Tongue size matters: revisiting the Mallampati classification system in patients with obstructive sleep apnea.

OBJECTIVE: The Mallampati classification system has been used to predict obstructive sleep apnea (OSA). Upper airway soft tissue structures are prone to fat deposition, and the tongue is the largest of these structures. Given that a higher Mallampati score is associated with a crowded oropharynx, we hypothesized that the Mallampati score is associated with tongue volume and an imbalance between tongue and mandible volumes. METHODS: Adult males underwent clinical evaluation, polysomnography, and upper airway CT scans. Tongue and mandible volumes were calculated and compared by Mallampati class. RESULTS: Eighty patients were included (mean age, 46.8 years). On average, the study participants were overweight (BMI, 29.3 ± 4.0 kg/m2) and had moderate OSA (an apnea-hypopnea index of 26.2 ± 26.7 events/h). Mallampati class IV patients were older than Mallampati class II patients (53 ± 9 years vs. 40 ± 12 years; p < 0.01), had a larger neck circumference (43 ± 3 cm vs. 40 ± 3 cm; p < 0.05), had more severe OSA (51 ± 27 events/h vs. 24 ± 23 events/h; p < 0.01), and had a larger tongue volume (152 ± 19 cm3 vs. 135 ± 18 cm3; p < 0.01). Mallampati class IV patients also had a larger tongue volume than did Mallampati class III patients (152 ± 19 cm3 vs. 135 ± 13 cm3; p < 0.05), as well as having a higher tongue to mandible volume ratio (2.5 ± 0.5 cm3 vs. 2.1 ± 0.4 cm3; p < 0.05). The Mallampati score was associated with the apnea-hypopnea index (r = 0.431, p < 0.001), BMI (r = 0.405, p < 0.001), neck and waist circumference (r = 0.393, p < 0.001), tongue volume (r = 0.283, p < 0.001), and tongue/mandible volume (r = 0.280, p = 0.012). CONCLUSIONS: The Mallampati score appears to be influenced by obesity, tongue enlargement, and upper airway crowding.

Muscle and visceral fat infiltration: A potential mechanism to explain the worsening of obstructive sleep apnea with age.

STUDY OBJECTIVES: Aging is a major risk factor for obstructive sleep apnoea (OSA) and is associated with increased upper airway collapsibility, but the mechanisms are largely unknown. We hypothesized that the increase in OSA severity and upper airway collapsibility with age are partially mediated by upper airway, visceral and muscle fat infiltration. METHODS: Male subjects underwent full polysomnography, upper airway collapsibility determination (Pcrit) after sleep induction with midazolam, upper airway and abdominal computed tomography. Tongue and abdominal muscle fat infiltration were assessed by the determination of muscle attenuation with computed tomography. RESULTS: Eighty-four males with a wide range of age (47 ± 13 years, range 22-69 years) and apnea-hypopnea index (AHI) (30 [14-60] events/h, range 1-90 events/h), were studied. Younger and older males were grouped according to the mean age. Despite similar body mass-index (BMI), older subjects had higher AHI, higher Pcrit, larger neck and waist circumference, higher visceral and upper airway fat volumes (P < 0.01) as compared to younger subjects. Age was associated with OSA severity, Pcrit, neck and waist circumference, upper airway fat volume and visceral fat (P < 0.05), but not with BMI. Older subjects had lower tongue and abdominal muscle attenuation as compared to younger subjects (P < 0.001). Age was inversely associated with tongue and abdominal muscle attenuation, indicating muscle fat infiltration. CONCLUSIONS: The associations between age, upper airway fat volume, visceral and muscle fat infiltration may help to explain the worsening of OSA and increased upper airway collapsibility with aging.

Tongue size matters: revisiting the Mallampati classification system in patients with obstructive sleep apnea / O tamanho da língua é importante: revisitando a classificação de Mallampati em pacientes com apneia obstrutiva do sono

ABSTRACT Objective: The Mallampati classification system has been used to predict obstructive sleep apnea (OSA). Upper airway soft tissue structures are prone to fat deposition, and the tongue is the largest of these structures. Given that a higher Mallampati score is associated with a crowded oropharynx, we hypothesized that the Mallampati score is associated with tongue volume and an imbalance between tongue and mandible volumes. Methods: Adult males underwent clinical evaluation, polysomnography, and upper airway CT scans. Tongue and mandible volumes were calculated and compared by Mallampati class. Results: Eighty patients were included (mean age, 46.8 years). On average, the study participants were overweight (BMI, 29.3 ± 4.0 kg/m2) and had moderate OSA (an apnea-hypopnea index of 26.2 ± 26.7 events/h). Mallampati class IV patients were older than Mallampati class II patients (53 ± 9 years vs. 40 ± 12 years; p < 0.01), had a larger neck circumference (43 ± 3 cm vs. 40 ± 3 cm; p < 0.05), had more severe OSA (51 ± 27 events/h vs. 24 ± 23 events/h; p < 0.01), and had a larger tongue volume (152 ± 19 cm3 vs. 135 ± 18 cm3; p < 0.01). Mallampati class IV patients also had a larger tongue volume than did Mallampati class III patients (152 ± 19 cm3 vs. 135 ± 13 cm3; p < 0.05), as well as having a higher tongue to mandible volume ratio (2.5 ± 0.5 cm3 vs. 2.1 ± 0.4 cm3; p < 0.05). The Mallampati score was associated with the apnea-hypopnea index (r = 0.431, p < 0.001), BMI (r = 0.405, p < 0.001), neck and waist circumference (r = 0.393, p < 0.001), tongue volume (r = 0.283, p < 0.001), and tongue/mandible volume (r = 0.280, p = 0.012). Conclusions: The Mallampati score appears to be influenced by obesity, tongue enlargement, and upper airway crowding.

RESUMO Objetivo: A classificação de Mallampati tem sido usada para prever a apneia obstrutiva do sono (AOS). As estruturas de tecidos moles das vias aéreas superiores são propensas a deposição de gordura, sendo a língua a maior dessas estruturas. Como existe uma relação entre um grau mais elevado na classificação de Mallampati e maior obstrução da orofaringe, aventamos a hipótese de que a classificação de Mallampati está relacionada com o volume da língua e com um desequilíbrio entre o volume da língua e o da mandíbula. Métodos: Homens adultos foram submetidos a avaliação clínica, polissonografia e TC das vias aéreas superiores. O volume da língua e o volume da mandíbula foram calculados e comparados conforme a classificação de Mallampati. Resultados: Foram incluídos 80 pacientes (média de idade: 46,8 anos). Em média, os participantes do estudo apresentavam sobrepeso (IMC = 29,3 ± 4,0 kg/m2) e AOS moderada (índice de apneias e hipopneias = 26,2 ± 26,7 eventos/h). Os pacientes da classe IV de Mallampati eram mais velhos que os da classe II (53 ± 9 anos vs. 40 ± 12 anos; p < 0,01) e apresentavam maior circunferência do pescoço (43 ± 3 cm vs. 40 ± 3 cm; p < 0,05), AOS mais grave (51 ± 27 eventos/h vs. 24 ± 23 eventos/h; p < 0,01) e maior volume da língua (152 ± 19 cm3 vs. 135 ± 18 cm3; p < 0,01). Os pacientes da classe IV de Mallampati também apresentavam maior volume da língua que os da classe III (152 ± 19 cm3 vs. 135 ± 13 cm3; p < 0,05), bem como maior relação entre o volume da língua e o da mandíbula (2,5 ± 0,5 cm3 vs. 2,1 ± 0,4 cm3; p < 0,05). A classificação de Mallampati apresentou relação com o índice de apneias e hipopneias (r = 0,431, p < 0,001), o IMC (r = 0,405, p < 0,001), a circunferência do pescoço e da cintura (r = 0,393, p < 0,001), o volume da língua (r = 0,283, p < 0,001) e o volume da língua/volume da mandíbula (r = 0,280, p = 0,012). Conclusões: A classificação de Mallampati aparentemente é influenciada pela obesidade, aumento da língua e maior obstrução das vias aéreas superiores.

Prevalence of chronic insomnia in patients with obstructive sleep apnea.

OBJECTIVES: To investigate the prevalence of and factors associated with chronic insomnia and obstructive sleep apnea (CIOSA) comorbidity in obstructive sleep apnea (OSA) patients. METHODS: Between March 2014 and March 2015, we conducted a prospective, cross-sectional study of 238 adults diagnosed with OSA according to polysomnography and International Classification of Sleep Disorders-Third Edition criteria. RESULTS: The prevalence of CIOSA was 29%. There was a trend towards older age in the CIOSA group. Sex was not associated with CIOSA. Sleep-maintenance and sleep-onset insomnia predominated in the sample. Beck's depression and anxiety inventory scores were higher in the CIOSA group. Both depression and anxiety symptoms were associated with CIOSA. The arousal and apnea-hypopnea indices were lower in the CIOSA group. CIOSA was also associated with age ≥ 60 years and current tobacco use. Severe OSA and alcohol use were negatively associated with CIOSA. CONCLUSIONS: Chronic insomnia is prevalent among OSA patients. Our study highlights the need for detailed evaluation of patients with sleep breathing disorders to diagnose other important sleep and mood disorders (such as depression and anxiety), given their frequent association.

Discriminating the severity of pharyngeal collapsibility in men using anthropometric and polysomnographic indices.

STUDY OBJECTIVES: Although obstructive sleep apnea results from the combination of different pathophysiologic mechanisms, the degree of anatomical compromise remains the main responsible factor. The passive pharyngeal critical closing pressure (Pcrit) is a technique used to assess the collapsibility of the upper airway and is often used as a surrogate measure of this anatomical compromise. Patients with a low Pcrit (ie, less collapsible airway) are potential candidates for non-continuous positive airway pressure therapies. However, Pcrit determination is a technically complex method not available in clinical practice. We hypothesized that the discrimination between low and high Pcrit can be estimated from simple anthropometric and polysomnographic indices. METHODS: Men with and without obstructive sleep apnea underwent Pcrit determination and full polysomnography. Receiver operating characteristics analysis was performed to select the best cutoff of each variable to predict a high Pcrit (Pcrit ≥ 2.5 cmH2O). Multiple logistic regression analysis was performed to create a clinical score to predict a high Pcrit. RESULTS: We studied 81 men, 48 ± 13 years of age, with an apnea-hypopnea index of 32 [14-60], range 1-96 events/h), and Pcrit of -0.7 ± 3.1 (range, -9.1 to +7.2 cmH2O). A high and low Pcrit could be accurately identified by polysomnographic and anthropometric indices. A score to discriminate Pcrit showed good performance (area under the curve = 0.96; 95% confidence interval, 0.91-1.00) and included waist circumference, non-rapid eye movement obstructive apnea index/apnea-hypopnea index, mean obstructive apnea duration, and rapid eye movement apnea-hypopnea index. CONCLUSIONS: A low Pcrit (less collapsible) can be estimated from a simple clinical score. This approach may identify candidates more likely to respond to non-continuous positive airway pressure therapies for obstructive sleep apnea.

Influence of interface and position on upper airway collapsibility assessed by negative expiratory pressure.

PURPOSE: Negative expiratory pressure (NEP) is a simple technique for the evaluation of upper airway collapsibility in patients with obstructive sleep apnea (OSA). Most studies evaluated NEP using a mouthpiece that may exclude the cephalic portion of the upper airway. We hypothesize that NEP determination is influenced by interface and position. METHODS: We evaluated patients with suspected OSA using polysomnography, NEP (-5 cmH2O in sitting and supine position with mouthpiece and nasal mask). A subgroup also underwent computed tomography (CT) of the upper airway. RESULTS: We studied a total of 86 subjects (72 male, age 46 ± 12 yrs, body mass index 30.0 ± 4.4 kg/m2, neck circumference 40.0 ± 3.5 cm, AHI 32.9 ± 26.4, range 0.5 to 122.5 events/hour). NEP was influenced by interface and position (p = 0.007), and upper airway was more collapsible with mouthpiece than with nasal mask in sitting position (p = 0.001). Position influenced NEP and was worse in supine only when evaluated by nasal mask. Expiratory resistance (R 0.2) at 0.2 s during NEP was significantly higher and independent of position with mouthpiece than with nasal mask (20.7 versus 8.6 cmH2O/L s-1, respectively, p = 0.018). NEP evaluated with nasal mask in supine position and with mouthpiece in sitting position, but not when evaluated with mouthpiece in supine position, were correlated with upper airway anatomical measurements including tongue dimensions and pharyngeal length. CONCLUSIONS: Interface and position influence NEP. NEP evaluated with nasal mask in supine position may convey more relevant information for patients under investigation for OSA than when evaluated with mouthpiece.

Upper Airway Collapsibility Assessed by Negative Expiratory Pressure while Awake is Associated with Upper Airway Anatomy.

STUDY OBJECTIVES: There is a growing interest to develop a simple method to characterize the mechanisms leading to upper airway collapse in order to guide treatment options in patients with obstructive sleep apnea (OSA). Critical closing pressure (Pcrit) during sleep is able to predict the anatomical component of OSA. However, Pcrit is a laborious method that is only used for research purposes. The application of negative expiratory pressure (NEP) is a simple method to assess upper airway collapsibility that can be easily performed during wakefulness. We hypothesized that NEP will be, similarly to Pcrit, associated with upper airway anatomy assessed by computed tomography (CT) scan. METHODS: Patients under investigation for OSA underwent polysomnography, CT of the upper airway, NEP while awake, and Pcrit during sleep. NEP was performed with -5 cm H2O in supine position using a nasal mask. Pcrit was measured during sleep induced by low doses of midazolam. RESULTS: Twenty-eight male subjects were studied (age 45 ± 13 y, body mass index 29.4 ± 4.9 kg/m2, apnea-hypopnea index (AHI) 30 ± 26, range 2 to 86 events/h). NEP and Pcrit were similarly associated with tongue area (r = 0.646 and r = 0.585), tongue volume (r = 0.565 and r = 0.613) and pharyngeal length (r = 0.580 and r = 0.611), respectively (p < 0.05 for all comparisons). NEP and Pcrit were also significantly correlated with AHI (r = 0.490 and r = 0.531). NEP and Pcrit were significantly higher in patients with severe OSA than the remaining population. CONCLUSIONS: NEP is a simple and promising method that is associated with the anatomical component of upper airway collapsibility. NEP may be valuable to select patients for noncontinuous positive airway pressure alternative therapies for OSA.

Impact of Acute Changes in CPAP Flow Route in Sleep Apnea Treatment.

BACKGROUND: CPAP is the gold standard treatment for OSA and was conceived to be applied through a nasal interface. This study was designed to determine the acute effects of changing the nasal CPAP route to oronasal and oral in upper airway patency during sleep in patients with OSA. We hypothesized that the oronasal route may compromise CPAP's effectiveness in treating OSA. METHODS: Eighteen patients (mean ± SD age, 44 ± 9 years; BMI, 33.8 ± 4.7 kg/m2; apnea-hypopnea index, 49.0 ± 39.1 events/hour) slept with a customized oronasal mask with nasal and oral sealed compartments connected to a multidirectional valve. Sleep was monitored by using full polysomnography and induced by low doses of midazolam. Nasal CPAP was titrated up to holding pressure. Flow route was acutely changed to the oronasal (n = 18) and oral route (n = 16) during sleep. Retroglossal area was continuously observed by using nasoendoscopy. RESULTS: Nasal CPAP (14.8 ± 4.1 cm H2O) was able to stabilize breathing in all patients. In contrast, CPAP delivered by the oronasal and oral routes promoted obstructive events in 12 (66.7%) and 14 (87.5%) patients, respectively. Compared with stable breathing during the nasal route, there was a significant and progressive reduction in the distance between the epiglottis and tongue base and the retroglossal area when CPAP was delivered by the oronasal and oral routes. CONCLUSIONS: CPAP delivered through the oronasal route may compromise CPAP's effectiveness in treating OSA.

Different Craniofacial Characteristics Predict Upper Airway Collapsibility in Japanese-Brazilian and White Men.

BACKGROUND: OSA pathogenesis is complex and may vary according to ethnicity. The anatomic component predisposing to OSA is the result of the interaction between bony structure and upper airway soft tissues and can be assessed using passive critical closing pressure (Pcrit). We hypothesized that Japanese-Brazilians and whites present different predictors of upper airway collapsibility, suggesting different causal pathways to developing OSA in these two groups. METHODS: Male Japanese-Brazilians (n = 39) and whites (n = 39) matched for age and OSA severity were evaluated by full polysomnography, Pcrit, and upper airway and abdomen CT scans for determination of upper airway anatomy and abdominal fat, respectively. RESULTS: Pcrit was similar between the Japanese-Brazilians and the whites (-1.0 ± 3.3 cm H2O vs -0.4 ± 3.1 cm H2O, P = .325). The Japanese-Brazilians presented smaller upper airway bony dimensions (cranial base, maxillary, and mandibular lengths), whereas the whites presented larger upper airway soft tissue (tongue length and volume) and a greater imbalance between tongue and mandible (tongue/mandibular volume ratio). The cranial base angle was associated with Pcrit only among the Japanese-Brazilians (r = -0.535, P < .01). The tongue/mandibular volume ratio was associated with Pcrit only among the whites (r = 0.460, P < .01). Obesity-related variables (visceral fat, BMI, and neck and waist circumferences) showed a similar correlation with Pcrit in the Japanese-Brazilians and the whites. CONCLUSIONS: Japanese-Brazilians and whites present different predictors of upper airway collapsibility. Although craniofacial bony restriction influenced Pcrit only in the Japanese-Brazilians, an anatomic imbalance between tongue and mandible volume influenced Pcrit among the whites. These findings may have therapeutic implications regarding how to improve the anatomic predisposition to OSA across ethnicities.

Sleep and glycemic control in type 1 diabetes.

OBJECTIVE: Our aim in the present study was to elucidate how type 1 diabetes mellitus (T1DM) and sleep parameters interact, which was rarely evaluated up to the moment. MATERIALS AND METHODS: Eighteen T1DM subjects without chronic complications, and 9 control subjects, matched for age and BMI, were studied. The following instruments used to evaluate sleep: the Epworth Sleepiness Scale, sleep diaries, actimeters, and polysomnography in a Sleep Lab. Glycemic control in T1DM individuals was evaluated through: A1C, home fingertip glucometer for 10 days (concomitant with the sleep diary and actimeter), and CGM or concomitant with continuous glucose monitoring (during the polysomnography night). RESULTS: Comparing with the control group, individuals with diabetes presented more pronounced sleep extension from weekdays to weekends than control subjects (p = 0.0303). Among T1DM, glycemic variability (SD) was positively correlated with sleep latency (r = 0.6525, p = 0.0033); full awakening index and arousal index were positively correlated with A1C (r = 0.6544, p = 0.0081; and r = 0.5680, p = 0.0272, respectively); and mean glycemia values were negatively correlated with sleep quality in T1DM individuals with better glycemic control (mean glycemia < 154 mg/dL). CONCLUSION: Our results support the hypothesis of an interaction between sleep parameters and T1DM, where the glycemic control plays an important role. More studies are needed to unveil the mechanisms behind this interaction, which may allow, in the future, clinicians and educators to consider sleep in the effort of regulating glycemic control.

Sleep and glycemic control in type 1 diabetes

Objective Our aim in the present study was to elucidate how type 1 diabetes mellitus (T1DM) and sleep parameters interact, which was rarely evaluated up to the moment. Materials and methods Eighteen T1DM subjects without chronic complications, and 9 control subjects, matched for age and BMI, were studied. The following instruments used to evaluate sleep: the Epworth Sleepiness Scale, sleep diaries, actimeters, and polysomnography in a Sleep Lab. Glycemic control in T1DM individuals was evaluated through: A1C, home fingertip glucometer for 10 days (concomitant with the sleep diary and actimeter), and CGM or concomitant with continuous glucose monitoring (during the polysomnography night). Results Comparing with the control group, individuals with diabetes presented more pronounced sleep extension from weekdays to weekends than control subjects (p = 0.0303). Among T1DM, glycemic variability (SD) was positively correlated with sleep latency (r = 0.6525, p = 0.0033); full awakening index and arousal index were positively correlated with A1C (r = 0.6544, p = 0.0081; and r = 0.5680, p = 0.0272, respectively); and mean glycemia values were negatively correlated with sleep quality in T1DM individuals with better glycemic control (mean glycemia < 154 mg/dL). Conclusion Our results support the hypothesis of an interaction between sleep parameters and T1DM, where the glycemic control plays an important role. More studies are needed to unveil the mechanisms behind this interaction, which may allow, in the future, clinicians and educators to consider sleep in the effort of regulating glycemic control. Arch Endocrinol Metab. 2015;59(1):71-8 .

Colapsabilidade da faringe durante o sono induzido: comparação entre descendentes de Japoneses e indivíduos Brancos

Introdução: A patogênese da apneia obstrutiva do sono (AOS) é complexa e pode variar de acordo com a etnia. O componente anatômico que predispõe à AOS é resultado da interação entre a estrutura óssea e partes moles da via aérea superior (VAS), e pode ser acessado através da pressão crítica de fechamento da faringe (Pcrit). Hipotetizamos que os descendentes de Japoneses e Caucasianos apresentam diferentes preditores para a colapsabilidade da VAS, sugerindo diferentes vias que levam ao desenvolvimento da AOS nestes dois grupos étnicos. Métodos: Homens descendentes de Japoneses (n=39) e Caucasianos (n=39), pareados para idade e gravidade da AOS, foram avaliados através de polissonografia (PSG), Pcrit e tomografia computadorizada (TC) da VAS e abdome para estudo da anatomia da via aérea e gordura abdominal, respectivamente. Resultados: Pcrit foi similar entre descendentes de Japoneses e Caucasianos (-1.0 ± 3.3 vs -0.4 ± 3.1 cmH20). Descendentes de Japoneses apresentaram menores dimensões ósseas craniofaciais (comprimento da base do crânio, maxila e mandíbula), enquanto que os Caucasianos apresentaram maior tamanho das partes moles da VAS (comprimento e volume da língua) e maior desbalanço entre o volume da língua e da mandíbula (razão entre o volume da língua e o volume da mandíbula). O ângulo da base do crânio apresentou associação com a Pcrit somente entre os descendentes de Japoneses (r=-0.535, p < 0.01). A razão volume da língua/volume mandibular se associou com a Pcrit somente nos Caucasianos (r=0.460, p < 0.01). Variáveis relacionadas à obesidade (IMC, circunferências cervical e abdominal, gordura visceral) mostraram correlação semelhante com a Pcrit em ambos os grupos...

Introduction: Obstructive sleep apnea (OSA) pathogenesis is complex and may vary according to ethnicity. The anatomical component predisposing to OSA is the result of the interaction between bony structure and upper airway soft tissues and can be assessed using passive critical closing pressure (Pcrit). We hypothesized that Japanese-Brazilians and Caucasians present different predictors to upper airway collapsibility, suggesting different causal pathways to develop OSA in these two groups. Methods: Male Japanese-Brazilians (n=39) and Caucasians (n=39) well matched for age and OSA severity were evaluated by full polysomnography, Pcrit and upper airway plus abdomen CT scans for determination of upper airway anatomy and abdominal fat, respectively. Results: Pcrit was similar between Japanese-Brazilians and Caucasians (-1.0 ± 3.3 vs -0.4 ± 3.1 cmH20). Japanese-Brazilians presented smaller upper airway bony dimensions (cranial base, maxillary and mandibular length) while Caucasians presented larger upper airway soft tissue (tongue length and volume) and greater imbalance between tongue and mandible (tongue/mandibular volume ratio). Cranial base angle was associated with Pcrit only among Japanese-Brazilians (r=-0.535, p < 0.01). Tongue/mandibular volume ratio was associated with Pcrit only among Caucasians (r=0.460, p < 0.01). Obesity-related variables (visceral fat, BMI, neck and waist circumferences) showed similar correlation with Pcrit in Japanese-Brazilians and Caucasians...

Upper airway collapsibility is associated with obesity and hyoid position.

STUDY OBJECTIVES: Upper airway anatomy plays a major role in obstructive sleep apnea (OSA) pathogenesis. An inferiorly displaced hyoid as measured by the mandibular plane to hyoid distance (MPH) has been consistently associated with OSA. The hyoid is also a common landmark for pharyngeal length, upper airway volume, and tongue base. Tongue dimensions, pharyngeal length, and obesity are associated with OSA severity, although the link between these anatomical variables and pharyngeal collapsibility is less well known. We hypothesized that obesity as measured by body mass index (BMI), neck and waist circumferences, and variables associated with hyoid position (pharyngeal length, upper airway volume, and tongue dimensions) would be associated with passive pharyngeal critical closing pressure (Pcrit). DESIGN: Cross-sectional. SETTING: Academic hospital. PATIENTS: 34 Japanese-Brazilian males age 21 to 70 y. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We performed computed tomography scans of the upper airway, overnight polysomnography, and Pcrit measurements in all subjects. On average, subjects were overweight (BMI = 28 ± 4 kg/m(2)) and OSA was moderately severe (apnea-hypopnea index = 29 [13-51], range 1-90 events/h). Factor analysis identified two factors among the studied variables: obesity (extracted from BMI, neck and waist circumferences) and hyoid position (MPH, pharyngeal length, tongue length, tongue volume, and upper airway volume). Both obesity and hyoid position correlated with Pcrit (r = 0.470 and 0.630, respectively) (P < 0.01). In addition, tongue volume, tongue length, pharyngeal length, and MPH correlated with waist and neck circumferences (P < 0.05). CONCLUSIONS: Pharyngeal critical closing pressure is associated with obesity and hyoid position. Tongue dimensions, pharyngeal length, and the mandibular plane to hyoid distance are associated with obesity variables. These findings provide novel insight into the potential factors mediating upper airway collapse in obstructive sleep apnea.

Bronchial casts attributed to the use of pegylated interferon and ribavirin.

We report the case of a 50-year-old male patient with a rare profile: bronchial casts associated with the use of pegylated interferon and ribavirin. The patient sought treatment in a pulmonology clinic with a history of progressive dyspnea for four months that had evolved to progressive cough followed by frequent and abundant elimination of bronchial casts. The patient was initially treated with bronchodilators, as well as with oral and inhaled corticosteroids. Fiberoptic bronchoscopy, bronchoalveolar lavage and sputum analysis were carried out but did not contribute to the elucidation of the diagnosis. The symptoms developed while the patient was receiving pegylated interferon and ribavirin for the treatment of hepatitis C. The symptoms resolved 30 days after the discontinuation of the treatment. To our knowledge, this is the first report of bronchial casts caused by the use of pegylated interferon and ribavirin.

Molde brônquico devido ao uso de interferon peguilado e ribavirina / Bronchial casts attributed to the use of pegylated interferon and ribavirin

Relatamos o caso de um homem de 50 anos com uma rara associação entre moldes brônquicos e o uso de interferon peguilado e ribavirina. O paciente procurou o serviço de pneumologia por apresentar, há quatro meses, dispneia progressiva que evoluiu com tosse progressiva seguida da expulsão de moldes brônquicos frequentes e abundantes. O paciente foi tratado inicialmente com medicações broncodilatadoras e uso de corticoide oral e inalatório. Foram realizados fibrobroncoscopia, lavado broncoalveolar e análise do escarro, os quais não acrescentaram informações para elucidação diagnóstica. Durante o período sintomático, o paciente fez uso de interferon peguilado e ribavirina para o tratamento de hepatite C. Após 30 dias da interrupção das medicações, o paciente ficou assintomático. Este é o primeiro relato sobre a associação entre molde brônquico e o uso de interferon peguilado e ribavirina.

We report the case of a 50-year-old male patient with a rare profile: bronchial casts associated with the use of pegylated interferon and ribavirin. The patient sought treatment in a pulmonology clinic with a history of progressive dyspnea for four months that had evolved to progressive cough followed by frequent and abundant elimination of bronchial casts. The patient was initially treated with bronchodilators, as well as with oral and inhaled corticosteroids. Fiberoptic bronchoscopy, bronchoalveolar lavage and sputum analysis were carried out but did not contribute to the elucidation of the diagnosis. The symptoms developed while the patient was receiving pegylated interferon and ribavirin for the treatment of hepatitis C. The symptoms resolved 30 days after the discontinuation of the treatment. To our knowledge, this is the first report of bronchial casts caused by the use of pegylated interferon and ribavirin.

[Secondary hypertrophic osteoarthropathy to lung cancer: a case report]. / Osteoartropatia hipertrófica secundária a neoplasia pulmonar: Relato de caso.

The secondary hypertrophic osteoarthropathy is a systemic change that affects the bones, joints and soft tissues and is secondary to any intrathoracic pathology. It is a syndrome of chronic proliferative periostitis of the long bones, clubbing of the fingers of the hands, feet or both, and olyarthritis or polyarthritis. We report one case of hypertrophic osteoarthropathy in a patient with lung mass with bulky diagnostic anatomopathological, adenocarcinoma.