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PubMed1992

Obstructive sleep apnoea and depression--diagnostic and treatment implications.

Sleep apnoea (OSA), a common sleep disorder, is well recognised as a cause of morbidity including psychiatric disorders. There is increasing recognition of the link between OSA and depression. Sleep changes are intrinsic to depressive disorders, most notably disturbances of REM sleep; OSA causes predominantly REM sleep disturbances. The neuro-vegetative features of depression are similar or identical to the symptoms of OSA-an issue which has not achieved wide clinical recognition. A growing number of studies confirm the statistical link between the two conditions. The implications are twofold: OSA needs to be excluded in cases of chronic or resistant depression and treatment of OSA will make it easier to treat the primary depressive disorder. A new method of treatment for OSA, the Sullivan continuous positive airway pump (CPAP), raises the theoretical possibility of treating depression by this means as well.

Adult↗

PubMed1998

What is the evidence that obstructive sleep apnoea is an important illness?

Obstructive sleep apnoea (OSA) is described by some authors as a potentially lethal disease and by others as an almost harmless condition. Excessive daytime sleepiness, neuropsychological dysfunction, altered quality of life, cardiovascular disease (systemic and pulmonary hypertension, cardiac arrhythmias, stroke and ischaemic heart disease) and increased mortality have been described as OSA complications. There is little argument that OSA may determine sleepiness, alter cognitive functions, and worsen quality of life, although with great interindividual variability: this should induce OSA to be considered an important illness per se, since sleepiness in OSA was shown to lead to important consequences, like road traffic accidents. Besides, OSA may interact with coexisting cardiac and respiratory disease and favour the appearance of heart and respiratory failure. Therefore, OSA is certainly also worth careful consideration as an important aggravating factor of other diseases. The evidence that obstructive sleep apnoea is an independent risk factor for cardiovascular complications other than owing to the recurrent transient blood pressure surges associated with apnoeas during sleep, and for an increased mortality is more conflicting. More studies are necessary to identify which characteristics of obstructive sleep apnoea may be considered important markers of its severity and as risk factors for different possible complications.

Accidents, Traffic↗

PubMed1999

Utility of home oximetry as a screening test for patients with moderate to severe symptoms of obstructive sleep apnea.

OBJECTIVE: To determine the value of home oximetry as a screening test in patients with moderate to severe symptoms of obstructive sleep apnea (OSA). DESIGN: Retrospective, observational study. SETTING: The Sleep Unit of a tertiary referral, university hospital. PATIENTS: 116 patients referred for evaluation of moderate to severe symptoms of OSA in which both home oximetry and polysomnography (PSG) were performed. INTERVENTIONS: NA. RESULTS: Three numerical oximetry indices were evaluated: average of desaturations > or =4% and average of resaturations > or =3% per hour of analysis time (DI4% and RI3%, respectively); and cumulative percentages of time spent at saturations below 90% (CT90%). A qualitative assessment was also performed. Oximetry indices were compared with apnea/hypopnea index (AHI) by simple linear regression and Bland-Altman analyses. Optimal cut-off points, in terms of sensitivity and specificity, for the oximetry indices were searched using ROC analysis, at an AHI threshold of > or =10. The correlation between AHI and the desaturation indices was r = 0.50 for CT90%, r = 0.60 for DI4%, and r = 0.58 for RI3%. No bias was found between PSG and oximetry indices in Bland-Altman plots. Neither the numerical indices nor the qualitative analysis achieved an adequate (>0.8) area under the ROC curve. A CT90% <0.79 excluded OSA with 84% sensitivity. A DI4% > or =31.4 or a RI3% > or =40.5 diagnosed OSA with 97% specificity. Using these values, 38% of the patients would have been correctly classified by oximetry alone, 10% would have been incorrectly classified, and 50% could not have been classified with certainty. Eleven (15%) OSA patients would have been missed by oximetry. CONCLUSIONS: Correlation between home oximetry and PSG was not high. Oximetry was more useful to confirm than to exclude OSA in our study. Qualitative assessment was not better than numerical analysis. The greatest value of oximetry in this setting seems to be as a tool to rapidly recognize and treat more severe OSA patients in waiting list for PSG.

Electroencephalography↗

PubMed1999

Orthognathic surgery correction of mandibular hypoplasia accompanying obstructive sleep apnea syndrome.

OBJECTIVE: To examine the surgical correction methods for treating cases of severe mandibular hypoplasia accompanying obstructive sleep apnea syndrome (OSAS). METHODS: Sixteen cases of severe mandibular hypoplasia were studied in which OSAS was documented by polysomnography (PSG) and cephalometric study. The obstructive site was at the base of the tongue. Surgical procedures such as temporomandibular joint (TMJ) reconstruction and bimaxillary, chin, and hyoid bone advancement were performed to improve each patient's profile, function, and occlusion, and to treat the OSAS. RESULTS: There were great improvements in patient's sleep and daytime quality of life. The pre- and postoperative changes of most PSG values and some cephalometric values (SNB, PAS) were statistically significant. CONCLUSIONS: Severe mandibular hypoplasia can cause not only abnormalities in profile and occlusion but also OSAS. The evaluation of OSAS and its treatment effects depend on PSG. It is also very important to confirm the obstructive site in the upper airway by cephalometric study and fiberoptic endoscopy. Orthognathic surgery procedures can advance the maxillary, chin, and hyoid bone, and expand the upper airway simultaneously. These procedures can treat OSAS. Cases of TMJ ankylosis with OSAS should be treated step by step.

Adolescent↗

PubMed2000

Treatment, airway and compliance effects of a titratable oral appliance.

STUDY OBJECTIVES: To measure the effects of a titratable anterior mandibular repositioner on airway size and Obstructive Sleep Apnea (OSA) and to evaluate its compliance. DESIGN: Before and after insertion sleep studies were obtained in a total of 38 OSA patients of varying severity from three different sites. Covert compliance was measured by means of a newly-developed, miniaturized, temperature-sensitive, imbedded monitor. Validity testing was completed in six adult volunteers who wore monitors imbedded into small acrylic appliances. MEASUREMENTS AND RESULTS: The mean RDI before treatment was 32.6 (SEM 2.1) and after the insertion of the appliance, the RDI was reduced to 12.1 (SEM 1.7, p<0.001). RDI was reduced to less than 15/hour in 80% of a group of moderate OSA patients (RDI 15 to 30) and in 61% of a group of severe OSA patients (RDI > 30) with respect to baseline RDI. Fiber optic video endoscopy was performed on 9 OSA patients with and without the appliance. No significant differences in hypopharynx or oropharynx cross sectional areas were found, but at the level of the velopharynx, the airway size was significantly increased (p<0.05). The index of agreement was 0.99 between the monitor clock time and the subject's log sheets. Compliance data from eight OSA subjects instructed to wear the appliance during sleep indicated that it was worn for a mean of 6.8 hours with a range of 5.6 to 7.5 hours per night. CONCLUSION: The titratable adjustable mandibular advancement appliance, made from thermoelastic acrylic, significantly reduces RDI in moderate to severe OSA patients, has a direct effect on airway size and is well worn throughout the night.

Adult↗

PubMed1998

Muscle fibre type and obstructive sleep apnea.

Muscular pharyngeal structural changes, as fibre type disproportion, have been described in patients affected by Obstructive Sleep Apnea (OSA) and in an animal experimental OSA model. The unsolved question is whether these muscular abnormalities are either secondary to a compensatory increased activity or due to a constitutionally determined reduction of slow-alpha motor neurons. In the present study Medium Pharyngeal Constrictor Muscles (MPCM) of OSA (n = 13) and non-OSA (n = 9) patients have been morphologically evaluated. In addition a needle biopsy of Vastus Lateralis Muscle (VLM) was performed in 5 randomly selected patients of each group. Our results confirmed a specific fibre type disproportion of MPCM of OSA patients compared to non-OSA ones with a type II predominance and aspecific myopathic changes such as fibrosis and central nuclei. No difference was found in the VLM of the two groups. This finding could be explained by a secondary adaptive transformation consequent to nocturnal upper airway resistance in OSA. In fact, it has been demonstrated in human muscle that heavy-resistance training may produce preferential type II fibre hypertrophy in stimulated muscle.

Adaptation, Physiological↗

PubMed1998

Obstructive sleep apnea patients use more health care resources ten years prior to diagnosis.

Because Obstructive Sleep Apnea Syndrome (OSAS) patients may be treated for comorbidities prior to OSAS diagnosis, we examined the health care utilization records of 181 OSAS patients and those of matched controls. We compared OSA patient health care utilization for a ten-year interval prior to diagnosis to those of randomized age-, gender-, and geographically-matched controls from the general population. We found that OSAS patients used approximately twice the resources (as defined by physician claims and stays in hospital) in the ten years prior to their diagnosis. Physician claims for cases totaled $686,365 ($3,972 per patient) compared to $356,376 ($1,969 per patient) for the controls for the length of the study. Utilization was significantly higher in 7 of 10 years prior to diagnosis. OSAS patients also had more hospitalizations: they had 1,118 nights (6.2 per patient) in hospital versus 676 nights (3.7 per patient) for controls over the ten-year period. Thus OSA patients are heavy users of health care resources ten years prior to diagnosis.

Case-Control Studies↗

PubMed2001

Evidence-based medicine and sleep apnea.

There is an increasing body of evidence that obstructive sleep apnea (OSA) affects systemic blood pressure and quality of life. The evidence linking OSA with other types of cardiovascular morbidity and mortality is not as strong. We review the current literature on the health impact, diagnosis, and treatment of OSA and provide a framework for evaluating levels of evidence in each of these areas, with the focus on high quality studies. Clinical prediction rules and unattended portable monitoring devices, such as digital oximeters, are inexpensive and have clinically useful likelihood ratios, sensitivity, and specificity, so they can be considered clinically useful in the evaluation of individuals suspected of having OSA. This approach has the potential to change the probability of disease in some patients to a level at which polysomnography is unnecessary. Recent randomized, placebo-controlled trials have indicated that treating OSA with continuous positive airway pressure improves quality of life, driving simulator performance, blood pressure, and sleepiness. The evidence in support of mandibular advancement is less strong, and surgical measures should be viewed as an option only after continuous positive airway pressure and mandibular advancement have been considered, given the paucity of evidence to support surgery. The quality of research done on the prognosis, diagnosis, and treatment of OSA has improved substantially in recent years. However, there remains a need for additional studies that evaluate ambulatory monitors and for larger randomized controlled trials of therapy with longer patient follow-up to verify the range of benefits that OSA patients can expect from the various treatment modalities.

Evidence-Based Medicine↗

PubMedDate not supplied

Sleep apnea: from the nose to the heart.

BACKGROUND: Obstructive sleep apnea (OSA) is a disorder consisting of repetitive obstruction of the upper airway during sleep accompanied by ineffective respiratory effort. METHODS: We developed this clinical review using an extensive MEDLINE review of the literature and data from our laboratories. This review examines (1) the prevalence of OSA; (2) the pathophysiology involved including the causes of obstruction, the physiologic stimuli, and resulting autonomic changes; (3) the cardiovascular manifestations; and (4) the therapeutic approaches to patients with OSA with emphasis on arrhythmia management. RESULTS AND CONCLUSIONS: OSA is highly prevalent and largely underdiagnosed. As part of a much broader spectrum of respiratory disturbances during sleep, OSA can result in a multitude of systemic manifestations. Structural changes occur in the airway to obstruct airflow during OSA, and the resulting apnea activates hypoxic and hypercapnic reflexes, which in turn lead to profound elevation in sympathetic nerve activity and cyclical changes in parasympathetic nerve activity. These autonomic effects are thought to contribute to the associated cardiovascular diseases (eg, hypertension) and frequently observed brady- and tachyarrhythmias. The ultimate goal in the treatment of OSA is to restore airway patency and sleep continuity and to improve daytime functioning and quality of life. Treatment usually results in improvement of clinical symptoms.

Aged↗

PubMed2002

[Study of serum leptin level in patients with obstructive sleep apnea].

OBJECTIVE: To explore the change of serum leptin in patients with obstructive sleep apnea syndrome (OSAS). METHODS: Polysomnography was performed in 58 patients with OSAS and in 21 simple obese controls without differences in age and body mass index (BMI). Serum leptin level was measured by radioimmunoassay. RESULTS: (1) The serum leptin level in patients with OSAS was higher, in both males (6.1 +/- 1.7) microg/L and females (19.5 +/- 9.9) microgram/L, than that in the simple obese controls [male (4.5 +/- 1.7) microgram/L, female (10.5 +/- 2.4) microgram/L] (P < 0.01, P < 0.05). (2) Serum leptin levels were significantly correlated with BMI in both OSAS patients (r = 0.64, P < 0.01) and simple obese controls (r = 0.59, P < 0.01), but only in OSAS patients was the leptin level significantly correlated with apnea and hypopnea index (AHI) (r = 0.47, P < 0.01) and with neck circumference (r = 0.64, P < 0.01). CONCLUSIONS: Serum leptin levels were higher in OSAS patients than in simple obese controls. Besides obesity and neck circumference, OSAS may also influence the leptin system, resulting in increased serum leptin level.

Body Mass Index↗

PubMed2002

[Platelet activation in obstructive sleep apnea syndrome].

The incidences of cardiovascular and cerebrovascular diseases are reportedly higher in patients with obstructive sleep apnea (OSA) than in OSA-free subjects, though the mechanism remains unknown. Recently, the contribution of activated platelets to a number of pathological conditions such as stroke or ischemic heart disease has been suggested. We hypothesized that the expression of activated platelet markers resulting from OSA might be higher than in healthy subjects. By flow cytometry using monoclonal antibodies, we measured two such markers, PAC-1 and CD 62 P, in OSA patients and healthy subjects. Twelve healthy men (age, 52.7 +/- 12.8 y/o; and body mass index (BMI), 22.2 +/- 16.1 kg/m2; mean +/- S.D.) and 20 male patients with OSA (age, 50 +/- 7.96 y/o; BMI, 28.1 +/- 3.3 kg/m2; apnea hypopnea index (AHI), 38.2 +/- 21.2 times/hr; and lowest SpO2, 75.6 +/- 11.3%) were enrolled in this study. PAC-1 expression was significantly higher in OSA patients (65.1 +/- 17.8%) than in healthy subjects (16.8 +/- 7.4%), as was CD 62 P expression (8.5 +/- 8.8% vs. 0.88 +/- 0.57%). The increase in PAC-1 expression was correlated with AHI and the arousal index. These findings suggest that activated platelet markers could be good indicators for untreated OSA.

Adult↗

PubMed2002

[Sleep apnea a risk factor of cardiovascular disease].

Obstructive sleep apnea (OSA) affects almost one fifth of the male and 10% of the female middle-aged population. Only one fifth of subjects with more or less severe disorder of breathing report simultaneous daytime sleepiness. There is growing research evidence for an independent association between OSA and cardiovascular disease (CVD). The suggestion that this link is not only correlative but also causative is strongly supported by a series of recent clinical and epidemiological studies. The association between OSA and traditionally recognized cardiovascular risk factors suggests that OSA may provide an additive and synergistic risk in cases with co-existing obesity, insulin resistance, diabetes and/or dyslipidaemia. These recent insights advocate better awareness of OSA and potentially also a wider use of screening-tools for early identification and treatment of sleep related breathing disorders. Moreover, current research within the fields of obesity and cardiovascular prevention needs to identify OSA as a study confounder. Continuous intense research into pathophysiological mechanisms and therapeutic possibilities of CVD related to OSA appears to be an important and potentially rewarding area of disease prevention.

Arrhythmias, Cardiac↗

PubMed2000

[The study about the characteristics of upper airway in obstructive sleep apnea syndrome].

OBJECTIVE: To investigate the upper airway (UA) characteristics of the patient's with obstructive sleep apnea syndrome (OSAS) and analyses the value of computer assisting fiberoptic pharyngoscopy with müller's maneuver (CFPMM) in topodiagnosis of OSAS. METHODS: The pharyngxes of 30 cases with OSAS and 30 controls were examined by CFPMM. The cross-section area at velo- and tongue-pharyngeal, pharyngeal collapsibility, sites of UA obstructive and their anatomical factors were measured and calculated and the correlation between the anatomical abnormalities of UA and outcomes of polysomnography (PSG) were analysed. RESULTS: 1. CFPMM can accurately measure and calculate the cross-section area of the upper airway. 2. mean areas of velopharyngeal and tongue-pharyngeal were significantly less than those in control subjects (all P < 0.05). OSAS patient's also showed relatively much larger collapsibility at sach site of the UA than controls. 3. At müller's maneuver, all the areas of OSAS patient's were below 40 mm2 and 60% cases appeared complete occlusion in pharyngeal. 4. All patient's had obstruction at velopharymx and airway collapses at multiple sites in 40% of cases. 5. At velopharyngeal the anatomical factors causing obstruction mainly were posterior displacement of soft palate, thicken and collapse of the pharyngeal wall. Besides the redundant lymph tissue at tongue base and posterior displacement of the tongue base, enlarged inferior pole of tonsil and collapse of pharyngeal wall played an important role at tongue-pharyngeal obstruction. 6. Diminished pharyngeal apertures and collapsibility were associated with increased rates of apnea and hypopnea index (P < 0.05). CONCLUSION: 1. CFPMM is able to measure and calculate UA's cross-section area and collapsibility, determine the site of obstruction, and helping the treatment. 2. Complete occlusion of UA at müller's maneuver is the criterion to determine site of UA obstruction in OSAS patient's during waking hours. 3. The anatomical abnormalities of UA of patients is reflects the severity of the OSAS.

Adult↗

PubMed2003

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

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

Adult↗

PubMed2003

General physicians' perspective of sleep apnea from a developing country.

To assess the knowledge of general physicians about the diagnosis and management of obstructive sleep apnea (OSA), a self-administered questionnaire, containing 15 questions, was distributed to 160 doctors attending a pulmonary CME program in March 2002. After 15 minutes of response time, the questionnaires were collected. The data were entered and analyzed using SPSS (Version 10.0) software. One hundred and twenty (75%) questionnaires were returned. Only 41% of responders had ever read an article about OSA and 36% had suspected it at least once in their practice. The majority (61-77%) of responders were aware of the common symptoms of OSA, but 55% did not recognize its association with hypertension. A significant number of doctors were not aware that OSA could occur in non-obese individuals (33%), women (42%) and children (39%). Only 25% of responders recognized that a history and blood tests were insufficient to make a reliable diagnosis of OSA. Half of the responders were aware of CPAP therapy for OSA, whereas 18% would have prescribed sedatives to treat sleep disturbances in OSA.

Child↗

PubMed2003

[Obstructive sleep apnea syndrome and genetics].

The obstructive apnea syndrome (OSA) is considered as a complex genetic disorder. Descriptive studies from several countries have consistently show familial aggregation of the apnea-hypopnea index and symptoms of OSA in both adults and children. Phenotypic markers of OSA have been identifies such as upper airway anomalies, abnormal breathing control, and obesity through which genes might act to increase susceptibility to OSA. The genetics of OSA may differ among racial groups. Two approaches have recently been used to investigate the genetics of OSA: a segregation analysis and a whole genome scan. Data suggested a common causal pathway regulating both OSA and obesity in Caucasian families.

Adult↗

PubMed2003

[Clinical study on oropharyngeal fatty infiltration on the pathogenesis of obstructive sleep apnea syndrome].

OBJECTIVE: To detect the effect of lipid metabolism, fatty infiltration of oropharyngeal tissues in the subjects with obstructive sleep apnea syndrome (OSAS) and its pathogenesis. METHOD: Nineteen subjects in OSAS group and 9 subjects in controlled group were chosen. The related clinical index including the size and weight of uvula in two groups were measured. Each composition of uvular tissue section (transverse section) in all subjects was measured by quantitative, morphometric image analysis technique. The uvular tissue sections were evaluated by light microscope (LM), 4 of them by transmission electron microscope (TEM). RESULT: 1. Subjects in OSAS group significantly had a greater body mass index, neck circumference, waist circumference, waist-to-hip circumference ratio (WHR), weight and size of uvula than those in controlled group. There were significant differences in TC, TG, LDL and TC/HDL between the two groups. 2. A significant difference in percentage of fat, muscle, fibrous tissue in uvula was also founded between the two groups. The serial tissue section of uvula in LM showed that there was excessive fatty infiltration that prominently founded in fibrous tissue and secondarily in muscle. And muscle fibers with partial atrophy and/or hypertrophy were prominent. We also detected that fibrous tissue and muscle fibers arranged in a disordered way. The uvula myofibril in TEM showed focal or spotted rough and deformity of Z line, sarcomere loss and vacuolation. Lipid droplet infiltration was also detected in adjoin of myofibril. 3. The degree of fatty infiltration of uvular tissue correlated with neck circumference, WHR, weight and size of uvula, TC and TC/HDL in two groups, and also had positive correlation with degree of OSAS recorded by AHI in OSAS group. CONCLUSION: The results suggested that lipid metabolic disorder might exist in subjects with OSAS. And abundant oropharyneal fatty infiltration might be an important role in pathogenesis of OSAS that possibly contributed to change the size and shape of pharyngeal airway and compliance of pharyngeal wall.

Adipose Tissue↗

PubMed2003

[The study of autonomic nervous activities in patients with obstructive sleep apnea syndrome].

OBJECTIVE: To explore the nocturnal variation of autonomic nervous system (ANS) in patients with obstructive sleep apnea syndrome (OSAS) and the transformation after surgery. METHOD: Sixty-one subjects with OSAS were recruited to undergo 7-hour nocturnal polysomnography(PSG) in sleep lab. Sixteen subjects with OSAS were performed PSG before and after UPPP. Sixteen subjects without OSAS were included as controls. Power spectrum analysis of heart rate variability (HRV) was performed in each subject. RESULT: The nocturnal of ANS activities were abnormal in patients with OSAS, especially the enhancement of sympathetic nervous activity. It increased gradually along with aggravating condition. The activities of sympathetic and vagus nerve were decreased significantly. CONCLUSION: There are abnormal ANS activities in patients with OSAS. Effective treatment of OSAS by surgery will significantly reduce the parameters of ANS, and redress the abnormality of heart rate and blood pressure.

Adult↗