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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↗

PubMed2001

[Obstructive sleep apnea syndrome and cardiovascular risk].

Numerous studies have shown that obstructive sleep apnea syndrome (OSAS) is associated with an increased cardiovascular morbidity and mortality. Obstructive sleep apnea syndrome and cardiovascular disorders are frequent diseases. They share several risk factors such as age, gender, obesity, smoking, and alcohol. Therefore it is difficult to demonstrate that OSAS is a cardiovascular risk factor, independent of previously known factors. Recent epidemiological studies and trials, consistent with the results of previous studies, have demonstrated a strong association between OSAS and systemic hypertension. They also suggest that there is a possible cause-effect relation between OSAS and coronary artery disease or cardiac arrhythmias. Studies demonstrating that early recognition and treatment of OSAS may be effective in reducing these cardiovascular complications are still needed.

Arrhythmias, Cardiac↗

PubMed1993

Development of nocturnal respiratory disturbance in untreated patients with obstructive sleep apnea syndrome.

Patient histories suggest that obstructive sleep apnea syndrome (OSAS) is a progressive condition. To investigate whether this could be shown in data from sleep recordings, 42 patients with OSAS were retrospectively studied. All had undergone a screening recording of respiration movements and oximetry at least 6 months (average, 16 months) prior to a diagnostic polysomnogram including these parameters. No treatment was given in the meantime. In the first recording, mean oxygen desaturation index (ODI, average number of desaturations of > 4 percent per sleeping hour) was 10; periodic, obstructive respiration movements occurred during (average) 36 percent of total estimated sleeping time, and mean nadir SaO2 was 85 percent. In the second recording, mean ODI was 21 (significant change, p = 0.0002), periodic respiration time was 61 percent, and nadir SaO2 was 80 percent (p = 0.0001, respectively). In 26 of 42 patients (62 percent), ODI had increased by > 50 percent. Increases in ODIs and periodic breathing were significantly correlated to increases in body weight. There were, however, exceptional patients with considerable increases in respiratory disturbance despite weight loss. The greatest changes were found in the patients who had the highest apnea indices in the polysomnograms. Early treatment may therefore be justified, since a borderline case may change to severe OSAS in 1 to 2 years' time. Follow-up recordings of untreated patients are important.

Aged↗

PubMed2004

Neurological perspective on obstructive and nonobstructive sleep apnea.

One of every 15 adults in the United States has at least moderate sleep apnea. The true prevalence is higher, as approximately 0.3 to 5% of adults with sleep apnea are undiagnosed. Sleep apnea has major health consequences; therefore, neurologists must recognize and treat sleep apnea syndromes appropriately. There are three main categories of sleep apnea: obstructive sleep apnea (OSA), central sleep apnea (CSA), and mixed sleep apnea. OSA results from upper airway obstruction, and CSA is due to lack of inspiratory muscle effort; mixed apnea results from a combination of these factors. Sleep apnea syndromes can present within the spectrum of "typical" neurological complaints, including forgetfulness, headaches, sleepiness, fatigability, seizures, and muscle and nerve weakness. A good sleep history, a nocturnal polysomnogram, and multiple sleep latency test are important in elucidating the diagnosis and validating the complaints of sleepiness. The gold standard for treatment of OSA is positive airway pressure, although some patients may benefit from surgical interventions designed to bypass the site of airway obstruction. With CSA, treatment is directed toward the underlying disorder. Patients with CSA may also benefit from several types of nasal positive airway pressure treatment, while some require mechanical ventilation.

Humans↗

PubMed1990

Severity of obstructive sleep apnea.

A four-level severity scale for obstructive sleep apnea is offered using four criteria: maximum oxygen desaturation, apnea/hyponea index, symptoms of excessive day-time sleepiness, and symptoms of related cardiac disease. Oxygen desaturation and the apnea/hyponea index for 175 patients, all having had uvulopalatopharyngoplasty surgery, showed 19% mild, 33% moderate, 17% moderately severe, and 31% severe obstructive sleep apnea. There was a very poor correlation between oxygen desaturations and number of obstructive events, which demands that both be used in any estimation of disease severity.

Humans↗

PubMed1994

Obstructive sleep apnea and the hyoid: a revised surgical procedure.

Obstructive sleep apnea syndrome results from a loss of muscular activity of pharyngeal dilators and airway collapse at the hypopharynx-base of tongue or the oropharynx-soft palate. The hyoid arch and its muscle attachments strongly affect hypopharyngeal airway patency and resistance. On the basis of these concepts and previous experience, a modified hyoid suspension procedure is presented. Fifteen consecutively treated surgical patients underwent an isolated modified hyoid suspension procedure to correct hypopharyngeal obstruction. Oropharyngeal-palatal obstruction had previously been corrected or was thought not to be a component of the obstruction. Treatment outcomes were based on objective polysomnographic data and subjective clinical correction of excessive daytime sleepiness. The polysomnographic data included analysis of the respiratory disturbance index and lowest oxyhemoglobin desaturation. On the basis of these criteria, 12 of 15 patients (75%) had correction of their excessive daytime sleepiness and marked improvement in their sleep disorder breathing. The mean preoperative respiratory disturbance index was 44.7 +/- 22.6, and the lowest oxyhemoglobin desaturation was 82% +/- 6%. The postoperative respiratory disturbance index and lowest oxyhemoglobin desaturation were 12.8 +/- 6.9 and 86% +/- 5%, respectively. The modified hyoid suspension procedure appears to offer significant adjunctive treatment for hypopharyngeal obstruction in obstructive sleep apnea syndrome.

Adult↗

PubMed2003

Measurement of changes in cytochrome oxidase redox state during obstructive sleep apnea using near-infrared spectroscopy.

STUDY OBJECTIVES: To use near-infrared spectroscopy to investigate the effect of obstructive sleep apnea on cytochrome oxidase, the terminal enzyme of the mitochondrial respiratory chain. DESIGN: Observational study. SETTING: Teaching hospital sleep unit. PATIENTS: Subjects with diagnosed moderate to severe obstructive sleep apnea were recruited from the sleep clinic. INTERVENTIONS: Subjects were invited to attend 2 daytime sleep-study sessions, which included near-infrared monitoring of cerebral oxygenation and cytochrome-oxidase oxidation state. In addition, in study session 1, full polysomnography was performed (8 subjects, 303 apneas), and in study session 2, arterial oxygen saturation, cerebral blood flow velocity, and blood pressure were monitored (7 subjects, 287 apneas). MEASUREMENTS AND RESULTS: In study session 1, mean (+/- SD) cytochrome-oxidase changes ranged from 0.48 +/- 0.08 microM to 0.13 +/- 0.05 microM. The magnitude of cytochrome-oxidase change correlated significantly with the magnitude of change in the cerebral tissue oxygenation index (P < .001). In study session 2, there were significant correlations between arterial oxygen-saturation changes and cytochrome-oxidase redox changes and between Doppler cerebral blood flow velocity changes and cytochrome-oxidase redox changes (P < .001 and P = .001, respectively). CONCLUSIONS: Changes in directly measured cerebral tissue saturation and changes in arterial saturation and cerebral blood flow velocity (the 2 main factors affecting cerebral oxygenation) are associated with changes in cytochrome-oxidase oxidation state. The reduced cerebral oxygenation that occurs during obstructive sleep apnea is associated with changes in the intracellular redox state.

Adult↗

PubMed2003

Genioglossus activity in children with obstructive sleep apnea during wakefulness and sleep onset.

A prominent role for upper airway neuromuscular control mechanisms in the pathophysiology of pediatric obstructive sleep apnea syndrome (OSAS) is suggested by the observation that obstruction does not occur during wakefulness and is infrequently seen during non-REM sleep. Using a custom intraoral surface electrode to record genioglossal activity (genioglossal electromyography [EMGgg]), normalized with a maximal maneuver, we studied 10 children with OSAS and 6 normal control subjects to determine EMGgg activity during (1) wakefulness, (2) the sleep onset period, and (3) stable non-REM sleep. We observed that the EMGgg activity in patients with OSAS compared with control subjects was significantly greater during wakefulness (3.6 +/- 1.8 vs. 1.6 +/- 1.8% maximum, p < 0.05) and had a greater decline during the early and late sleep onset period (p < 0.05). During stable non-REM sleep, EMGgg remained below the wakeful baseline in all normal control subjects but increased above the baseline in four of the patients with OSAS. We speculate that the increased EMGgg activity during wakefulness represents a reflex-driven neuromuscular compensation for an anatomically compromised airway. Furthermore, the larger decline in EMGgg at sleep onset observed in patients with OSAS is consistent with the relative loss of this reflex. Finally, the return of EMGgg activity above baseline in patients with severe OSAS suggests that some chemical or mechanical compensatory mechanisms remain active during stable non-REM sleep in children.

Adolescent↗

PubMed1998

[Effects of uvulopalatopharyngoplasty on patients with obstructive sleep apnea--the severity of preoperative tonsillar hypertrophy].

Predicting outcome following uvulopalatopharyngoplasty (UPPP) in obstructive sleep apnea is difficult. We hypothesized that UPPP is effective in obstructive sleep apnea patients with severe tonsillar hypertrophy. We examined the relationship between the severity of pre-operative tonsillar hypertrophy and the effect of UPPP in 38 patients with obstructive sleep apnea (oxygen desaturation index (ODI) > or = 20). The patients were classified into three groups according to the Mackenzie Classification of tonsillar hypertrophy. Ten patients were classified as grade 1 (M1) hypertrophy, i.e. tonsils just visible beyond the palatal arch. Five patients had grade 3 (M3) hypertrophy, i.e. tonsils appearing to contact each other at the midline. The remaining 23 patients had grade 2 (M2) hypertrophy, i.e. intermediate enlargement. We measured the apnea index, ODI, DST 90, and DST 85 (%time with SaO2 < or = 90% and < or = 85%, respectively) using a screening device for sleep apnea (Apnomonitor II, CHEST M. I. Co. Tokyo, Japan) before and after UPPP. Following UPPP, the mean ODI decreased significantly in all groups: 59 to 9/hr (p < 0.005) in the M3 group, 53 to 27/hr (p < 0.001) in the M2 group, and 48 to 33/hr (p < 0.05) in the M1 group. Post-UPPP ODI decreased by 83% in M3, 45% in M2, and 28% in M1 patients. Successful UPPP, defined by a post-UPPP ODI of less than 20/hr and a greater than 50% decrease in post-UPPP ODI, occurred in 80% of M3, 43% of M2, and 10% of M1 patients. We conclude that tonsillar hypertrophy can predict a successful response to UPPP in obstructive sleep apnea patients.

Adult↗

PubMed1984

A diagnostic approach to suspected obstructive sleep apnea in children.

Most children with obstructive sleep apnea will benefit from tonsillectomy and adenoidectomy. Although polygraphic monitoring remains the definitive diagnostic technique, we wondered if all children suspected of having OSA require such evaluation. We therefore administered a standardized questionnaire to the parents of 23 children with polygraphically proved OSA related to adenotonsillar hypertrophy, 46 age- and sex-matched normal children, and 23 children subsequently referred because of possible OSA. Significantly increased frequencies of the following symptoms were found in the OSA group compared with the control group: difficulty breathing during sleep, 96% vs 2%; apnea observed by the parents, 78% vs 5%; snoring, 96% vs 9%; restless sleep, 78% vs 23%; chronic rhinorrhea, 61% vs 11%; and mouth breathing when awake, 87% vs 18%. Using discriminant analysis, an OSA score was derived that correctly classified all control subjects and 22 of 23 patients with OSA. Considering the data from all groups, we found that (1) OSA scores greater than 3.5 were highly predictive of OSA requiring adenotonsillectomy; (2) no child with an OSA score less than -1 had OSA; and (3) in children with OSA scores between -1 and 3.5, polygraphic monitoring was required to determine the severity of sleep-related airway obstruction and the need for surgical treatment. Use of the OSA score should decrease the need for polygraphic monitoring and facilitate selection of children for tonsillectomy and adenoidectomy.

Adenoids↗

PubMed2004

The role of the Genial Bone Advancement Trephine system in conjunction with uvulopalatopharyngoplasty in the multilevel management of obstructive sleep apnea.

OBJECTIVES: The successful surgical management of obstructive sleep apnea (OSA) requires surgical procedures that address both retropalatal and retrolingual airway obstruction. The Genial Bone Advancement Trephine (GBAT) system is a new, 1-step system that allows for isolation and advancement of the genioglossus muscle via a guided trephine system. The purpose of this project was to describe our experience using the GBAT system to perform genioglossus advancement (GGA) in conjunction with uvulopalatopharyngoplasty (UPPP) in the surgical management of OSA. STUDY DESIGN: Retrospective analysis of 35 consecutive patients undergoing GGA using the GBAT system in conjunction with UPPP for the management of OSA during a 3-year period (1999 to 2002). RESULTS: Twenty-four patients had complete preoperative and postoperative polysomnographic data. A 70% reduction in the Respiratory Disturbance Index (RDI) and Apnea Index (AI) in the preoperative versus postoperative PSG (RDI, 52.9 +/- 17.1 versus 15.9 +/- 7.5; AI, 20.1 +/- 6.7 versus 6.1 +/- 4.5; P < or = 0.0001). The lowest oxygen desaturation increased from 80% to 88% (P = 0.0002), and the posterior airway increased from 7.9 to 12.6 mm (P < 0.0001). With a surgical cure defined as a greater than 50% reduction in the RDI and a final postoperative RDI of less than 20 events per hour, the true surgical cure rate was 67% (16 of 24 patients). CONCLUSIONS: The GBAT system performed in conjunction with UPPP can produce significant reductions in RDI and AI while improving the oxygen desaturation and enlarging the posterior airway space. The effective cure rates using the GBAT system are in agreement with previous reports in the literature using various GGA techniques. The GBAT may have some advantages in terms of simplicity and safety.

Adult↗

PubMed1992

Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.

Anecdotal reports suggest that obstructive sleep apnea syndrome (OSAS) patients may suffer from frequent nocturnal gastroesophageal reflux (GER) and that nasal continuous positive airway pressure may be an effective form of antireflux therapy in this population. To confirm these clinical impressions, we performed two consecutive days of 24-h esophageal pH monitoring, nocturnal esophageal pressure recording, and polysomnography on six OSAS patients complaining of regular nocturnal GER. On night one, the patients were untreated. Five of six subjects had abnormal amounts of nocturnal GER. Arousal, movement and swallowing were more frequent (p less than 0.043) and nadir intrathoracic pressure lower (p less than 0.005) in the 30 s prior to precipitous drops in esophageal pH (greater than or equal to 2 pH units) than during random control periods. A direct association between obstructive apneas and GER was not identified. On night two, nasal CPAP was administered and successfully treated apnea in five of six subjects. In these patients, there was also dramatic reduction in GER frequency and duration on CPAP. The mean percentage of time pH less than 4 dropped from 6.3 +/- 2.1 to 0.1 +/- 0.1 percent (p less than 0.025). We believe that OSAS may predispose to nocturnal GER by lowering intrathoracic pressure and increasing arousal and movement frequency. Nasal CPAP can correct these predisposing factors and reduce GER.

Adult↗

PubMed1994

[Obstructive sleep apnea and abnormal fatigue].

Obstructive sleep apnoea syndrome is characterized by irregular snoring during sleep, excessive daytime sleepiness and in some cases unwanted sleep attacks. The patient has a disturbed night sleep with numerous wakenings. Disturbed sleep at night causes daytime problems with attention, concentration and work performance. Furthermore, it may eventually result in errors and accidents. Excessive sleepiness sometimes necessitates the suspension of the patient's driving license. It is of importance to identify patients with obstructive sleep apnoea and daytime sleepiness, because the condition can be treated effectively. Many Danish patients are still unidentified. Diagnostic and treatment possibilities vary from one part of Denmark to another.

Fatigue↗

PubMed2002

Epidemiology of obstructive sleep apnea: a population health perspective.

Population-based epidemiologic studies have uncovered the high prevalence and wide severity spectrum of undiagnosed obstructive sleep apnea, and have consistently found that even mild obstructive sleep apnea is associated with significant morbidity. Evidence from methodologically strong cohort studies indicates that undiagnosed obstructive sleep apnea, with or without symptoms, is independently associated with increased likelihood of hypertension, cardiovascular disease, stroke, daytime sleepiness, motor vehicle accidents, and diminished quality of life. Strategies to decrease the high prevalence and associated morbidity of obstructive sleep apnea are critically needed. The reduction or elimination of risk factors through public health initiatives with clinical support holds promise. Potentially modifiable risk factors considered in this review include overweight and obesity, alcohol, smoking, nasal congestion, and estrogen depletion in menopause. Data suggest that obstructive sleep apnea is associated with all these factors, but at present the only intervention strategy supported with adequate evidence is weight loss. A focus on weight control is especially important given the expanding epidemic of overweight and obesity in the United States. Primary care providers will be central to clinical approaches for addressing the burden and the development of cost-effective case-finding strategies and feasible treatment for mild obstructive sleep apnea warrants high priority.

Adult↗

PubMed2000

Sleep and breathing disorders: the genesis of obstructive sleep apnea.

Sleep encompasses approximately a third of our lives; however, sleep and the disorders of sleep are not widely understood. Data suggest that sleep plays a restorative role in physiologic mechanisms and that long-term disruption of sleep may contribute to the development of disease. Nearly a third of the adult population is chronically afflicted by sleep disorders, and substantial economic loss is attributable to these disorders in terms of lost time, inefficiency, and accidents. Of the sleep disorders, obstructive sleep apnea (OSA) is one of the more common, clinically affecting up to 5% of the adult population. Obstructive sleep apnea contributes to the development of disease and has an adverse impact on daytime functioning in those affected by the disease. This article reviews basic sleep physiology, how these physiologic mechanisms are disrupted by OSA, and some of the techniques for treating patients with this disorder.

Adult↗

PubMed1994

[Mandibular advancement for the treatment of micrognathia with obstructive sleep apnea].

Fifteen patients with micrognathia and obstructive sleep apnea syndrome (OSAS) are presented. All patients were evaluated before and after surgery by physical examinations, cephalometric, fibroptic pharyngoscopy and oxygen saturation (SaO2). A method that allows isolated advancement of the genial tubercle and genioglossus muscle is described. The operation could enlarge the pharyngeal airway space at the base of the tongue (P < 0.05), increase SaO2 and decrease MP-H (P < 0.05) so that the symptoms of OSAS improved or disappeared. The facial symmetry and chin prominence also improved significantly. This method is simple and effective for the treatment of OSAS due to micrognathia and obviates the need for intermaxillary fixation. But it is not indicated for patients with severe malocclusion or airway obstruction on more than one sites.

Adolescent↗

PubMed2000

Gender differences in the polysomnographic features of obstructive sleep apnea.

We examined the influence of gender on the polysomnographic features of obstructive sleep apnea (OSA) in a retrospective study of 830 patients with OSA diagnosed by overnight polysomnography (PSG). The severity of OSA was determined from the apnea- hypopnea index (AHI) for total sleep time (AHI(TST)), and was classified as mild (5 to 25 events/h), moderate (26 to 50 events/h), and severe (> 50/events/h). Differences in OSA during different stages of sleep were assessed by comparing the AHI during non-rapid eye movement (NREM) (AHI(NREM)) and rapid eye movement (REM) (AHI(REM)) sleep and calculating the "REM difference" (AHI(REM) - AHI(NREM)). Additionally, each overnight polysomnographic study was classified as showing one of three mutually exclusive types of OSA: (1) mild OSA, which occurred predominantly during REM sleep (REM OSA); (2) OSA of any severity, which occurred predominantly in the supine position (S OSA); or (3) OSA without a predominance in a single sleep stage or body position (A OSA). The mean AHI(TST) for men was significantly higher than that for women (31.8 +/- 1.0 versus 20.2 +/- 1.5 events/h, p < 0. 001). The male-to-female ratio was 3.2:1 for all OSA patients, and increased from 2.2:1 for patients with mild OSA to 7.9:1 for those with severe OSA. Women had a lower AHI(NREM) than did men (14.6 +/- 1.6 versus 29.6 +/- 1.1 events/h, p < 0.001), but had a similar AHI(REM) (42.7 +/- 1.6 versus 39.9 +/- 1.2 events/h). Women had a significantly higher REM difference than did men (28.1 +/- 1.5 versus 10.3 +/- 1.1 events/h, p < 0.01). REM OSA occurred in 62% of women and 24% of men with OSA. S OSA occurred almost exclusively in men. We conclude that: (1) OSA is less severe in women because of milder OSA during NREM sleep; (2) women have a greater clustering of respiratory events during REM sleep than do men; (3) REM OSA is disproportionately more common in women than in men; and (4) S OSA is disproportionately more common in men than in women. These findings may reflect differences between the sexes in upper airway function during sleep in patients with OSA.

Female↗

PubMed2001

Objective sleepiness measures in pediatric obstructive sleep apnea.

OBJECTIVES: Excessive daytime sleepiness (EDS) occurs frequently in adult patients with obstructive sleep apnea (OSA). However, the incidence of EDS in children with OSA is unknown. METHODS: To determine overall daytime sleepiness in pediatric OSA, 54 children with OSA, 14 children with primary snoring (PS), and 24 controls (C) underwent an overnight diagnostic polysomnogram followed the next day by a multiple sleep latency test. RESULTS: The mean apnea index was 15.1 +/- 9.5 standard deviation in OSA, 1.1 +/- 0.5 in PS, and 0.1 +/- 0.3 in C. Mean sleep latencies were 23.7 +/- 3.0 minutes in C, 23.7 +/- 3.1 minute in PS, and 20.0 +/- 7.1 minute in OSA patients. However, only 7 children with OSA had mean sleep latencies <10 minutes. In addition, shorter sleep latencies were more likely to occur in more obese OSA patients and those with more severe apnea index, and oxyhemoglobin desaturation. CONCLUSIONS: Shortened sleep latencies occur in children with OSA, but EDS is infrequent and tends to develop among more severe and/or obese patients.

Case-Control Studies↗