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PubMed2006

[Recurrent pulmonary edema associated with obstructive sleep apnea syndrome].

A 70-year-old non-obese man with no history of cardiopulmonary disease presented 4 times to the emergency room because of sudden onset of seizure during sleep. Each time he recovered within a few hours without any medication. Nocturnal polysomnographic recording revealed severe obstructive sleep apnea syndrome (OSAS, AHI 52.4/Hr). Nasal continuous positive airway pressure (n-CPAP) therapy was performed with 10cmH2O of pressure. His symptoms of severe daytime sleepiness and seizure were diminished. CPAP was decreased from 10cmH2O to 6 cmH2O later, because the patient complained with its high pressure. He then felt daytime sleepiness and suffered seizures during sleep again, and was re-admitted to our hospital. Chest roentgenogram taken at this admission showed remarkable pulmonary edema. We found that the pulmonary edema was recognized every time on his chest roentgenogram taken when he complained seizure. In addition, subsequesnt roentgenograms also showed that the pulmonary edema was diminished soon. On the other hand, his AHI was high (24.7/hr) even when he was under 6cmH2O of n-CPAP. We concluded that incompletely treated OSAS might lead not only to pulmonary edema, but also to seizures in this patient.

Aged↗

PubMed2004

Determinants of heart rate variability in obstructive sleep apnea syndrome during wakefulness and sleep.

Heart rate variability (HRV) is mediated by at least three primary mechanisms: 1) vagal feedback from pulmonary stretch receptors (PSR), 2) central medullary coupling between respiratory and cardiovagal neurons (RCC), and 3) arterial baroreflex (ABR)-induced fluctuations. We employed a noninvasive experimental protocol in conjunction with a minimal model to determine how these sources of HRV are altered in obstructive sleep apnea syndrome (OSAS). Respiration, heart rate, and blood pressure were monitored in eight normal subjects and nine untreated OSAS patients in relaxed wakefulness and stage 2 and rapid eye movement sleep. A computer-controlled ventilator delivered inspiratory pressures that varied randomly from breath to breath. Application of the model to the corresponding subject responses allowed the delineation of the three components of HRV. In all states, RCC gain was lower in OSAS patients than in normal subjects (P < 0.04). ABR gain was also reduced in OSAS patients (P < 0.03). RCC and ABR gains increased from wakefulness to sleep (P < 0.04). However, there was no difference in PSR gain between subject groups or across states. The findings of this study suggest that the adverse autonomic effects of OSAS include impairment of baroreflex gain and central respiratory-cardiovascular coupling, but the component of respiratory sinus arrhythmia that is mediated by lung vagal feedback remains intact.

Adult↗

PubMed2002

Peripheral arterial tonometry for the diagnosis of obstructive sleep apnea.

Sleep related breathing disorders have been recognized as a risk factor for cardiovascular disorders. Peripheral arterial tonometry (PAT) allows to monitor vasoconstriction on the finger continuously and non-invasively. We investigated whether the rapid changes of autonomous function can be assessed by PAT. In 21 patients with obstructive sleep apnea and arterial hypertension we recorded PAT in parallel to cardiorespiratory polysomnography and invasive arterial blood pressure. The correlation between periodic PAT attenuations and the total number of apneas (r = 0.656, p < 0.01) and the total number of cortical arousal (r = 0.583, p < 0.01) were significant. The PAT signal cannot substitute blood pressure but allows a good recognition of apneas and subcortical arousal and gives additional information on changes of sympathetic and parasympathetic tone during sleep.

Adult↗

PubMed1998

[Obstructive sleep apnea and hypertension. Diagnostic procedure--exclusion of risk factors--nCPAP treatment].

Obstructive sleep apnea is a common illness with an estimated prevalence of 3% in the adult population. At least 50% of patients with obstructive sleep apnea also have hypertension, while approximately 30% of hypertensives also suffer from obstructive sleep apnea. This high level of coincidence together with the results of recent epidemiological studies and the frequent observation that hypertension may reverse under effective treatment for obstructive sleep apnea strongly suggest that this sleep disorder is an independent causal factor in the development of hypertension. The present paper considers the association of sleep apnea and hypertension and the resulting diagnostic and therapeutic consequences.

Adult↗

PubMed1994

[The usefulness of an alternative EEG scoring system in obstructive sleep apnea].

Careful analysis of the EEG in obstructive sleep apnea (OSA) patients according to the Rechtschaffen and Kales (R & K) criteria indicates that obstructive apneas (OA) are more frequently observed during stage 1 and 2 sleep than during slow wave sleep. However it is also obvious that OA can be recognised during R & K wakefulness stage (St W). The purpose of the present study was to see whether further partition of R & K St W could define a wakefulness stage during which no apneas occur. Ten patients with predominantly OSA were studied (OA-Index 20 +/- 5). Patients EEG were scored according to classic R & K and to modified criteria which further divided R & K St W. Three additional stages were defined (STW-a, STW-b, STW-c). The partitioning of STW of R & K allowed us to define a W-stage (STW-a) during which no apneas occur, and to identify alpha (STW-b) and drowsiness (STW-c) during which OA occur frequently.

Adult↗

PubMed2004

[Treatment of pediatric obstructive sleep apnea hypopnea syndrome].

OBJECTIVE: To evaluate treatment options of pediatric obstructive sleep apnea hypopnea syndrome (OSAHS) and their curative effect. METHODS: In this study, there are 59 confirmed pediatric obstructive sleep apnea hypopnea syndrome cases diagnosed by polysomnography (PSG). Among them, 54 cases were treated by tonsillectomy or/and adenoidectomy directed by transoral endoscopy. Continue positive airway pressure (CPAP) was used for 2 cases in long-term. Three cases were treated with other conservative therapy. OSA-18 (quality of life for children with obstructive sleep apnea 18 items) was adopted as a disease-specific quality-of-life follow-up survey before and after treatment. RESULTS: During perioperation period, no postoperative bleeding or acute respiratory obstruction occurred. Follow-up sleep study was carried out 12-18 months postoperatively, no complications of velopharyngeal insufficiency, nasopharyngeal stenosis or residual adenoid were found. OSA-18 scores showed that quality of life had been significant improved after operation in 76.3% (45 cases), sleep disturbance in 88.1% (52 cases) and physical symptoms in 67.8% (40 cases). The pressure level of long-term CPAP in 2 cases was about 5.6-7.8 cmH2O. 3 cases were slightly improved treated with conservative therapy. CONCLUSIONS: Surgical removal of upper airway obstruction caused by enlargement of tonsil and adenoid is one of the most effective treatment for pediatric OSAHS. Fibrous endoscopy and cephalometric analysis are helpful to confirm surgical indication. The advantages of transoral endoscopy directed adenoidectomy are as follows: clear and direct visualization, complete removal, without damaging of the peripheral structures.

Adenoidectomy↗

PubMed2000

[Hypertension and altered cardiovascular variability associated with obstructive sleep apnea].

In the past 5 years several epidemiologic studies have demonstrated that sleep-related breathing disorders are an independent risk factor for hypertension, probably resulting from a combination of repetitive episodes of hypoxia, hypercapnea, arousals, and a striking surge in sympathetic excitation, and altered baroreflex control during sleep. Obstructive sleep apnea (OSA) may lead to the cardiac arrhythmias and myocardial ischemia and it is a possible risk factor for stroke. We confirmed that nasal CPAP has been shown to lower blood pressure in some hypertensive OSA patients. Early recognition and treatment of sleep-apnea may improve cardiovascular function.

Baroreflex↗

PubMed2001

[Nasal CPAP treatment and hypertension and altered cardiovascular variability associated with obstructive sleep apnea (OSA)].

Baroreflex↗

PubMed2002

Utility of actigraphy in the diagnosis of obstructive sleep apnea.

STUDY OBJECTIVES: To determine whether adding actimetry to simplified polygraphy (respiratory-parameter monitoring without neurophysiologic variable recording) improves apnea-hypopnea index (AHI) evaluation as compared to simplified polygraphy alone. DESIGN: Comparison of AHI values obtained by all-night polysomnography and by simplified polygraphy with and without actimetry. SETTING: A teaching-hospital sleep laboratory in Garches, France. PATIENTS: 20 adults with suspected obstructive sleep apnea syndrome (OSAS). MEASUREMENTS AND RESULTS: Data were analyzed by two scorers working independently. AHI was calculated as the number of apneas and hypopneas per hour of sleep time (polysomnography: AHI-pg), per hour of time in bed (simplified polygraphy: AHI-tib), and per hour of actimetry-estimated total sleep time (AHI-act). AHI-pg showed that 12 patients had OSAS (AHI>10), which was severe (AHI > or =30) in eight. AHI-act was more closely correlated to AHI-pg (r=0.976) than was AHI-tib (r=0.940). According to the Bland and Altman method, AHI-tib underestimated the AHI in two patients and AHI-act overestimated the AHI in one patient. For the diagnosis of severe OSAS, sensitivity and negative predictive value were 50% and 75% with AHI-tib as compared to 88% and 92.5% with AHI-act. CONCLUSIONS: Actimetry, when added to simplified polygraphy, may assist in the diagnosis of OSAS.

Acceleration↗

PubMed2003

[Cardiovascular consequences of obstructive sleep apnea syndrome].

PURPOSE: This article is an update of past and current data on the relationship between obstructive sleep apnea syndrome and cardiovascular diseases. CURRENT KNOWLEDGE AND KEY POINTS: Obstructive sleep apnea syndrome is a common, but under-recognised, condition and should not be considered simplistically as the association of snoring and obesity. It may be suspected by the clinical history but a definite diagnosis requires the practice of polysomnography. Numerous studies have found a significant relationship between the presence of obstructive sleep apnea syndrome and the occurrence of cardiovascular events. Nonetheless, a definite causal relationship has only been established for the occurrence of hypertension. There are multiple immediate and delayed cardiovascular responses to the apneic events and thus there are many possible physiopathological mechanisms to explain the association of obstructive sleep apnea and cardiac and vascular events, the primary one being sympathetic hyperactivity. The prognosis of obstructive sleep apnea syndrome is closely related to the incidence of cardiovascular events. FUTURE PROSPECTS AND PROJECS: The existence of an independent relationship between obstructive sleep apnea syndrome and atherosclerosis is not yet demonstrated. The beneficial effects of continuous positive airway pressure, the treatment of choice for this condition, on the incidence of cardiovascular diseases remains to be confirmed although recent studies suggest that correct treatment of obstructive sleep apnea syndrome by continuous positive airway pressure may reduce the cardiovascular risk and in particular that of hypertension.

Arteriosclerosis↗

PubMed2006

Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea.

STUDY OBJECTIVE: To assess the clinical usefulness of the Mallampati score in patients with obstructive sleep apnea. Mallampati scoring of the orophyarynx is a simple noninvasive method used to assess the difficulty of endotracheal intubation, but its clinical usefulness has not been validated in patients with sleep-disordered breathing. DESIGN: Prospective multivariate assessment of a predictor variable. SETTING: The UCSF Sleep Disorders Center. PATIENTS OR PARTICIPANTS: One hundred thirty-seven adult patients who were evaluated for possible obstructive sleep apnea. INTERVENTIONS: Prospective determination of the Mallampati score, assessment of other variables for multivariate analysis, and subsequent overnight polysomnography. MEASUREMENTS AND RESULTS: The Mallampati score was an independent predictor of both the presence and severity of obstructive sleep apnea. On average, for every 1-point increase in the Mallampati score, the odds of having obstructive sleep apnea (apnea-hypopnea index> or = 5) increased more than 2-fold (odds ratio [per 1-point increase] = 2.5; 95% confidence interval: 1.2-5.0; p = .01), and the apnea-hypopnea index increased by more than 5 events per hour (coefficient = 5.2; 95% confidence interval: 0.2-10; p = .04). These results were independent of more than 30 variables that reflected airway anatomy, body habitus, symptoms, and medical history. CONCLUSION: Our results indicate that Mallampati scoring is a useful part of the physical examination of patients prior to polysomnography. The independent association between Mallampati score and presence and severity of obstructive sleep apnea suggests that this scoring system will have practical value in clinical settings and prospective studies of sleep-disordered breathing.

Body Mass Index↗

PubMedDate not supplied

Current treatment practices in obstructive sleep apnea and snoring.

PURPOSE: To determine current management strategies of otolaryngologists involved in the treatment of sleep-disordered breathing. MATERIALS AND METHODS: Survey of practitioners regarding their workup and treatment of patients suspected of obstructive sleep apnea. RESULTS: Of 305 respondents, 280 actively treated patients with obstructive sleep apnea or snoring, form the basis for this study. Respondents were from assorted practice settings, from a diverse geographic background, and varied length of time in practice. Although 48% see more than 3 new outpatients a week for snoring or obstructive sleep apnea, only 46% routinely ask their patients about sleep problems, and 49 % fail to ask all of their patients with sleep apnea about sleep-related automobile accidents. Although most regularly use nasopharyngoscopy, a significant proportion seldom uses the Müller maneuver. Most tend to rely predominantly on whole-night polysomnography, rather than split night or home testing. Half of respondents offer their patients with simple snoring more than 1 method of treatment. Although many different surgical procedures are offered by most, only 28% of respondents offer patients any procedure aimed at airway obstruction at the base of tongue level. CONCLUSIONS: Otolaryngologists, with their unique expertise in airway management, need to be more vigilant for patients with sleep-disordered breathing. The hypopharynx fails to be frequently addressed by the respondents and could lead to inadequate treatment of obstructive sleep apnea. Further research should seek to develop an evidence-based standard of care such that this disorder might be most effectively managed in the future.

Adult↗

PubMed2000

[Obstructive sleep apnea syndrome in a patient with superior vena cava syndrome caused by lung cancer].

A 48-year-old man was treated with chemotherapy and irradiation therapy for superior vena cava syndrome (SVCS) caused by adenocarcinoma of the lung, and his symptoms subsided temporarily. However, the same symptoms recurred, and severe snoring during sleep and daytime hypersomnolence developed. Obstructive sleep apnea syndrome (OSAS) was diagnosed by respiratory inductive plethysmography. After chemotherapy, the symptoms of edema of the face and arms, snoring, and daytime somnolence tendency were alleviated, and the patient's apnea hypopnea index decreased remarkably. In addition, lateral cephalograms disclosed improved patency of the upper respiratory tract and dilation of the soft palate. These findings suggested a relationship between SVCS and OSAS. OSAS may cause a deterioration of circulatory dynamics and the quality of life when it develops secondary to SVCS. Therefore, it is necessary to determine whether OSAS is present and accordingly provide suitable treatment in patients with SVCS.

Adenocarcinoma↗

PubMed1995

Uvulopalatopharyngoplasty: treatment of obstructive sleep apnea in neurologically impaired pediatric patients.

Bona fide obstructive sleep apnea is rare in the pediatric age group. Traditional surgical management for pediatric obstructive sleep apnea (OSA) is adenotonsillectomy alone, however, severely affected children may require uvulopalatopharyngoplasty (UPPP) or tracheostomy to relieve their obstruction. Children with OSA along with other medical maladies (e.g. cerebral palsy, down syndrome) pose an additional challenge to the otolaryngologist due to poor muscular tone and other medical problems which may complicate postoperative management. We report on 15 children (aged 23 months-13 years, mean 7.4 years), 12 with severe mental insufficiency, with documented OSA who underwent classical or modified UPPP. Twelve of 15 had clinical and/or objective improvement. We conclude that UPPP has a role in the management of neurologically-impaired children with OSA.

Adenoidectomy↗

PubMed2002

Mandibular advancement devices: rate of contraindications in 100 consecutive obstructive sleep apnea patients.

Mandibular advancement devices (MAD) should be contraindicated (Clark GT, Sleep Med Rev 1998;2:163-174) if there are: (1) insufficient teeth to support the device, (2) periodontal problems inducing tooth mobility, (3) active temporomandibular joint (TMJ) disorder, and (4) limited maximum protrusive distance (< 6 mm). The aim of the present study was to evaluate the proportion of the obstructive sleep apnea population that exhibits any contraindication (CI) to MAD. For this study there were 100 unselected adult patients consecutively diagnosed by polysomnography in a tertiary sleep laboratory. Clinical and radiologic evaluation of the dental, periodontal, and TMJ status of these 100 patients were performed by two expert maxillofacial surgeons, blind to each other, permitting the identification of MAD CIs. The two maxillofacial surgeons agreed on MAD absolute CIs in 96 of the 100 patients. CIs were identified in 34% of the patients. The nature of the CIs systematically referred to an insufficient number of remaining teeth (mean number of teeth lost: 7.8 +/- 6.1 with 31 patients having had more than 10 teeth removed). The tooth avulsions were significantly higher in contraindicated compared with noncontraindicated patients (16 +/- 8 versus 4 +/- 3, p < 0.00001). Periodontal abnormalities coexisted with dental CI in approximately half of the patients. A TMJ disorder was considered as significant enough to lead to CI in two patients. Dental and periodontal care was needed in 16 patients before the use of MAD could be considered. Conclusions were that primary CIs were present in 34% of 100 consecutive patients, mainly owing to dental problems. Moreover, another subgroup of patients (16%) required close supervision and follow-up to avoid impairment of preexisting TMJ and dental problems. Such a high rate of CI should be considered when the overall efficacy of oral appliances is compared with other treatments, such as surgery or nasal continuous positive airway pressure.

Adult↗

PubMed2003

The association of the severity of obstructive sleep apnea with plasma leptin levels.

OBJECTIVE: To examine whether circulating leptin levels correlate with the severity of disease in patients with obstructive sleep apnea. DESIGN: Prospective nonrandomized study. SETTING: Referral sleep laboratory for patients with sleep-disordered breathing and biochemistry laboratory. Patients Thirty-two subjects (mean +/- SD age, 47 +/- 12 years) who were referred for suspected sleep apnea underwent an overnight sleep study and fasting morning venous blood sampling. Patients were divided into 3 groups with respect to apnea-hypopnea index: (1) severe sleep apnea (n = 8), apnea-hypopnea index greater than 20; (2) mild sleep apnea (n = 12), apnea-hypopnea index between 5 and 20; and (3) nonapneic control (n = 12), apnea-hypopnea index less than 5. RESULTS: Leptin levels (mean +/- SD) were 21.2 +/- 8.6, 16.2 +/- 5.2, and 10.6 +/- 7.5 ng/mL (P =.005) in patients with severe and mild obstructive sleep apnea and nonapneic controls, respectively. Plasma leptin levels correlated positively with the degree of sleep-disordered breathing as recorded by the apnea-hypopnea index (r = 0.54, P =.001) and percentage of sleep time spent with oxygen saturation below 90% (r = 0.39, P =.02). CONCLUSIONS: Circulating leptin concentrations in patients with obstructive sleep apnea, independent of body mass index and age, are significantly higher than levels in nonapneic controls and there is a positive relationship between leptin concentrations and the severity of sleep apnea. Hyperleptinemia may be a prognostic marker of obstructive sleep apnea syndrome.

Adult↗

PubMed2004

Upper airway dynamic responses in children with the obstructive sleep apnea syndrome.

Normal children have a smaller upper airway than adults, but, nevertheless, snore less and have less apnea. We have previously shown that normal children have an upper airway that is resistant to collapse during sleep. We hypothesized that this resistance to collapse is due to preservation of upper airway neuromotor responses during sleep. Furthermore, we hypothesized that upper airway responses would be diminished in children with the obstructive sleep apnea syndrome (OSAS). We therefore compared the upper airway pressure-flow relationship during sleep between children with OSAS and controls. Measurements were made by correlating maximal inspiratory airflow with the level of nasal pressure applied via a mask. Neuromotor upper airway activation was assessed by evaluating the upper airway response to 1) hypercapnia and 2) intermittent, acute negative pressure. We found that children with OSAS had no significant response to either hypercapnia or negative pressure during sleep, compared with the normal children. After treatment of OSAS by tonsillectomy and adenoidectomy, there was a trend for normalization of upper airway responses. We conclude that upper airway dynamic responses are decreased in children with OSAS but recover after treatment. We speculate that the pharyngeal airway neuromotor responses present in normal children are a compensatory response for a relatively narrow upper airway. Further, we speculate that this compensatory response is lacking in children with OSAS, most likely due to either habituation to chronic respiratory abnormalities during sleep or to mechanical damage to the upper airway.

Adenoidectomy↗

PubMed2006

Obstructive sleep apnea: Should all children with Down syndrome be tested?

OBJECTIVES: To determine the incidence of obstructive sleep apnea syndrome in children aged 2 to 4 years with Down syndrome and to determine parents' ability to predict sleep abnormalities in this patient population. DESIGN: Prospective cohort study. SETTING: Tertiary care pediatric referral center. PATIENTS: Sixty-five children participating in a 5-year longitudinal study in which the otolaryngologic problems seen in Down syndrome were evaluated. Fifty-six completed overnight polysomnography (PSG) between 4 and 63 months of age (mean age, 42 months). INTERVENTIONS: Overnight PSG was performed. Parents also completed a questionnaire regarding their impressions of their child's sleep patterns before PSG. MAIN OUTCOME MEASURES: Polysomnograms were classified as abnormal if the obstructive index was greater than 1, if the carbon dioxide level was greater than 45 mm Hg for more than two thirds of the study or greater than 50 mm Hg for more than 10% of the study, and/or if there was unexpected hypoxemia less than 92% during sleep or repeated intermittent desaturations less than 90%. We also identified a group of children whose PSGs findings were normal except for an arousal index greater than 10 and were associated with increased work of breathing. RESULTS: The PSGs revealed that 57% of the children had abnormal results and evidence of obstructive sleep apnea syndrome. If we also include an elevated arousal index, 80% of the PSGs had abnormal results. Sixty-nine percent of parents reported no sleep problems in their children, but in this group, 54% of PSGs had abnormal results. Of the parents who reported sleep problems in their children, only 36% had abnormal sleep study results. CONCLUSION: Because of the high incidence of obstructive sleep apnea syndrome in young children with Down syndrome, and the poor correlation between parental impressions of sleep problems and PSG results, baseline PSG is recommended in all children with Down syndrome at age 3 to 4 years.

Child, Preschool↗