SLEEP DISORDERED BREATHING UPDATES ABSTRACTS March 2013 Table of Contents
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1. Reviews . 1 2. Physiology . 3 3. Consequences & Comorbidities . 5 4. Cardiovascular . 7 5. Diagnosis . 11 6. Applications . 13 7. Bilevel & NIV . 16 8. Computer control . 19 9. Surgery . 20 10. Oral Appliances . 22 11. Other Methods . 23 12. Obesity . 24
1.1 Obstructive sleep apnea syndrome (OSAS) and social support in elder patients. Tutuncu Recep; Karabulut Hayriye; Acar Baran; Babademen Mehmet Ali; Ciftci Bulent; Karasen Riza Murat Etimesgut Military Hospital, Department of Psychiatry, Kardelen M. Pera Sitesi, Turkey Archives of gerontology and geriatrics ( Netherlands ) Sep-Oct 2012 , 55 (2) p244-6 Copyright (c) 2011 Elsevier Ireland Ltd. All rights reserved. 1.2 Systematic evaluation of obstructive sleep apnea websites on the internet. Langille Morgan; Veldhuyzen van Zanten Sander; Shanavaz Shahryar-Ali; Massoud Emad Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, AB. Journal of otolaryngology - head & neck surgery Aug 2012 , 41 (4) p265-72 OBJECTIVE: To determine the quality and comprehensiveness of the websites on the Internet with information directed toward patients with obstructive sleep apnea (OSA). DESIGN: Systematic evaluation of websites on the Internet with information on OSA. SETTING: World Wide Web. METHODS: The search engine Google was queried with the term "obstructive sleep apnea." The first 50 results were evaluated. Only websites written in English and containing original information were reviewed. MAIN OUTCOME MEASURES: A data quality score (DQS) was generated by evaluating each website for the presence of 67 points of information relating to OSA. Each website was also evaluated using a Global Quality Score (GQS), the DISCERN instrument, the Flesch-Kincaid reading grade level, date of the last update, and sources of funding. RESULTS: Thirty-four websites met the inclusion criteria. The average DQS was 36 points (range 17-57). The average GQS was 2.9 (range 1-5). The average DISCERN score was 3.3 (range 1.9-4.7). The average reading grade level was 11.0 (range 5.0-15.8). Twenty-six websites (76%) provided authorship information. Twenty-five websites (74%) displayed a date of the last update. Of these, 12 websites were not updated within the past 2 years. Twenty websites (59%) provided a source of funding. CONCLUSIONS: There is a heterogeneous mixture of websites with varying quality on the Internet with information regarding OSA. Health care providers should be cognizant of the variety of information available for patients and be prepared to direct patients toward the high-quality information sources. Reviews with abstracts 3.1 Pathobiology of OSA-related dyslipidemia: focus on the liver 4.1 Sleep apnea, cardiac arrhythmias, and conduction disorders 4.2 Patent foramen ovale-obstructive sleep apnea relationships: pro and cons 4.3 Obstructive sleep apnea and stroke 5.1 Dynamic imaging assessment on the upper airway in patients with OSAHS 7.1 Non-invasive home mechanical ventilation: qualification, initiation, and monitoring 7.2 Non-invasive mechanical ventilation in COPD 7.3 Postoperative noninvasive ventilation 7.4 Non-invasive mechanical ventilation therapy in patients with heart failure 7.5 The role of noninvasive ventilation in the ventilator discontinuation process 8.1 CSR in chronic heart failure. Treatment with adaptive servoventilation therapy 8.2 Adaptive servoventilation for treatment of SDB in HF: a systematic review and meta-analysis 10.1 Is there a place for teaching OSA and snoring in the predoctoral dental curriculum? 11.1 Catheter-based arterial sympathectomy: hypertension and beyond 12.1 Obesity and sleep-related breathing disorders Citations with no abstracts Sleep apnea in elderly adults with chronic insomnia. Kinugawa Kiyoka; Doulazmi Mohamed; Sebban Claude; Schumm Sophie; Mariani Jean; Nguyen-Michel Vi-Huong Journal of the American Geriatrics Society ( United States ) Dec 2012 , 60 (12) p2366-8
Sleep apnea: what does that really mean? A commentary on Baranchuk: "Sleep apnea, cardiac arrhythmias, and conduction disorders". Stein Phyllis K Journal of electrocardiology ( United States ) Sep 2012 , 45 (5) p513-4 Comment on J Electrocardiol. 2012 Sep;45(5):508-12 Obstructive sleep apnoea and metabolic syndrome: put CPAP efficacy in a more realistic perspective. Pepin Jean-Louis; Tamisier Renaud; Levy Patrick Thorax ( England ) Dec 2012 , 67 (12) p1025-7 Comment on Thorax. 2012 Dec;67(12):1081-9
Surgical correction of maxillofacial skeletal deformities. Cottrell David A; Edwards Sean P; Gotcher Jack E Journal of oral and maxillofacial surgery Nov 2012 , 70 (11 Suppl 3) pe107-36
Is Cheyne-Stokes respiration friend or foe of heart failure? Yasuma Fumihiko Thorax ( England ) Jan 2013 , 68 (1) p106-7 Comment on Thorax. 2012 Apr;67(4):357-60
Cerebrovascular consequences of obstructive sleep apnea. Durgan David J; Bryan Robert M Department of Anesthesiology, Baylor College of Medicine, Houston, TX (D.J.D., R.M.B.). Journal of the American Heart Association ( England ) Aug 2012 , 1 (4) pe000091 Re: Sexual function in pre- and post-menopausal women with obstructive sleep apnea syndrome. Seftel Allen D Journal of urology ( United States ) Dec 2012 , 188 (6) p2315 Comment on Int J Impot Res. 2012 Nov-Dec;24(6):228-33 Right ventricular function during high-frequency oscillatory ventilation, use of NPPV for acute lung injury, and dexmedetomidine use for sedation during mechanical ventilation. Kummerfeldt Carlos E; DiVietro Matthew L; Nestor Jennings E Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, USA. American journal of respiratory and critical care medicine ( United States ) Dec 1 2012 , 186 (11) p1189-90 Comment on Crit Care Med. 2012 Feb;40(2):455-60 Comment on JAMA. 2012 Mar 21;307(11):1151-60 Comment on Crit Care Med. 2012 May;40(5):1539-45
Adaptive servo-ventilation - pressurization and oxygenation -. Ando Shin-ichi Circulation journal - official journal of the Japanese Circulation Society ( Japan ) 2012 , 76 (9) p2088-9 Comment on Circ J. 2012;76(9):2153-8
Relationship between atrial fibrillation and sleep-disordered breathing. Watanabe Ichiro Circulation journal - official journal of the Japanese Circulation Society ( Japan ) 2012 , 76 (9) p2084-5 Comment on Circ J. 2012;76(9):2096-103 Obstructive sleep apnoea--what is it and how can nurses help? McLellan Joanna; Beck Julie Cardiovascular Intensive Care Unit, Auckland City Hospital. Nursing New Zealand (Wellington, N.Z. - 1995) ( New Zealand ) Oct 2012 , 18 (9) p18-9
Obstructive sleep apnea, obesity, and atrial fibrillation--what is the mechanistic link? Liew Reginald Heart rhythm - the official journal of the Heart Rhythm Society ( United States ) Sep 2012 , 9 (9) p1417-8 Comment on Heart Rhythm. 2012 Sep;9(9):1409-16.e1
Acute hypoxemic respiratory failure in acquired immune deficiency syndrome: effects of NIV: the highest PEEP may not be best. Esquinas Rodriguez Antonio M; Cazaux Alexis; Langer Marcos; Cambursano Hugo Respiratory care ( United States ) Oct 2012 , 57 (10) p1699; author reply 1699-70 Comment on Respir Care. 2012 Feb;57(2):211-20 OSA is associated with the development and progression of diabetic retinopathy, independent of conventional risk factors and novel biomarkers for diabetic retinopathy. Rudrappa Supreeth; Warren Graham; Idris Iskandar British journal of ophthalmology ( England ) Dec 2012 , 96 (12) p1535 2. PHYSIOLOGY
2.1 Effects of testosterone therapy on sleep and breathing in obese men with severe OSA: a randomized placebo-controlled trial. Hoyos Camilla M; Killick Roo; Yee Brendon J; Grunstein Ronald R; Liu Peter Y Endocrine and Cardiometabolic Research Group, Woolcock Institute of Med Research, Uni of Sydney, Australia. Clinical endocrinology ( England ) Oct 2012 , 77 (4) p599-607 Copyright (c) 2012 Blackwell Publishing Ltd. 2.2 Inspiratory-resistive loading increases the ventilatory response to arousal but does not reduce genioglossus muscle activity on the return to sleep. Cori Jennifer M; Nicholas CL; Baptista Shaira; Huynh I; Rochford PD; O'Donoghue FJ; Trinder JA; Jordan Amy S Department of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia. Journal of applied physiology (Bethesda, Md. - 1985) ( United States ) Sep 2012 , 113 (6) p909-16 Arousals from sleep are thought to predispose to obstructive sleep apnea by causing hyperventilation and hypocapnia, which reduce airway dilator muscle activity on the return to sleep. However, prior studies of auditory arousals have not resulted in reduced genioglossus muscle activity [GG-electromyogram (EMG)], potentially because airway resistance prior to arousal was low, leading to a small ventilatory response to arousal and minimal hypocapnia. Thus we aimed to increase the ventilatory response to arousal by resistive loading prior to auditory arousal and determine whether reduced GG-EMG occurred on the return to sleep. Eighteen healthy young men and women were recruited. Subjects were instrumented with a nasal mask with a pneumotachograph, an epiglottic pressure catheter, and intramuscular GG-EMG electrodes. Mask CO(2) levels were monitored. Three- to 15-s arousals from sleep were induced with auditory tones after resting breathing (No-Load) or inspiratory-resistive loading (Load; average 8.4 cmH(2)O.l(-1).s(-1)). Peak minute ventilation following arousal was greater after Load than No-Load (mean +/- SE; 8.0 +/- 0.6 vs. 7.4 +/- 0.6 l/min, respectively). However, the nadir end tidal partial pressure of CO(2) did not differ between Load conditions (43.1 +/- 0.6 and 42.8 +/- 0.5 mmHg, respectively), and no period of reduced GG activity occurred following the return to sleep (GG- EMG baseline, minimum after Load and No-Load = 2.9 +/- 1.2%, 3.1 +/- 1.3%, and 3.0 +/- 1.3% max, respectively). These findings indicate that the hyperventilation, which occurs following tone-induced arousal, is appropriate for the prevailing level of respiratory drive, because loading did not induce marked hypocapnia or lower GG muscle activity on the return to sleep. Whether similar findings occur following obstructive events in patients remains to be determined. 2.3 Altitude illness is related to low hypoxic chemoresponse and low oxygenation during sleep. Nespoulet Hugo; Wuyam Bernard; Tamisier Renaud; Saunier Carole; Monneret Denis; Remy Judith; et al HP2 Laboratory, INSERM Unit 1042, Grenoble, France. European respiratory journal Sep 2012 , 40 (3) p673-80 Altitude illness remains a major cause of mortality. Reduced chemosensitivity, irregular breathing leading to central apnoeas/hypopnoeas, and exaggerated pulmonary vasoconstriction may compromise oxygenation. All factors could enhance susceptibility to acute mountain sickness (AMS). We compared 12 AMS-susceptible individuals with recurrent and severe symptoms (AMS+) with 12 "AMS-nonsusceptible" subjects (AMS-), assessing sleep-breathing disorders in simulated altitude as well as chemoresponsive and pulmonary vasoconstrictive responses to hypoxia. During exposure to simulated altitude, mean blood oxygen saturation during sleep was lower in AMS+ subjects (81.6 +/- 2.6 versus 86.0 +/- 2.4%, p<0.01), associated with a lower central apnoea/hypopnoea index (18.2 +/- 18.1 versus 33.4 +/- 24.8 events . h(-1) in AMS+ and AMS- subjects, respectively; p=0.038). A lower hypoxic (isocapnic) chemoresponsiveness was observed in AMS+ subjects (0.40 +/- 0.49 versus 0.97 +/- 0.46 L . min(-1).%; p<0.001). This represented the only significant and independent predictive factor for altitude intolerance, despite a higher increase in pulmonary artery systolic pressure in response to hypoxia, a lower lung diffusing capacity and a higher endothelin-1 level at baseline in AMS+ subjects (p<0.05). AMS+ subjects were more hypoxaemic whilst exhibiting fewer respiratory events during sleep owing to lower hypoxic (isocapnic) chemoresponsiveness. In conclusion, the reduction in peripheral hypoxic chemosensitivity appears to be a major causative factor for altitude intolerance. 2.4 A 3-year longitudinal study of sleep disordered breathing in the elderly. Sforza E; Gauthier M; Crawford-Achour Emilie; Pichot V; Maudoux D; Barthelemy Jean Claude; Roche Frederic Service de Physiologie Clinique, EFCR, CHU Nord - Niveau 6, Saint-Etienne, Franc European respiratory journal Sep 2012 , 40 (3) p665-72 Limited and controversial data exist on the natural evolution of sleep disordered breathing (SDB) in untreated individuals. This study examines the evolution of SDB over a 3-yr period in a community-based sample of elderly subjects. From the initial cohort of 854 healthy subjects aged mean +/- SD 68.4 +/- 0.8 yrs, 519 untreated subjects accepted clinical and instrumental follow-up 3.6 +/- 1.6 yrs later. SDB was defined as a respiratory disturbance index (RDI) >15 events . h(-1). At baseline, 202 (39%) subjects had an RDI <= 15 events . h(-1) and 317 (61%) had an RDI >15 events . h(-1). 3 yrs later, 280 (54%) subjects were non-SDB and 239 (46%) had SDB. Between evaluations, the RDI decreased from 22.3 +/- 16.2 to 16.4 +/- 13.0 events . h(-1), with a greater decrease in the number of cases with an RDI >30 events . h(-1) that in those with RDI >= 30 events . h(-1). In the non-SDB group, 81% had a stable RDI and 19% increased their RDI by a mean of 13.7 events . h(-1). In the SDB group, the RDI decreased to values <= 15 events . h(-1) in 36.6% of cases, 63.4% still having SDB. The RDI changes did not depend on weight changes. In healthy elderly subjects, the prevalence and severity of SDB did not show a tendency toward natural worsening, some cases having improvement or a remission independent of weight changes. These findings also suggest that in the elderly, natural SDB progression is still hypothetical. 2.5 Prevalence of and risk factors for obstructive sleep apnea syndrome in Brazilian railroad workers. Koyama Renata G; Esteves Andrea M; Oliveira e Silva L; Lira FS; Bittencourt Lia R A; Tufik S; de Mello Marco Tulio Centro de Estudo Multidisciplinar em Sonolencia e Acidentes, Sao Paulo, Brazil. Sleep medicine ( Netherlands ) Sep 2012 , 13 (8) p1028-32 Copyright (c) 2012 Elsevier B.V. All rights reserved. 2.6 Sleep disordered breathing in patients with primary Sjogren's syndrome: a group controlled study. Usmani Zafar A; Hlavac Michael; Rischmueller Maureen; Heraganahally Subash S; Hilditch Cassie J; et al Adelaide Institute for Sleep Health, Repatriation General Hospital, Australi Sleep medicine ( Netherlands ) Sep 2012 , 13 (8) p1066-70 Copyright (c) 2012 Elsevier B.V. All rights reserved. 2.7 The application of CT to localize the upper airway obstruction plane in patients with OSAHS. Tang Xu Lan; Yi Hong Liang; Luo Hui Ping; Xiong Yuan Ping; Meng Li Li; Guan Jian; Chen Bin; Yin Shan Kai Dept of Otolaryngology, Affiliated Shanghai Sixth People's Hospital of Shanghai Jiao Tong University, China. Otolaryngology Dec 2012 , 147 (6) p1148-53 OBJECTIVE: To identify a correlation in terms of airway obstruction between awake and sleep apnea using spiral computed tomography (CT). STUDY DESIGN: Case series with planned data collection. SETTING: College medical center. METHODS: Sixty-one patients diagnosed with obstructive sleep apnea/hypopnea syndrome (OSAHS) underwent CT scans under 3 conditions: quiet breathing while awake, the end of deep inspiration during wakefulness, and apnea while asleep. The upper airway morphology under the 3 conditions was compared, and the accuracy of the obstructive planes as determined by CT scans under the 2 awake conditions was analyzed while considering the obstructive planes that occurred during apnea as a reference. RESULTS: The differences in the anteroposterior diameter, lateral dimension, and cross-sectional area of the retropalatal and retroglossal regions among the 3 states were statistically significant. Obstruction of the retropalatal region occurred in 100%, whereas retroglossal obstruction occurred in 44.3% of the 61 cases during sleep apnea. The coincidence rate between the awake quiet breathing and the sleep apnea was 85.2% in the retropalatal obstruction and 52.5% in the retroglossal obstruction. The coincidence rate between the awake deep inspiration and the sleep apnea was 82.0% in the retropalatal obstruction and 54.1% in the retroglossal obstruction. CONCLUSION: The main obstructive plane in patients with OSAHS was the retropalatal region. An awake upper airway CT scan can properly diagnose palatopharyngeal obstruction; however, it is not suitable for detecting retroglossal obstruction.
3. CONSEQUENCES and COMORBIDITIES
3.1 Pathobiology of obstructive sleep apnea-related dyslipidemia: focus on the liver. Mirrakhimov Aibek E; Ali Alaa M Department of Internal Medicine, Saint Joseph Hospital, 2900 North Lake Shore, Chicago, IL 60657, USA. ISRN cardiology ( Egypt ) 2013 , 2013 p687069 Obstructive sleep apnea and dyslipidemia are common medical disorders that independently increase vascular morbidity and mortality. Current animal and human data show that, indeed, obstructive sleep apnea may mediate pathological alterations in cholesterol and triglyceride metabolism. The mechanisms involved are increased lipolysis, decreased lipoprotein clearance, and enhanced lipid output from the liver. Human evidence shows that the treatment of obstructive sleep apnea with continuous positive airway pressure leads to an improvement of postprandial hyperlipidemia. However, more studies are needed, to clarify the pathophysiology of the interrelationship between obstructive sleep apnea and dyslipidemia and whether treatment of obstructive sleep apnea will lead to an improvement in the lipid profile and, more importantly, reduce hyperlipidemia-related vascular outcomes. 3.2 The effect of allergic rhinitis on the degree of stress, fatigue and quality of life in OSA patients. Park Cheol Eon; Shin Seung Youp; Lee Kun Hee; Cho Joong Saeng; Kim Sung Wan Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Korea. European archives of oto-rhino-laryngology Sep 2012 , 269 (9) p2061-4 Both allergic rhinitis (AR) and obstructive sleep apnea (OSA) are known to increase stress and fatigue, but the result of their coexistence has not been studied. The objective of this study was to evaluate the amount of stress and fatigue when AR is combined with OSA. One hundred and twelve patients diagnosed with OSA by polysomnography were enrolled. Among them, 37 patients were diagnosed with AR by a skin prick test and symptoms (OSA-AR group) and 75 patients were classified into the OSA group since they tested negative for allergies. We evaluated the Epworth sleepiness scale (ESS), stress score, fatigue score, ability to cope with stress, and rhinosinusitis quality of life questionnaire (RQLQ) with questionnaires and statistically compared the scores of both groups. There were no significant differences in BMI and sleep parameters such as LSAT, AHI, and RERA between the two groups. However, the OSA-AR group showed a significantly higher ESS score compared to the OSA group (13.7 +/- 4.7 vs. 9.3 +/- 4.8). Fatigue scores were also significantly higher in the OSA-AR group than in the OSA group (39.8 +/- 11.0 vs. 30.6 +/- 5.4). The OSA-AR group had a significantly higher stress score (60.4 +/- 18.6 vs. 51.2 +/- 10.4). The ability to cope with stress was higher in the OSA group, although this difference was not statistically significant. RQLQ scores were higher in the OSA-AR group (60.2 +/- 16.7 compared to 25.1 +/- 13.9). In conclusion, management of allergic rhinitis is very important in treating OSA patients in order to eliminate stress and fatigue and to minimize daytime sleepiness and quality of life. 3.3 The impact of sleep apnoea syndrome on nocturia according to age in men. Kang Suk-Hoon; Yoon In-Young; Lee Sang Don; Kim Jeong-Whun Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea. BJU international ( England ) Dec 2012 , 110 (11 Pt C) pE851-6 Copyright (c) 2012 THE AUTHORS. BJU INTERNATIONAL (c) 2012 BJU INTERNATIONAL. 3.4 Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Kaw R; Chung F; Pasupuleti V; Mehta J; Gay P C; Hernandez A V Department of Hospital Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA British journal of anaesthesia ( England ) Dec 2012 , 109 (6) p897-906 BACKGROUND: Obstructive sleep apnoea (OSA) is often undiagnosed before elective surgery and may predispose patients to perioperative complications. METHODS: A literature search of PubMed-Medline, Web of Science, Scopus, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to November 2010 was conducted. Our search was restricted to cohort or case-control studies in adults diagnosed with OSA by screening questionnaire, oximetry, or polysomnography. Studies without controls, involving upper airway surgery, and with OSA diagnosed by ICD-9 codes alone were excluded. The primary postoperative outcomes were desaturation, acute respiratory failure (ARF), reintubation, myocardial infarction/ischaemia, arrhythmias, cardiac arrest, intensive care unit (ICU) transfer, and length of stay. RESULTS: Thirteen studies were included in the final analysis (n=3942). OSA was associated with significantly higher odds of any postoperative cardiac events [45/1195 (3.76%) vs 24/1420 (1.69%); odds ratio (OR) 2.07; 95% confidence interval (CI) 1.23-3.50, P=0.007] and ARF [33/1680 (1.96%) vs 24/3421 (0.70%); OR 2.43, 95% CI 1.34-4.39, P=0.003]. Effects were not heterogeneous for these outcomes (I(2)=0-15%, P>0.3). OSA was also significantly associated with higher odds of desaturation [189/1764 (10.71%) vs 105/1881 (5.58%); OR 2.27, 95% CI 1.20-4.26, P=0.01] and ICU transfer [105/2062 (5.09%) vs 58/3681 (1.57%), respectively; OR 2.81, 95% CI 1.46-5.43, P=0.002]. Both outcomes showed a significant degree of heterogeneity of the effect among studies (I(2)=57-68%, P<0.02). Subgroup analyses had similar conclusions as main analyses. CONCLUSIONS: The incidence of postoperative desaturation, respiratory failure, postoperative cardiac events, and ICU transfers was higher in patients with OSA. 3.5 Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. D'Apuzzo Michele R; Browne James A Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia 22908, USA. Journal of arthroplasty ( United States ) Sep 2012 , 27 (8 Suppl) p95-8 Copyright (c) 2012 Elsevier Inc. All rights reserved. 3.6 Ambulatory office visits and medical comorbidities associated with obstructive sleep apnea. Bhattacharyya Neil; Kepnes Lynn J Division of Otolaryngology, Brigham & Women's Hospital, Boston, MA 02115, USA Otolaryngology--head and neck surgery Dec 2012 , 147 (6) p1154-7 OBJECTIVE: (1) Understand the epidemiology of obstructive sleep apnea (OSA) ambulatory office visits in the United States. (2) Quantify the prevalence of comorbid illnesses that are likely to occur in the setting of OSA. METHODS: From the 2008-2009 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys, adult cases with a diagnosis of OSA were extracted. The epidemiology of OSA was determined. The prevalences of comorbid priority illnesses (obesity, asthma, cerebrovascular disease, depression, hypertension, and ischemic heart disease) were also determined. STUDY DESIGN: Cross-sectional analysis of a national survey database. SETTING: Ambulatory care settings in the United States. RESULTS: There were an estimated 4.1 +/- 1.2 million annual visits with a diagnosis of OSA (60% +/- 3.2% men; mean age, 56.4 +/- 0.9 years). There were 419,000 +/- 28,000 visits annually to otolaryngologists for OSA. Comorbid illnesses were obesity (23.8% +/- 5.2%), asthma (14.3% +/- 3.0%), cerebrovascular disease (2.5% +/- 1.5%), depression (23.2% +/- 2.6%), hypertension 53.8% +/- 3.9%), and ischemic heart disease (10.3% +/- 3.0%). Adjusting for age, sex, ethnicity, obesity, and race, statistically significant increased odds for the presence of obesity (3.6, P < .001), asthma (2.7, P < .001), depression (2.5, P < .001), and hypertension (2.0, P < .001) with OSA were noted. Increased odds for cerebrovascular disease and ischemic heart disease were not identified (P = .725 and P = .083, respectively). CONCLUSION: Obstructive sleep apnea is a relatively common diagnosis in ambulatory and otolaryngologic care. It is associated with a significantly increased prevalence of several key priority health care conditions in the United States. Otolaryngologists and health care providers should be aware of these associations, understanding the potentially broad impact of OSA on general health. 3.7 Obstructive sleep apnea increases hemoglobin A1c levels regardless of glucose tolerance status. Tamura Akira; Kawano Yoshiyuki; Watanabe Toru; Kadota Junichi Internal Medicine 2, Oita University, Yufu, Japan. Sleep medicine ( Netherlands ) Sep 2012 , 13 (8) p1050-5 Copyright (c) 2012 Elsevier B.V. All rights reserved. 3.8 High prevalence of sleep disordered breathing in patients with diabetic macular edema. Mason Rebecca H; West Sophie D; Kiire Christine A; Groves Dawn C; Lipinski Helen J; Jaycock Alyson; et al Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom Retina (Philadelphia, Pa.) ( United States ) Oct 2012 , 32 (9) p1791-8 BACKGROUND: Diabetic retinopathy is more common and severe in patients with sleep disordered breathing (SDB). This study aimed to establish whether this is also true for patients with diabetic clinically significant macular edema (CSME). It is hypothesized that SDB, through intermittent hypoxia and blood pressure oscillations, might provoke worsening of CSME. METHODS: Patients with CSME had a home sleep study (ApneaLink; ResMed) to identify SDB. These results were compared with relevant control populations. Macular thickness was measured using optical coherence tomography, and retinal photographs were graded to assess the severity of retinopathy. RESULTS: Eighty of 195 patients (40 men) consented, with average age of 64.7 (11.7) years, neck circumference of 40.4 (5.4) cm, body mass index of 30.2 (6.2) kg/m2, glycosylated hemoglobin (HbA1c) 7.8% (1.4%) [62 (8.0) mmol/mol], and Epworth sleepiness scale of 7.4 (4.8). Overall, 54% had an oxygen desaturation index >= 10, and 31% had an apnea-hypopnea index >= 15. This SDB prevalence is probably higher than would be expected from the available matched control data. Those with SDB were not sleepier, but they were older and more obese. No significant relationship was identified between the degree of macular thickness and the severity of SDB. CONCLUSION: Individuals with CSME have a high prevalence of SDB. Sleep disordered breathing may contribute to the pathophysiology of CSME, but the mechanism remains unclear. Given the high prevalence, retinal specialists should perhaps consider a diagnosis of SDB in patients with CSME. 3.9 Sleep-disordered breathing symptoms among African-Americans in the Jackson Heart Study. Fulop Tibor; Hickson DeMarc A; Wyatt Sharon B; Bhagat Rajesh; Rack M; Gowdy O; Flessner MF; Taylor Herman A School of Medicine, University of Mississippi Medical Center, Jackson, United States Sleep medicine ( Netherlands ) Sep 2012 , 13 (8) p1039-49 Copyright (c) 2012 Elsevier B.V. All rights reserved. 4. CARDIOVASCULAR 4.1 Sleep apnea, cardiac arrhythmias, and conduction disorders. Baranchuk Adrian Cardiology Division, Kingston General Hospital, Queen's University, Kingston, Can Journal of electrocardiology ( United States ) Sep 2012 , 45 (5) p508-12 Comment in J Electrocardiol. 2012 Sep;45(5):513-4 Copyright (c) 2012 Elsevier Inc. All rights reserved. 4.2 Patent foramen ovale-obstructive sleep apnea relationships: pro and cons. Rigatelli Gianluca; Sharma Sunil Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Italy Cardiovascular revascularization medicine - including molecular interventions Sep-Oct 2012 , 13 (5) p286-8 Copyright (c) 2012 Elsevier Inc. All rights reserved. 4.3 [Obstructive sleep apnea and stroke]. Obstruktive Schlaf-Apnoe und Schlaganfall. Dumitrascu R; Tiede H; Rosengarten B; Schulz R Medizinische Klinik II, Universitatsklinik Giessen und Marburg, Standort Giessen. Pneumologie (Stuttgart, Germany) ( Germany ) Aug 2012 , 66 (8) p476-9 Copyright (c) Georg Thieme Verlag KG Stuttgart . New York. 4.4 Impaired endothelial function in persons with obstructive sleep apnoea: impact of obesity. Namtvedt Silje K; Hisdal Jonny; Randby Anna; Agewall Stefan; Stranden E ; Somers V; Rosjo H; Omland Torbjorn Department of Internal Medicine, Division of Medicine, Akershus University Hospital, Lorenskog, Norway. Heart (British Cardiac Society) ( England ) Jan 2013 , 99 (1) p30-4 OBJECTIVE: Obstructive sleep apnoea (OSA) and obesity are both associated with endothelial dysfunction, which precedes the development of atherosclerosis. As obesity is highly prevalent in OSA, we wanted to test the hypothesis that OSA is associated with endothelial dysfunction independently of obesity. DESIGN: Cross-sectional, population-based study. SETTING: Norwegian university hospital. PATIENTS: Seventy-one subjects (median age 44 years, 35% female) were recruited from a population-based study in Norway. Participants were categorised as obese (body mass index (BMI) >=30 kg/m(2)), non-obese (BMI<30 kg/m(2)) with OSA (apnoea-hypopnoea index (AHI)>=10), or non-obese without OSA (AHI<5). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Endothelial function measured by brachial artery ultrasound and expressed as percentage of flow-mediated dilation (FMD%). RESULTS: When non-obese subjects without OSA were used as the reference (FMD% (mean+/-SD) 10.1+/-6.3), endothelial function was found to be impaired in subjects with OSA (FMD% 6.4+/-3.2) (p=0.003). FMD% did not differ between obese (6.0+/-3.4) and non-obese (6.7+/- 3.1) OSA subjects (p=0.3). By univariate linear regression analysis, AHI, BMI, gender and baseline brachial artery diameter were significantly associated with FMD%. When these variables were entered into a multivariate model, only AHI was significantly associated with FMD%. CONCLUSIONS: OSA is associated with endothelial dysfunction independently of obesity and conventional risk factors. 4.5 Coexistence of visceral fat accumulation and SDB correlates with coronary artery disease. Nakagawa Yasuhiko; Kishida Ken; Funahashi Tohru; Yanagi Koji; Shimomura Iichiro Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan. Journal of atherosclerosis and thrombosis ( Japan ) 2012 , 19 (8) p728-35 AIM: Visceral adiposity is linked with sleep-disordered breathing (SDB) (called Syndrome Z), and both correlate with coronary artery disease (CAD). The aim of the present study was to determine the significance of excess visceral fat, SDB and circulating levels of biomarkers in CAD in Japanese men. METHODS: SDB, visceral fat area (VFA), and circulating levels of biomarkers were assessed in 60 Japanese male patients who underwent coronary angiography and overnight cardiorespiratory monitoring. RESULTS: Age-adjusted logistic analysis showed a significant relationship between CAD and diabetes, hypertension, dyslipidemia, SDB (AHI >=5 events/hour), visceral fat accumulation (VFA >=100 cm(2)), the combination of visceral fat accumulation and hypertension or dyslipidemia, as well as the combination of visceral fat accumulation and SDB. Patients with VFA >=100 cm(2) and SDB had significantly lower serum adiponectin levels and higher serum soluble CD40 ligand levels than those with VFA<100 cm(2) and SDB. The prevalence of CAD was significantly higher in patients with VFA >=100 cm(2) and SDB than in patients with VFA <100 cm(2) and AHI <5 events/hour, patients with VFA<100 cm(2) and AHI >=5 events/hour or patients with VFA >=100 cm(2) and AHI <5 events/hour (93% versus 14%, p <0.001, 53%, p <0.01 or 63%, p <0.01, respectively). CONCLUSIONS: The present study indicates that patients with both visceral fat accumulation and SDB develop CAD in association with hypoadiponectinemia and inflammatory activity. 4.6 Inverse relationship of subjective daytime sleepiness to sympathetic activity in patients with HF and OSA Taranto Montemurro Luigi; Floras John S; Millar Philip J; Kasai Takatoshi; Gabriel Joseph M; Spaak Jonas; et al Sleep Research Laboratory of the Toronto Rehabilitation Institute, Canada Chest ( United States ) Nov 2012 , 142 (5) p1222-8 BACKGROUND: Patients with heart failure (HF) and obstructive sleep apnea (OSA) are less sleepy than patients with OSA but without HF. Furthermore, unlike the non-HF population, in the HF population, the degree of daytime sleepiness is not related to the apnea-hypopnea index (AHI). The sympathetic nervous system plays a critical role in alertness. HF and OSA both increase sympathetic nervous system activity (SNA) during wakefulness. We hypothesized that in patients with HF and OSA, the degree of subjective daytime sleepiness would be inversely related to SNA. METHODS: Daytime muscle SNA (MSNA) was recorded in patients with HF and OSA. Subjective daytime sleepiness was assessed by the Epworth Sleepiness Scale (ESS). RESULTS: We studied 27 patients with HF and OSA and divided them into two groups based on the median ESS score: a less sleepy group, with an ESS score < 6 (n = 13), and a sleepier group, with an ESS score >= 6 (n = 14). The less sleepy group had higher MSNA than did the sleepier group (82.5 +/- 9.9 bursts/100 cardiac cycles vs 69.3 +/- 18.6 bursts/100 cardiac cycles; P = .037) and a longer sleep-onset latency (33 +/- 29 min vs 14 +/- 13 min; P = .039). The ESS score was inversely related to MSNA (r = -0.63; P < .001) but not to the AHI, arousal index, or indices of oxygen desaturation. CONCLUSIONS: In patients with HF and OSA, the degree of subjective daytime sleepiness is inversely related to MSNA. This relationship is likely mediated via central adrenergic alerting mechanisms. These findings help to explain the previously reported lack of daytime hypersomnolence in patients with HF and OSA. 4.7 Factors associated with increased carotid intima-media thickness in OSAHS Tan Teng-Yeow; Liou Chia-Wei; Friedman Michael; Lin Hsin-Ching; Chang Hsueh-Wen; Lin Meng-Chih Division of Cerebrovascular Disease, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. Neurologist ( United States ) Sep 2012 , 18 (5) p277-81 BACKGROUND: Obstructive sleep apnea/hypopnea syndrome (OSAHS) is strongly associated with the increase of cardiovascular and cerebrovascular disorders. Carotid intima-media thickness (IMT) is used as a surrogate marker for subclinical or early atherosclerosis. Knowledge regarding early atherosclerosis in patients with OSAHS is scarce, and factors predicting carotid IMT have not been well studied. OBJECTIVE: To compare IMT in patients with OSAHS versus controls and explore the factors associated with increased IMT in OSAHS. METHODS: One hundred fifty-six OSAHS patients and 35 controls without history of vascular events, hypertension, and diabetes mellitus who underwent polysomnography were consecutively enrolled. Carotid IMT was measured using B-mode ultrasonography. Body mass index, waist circumference, hip circumference, waist-to-hip circumference ratio, Epworth Sleepiness Scale, and polysomnographic variables including arousal index, apnea/hypopnea index, mean oxygen saturation, and lowest oxygen saturation were assessed. Fasting plasma glucose, blood lipid profile, and high-sensitivity C-reactive protein were measured. RESULTS: Average carotid IMT of OSAHS patients was significantly thicker than controls (0.66 vs. 0.58 mm, P=0.002) and multivariable logistic regression analysis revealed that arousal index [odds ratio (OR), 0.77; confidence interval (CI), 0.63-0.95; P=0.01] and lowest oxygen saturation (OR, 1.91; CI, 1.24-2.95; P=0.003) were significantly associated with OSAHS patients. Among the OSAHS patients, age (OR, 1.16; CI, 1.10-1.22; P<0.0001), fasting plasma glucose (OR, 1.05; CI, 1.01-1.10; P=0.04), low-density lipoprotein cholesterol (OR, 1.03; CI, 1.02-1.05; P<0.0001), and high-sensitivity C-reactive protein (OR, 1.48; CI, 1.13-1.95; P=0.005) were significantly associated with patients with IMT>=0.65 mm. CONCLUSIONS: IMT was thicker in OSAHS patients without history of vascular events, hypertension, and diabetes mellitus. This study demonstrates that early atherosclerosis exists in this group of patients. 4.8 High levels of inflammation and insulin resistance in obstructive sleep apnea patients with hypertension. Qian Xiaoshun; Yin Tong; Li Tianzhi; Kang Chunyan; Guo Ruibiao; Sun Baojun; Liu Changting Dept of Geriatric Respiratory Disease, General Hospital of People's Liberation Army, Chi Inflammation ( United States ) Aug 2012 , 35 (4) p1507-11 Hypertension induced by obstructive sleep apnea (OSA) may be multifactorial in origin, and systemic inflammation is one of the major factors. However, OSA patients do not always have the identical probability with hypertension even in patients with the same history and degree of OSA. The aim of this study was to compare the levels of inflammation and insulin resistance in two groups of patients who had the same degree as well as the same long history of OSA, but with/without hypertension. OSA patients (Apnea Hyponea Index, AHI >= 40/h, n = 70) were examined by polysomnography and blood analysis for the measurements of fasting plasma glucose, serum insulin (FINS), high- sensitivity C-reactive protein (CRP), peptide C,TNF-alpha, IL-6, and IL-10. Patients with hypertension (n = 40) had higher level of LDL-C and lower HDL-C levels than patients without hypertension. Almost half (16/40) of OSA patients with hypertension had family history of hypertension. Moreover in OSA patients with hypertension, the levels of TNF-alpha, IL- 6, and CRP were higher, but IL-10 was lower than those without hypertension. FINS, peptide C, HOMA-IR, and HOMA- islet were also higher in OSA patients with hypertension. OSA patients with hypertension have higher level of inflammation and insulin resistance. Systemic inflammation and insulin resistance are both important factors for the development of hypertension in OSA patients. 4.9 Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study. O'Brien LM; Bullough A S; Owusu Jocelynn T; Tremblay KA; Brincat C A; Chames MC; Kalbfleisch JD; Chervin RD Dept of Neurology, Sleep Disorders Center, Uni of Michigan School of Medicine, USA American journal of obstetrics and gynecology ( United States ) Dec 2012 , 207 (6) p487.e1-9 Copyright (c) 2012 Mosby, Inc. All rights reserved. 4.10 At 68 years, unrecognised sleep apnoea is associated with elevated ambulatory blood pressure. Roche Frederic; Pepin Jean-Louis; Achour-Crawford Emilie; Tamisier Renaud; Pichot Vincent; et al CHU Nord, Faculte de Med Jaques Lisfranc, PRES Universite de Lyon, Franc European respiratory journal Sep 2012 , 40 (3) p649-56 After the age of 65 yrs the specific impact of unrecognised sleep-related breathing disorders (SRBD) on 24-h blood pressure (BP) levels remains under debate. We tested the cross-sectional relationship between the severity of obstructive sleep apnoea/hypopnoea (OSAH) and the increase of BP using ambulatory BP monitoring (ABPM) in the PROOF (PROgnostic indicator OF cardiovascular and cerebrovascular events study)-SYNAPSE (Autonomic Nervous System Activity, Aging and Sleep Apnea/Hypopnea study) cohort. 470 subjects (aged 68 yrs) neither treated for hypertension nor diagnosed for SRBD were included. All subjects underwent ABPM, and unattended at-home polygraphic studies. OSAH was defined by an apnoea/hypopnoea index (AHI) >15 . h(-1). The severity of the sleep apnoea was also quantified as the index of dips in oxyhaemoglobin saturation >3% (ODI). Results are expressed in per protocol analysis. Severe OSAH (AHI >30 . h(-1), 17% of subjects) was associated with a significant 5 mmHg increase in both diurnal and nocturnal systolic BP (SBP), and with a nocturnal 3 mmHg increase in diastolic BP (DBP). Systolic (mean SBP >135 mmHg) or diastolic (mean DBP >80 mmHg) hypertension were more frequently encountered in subjects suffering from moderate (AHI 15-30) or severe OSAH. After adjustment, the independent association between severe OSAH and 24-h systolic hypertension remained significant (OR 2.42, 95% CI 1.1-5.4). The relationship was further reinforced when SRBD severity was expressed using ODI >10 . h(-1). The impact of unrecognised SRBD on BP levels also exists at the age of 68 yrs. The hypoxaemic load appears to be the pathophysiological cornerstone for such a relationship. 4.11 Reduced larger von Willebrand factor multimers at dawn in OSA plasmas reflect severity of apnoeic episodes. Koyama Noriko; Matsumoto Masanori; Tamaki Shinji; Yoshikawa Masanori; Fujimura Yoshihiro; Kimura Hiroshi Second Department of Internal Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan. European respiratory journal Sep 2012 , 40 (3) p657-64 Plasma von Willebrand factor (VWF), produced in and released from vascular endothelial cells by various stimuli including hypoxia, induces platelet aggregation under high shear stress and plays dual pivotal roles in haemostasis and thrombosis within arterioles, which are regulated by the size of vWF multimers (VWFMs). Patients with obstructive sleep apnoea (OSA) have increased risk of thrombotic cardiovascular events, but the pathogenesis is unclear. We examined the relationship between VWF and OSA by measuring VWF antigen (VWF:Ag), VWFMs, VWF collagen binding activity (VWF:CB) and a disintegrin-like, metalloproteinase, and thrombospiondin type 1 motifs 13. A total of 58 OSA patients were enrolled. Blood samples were collected before sleep, after sleep, and after one night of nasal continuous positive airway pressure therapy. Based on VWFM analysis, OSA patients were classified into three groups; consistently normal VWFMs (group 1, n=29), increased high molecular weight (HMW)-VWFMs at 06:00 h (group 2, n=18), and decreased or absent HMW-VWFMs at 06:00 h (group 3, n=11). Patients in group 3 had significantly worse apnoea/hypopnoea index; VWF:CB followed a similar pattern. We observed a significant decrease in platelet count between 21:00 h and 06:00 h in OSA patients, potentially associated with reduced larger VWFMs together with decreased VWF:Ag levels. Severe OSA may contribute to an arterial pro-thrombotic state. 4.12 SDB is an independent risk factor of aborted sudden cardiac arrest in patients with coronary artery spasm. Sakakibara Mamoru; Yamada Shiro; Kamiya Kiwamu; Yokota Takashi; Oba Koji; Tsutsui Hiroyuki Dept of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, J Circulation journal - official journal of the Japanese Circulation Society ( Japan ) 2012 , 76 (9) p2204-10 BACKGROUND: Sleep-disordered breathing (SDB) is often associated with sudden cardiac arrest (SCA) during sleep. Coronary artery spasm (CS) also occurs during sleep and is rarely associated with SCA, but the role of SDB in the risk of SCA is unknown in CS patients. This study evaluated the breathing patterns during sleep in CS patients with a prior history of aborted SCA. METHODS AND RESULTS: This study enrolled 24 patients (age 61.6 +/- 11.0 years, male/female 19/5) with CS proven by an acetylcholine provocation test. They were divided into 2 groups: prior history of aborted SCA due to fatal arrhythmia (SCA group; n=9) and no such history (no-SCA group; n=15). Patients underwent overnight polysomnography with ambulatory electrocardiography. The overall prevalence of SDB (apnea hypopnea index >=15) was 45.8% in this cohort. SDB was more frequent in the SCA group than in the no-SCA group (88.9% vs. 20.0% P=0.001) and identified as a pivotal risk factor of aborted SCA (odds ratio: 38.9, 95% CI: 2.80-1,498.2, P=0.01). Very-low- frequency was significantly correlated with the apnea hypopnea index in patients with SCA (P=0.01, r=0.78) during sleep. CONCLUSIONS: SDB is a significant risk factor for SCA in CS patients and autonomic instability during sleep might be involved in this association. 4.13 A case of paradoxical embolic ST-segment elevation myocardial infarction triggered by sleep apnea. Kujime Shingo; Hara Hidehiko; Enomoto Yoshinari; Yoshikawa Hisao; Itaya Hideki; Noro Mahito; et al Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Japan. Internal medicine (Tokyo, Japan) ( Japan ) 2012 , 51 (14) p1851-5 This report describes an obese 39-year-old man who experienced ST-segment elevation myocardial infarction with total thrombotic occlusion of the right coronary artery. Culprit vessel flow was improved by aspiration. Data suggested that myocardial infarction had resulted from paradoxical embolus via a patent foramen ovale triggered by the Mueller maneuver, which had induced negative intrathoracic pressure following an acute increase of right-heart volume in the context of obesity and sleep-disordered breathing (SDB). Obesity is increasing among younger populations and it represents a risk for SDB and thrombosis. Thus, this mechanism should be included within the differential diagnosis for myocardial infarction in young patients. 4.14 Clinical impact of screening for sleep related breathing disorders in atrial fibrillation. Altmann David R; Ullmer Elke; Rickli Hans; Maeder Micha T; Sticherling C; Schaer BA; Osswald S; Ammann Peter Division of Cardiology, Kantonsspital St. Gallen, Switzerland. International journal of cardiology ( Netherlands ) Feb 9 2012 , 154 (3) p256-8 Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved. 4.15 Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio are prolonged in patients with mod-severe OSA. Kilicaslan Fethi; Tokatli Alptug; Ozdag Fatih; Uzun Mehmet; Uz Omer; Isilak Zafer; Yiginer Omer; et al Department of Cardiology Department of Neurology, GATA Haydarpasa Hospital, Istanbul, Turkey. Pacing and clinical electrophysiology - PACE ( United States ) Aug 2012 , 35 (8) p966-72 Copyright (c)2012, The Authors. Journal compilation (c)2012 Wiley Periodicals, Inc. 4.16 Evaluation of atrial electromechanical delay and left atrial mechanical function in patients with OSA : Cardiac involvement in patients with OSA. Karabag Turgut; Aydin Mustafa; Altin Remzi; Dogan Sait M; Cil Cem; Buyukuysal Cagatay; Sayin Muhammet R Department of Cardiology, Zonguldak Karaelmas University, Zonguldak, Turkey Wiener klinische Wochenschrift ( Austria ) Jul 2012 , 124 (13-14) p444-52 OBJECTIVE: The aim of this study was to evaluate atrial electromechanical delay measured by tissue Doppler imaging and left atrial mechanical function in patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: Fourty- seven moderate-to-severe OSA patients who were newly diagnosed by polysomnography (Apnea-hypopnea index >= 15 events/h, 32 males, mean age 49.4 +/- 11.5) and 30 patients who had no OSA in polysomnography (Apnea-hypopnea index < 5 events/h, 21 males, mean age 45.4 +/- 9.1) were included in the study. Using tissue Doppler, diastolic functions, atrial electromechanical coupling were measured from the lateral mitral, septal, and tricuspid annulus. Inter, intra, and left atrial electromechanical delay were calculated (lateral-tricuspid, septum-tricuspid, lateral-septal). Left atrial volumes (maximal, minimal, and presystolic) were measured by the method of discs in the apical four-chamber view and were indexed to body surface area. Mechanical function parameters of the left atrium were also calculated. RESULTS: Interatrial, intraatrial, and left atrial electromechanical delays were significantly higher in the OSA group compared to the control group. Passive emptying fraction was significantly decreased, volume at the beginning of atrial systole and active emptying volume were significantly increased in OSA patients compared to the controls. The apnea-hypopnea index was significantly associated with interatrial and intraatrial electromechanical delay, passive emptying fraction, and conduit volume. CONCLUSIONS: Electromechanical delay was markedly prolonged and left atrial electromechanical function was impaired in untreated OSA patients. These impairments worsen with increasing severity of OSA. 4.17 Positional central apnea and vascular medullary compression. DelRosso Lourdes; Gonzalez-Toledo Eduardo; Chesson Andrew L; Hoque Romy Department of Neurology, Division of Sleep Medicine, Louisiana State University School of Medicine, USA. Neurology ( United States ) Nov 20 2012 , 79 (21) p2156-7 A 66-year-old man with hypertension presented with complaints of excessive daytime sleepiness (Epworth Sleepiness Score 14/24), dyspnea upon exertion, and episodes of noninjurious dream-enacting behavior. He reported tongue biting when sleeping in the right lateral decubitus position. Medications included atenolol 12.5 mg, lovastatin 20 mg, doxazosin 2 mg, amlodipine 5 mg, isosorbide mononitrate 60 mg, and aspirin 81 mg. He denied headaches, visual changes, dysarthria, dysphagia, or localized weakness. He denied use of alcohol, tobacco, or drugs. 4.18 Wake-up stroke and TIA due to paradoxical embolism during long OSA: a cross-sectional study. Ciccone Alfonso; Proserpio Paola; Roccatagliata Daria Valeria; Nichelatti Michele; Gigli Gian Luigi; et al Stroke Unit and Department of Neurology, Niguarda Ca' Granda Hospital, Milan, Italy. Thorax ( England ) Jan 2013 , 68 (1) p97-104 BACKGROUND AND PURPOSE: Long obstructive sleep apnoeas (LOSAs) can cause brain ischaemia through paradoxical embolism since they can lead to right to left shunting (RLSh) but this has never been assessed as a risk factor for stroke. We investigated whether the combination of LOSA and RLSh is associated with ischaemic stroke or transient ischaemic attack (TIA) on waking (wake-up stroke). METHODS: We prospectively considered patients aged over 18 years, admitted to 13 stroke units for acute ischaemic stroke or TIA. Patients had to be able to give consent, to specify whether the event occurred on waking, and to cooperate sufficiently to undergo contrast transcranial Doppler examination and cardiorespiratory sleep study within 10 days of the onset of symptoms. Single LOSA events, lasting 20 s or more, were considered a possible harbinger of RLSh. RESULTS: Between April 2008 and March 2010, 335 patients (109 women; 61 TIA, mean age 64 years) were enrolled; 202 (60%) had at least one LOSA and 116 (35%) a RLSh; 69 (21%) had both. There were significantly more wake-up strokes/TIAs in subjects with RLSh plus LOSA than those without this association (27/69 vs 70/266; OR 1.91, controlled for age, sex, hypertension, diabetes, atrial fibrillation, antithrombotic therapy; 95% CI 1.08 to 3.38; p=0.03). No other risk factor was associated with an increase in the incidence of events on waking. CONCLUSIONS: The study suggests that the combination of LOSA and RLSh could be a new major, potentially treatable risk factor for cerebrovascular ischaemic events. 5. DIAGNOSIS
5.1 [Dynamic imaging assessment on the upper airway in patients with OSAHS]. Yan Zhiqiang; Sun Jianjun Journal of clinical otorhinolaryngology, head, and neck surgery ( China ) Apr 2012 , 26 (8) p381-4 It is vital to make an individual plan for each patient with obstructive sleep apnea-hypopnea syndrome (OSAHS) according to the obstruction sites. The high resolution anatomical information of upper airway and soft tissue can be obtained, especially by MRI and CT scans. Dynamic and state-dependent imaging techniques are beneficial to study stereo changes of anatomy and morphology of upper airway in quiet breathing, sleeping or airway closure. Although dynamic imaging examination has value in diagnosis and treatment of OSAHS, there has no uniform position diagnosis standard. This article reviews the history of dynamic imaging study on OSAHS, the advantages and disadvantages of various imaging technologies and prospects of imaging position diagnosis. 5.2 [Acoustic characteristics of snoring sound in patients with obstructive sleep apnea hypopnea syndrome]. Yang Yi; Qin Yong; Haung Weining; Peng Hao; Xu Huijie Department of Otorhinolaryngology-Head and Neck Surgery, Peking University First Hospital, Beijing, 100034, China. Journal of clinical otorhinolaryngology, head, and neck surgery ( China ) Apr 2012 , 26 (8) p360-3 OBJECTIVE: To investigate the acoustic characteristics of snoring sound in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). METHOD: Thirty-one patients with OSAHS were included in this study. Natural overnight snoring was digitally recorded and polysomnography (PSG) was performed simultaneously. Thirty hundred and ten snores which after obstructive apnea and 310 continuous snores which not after obstructive apnea were extracted and peak frequency, maximal frequency, mean frequency,central frequency and power ratio were analyzed. RESULT: The maximal frequency, peak frequency, mean frequency and central frequency of the snores which after obstructive apnea was higher than that of the continuous snores. But 800 Hz power ratio of the snores which after obstructive apnea was lower than those of the continuous snores. The differences of all parameters were of statistical significance (P<0.01 or 0.05). The patients were divided into mild, moderate and severe groups according to AHI, it were seen that in mild patients group peak frequency, central frequency and 800 Hz power ratio were of statistical difference (P<0.01); and in moderate and severe patients groups,in addition to fc, the rest of the index difference was statistically significance except central frequency (P<0.01 or 0.05). CONCLUSION: 800 Hz power ratio is a good index for distinguishing the two kind of snores of OSAHS patients. It indicates that it is feasible to study the OSAHS by way of snore monitoring and analyzing technique employed in this study. 5.3 [Primary evaluation of the simplified Chinese version of STOP-Bang scoring model in predicting OSAHS]. Yu Yang; Mei Wei; Cui Yonghua Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China Journal of clinical otorhinolaryngology, head, and neck surgery ( China ) Mar 2012 , 26 (6) p256-9 OBJECTIVE: To evaluate the predictive significance of the simplified Chinese STOP-Bang (S-B) scoring model in predicting obstructive sleep apnea hypopnea syndrome(OSAHS). METHOD: A total of 114 cases with suspected OSAHS were included in this study. S-B questionnaire was filled before polysomnography (PSG) monitoring. According to the PSG monitoring results the patients were divided into simple snoring, mild, moderate and severe OSAHS groups. The average S-B scores and the ratio of patients with S-B score > or = 3 were compared among the four groups respectively. The accuracy of S-B scoring model was analyzed and predictive significance was evaluated. RESULT: Eighty nine of 114 (78.1%) patients were classified as being at high risk of OSAHS by S-B scoring. The S-B scores showed an accrescent tendency as the severity of OSAHS increased. The scores in the four groups were 2.74 +/- 1.39, 3.25 +/- 1.16, 4.30 +/- 1.20, 4.79 +/- 1.41 respectively. Significant difference in S-B scores was found between severe OSAHS group and the other three groups respectively (P < 0.01), and also between moderate OSAHS group and mild OSAHS/simple snoring group (P < 0 01). The ratio of patients with high risk of OSAHS predicted by S-B scoring in OSAHS group (85.7%) was significantly higher than that in simple snoring group (47.8%) (P < 0.01). The sensitivities of S-B scoring model for AHI > or = 5 > or = > 15 and > or = 30 were 85.7%, 92 5% and 100%, respectively; the negative predictive values were 48.0% ,80.0% and 100%. The coincidence rate of S-B scoring model with golden standard to diagnose OSAHS was 78 9 . The area under the ROC curve at AHI cutoff of greater than or equal to 5 was 0 774. CONCLUSION: S-B scoring model can be used to evaluate patients with high risk of OSAHS. It is a concise and easy-to-use tool to screen and predict moderate and severe OSAHS with relative high sensitivity and negative predictive value. 5.4 Total duration of apnea and hypopnea events and average desaturation show significant variation in patients with a similar AHI. Muraja-Murro A; Nurkkala J; Tiihonen P; Hukkanen T; Tuomilehto H; Kokkarinen J; Mervaala E; Toyras J Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finl Journal of medical engineering & technology ( England ) Nov 2012 , 36 (8) p393-8 Obstructive sleep apnea (OSA) is commonly diagnosed based on the apnea-hypopnea index (AHI). Presently, novel indices were introduced for sleep apnea severity: total duration of sleep apnea and hypopnea events (TAHD%) and a combined index including duration and severity of the events (TAHD% x average desaturation). Two hundred and sixty- seven subjects were divided based on their AHI into four categories (normal, mild, moderate, severe OSA). In the most severe cases TAHD% exceeded 70% of the recorded time. This is important as excessive TAHD% may increase mortality and cerebro-vascular complications. Moreover, simultaneous increase in duration and frequency of apnea and hypopnea events leads to a paradoxical situation where AHI cannot increase along severity of the disease. Importantly, the combined index including duration and severity of the events showed significant variation between patients with similar apnea-hypopnea indices. To conclude, the present results suggest that the novel parameters could give supplementary information to AHI when diagnosing the severity of OSA. 5.5 Predicting obstructive sleep apnea among women candidates for bariatric surgery. Sharkey Katherine M; Machan Jason T; Tosi Christine; Roye G Dean; Harrington David; Millman Richard P Department of Medicine, Rhode Island Hospital/Alpert Medical School of Brown University, USA. Journal of women's health (2002) ( United States ) Oct 2010 , 19 (10) p1833-41 BACKGROUND: More women than men pursue bariatric surgery for treatment of obesity. Untreated obstructive sleep apnea (OSA) in bariatric patients increases perioperative morbidity and mortality, and, therefore, most bariatric surgeons screen for OSA with polysomnography (PSG). We sought to develop a model for predicting OSA in women seeking bariatric surgery in order to use this diagnostic resource most efficiently. METHODS: We identified 296 women who had PSG in preparation for bariatric surgery. Regression and logistic regression analyses were used to assess the relationship between history and physical examination findings and OSA severity. After developing best statistical models, we constructed a summary index to identify patients exceeding clinical thresholds for mild (apnea-hypopnea index [AHI] >= 5) and moderate to severe disease (AHI >= 15). RESULTS: In our sample, most women (86%) had OSA, and more than half (53%) had moderate to severe disease. Multiple logistic regression showed that age, body mass index (BMI), neck circumference, hypertension, witnessed apneas, and snoring predicted AHI. Diabetes mellitus and daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) were not significant predictors of OSA. Prediction models were statistically significant but had poor specificity for predicting OSA severity. CONCLUSIONS: OSA is highly prevalent in symptomatic and asymptomatic women planning bariatric surgery for obesity. Best prediction models based on clinical characteristics did not predict disease severity under conditions superior to those in which they might be applied. In light of the perioperative risks associated with OSA in bariatric patients, all women considering bariatric surgery for obesity should be evaluated for OSA with PSG. 5.6 Is portable monitoring accurate in the diagnosis of OSAS in chronic pulmonary obstructive disease? Oliveira Marcia Goncalves; Nery Luiz Eduardo; Santos-Silva Rogerio; Sartori Denis Eduardo; Alonso FF; et al Disciplina de Pneumologia, Dept de Clinica Medica, Universidade Federal de Sao Paulo - UNIFESP, Brazil. Sleep medicine ( Netherlands ) Sep 2012 , 13 (8) p1033-8 Copyright (c) 2012 Elsevier B.V. All rights reserved. 5.7 Employer-mandated sleep apnea screening and diagnosis in commercial drivers. Berger Mark; Varvarigou Vasileia; Rielly Albert; Czeisler Charles A; Malhotra Atul; Kales Stefanos N Precision Pulmonary Diagnostics, Houston, TX, USA. Journal of occupational and environmental medicine Aug 2012 , 54 (8) p1017-25 INTRODUCTION: Obstructive sleep apnea (OSA) is common among commercial drivers and associated with health/safety risks, leading several trucking firms to mandate OSA screening. METHODS: A total of 19,371 commercial drivers were screened for OSA with an online questionnaire (Somni-Sage reg) through employer mandates. Questionnaire and polysomnography results were analyzed retrospectively. RESULTS: Screening categorized 5908 drivers (30%) as higher risk. To date, employers have sent 2103 higher-risk drivers for polysomnography, demonstrating that 68% of high-risk drivers tested had an apnea-hypopnea index (AHI) greater than 10 and 80% had an AHI of 5 or more. A conservative prevalence estimate for OSA (AHI > 10) was 21% among the drivers studied. CONCLUSIONS: Online screening followed by polysomnography for high-risk drivers demonstrates as many as 21% of commercial drivers may have OSA. Mandatory screening can have a high yield among commercial drivers. 6. APPLICATIONS
6.1 CPAP improves sleepiness but not calculated vascular risk in patients with minimally symptomatic OSA: the MOSAIC randomised controlled trial. Craig Sonya Elizabeth; Kohler Malcolm; Nicoll Debby; Bratton Daniel J; Nunn Andrew; Davies Robert; Stradling John Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK Thorax ( England ) Dec 2012 , 67 (12) p1090-6 BACKGROUND: Continuous positive airway pressure (CPAP) for symptomatic obstructive sleep apnoea (OSA) improves sleepiness and reduces vascular risk, but such treatment for the more prevalent, minimally symptomatic disease is contentious. METHODS: This multicentre, randomised controlled, parallel, hospital-based trial across the UK and Canada, recruited 391 patients with confirmed OSA (oxygen desaturation index >7.5/h) but insufficient symptoms to warrant CPAP therapy. Patients were randomised to 6 months of auto-adjusting CPAP therapy, or standard care. Coprimary endpoints were change in Epworth Sleepiness Score (ESS) and predicted 5-year mortality using a cardiovascular risk score (components: age, sex, height, systolic blood pressure, smoking, diabetes, cholesterol, creatinine, left ventricular hypertrophy, previous myocardial infarction or stroke). Secondary endpoints included some of the individual components of the vascular risk score, objectively measured sleepiness and self-assessed health status. RESULTS: Of 391 patients randomised, 14 withdrew, 347 attended for their follow-up visit at 6 months within the predefined time window, of which 341 had complete ESS data (baseline mean 8.0, SD 4.3) and 310 had complete risk score data. 22% of patients in the CPAP group reported stopping treatment and overall median CPAP use was 2 : 39 h per night. CPAP significantly improved subjective daytime sleepiness (adjusted treatment effect on ESS -2.0 (95% CI -2.6 to -1.4), p<0.0001), objectively measured sleepiness and self-assessed health status. CPAP did not improve the 5-year calculated vascular risk or any of its components. CONCLUSIONS: In patients with minimally symptomatic OSA, CPAP can reduce subjective and objective daytime sleepiness, and improve self-assessed health status, but does not appear to improve calculated vascular risk. 6.2 Cardiometabolic changes after CPAP for obstructive sleep apnoea: a randomised sham-controlled study. Hoyos Camilla M; Killick Roo; Yee Brendon J; Phillips Craig L; Grunstein Ronald R; Liu Peter Y Endocrine and Cardiometabolic Research Group, Woolcock Institute of Med Research, Uni of Sydney, Australia. Thorax ( England ) Dec 2012 , 67 (12) p1081-9 Comment in Thorax. 2012 Dec;67(12):1025-7 RATIONALE AND OBJECTIVES: Impaired insulin sensitivity (ISx), increased visceral abdominal fat (VAF) and liver fat are all central components of the metabolic syndrome and characteristics of men with obstructive sleep apnoea (OSA). The reversibility of these observed changes with continuous positive airway pressure (CPAP) treatment in men with OSA has not been systematically studied in a randomised sham-controlled fashion. METHODS: 65 men without diabetes who were CPAP naive and had moderate to severe OSA (age=49+/-12 years, apnoea hypopnoea index (AHI)=39.9+/-17.7 events/h, body mass index=31.3+/-5.2 kg/m(2)) were randomised to receive either real (n=34) or sham (n=31) CPAP for 12 weeks. At 12 weeks, all subjects received real CPAP for an additional 12 weeks. MEASUREMENTS AND MAIN RESULTS: Main outcomes were the change at week 12 from baseline in VAF, ISx and liver fat. Other metabolic outcomes were changes in the disposition index, total fat, and blood leptin and adiponectin concentrations. The AHI was lower on CPAP compared with sham by 33 events/h (95% CI-43.9 to -22.2, p<0.0001) after 12 weeks. There were no between-group differences at 12 weeks in VAF (-13.0 cm(3), -42.4 to 16.2, p=0.37), ISx (-0.13 (min(-1))(muU/ml))(-1), - 0.40 to 0.14, p=0.33), liver fat (-0.5 cm(3), -3.8 to 2.7, p=0.74) or any other cardiometabolic parameter. At 24 weeks, ISx (3.2x10(4) (min(-1))(muU/ml))(-1), 0.9x10(4) to 6.0x10(4), p=0.009), but not VAF (-1.4 cm(3), -19.2 to 16.4, p=0.87) or liver fat (-0.2 Hounsfield units, -2.4 to 2.0, p=0.83) were improved compared with baseline in the whole study group. CONCLUSION: Reducing visceral adiposity in men with OSA cannot be achieved with CPAP alone and is likely to require weight-loss interventions. Longer-term effects of CPAP on other cardiometabolic markers such as ISx require further investigation to fully examine time dependencies. TRIAL REGISTRATION NUMBER: ACTRN12608000301369. 6.3 Effect of CPAP therapy on cardiovascular risk factors in patients with type 2 diabetes and OSA Myhill Paul C; Davis Wendy A; Peters Kirsten E; Chubb S A Paul; Hillman David; Davis Timothy M E University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Australia. Journal of clinical endocrinology and metabolism ( United States ) Nov 2012 , 97 (11) p4212-8 CONTEXT: Few prospective intervention studies have examined the effect of continuous positive airway pressure (CPAP) therapy on cardiovascular disease (CVD) risk factors in diabetes. OBJECTIVE: Our objective was to determine whether CPAP improves CVD risk factors in patients with type 2 diabetes and obstructive sleep apnea (OSA). DESIGN AND SETTING: This was a randomized parallel group intervention trial in an urban Australian community. PATIENTS: Fifty- nine participants of the Fremantle Diabetes Study Phase II at high risk for OSA consented to confirmatory polysomnography followed by randomization to a 3-month CPAP intervention initiated early (<1 wk) or late (1-2 months). MAIN OUTCOME MEASURES: Patients were assessed before and 1 and 3 months after CPAP started. Tests for repeated measures were used to compare variables of interest over time. Results: Forty-four patients (75%) completed the study. Their mean +/- sd age was 66.1 +/- 8.8 yr, and 61.4% were male. Completers and noncompleters had similar age, sex, diabetes duration, apnea-hypopnea index, and Epworth Sleepiness Scale (P >= 0.29). There were no differences in outcome between early and late randomization, and the data were pooled. The Epworth Sleepiness Scale decreased between entry and 1 month [-4.8 (-6.5 to -3.1), P < 0.001]. Blood pressure improved between entry and 3 months (from 149 +/- 23/80 +/- 12 to 140 +/- 18/73 +/- 13 mm Hg; P <= 0.007). Pulse rate declined within the first month [- 6 (-10 to -2) beats/min, P = 0.002]. Glycemic control and serum lipids, which were mostly within recommended target ranges at entry, did not change. CONCLUSIONS: Three months of CPAP in community-based people with type 2 diabetes significantly decreased blood pressure and pulse rate but did not influence metabolic control. 6.4 Modest changes in cerebral glucose metabolism in patients with SAS after CPAP treatment. Ju Gawon; Yoon In-Young; Lee Sang Don; Kim Yu Kyeong; Yoon Eunjin; Kim Jeong-Whun Department of Neuropsychiatry, Chungbuk National University Hospital, Cheongju, Korea. Respiration; international review of thoracic diseases ( Switzerland ) 2012 , 84 (3) p212-8 Copyright (c) 2012 S. Karger AG, Basel. 6.5 The effects of CPAP treatment on nasal mucosa in patients with obstructive sleep apnea. Saka Cem; Vuralkan Erkan; Firat Ibrahim Hikmet; Alicura Sibel; Hucumenoglu Sema; Akin I; Ardic S; Gokler Ayhan Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital, Irfan Bastug cd Diskapi, Ankara, Turkey. European archives of oto-rhino-laryngology Sep 2012 , 269 (9) p2065-7 The aim of the study was to demonstrate the effects of nasal CPAP treatment on the morphology and function of nasal mucosa in patients with obstructive sleep apnea (OSA). Patients with complaints relevant to OSA underwent respiratory function tests, arterial blood gas analyses and polysomnography. Saccharine test and nasal biopsies were performed to assess the mucociliary transport time and to observe the histopathological changes in patients with apnea-hypopnea index >=15 in whole night polysomnography. Tissue samples were obtained from middle and inferior turbinates and septal mucosa to observe the degree of inflammation and fibrosis by semiquantitative means. Biopsies and mucociliary transport test were performed before and 3 months after the initiation of CPAP treatment. A total of 25 patients with a mean age of 52 were enrolled in the study. While the pretreatment mucociliary transport time before and 3 months after the treatment were 10.50 and 11.50 min respectively. The difference between these values was statistically insignificant. Mean apnea-hypopnea index was 63.19, while mean partial oxygen pressure was 75.46 mmHg. Nasal CPAP treatment was introduced with a mean pressure of 9.54 cmH2O. The degree of inflammation and fibrosis was found to be significantly increased after CPAP treatment. Nasal CPAP leads to alterations in mucosa. Efforts should be directed to make CPAP treatment a safer method via protecting the morphologic and functional properties of the nasal mucosa. 6.6 Effects of CPAP-therapy on brain electrical activity in OSA patients: a combined EEG study using LORETA and Omega complexity : reversible alterations of brain activity in OSAS. Toth Marton; Faludi Bela; Kondakor Istvan Department of Neurology, University of Pecs, Pecs, Hungary. toth Brain topography ( United States ) Oct 2012 , 25 (4) p450-60 Effects of initiation of continuous positive airway pressure (CPAP) therapy on EEG background activity were investigated in patients with obstructive sleep apnea syndrome (OSAS, N = 25) to test possible reversibility of alterations of brain electrical activity caused by chronic hypoxia. Normal control group (N = 14) was also examined. Two EEG examinations were done in each groups: at night and in the next morning. Global and regional (left vs. right, anterior vs. posterior) measures of spatial complexity (Omega complexity) were used to characterize the degree of spatial synchrony of EEG. Low resolution electromagnetic tomography (LORETA) was used to localize generators of EEG activity in separate frequency bands. Before CPAP-treatment, a significantly lower Omega complexity was found globally and over the right hemisphere. Due to CPAP-treatment, these significant differences vanished. Significantly decreased Omega complexity was found in the anterior region after treatment. LORETA showed a decreased activity in all of the beta bands after therapy in the right hippocampus, premotor and temporo-parietal cortex, and bilaterally in the precuneus, paracentral and posterior cingulate cortex. No significant changes were seen in control group. Comparing controls and patients before sleep, an increased alpha2 band activity was seen bilaterally in the precuneus, paracentral and posterior cingulate cortex, while in the morning an increased beta3 band activity in the left precentral and bilateral premotor cortex and a decreased delta band activity in the right temporo-parietal cortex and insula were observed. These findings indicate that effect of sleep on EEG background activity is different in OSAS patients and normal controls. In OSAS patients, significant changes lead to a more normal EEG after a night under CPAP-treatment. Compensatory alterations of brain electrical activity in regions associated with influencing sympathetic outflow, visuospatial abilities, long-term memory and motor performances caused by chronic hypoxia could be reversed by CPAP-therapy. 6.7 Long-term stabilization of respiratory conditions in patients with spinal muscular atrophy type 2 by CPAP: a report of two cases. Katayama Masahiro; Naritomi Hiroaki; Nishio Hisahide; Watanabe Toshiya; Teramoto Shoji; Kanda Fumio; et al Department of Neurology, Senri Chuou Hospital, Shinsenri-higashi machi 1-4-3, Ja Kobe journal of medical sciences ( Japan ) 2011 , 57 (3) pE98-105 Spinal muscular atrophy (SMA) type 2 is a motor neuron disease that leads to severe congenital muscle atrophy. The majority of adult patients are at risk of death due to respiratory failure. Here, we report on two patients with SMA type 2 who repeatedly developed bronchitis and pneumonia. The patient in Case 1 was a 48-year-old female lacking exon 7 of the survival motor neuron gene (SMN) 1. The patient in Case 2 was a 37-year-old female lacking exons 7 and 8 in SMN 1 and exon 5 in the neuronal apoptosis inhibitory protein (NAIP) gene. We applied continuous positive airway pressure (CPAP) in both cases because their data on polysomnography showed obstructive sleep apnea (OSA). CPAP treated their respiratory symptoms as well as those due to OSA. Moreover, CPAP stabilized the respiratory condition of Case 1 for seven years and seven months and that of Case 2 for five years and four months. These findings suggest that CPAP alone can achieve long-term improvement in the respiratory condition in patients with SMA type 2. 6.8 Change in frequency of periodic limb movements during sleep with usage of CPAP in OSAS. Aritake-Okada Sayaka; Namba Kazuyoshi; Hidano Natsuki; Asaoka Shoichi; Komada Yoko; Usui Akira; et al Department of Somnology, Tokyo Medical University, Tokyo 160-0023, Japan. Journal of the neurological sciences ( Netherlands ) Jun 15 2012 , 317 (1-2) p13-6 Copyright (c) 2012. Published by Elsevier B.V. 6.9 The differences in sleep profile changes under CPAP therapy between non-obese, obese and severely obese sleep apnea patients. Antczak J; Horn B; Richter A; Bodenschatz R; Latuszynski K; Schmidt E W; Jernajczyk W Sleep Center at the Kuchwald Hospital, Chemnitz, Germany Journal of physiology and pharmacology Jun 2012 , 63 (3) p263-9 Sleep disturbances in obstructive sleep apnea are caused mainly by repetitive apneas and hypopneas. An alternative factor contributing to disordered sleep may be the obesity, which is frequently associated with sleep apnea. The sleep disturbing effect of obesity was found previously in obese nonapneic subjects. The aim of this study was to evaluate the effect of obesity on sleep quality in sleep apnea patients in particular in patients under continuous positive airway pressure (CPAP) with successfully normalized respiration. We reviewed the archive data of 18 non-obese, 18 obese and 17 severely obese age and gender matched sleep apnea patients treated with CPAP. The polysomnographic parameters from the diagnostic night, from the second night under CPAP and from the follow up night (after three months of CPAP use) were compared. Before CPAP the apnea hypopnea index was worse in obese and in severely obese group and it normalised under CPAP in all groups. The severely obese group showed more light sleep and less REM sleep before CPAP and inversely - less light and more REM sleep in the second night under CPAP than the non-obese group. In the follow up, there was no differences in sleep profile between groups. This study indicates obesity does not affect the sleep independently of respiratory disorders. Before therapy it is associated with more severe sleep apnea and indirectly with worse sleep quality. 6.10 Feasibility of continuous positive airway pressure by primary care paramedics. Cheskes Sheldon; Thomson Sue; Turner Linda Sunnybrook-Osler Centre for Prehospital Medicine, Toronto, Ontari Prehospital emergency care Oct-Dec 2012 , 16 (4) p535-40 INTRODUCTION: Continuous positive airway pressure (CPAP) has been used effectively in the prehospital environment for a wide range of respiratory emergencies. The feasibility of CPAP when used by primary care paramedics (PCPs) has not been established. OBJECTIVE: We sought to study the feasibility of prehospital CPAP when used by paramedics trained to the primary care paramedic (PCP) level compared with those trained to the advanced care paramedic (ACP) level. Our hypothesis was that the feasibility of CPAP use by paramedics trained to the PCP level is similar to that of paramedics trained to the ACP level. METHODS: We conducted an observational study of 302 consecutive cases of CPAP use over one year beginning June 25, 2009. We defined compliant use as 100% adherence to the provincial CPAP medical directive. The criteria for compliance included specifics of patient presentation, vital signs, and appropriate documentation by the paramedic, as well as proper use, titration, and discontinuation of CPAP equipment according to protocol. Data were abstracted from ambulance call reports. RESULTS: Using the criteria set out for compliant CPAP use, the highest level of compliance among the ACPs and the PCPs was 98.6% and 98.9%, respectively, for documenting indication for CPAP use. The lowest level of compliance among the ACPs was 84.4% for titration of CPAP during treatment, and the lowest level of compliance among the PCPs was 90% for adherence to criteria for CPAP application according to patients' vital signs. Overall, the criteria for compliant use of CPAP were met for 76.8% (232/302) of the call reports examined. The rate of compliant use of CPAP was 75.9% (161/212) for ACP calls and 78.9% (71/90) for PCP calls. The difference between rates of compliant use for ACP calls versus PCP calls was not statistically significant (chi(2) [1 df] = 0.31, p = 0.66). CONCLUSIONS: This study found no significant difference in the compliant use of prehospital CPAP between paramedics trained to the PCP level and those trained to the ACP level. This study suggests that CPAP use by PCP-level paramedics may be feasible. Further study is required to determine whether compliance translates to safe use of prehospital CPAP by PCP-level paramedics. 6.11 Re-expansion pulmonary edema in a patient with total pneumothorax: a hazardous outcome. Sakellaridis Timothy; Panagiotou Ioannis; Arsenoglou Athanassios; Kaselouris Konstantinos; Piyis Anastasios Department of Thoracic Surgery, 401 Military Hospital of Athens, Greece. sakellaridi General thoracic and cardiovascular surgery ( Japan ) Sep 2012 , 60 (9) p614-7 Re-expansion pulmonary edema (REPE) is a rare complication of treatment of spontaneous pneumothorax or large pleural effusions. As a complication of spontaneous pneumothorax treatment, only few cases are documented, and even fewer document the role of non-invasive continuous positive airway pressure mechanical ventilation for treatment of this rare entity. We present a case of 23-year-old man who presented with left-sided pneumothorax, developed unilateral REPE and was treated with non-invasive continuous positive airway pressure. 7. BILEVEL & NIV 7.1 [Non-invasive home mechanical ventilation: qualification, initiation, and monitoring]. Nieinwazyjna wentylacja w warunkach domowych--kwalifikacja, rozpoczecie i monitorowanie. Kampelmacher Mike J Director of the Centre for Home Mech Vent, Uni Med Centre, The Netherlands Pneumonologia i alergologia polska ( Poland ) 2012 , 80 (5) p482-8 Following the introduction of non-invasive positive pressure ventilation (NPPV), the number of patients using home mechanical ventilation has increased substantially and continues to rise worldwide. This is primarily explained by both the effectiveness and comfort that are offered by NPPV in most patients, and particularly in patients with chest wall and neuromuscular diseases. For clinically stable patients the qualification for NPPV largely depends on the presence of complaints or signs of (nocturnal) hypoventilation with accompanying hypercapnia. For patients who are referred by an ICU there are additional prerequisites. In any case, the aims of NPPV should be met and NPPV should be effective. The initiation of NPPV, whether in the clinic or not, should always be tailored to the individual patient. Based on effectiveness, safety, and comfort, the best ventilator has to be chosen. Although with modern interfaces NPPV may be provided continuously, for continuing NPPV over the years, adding manual and/or mechanical cough augmentation techniques is usually mandatory. To control the ongoing effectiveness of NPPV regular monitoring of the patient is essential, and nowadays transcutaneous measurement of CO2 seems the most reliable and appropriate technique. For trend analysis, downloaded data of modern ventilators may be helpful as well. The ultimate goal of NPPV, to prevent tracheotomy, can only be reached if the patient has continuous access to a centre with expertise in cough augmentation techniques and both nocturnal and diurnal NPPV. 7.2 [Non-invasive mechanical ventilation in COPD]. Nichtinvasive Beatmung bei COPD. Funk G-C Interne Lungenabteilung mit Intensivstation, Otto-Wagner-Spital, Osterreic Medizinische Klinik, Intensivmedizin und Notfallmedizin ( Germany ) Apr 2012 , 107 (3) p185-91 Non-invasive mechanical ventilation is the preferred method for the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). Primary contraindications and stopping criteria must be regarded to avoid delaying endotracheal intubation. The primary interface is usually a nasal-oral mask. Cautious sedation can facilitate non- invasive ventilation in some patients. Under certain circumstances non-invasive ventilation may enable successful extubation in COPD patients with prolonged weaning. COPD patients can also benefit from preventive non-invasive ventilation in order to avoid re-intubation after a planned extubation. Domiciliary nocturnal non-invasive ventilation is an option for some patients with COPD in chronic hypercapnic respiratory failure. This treatment should be established in a specialised unit. 7.3 Postoperative noninvasive ventilation. Neligan Patrick J Department of Anesthesia & Intensive Care, Galway University Hospitals, Irel Anesthesiology clinics ( United States ) Sep 2012 , 30 (3) p495-511 Copyright (c) 2012 Elsevier Inc. All rights reserved. 7.4 [Non-invasive mechanical ventilation therapy in patients with heart failure]. Kalp yetersizligi hastalarinda noninvaziv mekanik ventilasyon tedavisi. Dursunoglu Dursun; Dursunoglu Nese Pamukkale Universitesi Tip Fakultesi, Kardiyoloji Anabilim Dali, Denizli, Turkey Anadolu kardiyoloji dergisi - AKD = the Anatolian journal of cardiology ( Turkey ) May 2012 , 12 (3) p261-8 Non-invasive mechanical ventilation (NIMV) therapy in patients with acute heart failure (HF) improves left ventricular functions via decreasing left ventricular afterload and reduces intubation rate and short-term mortality. In patients with chronic HF, NIMV therapy eliminates central and obstructive apneas and Cheyne-Stokes respiration, and improves morbidity. There are essentially three modes of NIMV that are used in the treatment of HF: Continuous positive airway pressure (CPAP), bilevel positive airway pressure (BIPAP) and adaptive servo-ventilation (ASV). Hereby, NIMV therapy in patients with acute and chronic HF is reviewed as well as methods, indications, effectiveness and complications. 7.5 The role of noninvasive ventilation in the ventilator discontinuation process. Hess Dean R Respiratory Care Services, Massachusetts General Hospital, Harvard Medical School, USA Respiratory care ( United States ) Oct 2012 , 57 (10) p1619-25 In recent years, there has been increasing interest in the use of noninvasive ventilation (NIV) in the post-extubation period to shorten the length of invasive ventilation, to prevent extubation failure, and to rescue a failed extubation. The purpose of this review is to summarize the evidence related to the use of NIV in these settings. NIV can be used to allow earlier extubation in selected patients who do not successfully complete a spontaneous breathing trial (SBT). Its use in this setting should be restricted to patients who are intubated during an exacerbation of COPD or patients with neuromuscular disease. This category of patients should be good candidates for NIV and should be extubated directly to NIV. In patients who successfully complete an SBT, but are at risk for extubation failure, NIV can be used to prevent extubation failure. These patients should also be good candidates for NIV and should be extubated directly to NIV. NIV should be used cautiously in patients who successfully complete an SBT, but develop respiratory failure within 48 hours post-extubation. In this setting, NIV is indicated only in patients with hypercapnic respiratory failure. Reintubation should not be delayed if NIV is not immediately successful in reversing the post-extubation respiratory failure. Evidence does not support routine use of NIV post-extubation. 7.6 [Clinical observation of home NPPV in hypercapnic patient with stable severe COPD]. Lu Peng; Wu Xiao-mei; Li Zhao-guo; Yang Cheng-cheng Department of Respiratory Medicine, Second Affiliated Hospital, Harbin Medical University, Harbin 150086, China. Zhonghua yi xue za zhi ( China ) Feb 14 2012 , 92 (6) p401-4 OBJECTIVE: To evaluate the efficacy and safety of home noninvasive positive pressure ventilation (HNIPPV) in hypercapnic patients with stable severe chronic obstructive pulmonary disease (COPD). METHODS: Forty four patients (30 males and 14 females, mean age 68.5 years (range: 60 - 80)) were recruited from a total of 106 patients with arterial PaCO2 >= 55 mm Hg in Second Hospital Affiliated to Harbin Medical University from January 2009 to December 2010. Their clinical data were collected and analyzed. The patients in the HNIPPV group (n = 20) accepted tiotropium bromide, doxofylline tablets and HNIPPV treatment while those in the control group (n = 24) tiotropium bromide, doxofylline tablets and a low-flow inhalation of oxygen. The entire observation period was 6 months. The parameters before and after 6- month follow-up were compared, including lung function test, 6-min walking distance (6MWD), arterial blood gases (PaO2 and PaCO2), dyspnea grade, scores of emotional disorders and mean pulmonary artery pressure (mPAP). RESULTS: No significant difference existed in the baseline data between the HNIPPV and control groups. The forced expiratory volume in one second (FEV(1)), forced vital capacity (FVC), inspiratory capacity (IC), 6MWD, PaO2, PaCO2, dyspnea grade, hospitalization rate, anxiety scores, depression scores and mPAP showed no significant difference between the HNIPPV and control groups before treatment. However, at Month 6, the differences of IC, 6MWD, PaO2, PaCO2, dyspnea grade, anxiety scores, depression scores and mPAP in HNIPPV group ((1.80 +/- 0.14) L, (266 +/- 24) m, (62.6 +/- 4.6) mm Hg, (46.8 +/- 2.2) mm Hg, (2.2 +/- 0.5), (6.5 +/- 2.4), (6.0 +/- 1.6), (33.8 +/- 2.4) mm Hg) were statistically significant compared with the control group ((1.62 +/- 0.14) L, (194 +/- 23) m, (56.2 +/- 3.8) mm Hg, (55.6 +/- 3.0) mm Hg, (3.2 +/- 0.6), (10.6 +/- 2.8), (10.2 +/- 2.4), (36.6 +/- 2.4) mm Hg) (P values: 0.031, 0.018, 0.025, 0.026, 0.001, 0.013, 0.002, 0.014 respectively). FEV(1) and FVC in the HNIPPV group improved slightly but with no statistically significant difference (all P > 0.05). Two patients in the control group were taken to hospital because of acute exacerbation. And hospitalization rates increased in the control group. But no statistically significant difference existed between the HNIPPV and control groups (P > 0.05). The tolerance and compliance of HNIPPV in the HNIPPV group were better and the patients in the HNIPPV group had no pulmonary barotraumas. CONCLUSION: HNIPPV plus tiotropium bromide and doxofylline tablets is both effective and safe in the treatment of hypercapnic patient with stable severe COPD. 7.7 [Effect of invasive and NPPV on plasma brain natriuretic peptide in patients with COPD and severe RF] Yang Hong-hui; Zhou Yan Department of Respiratory Medicine, Third Xiangya Hospital, Central South University, Changsha 410013, China. Nan fang yi ke da xue xue bao = Journal of Southern Medical University ( China ) Oct 2010 , 30 (10) p2377-9 OBJECTIVE: To investigate the change in plasma brain natriuretic peptide (BNP) in patients with chronic obstructive pulmonary disease (COPD) and severe respiratory failure receiving invasive or non-invasive positive pressure ventilation. METHODS: Fifty-six patients with COPD and severe respiratory failure were randomized into non-invasive ventilation group (n=28) to receive facial mask ventilation and invasive ventilation group (n=28) to have mechanical ventilation by tracheal intubation or tracheal incision. The changes of blood gas and BNP before and 24 h after the ventilation were observed. RESULTS: The indexes of blood gas analysis such as pH, PO2 and PaCO2 in the invasive ventilation group were better than those in the non-invasive ventilation group (P<0.05). The plasma levels of BNP of the invasive ventilation group were much lower 24 h after the treatment than that of the non-invasive ventilation group (P<0.05). CONCLUSION: Invasive ventilation produces better effect than non-invasive ventilation in the treatment of COPD with severe respiratory failure. Plasma concentrations of BNP has significant clinical value to evaluate the effect of mechanical ventilation. 7.8 Nonalcoholic steatohepatitis in bariatric patients with a diagnosis of obstructive sleep apnea. Weingarten Toby N; Mantilla Carlos B; Swain James M; Kendrick Michael L; Oberhansley Jeff M; et al Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA. Obesity facts ( Switzerland ) 2012 , 5 (4) p587-96 OBJECTIVE: To study a possible association between obstructive sleep apnea (OSA) severity, managed with noninvasive ventilation, and nonalcoholic steatohepatitis (NASH) in bariatric surgical patients. METHODS: Medical records of 218 bariatric surgical patients who underwent liver biopsy were reviewed. OSA severity was determined from preoperative polysomnography (apnea-hypopnea index (AHI) <= 15 no/mild OSA vs. AHI >= 16 moderate/severe OSA). Patients diagnosed with OSA were prescribed noninvasive ventilation. Patients were categorized according to liver histopathology into 3 groups: (i) no liver disease or simple steatosis, (ii) mild NASH (steatosis with necroinflammation and mild fibrosis (stage 0-1)), and iii) advanced NASH (steatosis with necroinflammation and more advanced fibrosis (stage >= 2)). RESULTS: 125 patients (57%) had no/mild OSA, and 93 (43%) had moderate/severe OSA. There was no difference in serum aminotransferases between patients by OSA severity classification. There was a high prevalence of hepatic histopathological abnormalities: 84% patients had steatosis, 57% had necroinflammation, 34% had fibrotic changes, and 14% had advanced NASH. There was no association between severity of NASH and severity of OSA. CONCLUSIONS: There is no association between stage of steatohepatitis and OSA severity among morbidly obese patients managed with noninvasive ventilation. 7.9 Diaphragm pacing and noninvasive respiratory management of amyotrophic lateral sclerosis/MND. Mahajan Kedar R; Bach John Robert; Saporito Lou; Perez Nick University of Medicine and Dentistry of New Jersey-New Jersey Medical School, University Hospital, USA. Muscle & nerve ( United States ) Dec 2012 , 46 (6) p851-5 Copyright (c) 2012 Wiley Periodicals, Inc. 7.10 Noninvasive high-frequency percussive ventilation in the prone position after lung transplantation. Feltracco P; Serra E; Barbieri S; Milevoj M; Michieletto E; Carollo C; Rea F; Zanus G; Boetto R; Ori C Department of Pharmacology and Anesthesiology, University Hospital of Padua, Italy Transplantation proceedings ( United States ) Sep 2012 , 44 (7) p2016-21 Copyright (c) 2012 Elsevier Inc. All rights reserved.
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June 17, 2007 The Boys in the Band Are in AARP By DARREN REIS isn’t opposed to the band practice that takes place in his house every Tuesday night. But there’s only so much loud rock music he is willing to tolerate. So when the umpteenth rendition of the Monkees’ “Last Train to Clarksville” starts rattling the windows, he goes downstairs, knocks on the door and makes his entreaty: �