs to be further investigated.

Adult↗

PubMed2001

Schizophrenia, obesity, and obstructive sleep apnea.

BACKGROUND: This study evaluated the risk factors for obstructive sleep apnea in psychiatric patients. METHOD: The subjects were 364 patients referred to a sleep disorders consultation service from an inpatient psychiatric hospital. Seventy-eight percent underwent polysomnographic testing. Rates of obstructive sleep apnea in different diagnostic groups (established by clinical DSM-III-R diagnosis) were retrospectively assessed. RESULTS: Logistic regression demonstrated significant independent effects of age (p = .046), gender (p = .002), body mass index (p < .001), and chronic neuroleptic use (p = .012) on the presence of obstructive sleep apnea (defined as more than 20 instances of apnea and/or hypopnea per hour of sleep). Patients with schizophrenia were significantly heavier and had higher rates of sleep apnea than did other psychiatric patients. CONCLUSION: Obesity, male gender, and chronic neuroleptic administration are risk factors for obstructive sleep apnea in psychiatric patients. Since patients with schizophrenia are often on long-term neuroleptic treatment, they may have high rates of obstructive sleep apnea, mediated via the weight gain produced by such medications. Overweight psychiatric patients and those on chronic neuroleptic treatment (e.g., patients with schizophrenia) should be evaluated for sleep apnea if signs and symptoms of this disorder are present.

Adult↗

PubMed1988

Increasing the functional residual capacity may reverse obstructive sleep apnea.

We describe the reversal of obstructive sleep apnea with a 0.5 L increase in the functional residual capacity (FRC) in a patient with sleep apnea syndrome. The patient had been treated with medroxyprogesterone acetate for 8 months. The increase in FRC was obtained by applying a constant negative extrathoracic pressure (NEP) with a poncho-type respirator. With pulmonary inflation, there was a dramatic decrease in the apnea index and the percent apnea time, and an improvement in sleep architecture. At all sleep stages, the desaturation duration was shorter with NEP. The exact mechanisms by which pulmonary expansion improved sleep apnea in this patient remain unclear; lung volume dependence of upper airway patency and the improvements in apnea-induced desaturation may be contributing factors. Our observation illustrates that lung volumes may be an important factor in the pathophysiology of obstructive sleep apnea, especially in the apnea onset and in the apneic-induced desaturation.

Airway Obstruction↗

PubMed1995

Update on upper airway surgery for obstructive sleep apnea.

Uvulopalatopharyngoplasty has limited efficacy in treating obstructive sleep apnea, with excellent results achieved in fewer than half of patients who undergo this procedure. Attempting to select patients who have only retropalatal collapse of the pharynx increases the likelihood of a successful outcome. Although this type of patient selection has been attempted with various techniques, the validity of these approaches is not documented. Objective studies of the airway of awake and asleep patients with obstructive sleep apnea using fiberoptic flexible pharnygoscopy and manometry points to the disparity between observations and complexity of adequate assessment of the mechanism and pattern of pharyngeal collapse. Various approaches to treating the patient with obstructive sleep apnea surgically include uvulopalatopharyngoplasty, genioglossal advancement and hyoid myotomy and suspension, and maxillomandibular advancement. Results of these procedures vary in different reports, possibly due to variation in patient populations or surgical technique. Optimal treatment requires careful consideration of many patient variables and involves the use of a protocol that includes several surgical procedures. Laser-assisted uvulopalatoplasty lacks documentation of efficacy for patients with obstructive sleep apnea. The efficacy of this procedure is likely to prove very limited. Until its proper place in the surgical armamentarium is known, caution is warranted.

Humans↗

PubMed2003

Oxygen administration improves the serum level of nitric oxide metabolites in patients with obstructive sleep apnea syndrome.

OBJECTIVES AND BACKGROUND: Nocturnal apnea and hypoxia are implicated in the pathogenesis of pulmonary and systemic hypertension in obstructive sleep apnea syndrome (OSAS). We have hypothesized that vasodilating factors including nitric oxide (NO) are affected by nocturnal apnea and hypoxia in patients with OSAS. METHOD: We examined the serum level of NO production in 24 patients with OSAS (mean age 54.2+/-7.9 years) and 24 age-matched control subjects (53.4+/-8.1 years) and tested the effects of oxygen administration on the production of NO in the patients. RESULTS: The serum level of nitrite/nitrates (NO(x)), which are stable metabolites of NO, was lower in patients with OSAS than in control subjects. Administration of 1-2 l/min of oxygen during night increased the patients' NO(x) level from 35.6+/-7.3 to 57.8+/-11.6 microM. Compressed air administration did not affect the NO(x) level in the patients. CONCLUSION: These results indicate that systemic NO production is impaired in OSAS patients, possibly due to nocturnal hypoxia.

Case-Control Studies↗

PubMed2000

Obstructive sleep apnea: an unrecognized but prevalent condition.

Obstructive sleep apnea remains an unrecognized and under appreciated disease. The reported prevalence ranges from 2% to 10%. Risk factors include obesity, increased neck circumference, and certain ethnic groups. An apnea index > 20 is associated with higher mortality rate.

Cardiovascular Diseases↗

PubMed2005

Brain preconditioning and obstructive sleep apnea syndrome.

Intermittent hypoxia stimulates the development of adaptive responses, called preconditioning. This process is partially mediated by genetic remodeling, via hypoxia inducible factor (HIF), which induces long-term adaptation processes and is responsible for the increase of levels of vascular endothelial growth factor (VEGF), erythropoietin (Epo), atrial natriuretic peptide (ANP), and nitric oxide (NO). The synthesis of brain-derived neurotrophic factor (BDNF) participates in the control of neural plasticity after hypoxia. The mechanisms of neuroprotection against hypoxia may be related to vascular adjustments and to central neurogenic neuroprotection. Some of the factors known to be involved in the development of the mechanism of neuroprotection are also present in the responses to repetitive apneas that occur during sleep in patients with obstructive sleep apnea (OSA) syndrome, who are frequently exposed to severe sleep hypoxemia. It appears that OSA syndrome represents a clinical example of preconditioning and the development of adaptive responses to intermittent hypoxia.

Adaptation, Biological↗

PubMed1997

Sleep-related myocardial ischemia and sleep structure in patients with obstructive sleep apnea and coronary heart disease.

STUDY OBJECTIVES: Patients with coronary heart disease (CHD) and obstructive sleep apnea may have an increased cardiac risk due to nocturnal myocardial ischemia triggered by apnea-associated oxygen desaturation. Sleep structure in patients with obstructive sleep apnea is fragmented by activation of the central nervous system (CNS) (arousal) due to obstructive apneas. Nocturnal myocardial ischemia may lead to activation of the CNS as well. PATIENTS: Fourteen patients with obstructive sleep apnea and CHD disease and seven patients suffering from obstructive sleep apnea without CHD were studied. Overnight sleep studies and simultaneous six-lead ECG recordings were performed. In addition, sleep studies and ECG recordings were performed with administration of a sustained-release nitrate in these patients in a double-blinded crossover design. RESULTS: Analysis of three nights' recordings revealed 144 episodes of nocturnal myocardial ischemia in six subjects. Five patients had underlying CHD and one patient exhibited diffuse wall defects of the coronary arteries; also, 85.4% of ischemic episodes were concomitant with apneas and oxygen desaturation > 3%, and 77.8% of ischemic episodes occurred during rapid eye movement (REM) sleep, although total amount of REM sleep was only 18% of total sleep time. Mean oxygen saturation was significantly lower (p < 0.05) during apnea-associated ischemic episodes than during nonapnea-associated ischemia (77.3% vs 93.1%). Nitrate administration did not reduce ischemic episodes. Sleep architecture (macrostructure) exhibited a reduction in sleep stages non-REM 3 and 4 and REM sleep. Comparing the microstructure of sleep (arousals) within episodes with and without ischemia but similar criteria like sleep stage, apnea activity, and oxygen saturation, we found significantly more (p < 0.01) and severe (p < 0.001) arousals during periods with myocardial ischemia than during control episodes. In addition, microstructure of sleep was disturbed by myocardial ischemia itself in absence of apneas. CONCLUSION: It is concluded that patients with CHD and obstructive sleep apnea are endangered by apnea-associated ischemia and that these ischemic episodes lead to activation of the CNS and additional fragmentation of sleep. Patients with nocturnal ischemia should be screened for underlying sleep apnea even if nitrate therapy fails.

Aged↗

PubMed1994

Relation between polysomnographic parameters and apnea index in obstructive sleep apnea syndrome.

We performed overnight polysomnography in 77 patients for diagnosis of sleep apnea syndrome (SAS) and assessment of severity. Patients were classified into 3 groups according to apnea index (AI): group 1 (G1; no SAS), AI < or = 10 (21 patients), group 2 (G2; moderate SAS), 10 < AI < 40 (34 patients), and group 3 (G3; severe SAS), AI > or = 40 (22 patients). In all 3 groups, 60% of the apneas were obstructive, but the proportion of mixed apnea increased from G1 to G3 (6% in G1, 12% in G2, and 24% in G3). The duration of REM sleep was shorter in G2 and G3 than in G1 (G1 61 min, G2 44 min, G3 41 min; p < 0.03). In G3 a dramatic decrease in deep sleep was noted in comparison with G1 and G2 (G1 29 min, G2 31 min, G3 10 min). The distribution of the apnea in the different sleep stages was similar in G3; in G2, 16 patients had a REM apnea predominance, but in this subgroup duration of REM sleep was longer and AI was lower than in the other 18 G2 patients. So, absence of sleep stage apnea predominance and high proportion of mixed apnea were observed in the most severe SAS.

Carbon Dioxide↗

PubMed2003

Laser-assisted uvulopalatoplasty for the treatment of snoring and mild obstructive sleep apnea syndrome.

OBJECTIVE: To determine the efficacy of the laser-assisted uvulopalatoplasty (LAUP) procedure on snoring and Apnea-Hypopnea-Index (AHI) improvement in patients with snoring and mild obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: Prospective, nonrandomized, nonblinded assessment of outcomes after LAUP in patients suffering from benign habitual snoring and/or mild OSAS. METHODS: Fifty-nine patients with habitual snoring and 25 patients with mild OSAS underwent LAUP (6 of them underwent simultaneous classic tonsillectomy and 20 carbon-dioxide laser tonsillotomy). All patients and their bed partners completed pre- and post-treatment questionnaires ranking snoring, whereas the patients with mild OSAS underwent postoperative polysomnography (PSG). RESULTS: During a 6-month to 5-year follow-up (mean 40 months), 91.5% of the patients with habitual snoring reported significant short-term improvement based on post-treatment questionnaires, whereas 79.7% reported long-term subjective improvement. Nineteen of 25 patients (76%) with mild OSAS reported significant improvement of snoring based on posttreatment questionnaires. According to the postoperative PSG, only 2% showed a worse AHI, whereas 60% showed reduction of the AHI to < or = 5. Eight patients (32%) showed little or no improvement of AHI. CONCLUSIONS: LAUP, in combination with carbon-dioxide laser tonsillotomy in some cases, is a safe, cost-effective, outpatient procedure for the treatment of many cases of habitual snoring and mild OSAS when preceded by careful selection of the candidates.

Adult↗

PubMed1992

Effect of clonidine in obstructive sleep apnea.

The current treatment of choice for obstructive sleep apnea is continuous positive airway pressure. However, not all patients tolerate this form of therapy. We evaluated the effect of clonidine hydrochloride, an alpha 2-adrenergic agonist with REM-suppressant activity, in eight male patients with obstructive sleep apnea. In each patient, sleep-stage distribution and breathing pattern in two all-night sleep studies performed during a 10-day course of clonidine were compared with those of two control and two placebo nights. A dose of 0.2 mg of clonidine administered orally at bedtime totally suppressed REM sleep in two patients. In the other six patients, the same dose decreased percent time spent in REM sleep from a control of 13.4 +/- 1.0 to 8.6 +/- 1.4% (mean +/- SEM, p less than 0.05). The latency to REM sleep increased in the latter group from a control of 129 +/- 9 to 308 +/- 24 min (p less than 0.001). Clonidine had no effect on the frequency and duration of non-REM breathing abnormalities. Under clonidine, the level of nocturnal hypoxemia improved in six patients. This was due to a total suppression of REM and the consequent lack of REM apneas in two patients. In four patients, upper airway obstruction disappeared during period of unsuppressed REM sleep, and SaO2 remained above 90% throughout this sleep stage. Clonidine transformed the pattern of sleep-disordered breathing during unsuppressed REM in the other two patients from that of repetitive obstructive hypopneas associated with persistent hypoxemia to occlusive apneas and cyclical hypoxemia. These results were observed consistently in all patients during both clonidine-sleep studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1993

Neurostimulation for obstructive sleep apnea: investigations.

Neurostimulation of the upper airway muscles (accessory muscles of respiration) was accomplished in anesthetized dogs and sleeping humans by electrical stimulation of the hypoglossal nerves. Such stimulations relieved partial airway obstructions in dogs. They also aborted (shortened) obstructive sleep apnea events in humans who suffer with obstructive sleep apnea syndrome. In one subject, stimulations delivered in advance of apneic events (by automatic cycling) prevented apneas. Neurostimulation for obstructive sleep apnea may be an important concept for future research and development.

Animals↗