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PubMed1998

Preoperative, intraoperative, and postoperative management of patients with obstructive sleep apnea syndrome.

The patient with untreated, obstructive sleep apnea may present difficult or potentially life-threatening challenges to the surgical team. This is true even if the anticipated surgery is remote to the upper airway. Preoperative recognition of the obstructive apnea is essential as the first step in preventing potential complications. When recognized, intraoperative and postoperative initiative can result in a satisfactory outcome.

Cephalometry↗

PubMed1995

Enuresis in an adult female with obstructive sleep apnea.

Adult onset enuresis accompanied by obstructive sleep apnea has been reported rarely. A female patient was referred to our clinic with complaints of of a 15-year history of loud snoring and sleep apnea as well as enuresis, which was treated successfully with imipramine and acetazolamide. The mechanism of enuresis and its relationship to upper airway obstruction are reviewed here with reference to the findings of polysomnography and sleep cystometry.

Acetazolamide↗

PubMed1993

The relationship between the severity of sleep apnea syndrome and 24-h blood pressure values in patients with obstructive sleep apnea.

Automated ambulatory 24-h BP monitoring was made in 38 patients with obstructive sleep apnea syndrome. Stepwise multiple regression analysis revealed that diastolic, systolic, and mean BP values during sleep as well as during wakefulness were significantly related to apnea/hypopnea index and age. Minimal arterial O2 saturation and total sleep time also significantly contributed to diastolic and mean BP values during sleep. Body mass index did not significantly contribute to any of the BP values. These results support a causal relationship between the severity of sleep apnea syndrome and systemic hypertension.

Adult↗

PubMed2003

Effects of obstructive sleep apnea syndrome on serum aminotransferase levels in obese patients.

PURPOSE: Obesity has been associated with obstructive sleep apnea and hepatic steatosis. We investigated the effects of obstructive sleep apnea and treatment with nasal continuous positive airway pressure (CPAP) on serum aminotransferase levels in obese patients. METHODS: We studied 40 obese men with obstructive sleep apnea syndrome. None had hepatitis B antigen or C antibody, autoimmune disease, or an excessive intake of alcohol. Serum levels of aspartate aminotransferase, alanine aminotransferase, triglyceride, glucose, insulin, and leptin were determined in the afternoon and in the morning immediately after sleep, before and after nasal CPAP treatment. RESULTS: Aminotransferase levels were abnormal in 35% (n = 14) of patients. Before treatment, mean (+/- SD) aspartate aminotransferase levels were higher in the morning than in the previous afternoon (presleep, 34 +/- 20 IU/L; postsleep, 39 +/- 28 IU/L; P = 0.006). The overnight mean increases in aminotransferase levels were less marked after the first night of nasal CPAP treatment (aspartate aminotransferase: from 6 +/- 11 IU/L to 2 +/- 6 IU/L, P = 0.0003; alanine aminotransferase: from 5 +/- 9 IU/L to 2 +/- 6 IU/L, P = 0.006). Leptin levels (n = 23) decreased significantly after treatment (P = 0.0002), whereas insulin resistance (calculated by the homeostasis model assessment method) and triglyceride levels were unchanged. Improvements in aspartate and alanine aminotransferase levels were maintained after 1 and 6 months of nasal CPAP treatment. CONCLUSION: Nasal CPAP therapy may have beneficial effects on serum aminotransferase abnormalities in obese patients who have obstructive sleep apnea.

Alanine Transaminase↗

PubMed1992

Glossopexia--evaluation of a new surgical method for treating obstructive sleep apnea syndrome.

Uvulopalatopharyngoglossoplasty, UPPGP, is a modification of the uvulopalatopharyngoplasty, UPPP, technique, originally used for surgical treatment of the obstructive sleep apnea syndrome. The first method seems to be the more successful. However, polysomnography performed after UPPGP showed that about 35% of the patients still had obstructive apnea periods during sleep. Eight of these patients were reoperated with a new technique which is a combination of partial tongue resection and anterior suspension of the tongue (glossopexia). After glossopexia all the patients were subjectively relieved of their symptoms. However, polysomnography carried out postoperatively demonstrated that only 2 patients were objectively cured. The authors want to stress the necessity of meticulous polysomnographical registration pre- and postoperatively. Subjective and objective parameters recorded before and after surgery are discussed.

Airway Obstruction↗

PubMed2001

Prevalence of obstructive sleep apnea syndrome in a cohort of 1,207 children of southern Italy.

STUDY OBJECTIVE: To determine the prevalence of sleep-related breathing disturbances in a large cohort of school-aged and preschool-aged children of Southern Italy. DESIGN AND SETTING: This cross-sectional prevalence study was designed in two phases: a screening phase aimed to identify symptomatic children from a cohort of 1,207 by a self-administered questionnaire, and an instrumental phase for the definition of sleep-related disorders. PATIENTS AND METHODS: One thousand two hundred seven children were screened by a self-administered questionnaire. There were 612 female children (51%) and 595 male children (mean age, 7.3 years; range, 3 to 11 years). According to answers, children were classified in three groups: nonsnorers, occasional snorers, and habitual snorers. All habitual snoring children underwent a polysomnographic home evaluation, and those with an oxygen desaturation index > 2 were considered for nocturnal polygraphic monitoring (NPM). Children with an apnea/hypopnea index > 3 received a diagnosis of obstructive sleep apnea syndrome (OSAS). RESULTS: A total of 895 questionnaires (74.2%) were returned and scored; 710 children (79.3%) were identified as nonsnorers, 141 children (15.8%) were identified as occasional snorers, and 44 children (4.9%) were identified as habitual snorers. The percentage of male children who were habitual snorers was higher than the percentage of female children who were habitual snorers (6.1% vs 3.7%, respectively; p < 0.09). OSAS was diagnosed in nine children by NPM. CONCLUSION: The lower limit of prevalence of OSAS in childhood is 1% (95% confidence interval [CI], 0.8 to 1.2). If we add the five children who underwent adenoidectomy and/or tonsillectomy because of worsening clinical condition and the two children who were shown to have evidence of OSAS on domiciliary oximetry, then the prevalence is 1.8% (higher limit of prevalence; 95% CI, 1.6 to 2.0).

Child↗

PubMed2005

Obstructive sleep apnea in atrial fibrillation patients.

A high prevalence of obstructive sleep apnea has been demonstrated in patients with atrial fibrillation. Our comments want to emphasize the importance of identifying and treating a large proportion of patients with atrial fibrillation who have undiagnosed obstructive sleep apnea as an additional preventive strategy for atrial fibrillation patients.

Atrial Fibrillation↗

PubMed2003

Nonprescription treatments of snoring or obstructive sleep apnea: an evaluation of products with limited scientific evidence.

PURPOSE: To evaluate the level of evidence regarding the safety and efficacy of nonprescription therapies used to treat snoring and obstructive sleep apnea, and form a consensus statement based on available data. REVIEWERS: Members of the American Academy of Sleep Medicine's Clinical Practice Review Committee. METHODS: A search of PubMed database using MeSH terms snore, apnea, and obstructive sleep apnea in August, 2002, including only articles published in English between 1990 and 2002 and of the World Wide Web, using Google search engine and the key words snoring and obstructive sleep apnea. Letters were sent to manufacturers of lubricant oral and nasal products requesting copies of scientific studies to support their claims. RESULTS AND CONCLUSIONS: Given the paucity and quality of scientific literature regarding the nonpharmacologic treatment of snoring and obstructive sleep apnea, members of the Clinical Practice Review Committee had insufficient information to develop standards of practice recommendations. Nevertheless, substantial publicity regarding such treatments is available to the general public. Very limited data are available to support a beneficial effect of these devices on snoring and minimal evidence is available to support their use in treating obstructive sleep apnea. Studies are limited by small numbers of participants and, in some instances, inadequate design, lack of statistical analysis, and sparse use of objective measurements. Many studies do not evaluate product safety, especially over extended use. Physicians may find this information useful in counseling their patients.

Consumer Product Safety↗

PubMed2005

Obstructive sleep apnea syndrome: effect of respiratory events and arousal on pulse wave amplitude measured by photoplethysmography in NREM sleep.

The objective of the study is to evaluate changes in finger pulse wave amplitude (PWA), as measured by photoplethysmography, and heart rate (HR), related to obstructive respiratory events and associated arousals during sleep. We analyzed 1,431 respiratory events in NREM sleep from 12 patients according to (1) the type of event (apnea, hypopnea, upper airway resistance episode) and (2) the duration of the associated EEG arousal (>10, 3-10, <3 s). Obstructive respiratory events provoked a relative bradycardia and vasodilation followed by HR increase and vasoconstriction. Relative PWA changes were significantly greater than HR changes. These responses differed significantly according to EEG-arousal grades (time x arousal interaction, p<0.0001), with longer arousals producing greater responses, but not to the type of respiratory event (time x event interaction, p = ns). Obstructive respiratory events provoke HR and PWA changes, the magnitude seemingly related to the intensity of central nervous activation, with PWA changes greater than HR. PWA obtained from a simple pulse oxymeter might be a valuable method to evaluate sleep fragmentation in sleep breathing disorders.

Arousal↗

PubMed1996

Cephalometric comparisons of craniofacial and upper airway structure by skeletal subtype and gender in patients with obstructive sleep apnea.

To investigate whether patients with obstructive sleep apnea (OSA) have abnormalities in their craniofacial and upper airway (UA) structures compared with normal subjects, cephalometric comparisons were systematically performed in both the upright and the supine positions in subjects with and without OSA, who were then grouped according to their craniofacial skeletal type and gender. A total of 347 patients with OSA and 101 control subjects were divided into male and female groups and then classified into Class I (CI), Class II, Division 1 (CII/1), Class II, Division 2 (CII/2), and Class III (CIII) skeletal subtypes. In the upright position, the most atypical craniofacial and UA structure was shown in male patients with CI OSA. In patients with OSA, the degree of UA abnormalities was less in the supine position regardless of skeletal subtype. In the supine position, the most atypical craniofacial and UA structure was also shown in male patients with CI OSA; there were no significant differences between male patients with CII/2 OSA and control subjects or between female patients with CI OSA and control subjects. With a change in body position from upright to supine, distinctive changes in the UA structure in both patients with OSA and control subjects occurred, according to skeletal subtype and gender. We conclude that there are a series of characteristics of craniofacial and UA structure that differ between patients with OSA and control subjects matched for skeletal subtype and gender. These differences may predispose to UA obstruction during sleep in patients with OSA.

Adult↗

PubMed1988

Surgical management of obstructive sleep apnea in children with Down syndrome.

Obstructive sleep apnea (OSA) is relatively common in children with Down Syndrome due to anatomical and immunological variations which place them at particular risk. Secondary cardio-respiratory complications of upper airway obstruction may be found at the time of initial diagnosis; these require medical therapy before surgical correction of the OSA is attempted. The selection of appropriate surgical therapy is influenced by the anatomical structure of the individual child. Tonsillectomy and adenoidectomy alone infrequently provide lasting relief of obstruction for these children. We have found that uvulopalatopharyngoplasty (UPPP), with or without simultaneous anterior reduction of the tongue, alleviates this form of airway obstruction. This paper describes the procedures and reports our experience of six patients with Down syndrome.

Adolescent↗

PubMed2003

The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea.

OBJECTIVE: To determine the long-term success and morbidity of tracheostomies for patients with severe obstructive sleep apnea. STUDY DESIGN: A retrospective study of patients who have undergone tracheostomy for documented obstructive sleep apnea at Hennepin County Medical Center since 1979. METHODS: Retrospective chart review of all tracheostomy patients operated January 1, 1979, to June 30, 1999, were evaluated. Follow-up data from patient records, death certificates, and DMV. RESULTS: Seventy-nine patients (70 men and 9 women; age range, 25-70 y; mean age, 47 y) received tracheostomies at a regional sleep disorder center. Respiratory distress index ranged from 45 to 146 (mean value, 81). Tracheostomy eliminated obstructive sleep apnea in all cases. Follow-up ranged from 3 months to 20 years (mean period, 8.3 y). In all, 16 patients had decannulation (range, 2 mo to 13 y): 5 of the patients chose continuous positive airway pressure, 3 grew intolerant of their tracheostomy, 3 had obstructive sleep apnea fully resolve after uvulopalatopharyngoplasty, 3 unknown diagnosis for decannulation, 2 had significant weight loss. Morbidity seen within the first year was primarily limited to granulation tissue, infection, and stoma revision. Fourteen deaths were identified. Average age at time of death was 62 years. Five deaths were cardiopulmonary related, four were from cancer, two were from postoperative complications of unrelated surgery, and one was from aspiration. Tracheostomy-related mortality included one postoperative myocardial infarction and one tracheal-innominate fistula. CONCLUSION: Severe obstructive sleep apnea and its comorbid conditions are effectively treated in the long term with tracheostomy. Initial management of more frequent complication is well tolerated. Significant morbidity and mortality are low. Chances of obstructive sleep apnea resolution allowing decannulation remain poor.

Adult↗

PubMed1997

Surgical treatment of obstructive sleep apnea in neurologically compromised patients.

Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.

Adenoidectomy↗

PubMed1997

Correlation between anthropometric measurements of the oropharyngeal area and severity of apnea in patients with snoring and obstructive sleep apnea.

The aim of this study was to investigate the relationship between severity of apnea and anthropometric oropharyngeal measurements in patients with snoring and obstructive sleep apnea. A total of 22 patients complaining of snoring and apneic spell during sleep were evaluated by polysomnographic and anthropometric measurements of the oropharyngeal area. The horizontal width of the uvula at the mid-point and the length of the uvula were measured using a T-shaped ruler. The distance between the anterior pillars, posterior pillars and retromolar raphes were also measured. The correlation between these anthropometric measurements and polysomnographic parameters including the respiratory disturbance index (RDI) and the lowest arterial O2 saturation level (lowest SaO2) of the patients were analyzed. Of the anthropometric measurements, the horizontal width of the uvula showed a significant correlation with RDI and lowest SaO2. The results of the present study indicate that patients with broader uvula may have severer sleep apnea and that anthropometric oropharyngeal measurements may give additional information to polysomnographic findings for selecting surgical candidates.

Adult↗

PubMed1996

Respiratory effort. A factor contributing to sleep propensity in patients with obstructive sleep apnea.

To test the hypothesis that respiratory effort during obstructive apneas contributes, together with hypoxemia and sleep fragmentation, to excessive daytime sleepiness, we investigated the relationship between daytime sleepiness and polysomnographic variables in 44 patients with obstructive sleep apnea (OSA). In all patients, daytime sleep propensity was assessed by an 11-item standardized self-questionnaire yielding a sleepiness score and by a modified sleep latency test yielding a mean sleep latency. Respiratory effort during apneas was evaluated by measuring esophageal pressure swings using an esophageal balloon. Within each apneic cycle, we measured the esophageal pressure swings during the first three and the last three occluded efforts during the apnea to define the overall increase, its ratio to apnea duration, and the maximal effort developed during obstruction. In the group of patients as a whole, the sleepiness score was negatively correlated with the mean sleep latency (r=-0.38, p=0.01). The sleepiness score was correlated with the indexes of respiratory effort during apneas (ie, the overall increase, its ratio to apnea duration, and the maximal end-apneic swing in esophageal pressure) and with the apnea+hypopnea index. The mean sleep latency was correlated with all indexes of nocturnal hypoxemia (ie, the mean lowest oxyhemoglobin saturation [SaO2] and the index of apnea associated with a fall in SaO2 below 90% and 80%). We conclude that the degree of respiratory effort during obstructive apneas contributes to self-rated sleep propensity in patients with OSA.

Adult↗

PubMed2006

A double-blind, placebo-controlled, crossover study of sildenafil in obstructive sleep apnea.

BACKGROUND: Sildenafil prolongs the action of cyclic guanosine monophosphate and nitric oxide by inhibiting cyclic guanosine monophosphate-specific phosphodiesterase 5. It is largely used for erectile dysfunction, a highly prevalent condition in obstructive sleep apnea. Because nitric oxide promotes upper airway congestion, muscle relaxation, and pulmonary vasodilation, the aim of this study was to establish the impact of a single 50-mg dose of sildenafil on the sleep of patients with severe obstructive sleep apnea. METHODS: Thirteen [corrected] middle-aged men with severe obstructive sleep apnea were consecutively selected for this double-blind, placebo-controlled, crossover study. Exclusion criteria were obesity, cardiovascular and/or respiratory disease, and conditions that interfere with sleep. All-night polysomnography was preceded by a single 50-mg dose of sildenafil or matching placebo randomly administered at bedtime, after a washout period of 1 week. RESULTS: In comparison to placebo, a single 50-mg dose of sildenafil significantly increased the percentage of total sleep time with an arterial oxygen saturation of less than 90% (mean +/- SD, 15.6% +/- 9.6% vs 7.9% +/- 3.3%, [corrected] P < .01), without a difference in the nadir of oxygen desaturation. The mean arterial oxygen saturation also decreased (92.1% +/- 1.9% vs 93.8% +/- 1.3%, P = .03), [corrected] and the desaturation index increased (30.3 +/- 14.5 [corrected] events per hour vs 18.5 +/- 9.1 [corrected] events per hour, P < .001). There was an increase in apnea-hypopnea index (48.1 +/- 20.8 [corrected] events per hour vs 32.3 +/- 11.3 [corrected] events per hour, P = .001), [corrected] involving mostly obstructive events. CONCLUSION: In patients with severe obstructive sleep apnea, a single 50-mg dose of sildenafil at bedtime worsens respiratory and desaturation events.

Cross-Over Studies↗

PubMed2000

Effects of a mandibular repositioner on obstructive sleep apnea.

The purpose of this study was to investigate the effects of a mandibular repositioner on airway, sleep, and respiratory variables in patients with obstructive sleep apnea. Twenty-two patients selected for this study were confirmed with a diagnosis of obstructive sleep apnea based on initial nocturnal polysomnography. The patients were fitted with a mandibular repositioner designed to hold the mandible anteroinferiorly. Six months later, an outcome polysomnographic study was undertaken for each patient with the appliance in place. Lateral cephalometric radiographs in the upright position were also obtained before and after 6 months of treatment. The respiratory disturbance index decreased in 21 of the 22 patients with the appliance in place. The mean respiratory disturbance index of the 22 patients decreased significantly from 40.3 to 11.7 events per hour (P <.01). Some 59.1% of subjects were considered a treatment success with follow-up respiratory disturbance index < 10 events per hour. The mean minimum blood oxygen saturation level during sleep also improved significantly from 73.4% to 81.3% (P <. 01). The mandibular repositioner was constructed to position the mandible at 75% of the maximal mandibular advancement and with a 7 mm opening between the upper and lower incisors, and no aberrant effect on temporomandibular joint was noted. The retropalatal airway space increased and the cross-sectional area of the soft palate and the vertical distance of the hyoid bone to the mandibular plane decreased significantly. The tongue posture became significantly flatter. A significant linear correlation was found between the reduction in apnea index and specific craniofacial skeletal structures (length of anterior cranial base, mandibular plane angle, and upper to lower facial height ratios, P <.05). Subjects with a smaller reduction in apnea index tended to have shorter anterior cranial bases, steeper mandibular planes, and smaller upper to lower facial height ratios. We conclude that a mandibular repositioner may be an effective treatment alternative for obstructive sleep apnea and that a reduction in the frequency of apneic episodes is mainly attributed to the effects of the appliance on oropharyngeal structures.

Adult↗

PubMed2003

Variables affecting the occurrence of gastroesophageal reflux in obstructive sleep apnea patients.

A number of recent studies have suggested that apnea and/or hypopnea episodes may be in a causal relationship with nocturnal gastroesophageal reflux (GER) episodes in obstructive sleep apnea (OSA) patients. In this study, we addressed the possible factors that may affect the occurrence of reflux events in OSA patients. For this reason, we investigated respiratory and sleep parameters in OSA patients with or without nocturnal GER episodes. Nineteen patients who were referred to the sleep laboratory for suspected sleep apnea were included in the study. All subjects underwent polysomnographic evaluation simultaneously with distal and proximal esophageal pH monitoring. During the recording period, a total of 134 reflux events, 134 from distal probes and none from proximal probes, were recorded. We divided patients into two groups: (1) nocturnal GER-positive patients ( n=8; age: 41.9+/-11.9) and (2) nocturnal GER-negative patients ( n=11; age: 45.4+/-3.3). We compared demographic, respiratory and sleep parameters between the two groups. Then we analysed the time relation between GER episodes and obstructive respiratory events. The two groups were matched by age and body mass index. Sleep and respiratory parameters were not different between the two groups. In conclusion, we suggested that age, body mass index and the severity of disease in obstructive sleep apnea patients are not effective determinants of gastroesophageal reflux. There is no sufficient evidence to accept arousals and obstructive apneas as primary causes of gastroesophageal reflux and vice versa. And finally, sleep macroorganisation has no impact on the occurrence of GER in OSAS.

Adult↗