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PubMed2006

Metabolic risk factors for vascular disease in obstructive sleep apnea: a matched controlled study.

RATIONALE: Obstructive sleep apnea (OSA) is reported to have a metabolic profile predisposing to cardiovascular disease. However, previous case-control studies have not adequately controlled for confounders. OBJECTIVES: To determine whether OSA is associated with increased insulin resistance and related metabolic risk factors. METHODS: We performed a matched case-control study (n = 42) examining putative metabolic risks among men with OSA attending a sleep clinic (apnea-hypopnea index [AHI] > 15] compared with no OSA (AHI < 5). Participants were matched for age +/- 5 yr, body mass index +/- 10%, and current smoking status. They were free of diabetes, clinically demonstrable cardiovascular disease, marked hypertension, and dyslipidemia. MEASUREMENTS AND MAIN RESULTS: Mean +/- SD AHI was higher in patients with OSA (40 +/- 27) than in control subjects (3 +/- 1.3, p = 0.02), and median (interquartile range) nocturnal oxygen saturation was lower (OSA, 83 [76-88]; control, 91 [90-93]%; p < 0.001). Patients with OSA had a higher median (interquartile range) homeostasis model assessment score for insulin resistance (OSA, 1.7 [0.8-4.1]; control, 1.0 [0.7-1.8] mU.mmol/L(2); p = 0.02), total cholesterol (OSA, 5.6 [4.8-6.2]; control, 4.8 [4.3-5.4] mmol/L; p = 0.049), and low-density-lipoprotein cholesterol (OSA, 3.8 [2.9-4.2]; control, 3.1 [2.6-3.6] mmol/L; p = 0.04). Patients with OSA had higher 24-h and nocturnal (12-h) urinary norepinephrine excretion and plasma leptin levels, and lower insulin-like growth factor (IGF)-1 levels (all, p < or = 0.02). Multiple linear regression, adjusting for central obesity, age, and alcohol consumption, confirmed an independent association between OSA and metabolic risks (all, p < 0.05), with a trend for IGF-1 (p = 0.053). CONCLUSIONS: In a sleep clinic population, men with OSA and no identifiable cardiovascular disease have increased insulin resistance and other metabolic changes that act to increase the risk of vascular disease, compared with age- and body mass index-matched attendees without OSA.

Body Mass Index↗

PubMed2006

Normalization of memory performance and positive airway pressure adherence in memory-impaired patients with obstructive sleep apnea.

BACKGROUND: Although the treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) has been shown to be effective, nightly adherence to treatment remains poor. The objective of this study was to examine the degree to which various levels of PAP therapy adherence normalized verbal memory function after 3 months of therapy in patients with OSA who were memory-impaired prior to the initiation of PAP therapy. METHODS: Participants were administered neuropsychological testing prior to the initiation of PAP treatment and at a 3-month follow-up visit. Fifty-eight memory-impaired participants were categorized into the following three groups based on 3 months of adherence to PAP therapy: (1) poor users (n = 14), participants who averaged < 2 h of PAP use per night; (2) moderate users (n = 25), participants who averaged 2 to 6 h of PAP use per night; and (3) optimal users (n = 19), participants who averaged > 6 h of PAP use per night. RESULTS: Logistic regression analyses revealed that the odds of optimal users exhibiting normalization of memory function following 3 months of PAP therapy were 7.9 times (p = 0.01) the odds of poor users exhibiting normalization of memory abilities. Overall, 21% of poor users, 44% of moderate users, and 68% of optimal users exhibited memory performance in the clinically normal range following 3 months of PAP use (chi(2) = 7.27; p = 0.03). CONCLUSIONS: These preliminary findings indicate that impaired verbal memory performance in patients with OSA may be reversible with optimal levels of PAP treatment. OSA patients exhibiting verbal memory impairments may experience a clinically meaningful benefit in their memory abilities when they use PAP for at least 6 h per night.

Adult↗

PubMed2006

Improving Health-Related Quality of Life in Patients with Obstructive Sleep Apnea : What are the Available Options?

Obstructive sleep apnea (OSA) syndrome is a common and often life-altering sleep-related breathing disorder. It not only adversely affects cardiovascular health, but the quality of life of these patients is also often significantly compromised. They experience excessive daytime sleepiness and poor cognitive, social and exercise performance. Furthermore, they often have marital problems with increased divorce rates, depression, and poor job performance.Our purpose in writing this review is to highlight the various neuropsychiatric domains that are affected in OSA patients and to emphasize that identifying and treating this condition can significantly improve the quality of life of these individuals. In recent years there has been ample evidence supporting the role of treatment for OSA to improve cardiovascular outcomes. We provide similar evidence supporting the treatment of OSA to improve health-related quality of life outcomes for these patients. Surgical, non-surgical and pharmacologic modalities are currently available as effective options for the treatment of OSA, with continuous positive airway pressure therapy appearing to be the most promising.

Continuous Positive Airway Pressure↗

PubMed2005

Facial axis angle as a risk factor for obstructive sleep apnea.

OBJECTIVE: Many Japanese patients with obstructive sleep apnea (OSA) are less obese than Caucasian OSA patients despite their similar severity of OSA, suggesting that their etiology of OSA may differ. The purpose of this study was to identify bony factors associated with OSA in the Japanese population. METHODS: The clinical records of study subjects were retrospectively reviewed, and cephalometric measurements based on Sella-Nasion references and the Ricketts method were statistically compared. PATIENTS: Two hundred and six consecutive Japanese men complaining of habitual snoring and daytime sleepiness were enrolled in the study. All subsequently underwent an overnight polysomnographic examination. RESULTS: Multiple regression analysis showed that the body mass index (p<0.0001) and facial axis angle (p=0.007) were the dominant overall determinants for the apnea hypopnea index. The sella to nasion to subspinale angle (SNA) and sella to nasion to supramentale angle (SNB) were lower in the non-obese, severe group than for non-obese, mild and moderate patients with OSA (p=0.0047 and 0.0016, respectively). CONCLUSION: The risk factors for OSA in Japanese men may be obesity and the dolico facial pattern seen by the Ricketts method. In addition, a smaller SNA and SNB seem to be associated with the severity of OSA in non-obese patients.

Adult↗

PubMed2000

Morning increase of whole blood viscosity in obstructive sleep apnea syndrome.

OBJECTIVE: Patients affected by obstructive sleep apnea syndrome (OSAS) have an increased risk of cardiovascular diseases such as stroke and myocardial infarction. The pathophysiological mechanisms leading to increased vascular risk are still matter of debate. A relative morning hyperviscosity could be one of the leading mechanisms of cardiovascular morbidity which is actually known to be especially high in the morning hours. METHODS: Whole blood viscosity (WBV) at seven shear rates, ranging from 0.47 to 118 sec(-1), haematocrit (Hct), and plasma fibrinogen (F) concentration, were measured on venous blood samples in 12 patients with OSAS and in 8 healthy controls at 8-9 p.m. and at 7-8 a.m. the morning after. WBV values were normalized on Hct by the computation of the standardised normal deviate z on the normal database of the laboratory. RESULTS: No changes were observed in controls. Hct, F and normalized WBV (independently from Hct changes) significantly increased in the morning hours in OSAS patients. CONCLUSIONS: Viscosity of whole blood increases in the morning in OSAS patients but not in healthy controls. This condition may be related to the increased susceptibility to cerebral ischemia in patients affected by OSAS, particularly evident in the early morning.

Adult↗

PubMed2002

Resolution of dyshidrotic dermatitis of the hand after treatment with continuous positive airway pressure for obstructive sleep apnea.

Eczema of the palm and obstructive sleep apnea (OSA) are common disorders. Proinflammatory cytokines and cell adhesion molecules are elevated in both of these disorders. We describe an unusual patient with OSA who had recurrent free remission of dermatitis after treatment with continuous positive airway pressure. We speculate that the resolution of the patient's skin condition may reflect the effects of increased tissue oxygenation during sleep, reduced sleep fragmentation, and/or a reduction in sympathetic tone associated with successful sleep apnea treatment.

Cytokines↗

PubMed2004

Obstructive sleep apnea syndrome: the diagnostic strategy dilemma.

Obstructive sleep apnea syndrome is a major public health hazard affecting 2-4% of the adult population; only 10% of these patients are recognized by healthcare providers. In the last decade the number of referrals for polysomnography increased threefold in Israel, compared to 12-fold worldwide, and is expected to increase even more in the coming years. This constant demand for PSG studies is beyond the current capacity of sleep laboratories, thus preventing diagnosis for most patients with suspected OSAS. In the current review, we examine problems facing decision-makers on how to treat the increasing flood of patients presenting with symptoms suggestive of sleep-disordered breathing. We evaluate the cost-effectiveness of current technologies for OSA diagnosis, i.e., laboratory versus at-home technologies. We conclude that no current alternative exists to the use of PSG for OSA diagnosis. When at-home technologies are suggested for OSAS diagnosis, data should be provided on factors influencing its cost-effectiveness, e.g., accuracy rates of diagnosis, relative cost of human resources, and case-mix of patients tested. Since PSG remains the gold standard for diagnosis of OSAS, in Israel resources should be allocated to increasing the volume of beds for PSG studies in order to increase access to diagnosis and treatment, which in turn provides better quality of life, saves scarce resources of the healthcare system, prevents unnecessary accidents and increases workers' productivity.

Home Care Services, Hospital-Based↗

PubMed2006

Incremental risk of obstructive sleep apnea on cardiac surgical outcomes.

AIM: Obstructive sleep apnea (OSA) is not generally acknowledged as a perioperative risk factor. High incidence of Sleep disordered breathing has been noticed in patients with cardiovascular disease. The Sleep Heart Health Research Study Group found Apnea-Hypopnea indices (AHI) as modest as 1-10 to be associated with cardiovascular disease manifestations. Given the lack of data we chose to study the incremental risk of OSA in patients undergoing cardiac surgery. METHODS: We looked at 25 587 patients who underwent cardiac surgery at the Cleveland Clinic. Of these, 37 patients were also identified on the Cleveland Clinic Sleep center database as having OSA. Each of these 37 cases were propensity matched for multiple covariates with 5 controls within a distance of 0.001 units. An assumption was made that if the surgery was performed within two years of the diagnosis of OSA, the patient had OSA at the time of the surgery. RESULTS: Higher incidence of encephalopathy (p=0.008), postoperative infection (0.028) and increased ICU length of stay (p=0.031) were noted in the group with OSA after cardiac surgery. The difference in the rates of infection was mostly accounted for by the presence of mediastinitis (8.1% vs 1.6%). Differences in the rates of reintubation, tube time, and overall postoperative morbidity were not statistically significant. CONCLUSIONS: | Increased risk for postoperative complications is suggested in patients with OSA undergoing cardiac surgery. This risk is underestimated on account of lack of awareness about the incidence of OSA in the general population and the cardiovascular population in particular, difficulties in clinical suspicion and diagnosis and limited use of polysomnography.

Aged↗

PubMed1994

Ventilatory responses during wakefulness in children with obstructive sleep apnea.

The pathophysiology of the obstructive sleep apnea syndrome (OSAS) is not fully understood. In children, airway obstruction secondary to tonsilloadenoidal hypertrophy is the leading cause of OSAS. However, not all children with tonsilloadenoidal hypertrophy develop OSAS. Thus, other factors, including abnormalities in ventilatory control, may contribute to the etiology of OSAS. To test this, we performed polysomnography and hypercapnic and hypoxic ventilatory response testing in 20 children and adolescents with OSAS (mean age, 8 +/- 3 [SD] yr) and 19 control subjects. Only two children with OSAS were obese. Children with OSAS had an apnea index of 16 +/- 20, peak PETCO2 of 54 +/- 5 mm Hg, and SaO2 nadir of 84 +/- 13% during polysomnography. Ventilatory responses were performed by rebreathing techniques. The slope of the hypercapnic ventilatory responses, corrected for body surface area, was 1.74 +/- 0.79 L/min/m2/mm Hg PETCO2 in children with OSAS and 1.45 +/- 0.58 L/min/m2/mmHg PETCO2 in control subjects (NS). Hypoxic ventilatory responses, corrected for body surface area, were -0.94 +/- 0.49 L/min/m2/% SaO2 in children with OSAS and -0.95 +/- 0.45 L/min/m2/% SaO2 in control subjects (NS); however, the sample size was small. There was a weak inverse correlation between the slope of the hypercapnic ventilatory response and the duration of hypoventilation during polysomnography (r = -0.44, p < 0.05). We conclude that children with OSAS have normal ventilatory responses to hypercapnia, and they may have normal ventilatory responses to hypoxia. We speculate that abnormal central ventilatory drive plays little if any role in the pathogenesis of pediatric OSAS.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenoids↗

PubMed1991

[Effects of uvulopalatopharyngoplasty in obstructive sleep apnea syndrome].

Thirty-one patients with obstructive sleep apnea syndrome underwent uvulopalatopharyngoplasty (UPPP). After three months, the average apnea/hypopnea index (AHI) decreased from 352.2 +/- 138.2 (mean +/- SD) to 182.2 +/- 140.4 episodes/hr and the duration of oxygen desaturation (less than 85%) decreased from 38.4 +/- 48.6 to 13.2 +/- 25.8 minutes. Although only 51.6% patients had a reduction of AHI greater than 50%, a questionnaire study revealed that most patients had subjective improvement of clinical symptoms and only mild complications were noted. We tried to find out the correlation between the efficacy of UPPP and the severity of obstructive sleep apnea and obese but failed. It is concluded that UPPP is the treatment of choice for obstructive sleep apnea syndrome in selective patients.

Female↗

PubMed2004

Changes in quality of life and respiratory disturbance after extended uvulopalatal flap surgery in patients with obstructive sleep apnea.

OBJECTIVE: To evaluate the subjective and objective outcomes of extended uvulopalatal flap (EUPF) surgery in patients with obstructive sleep apnea. DESIGN: Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Snore Outcomes Survey (SOS), Epworth Sleepiness Scale (ESS), and polysomnography were performed preoperatively and then 6 months postoperatively. SETTING: Tertiary care, sleep disorders referral center. PATIENTS: Fifty-five consecutive patients (52 men and 3 women; mean age, 45 years) with obstructive sleep apnea. INTERVENTION: EUPF surgery. MAIN OUTCOME MEASURES: Overnight polysomnography variables included respiratory distress index (RDI), snore index, minimum oxygen saturation, sleep stages 1 and 2, sleep stages 3 and 4, rapid eye movement, and sleep efficiency. Questionnaire variables included SF-36, SOS, and ESS scores. Success of the operation was defined as a more than 50% reduction of the RDI from the initial value and a postoperative RDI of less than 20. RESULTS: The overall success rate of the EUPF surgery was 82%; the RDI, snore index, and minimum oxygen saturation improved significantly after surgery (P<.001). Sleep architecture in overnight polysomnography remained unchanged (P=.48 and P=.74). Patients demonstrated significant improvement in both their SOS and ESS scores (P<.001) and significant increases in 7 of 8 SF-36 subscales (P<.05 for all). However, there was poor correlation between the improvement in quality of life and the reduction in sleep-related respiratory events. CONCLUSIONS: Extended uvulopalatal flap surgery can greatly reduce sleep-related adverse events and proves to be an effective therapy to enhance the quality of life of patients with obstructive sleep apnea. This study also suggests that subjective and objective outcomes are equally important when reporting the results of EUPF surgery.

Adult↗

PubMed1998

Surgical options for obstructive sleep apnea.

The pathology associated with obstructive sleep apnea is cumulative and progressive. When patients fail to improve with continuous nasal airway pressure or other, less-invasive treatments, surgery should be considered. The initial approach to the surgical patient is identification of all areas of potential obstruction. There are often several sites of obstruction, which can occur anywhere in the upper respiratory tract. One or more procedures may be needed to address these areas. The objective of surgery is to relieve these obstructing sites without interfering with the normal functionality of the upper airway.

Humans↗

PubMed2000

[Upper airway occlusion sites of obstructive sleep apnea].

OBJECTIVE: To locate the obstruction sites in patients with obstructive sleep apnea syndrome (OSAS) during sleep by MRI imaging and dynamic fiberoptic pharyngoscopy. METHODS: Fifteen OSAS patients confirmed by polysomnography (PSG) underwent ultrafast MR imaging during sleep. Their sequential midline sagittal and axial images were obtained and displayed in the cine mode. Then we examined the upper airway of the retropalate region (RP), retroglottal region (RG) and epiglottal region (EPG). We also did dynamic fiberoptic pharyngoscopy examination during sleep in 8 patients in another night. RESULTS: Among the 15 patients, 3 had only RP region obstruction, 2 had only RG region obstruction, and the other 10 had both RP & RG airway obstruction. In the 8 cases monitored with both MRI and fiberoptic pharyngoscopy, the results obtained from the 2 methods were identical. CONCLUSION: MRI and fiberoptic pharyngoscopy are useful in locating the pharyngeal airway obstruction sites of OSAS patients and would be helpful in selecting treatment measures.

Adult↗

PubMed2004

[Pulmonary hypertension in patients with pure obstructive sleep apnea].

UNLABELLED: Patients with obstructive sleep apnoea (OSA) every night experience recurrent episodes of alveolar hypoxia. Alveolar hypoxia is the most potent pulmonary vasoconstrictor causing remodeling of pulmonary arteries and pulmonary hypertension. Development of pulmonary hypertension in patients with OSA is rather rarely observed but still discussed. We studied pulmonary haemodynamics, using Swan Ganz thermodilution catheter, in 67 patients (64 M and 3 F, mean age 45 years) with severe OSA (in full polysomnography mean AHI = 62) and normal pulmonary function data. We observed normal mean haemodynamic values at rest: PPA 15,8 mm Hg, PW 6.8 mm Hg, CO 5.6 L/min. PVR 150 dyn.sec.cm(-5). In 11 pts (16%) the pulmonary artery pressure at rest was elevated (PPA 23.9 mm Hg and PVR 234 dyn.sec.cm(-5)), they were younger, more obese and had higher number of apneic episodes per hour of sleep. During mild exercise (44 pts) PPA rose from 15.8 mm Hg to 29.8 mm Hg and was abnormally high in 17 pts. IN CONCLUSION: we observed pulmonary hypertension at rest in 16% patients with severe OSA, but during exercise in about 40%.

Adult↗

PubMed1994

Obstructive sleep apnea.

The high prevalence of obstructive sleep apnea (OSA) has only recently been appreciated, in part because the symptoms and signs of chronic sleep disruption are often overlooked in spite of their debilitating consequences. They typically develop insidiously during a period of years. We now know that the lives of millions of people each year are significantly impaired by the sequelae of OSA. Many of these patients go unrecognized, with tremendous medical and economic consequences for individual patients and for society. Evidence indicates that chronic, heavy snoring may be associated with increased long-term cardiovascular and neurophysiologic morbidity. Therefore considerable interest lies in the study of the epidemiology and the natural history of these related disorders. The fundamental problem in OSA is the periodic collapse of the pharyngeal airway during sleep. The pathophysiology of this phenomenon is reviewed in some detail. During apneas caused by obstruction, airflow is impeded by the collapsed pharynx in spite of continued effort to breathe. This causes progressive asphyxia, which increasingly stimulates breathing efforts against the collapsed airway, typically until the person is awakened. Hypopneas predominate in some patients and are caused by partial pharyngeal collapse. The clinical sequelae of OSA relate to the cumulative effects of exposure to periodic asphyxia and to sleep fragmentation caused by apneas and hypopneas. Some patients with frequent, brief apneas and hypopneas and normal underlying cardiopulmonary function may have considerable sleep disruption without much exposure to nocturnal hypoxia. Patients with sleep apnea often have excessive daytime sleepiness. As the disorder progresses, sleepiness becomes increasingly irresistible and dangerous, and patients develop cognitive dysfunction, inability to concentrate, memory and judgment impairment, irritability, and depression. These problems may lead to family and social problems and job loss. Cardiac and vascular morbidity in OSA may include systemic hypertension, cardiac arrhythmias, pulmonary hypertension, cor pulmonale, left ventricular dysfunction, stroke, and sudden death. The challenge for the clinician is to routinely consider the diagnosis and to incorporate several basic questions in the historical review of systems regarding daytime or inappropriate sleepiness. The diagnosis of OSA is made with polysomnography, and the decision to treat is based on an overall assessment of the severity of sleep-disordered breathing, sleep fragmentation, and associated clinical sequelae. The therapeutic options for the management of OSA are reviewed. Recognition and appropriate treatment of OSA and related disorders will often significantly enhance the patient's quality of life, overall health, productivity, and safety on the highways.

Adult↗

PubMed1983

Cephalometric analyses and flow-volume loops in obstructive sleep apnea patients.

Fifteen patients with obstructive sleep apnea syndrome (OSAS) and 10 controls were studied. Polygraphic monitoring during sleep confirmed the presence or absence of OSAS. Ten OSAS patients and five controls had cephalometric analysis and 12 OSAS patients and five controls had a flow-volume loop study during wakefulness. Seven OSAS patients were submitted to both analyses. Flow-volume loops were unable to detect extrathoracic airway obstruction in six out of 12 OSAS patients. One control was found with positive results. Six out of seven subjects with positive flow-volume loops were overweight (greater than or equal to 30% ideal weight). Cephalograms were very useful in demonstrating mandibular deficiencies in OSAS patients. The length of the soft palate and the position of the hyoid bone, together with the measurement of the posterior airway space, are criteria of great interest in OSAS patients. Cephalometric analysis is recommended in all OSAS patients scheduled for surgical procedure. None of these tests, however, whether alone or in combination, is capable of identifying all cases of OSAS.

Adolescent↗

PubMed1996

Obstructive sleep apnea syndrome (OSAS) in children: diagnostic challenges.

Obstructive sleep apnea syndrome (OSAS) is increasingly recognized in the pediatric population. It is characterized by a combination of partial upper airway obstruction and intermittent obstructive apnea that disrupts normal ventilation and sleep. It is estimated to occur in 1-3% of children with a peak age of 2 to 5 years. Common symptoms include habitual snoring, difficulty breathing during sleep, restlessness, and witnessed apnea. Adenotonsillar hypertrophy is the most common associated condition in otherwise normal children, but cranialfacial abnormalities, neuromuscular diseases, and obesity are also predisposing factors. Severe OSAS can have serious neurobehavioral and cardiorespiratory consequences including excessive daytime sleepiness, growth failure, school failure, behavioral problems, cor pulmonale, or even death. Diagnosis is based on data from the history, physical exam, and laboratory studies that confirm the presence and severity of the upper airway obstruction. Polysomnography has been the diagnostic tool of choice. Treatment depends on the severity of symptoms and the underlying anatomic and physiologic abnormalities. Since childhood OSAS is usually associated with adenotonsillar hypertrophy, the majority of cases are amenable to surgical treatment. However, there is increasing pediatric experience with CPAP therapy when tonsillectomy and adenoidectomy are either unsuccessful or inappropriate.

Adenoidectomy↗

PubMed1996

Effect of topical upper airway anesthesia on apnea duration through the night in obstructive sleep apnea.

It has previously been reported that the duration of obstructive apneas increases from the beginning to the end of the night (M. Charbonneau, J. M. Marin, A. Olha, R. J. Kimoff, R. D. Levy, and M. Cosio. Chest 106: 1695-1701, 1994). The purpose of this study was to test the hypothesis that stimulation of upper airway (UA) sensory receptors during obstructed inspiratory efforts contributes to arousal and apnea termination and that a progressive attenuation of this mechanism through the night contributes to apnea lengthening. We studied seven patients (six men, one woman) with severe obstructive sleep apnea (apnea-hypopnea index = 93 +/- 26 events/h) during two consecutive nights of polysomnographic monitoring. On one night (random order), we performed topical UA anesthesia with 0.2% tetracaine and on the control night, sham anesthesia. We measured apnea duration, esophageal pressure (Pes) during apneas, and apneic O2 desaturation. Consistent with previous findings, apnea duration, number of efforts per apnea, and peak Pes at end apnea increased from the beginning to the end of the control nights. UA anesthesia produced a significant increase in apnea duration at the beginning of the night but no change in apnea length at the end of the night. Peak Pes and the rate of increase in Pes during the anesthesia nights were greater than during control nights, but the rate of increase in Pes was similar for the beginning and end of the control and anesthesia nights. These findings suggest that UA sensory receptors play a role in mediating apnea termination at the beginning of the night but that the contribution of these receptors diminishes as the night progresses such that greater inspiratory efforts are required to trigger arousal, leading to apnea prolongation.

Adult↗