The association between dysphagia and OSA.

OBJECTIVE: The aim of our study was to investigate the presence of dysphagia in patients with Obstructive Sleep Apnoea (OSA) and to correlate swallowing impairment with hypnologic and anatomic parameters. METHODS: The study population includes 36 patients suffering from OSA. Patients were divided into two groups using the presence of dysphagia as a distinctive parameter. Group 1 included 27 OSA patients without signs of dysphagia and Group 2 included 9 OSA patients with signs of dysphagia. RESULTS: The age of patients in Group 2 was higher compared with the age of patients in Group 1. Analysis of Continuous Positive Airway Pressure (CPAP), obtained in the titration phase, showed that OSA patients with signs of dysphagia required a higher level of CPAP pressure than those who were not affected by swallowing abnormalities (12.6 ± 1 vs 10.5 ± 1.9 p = 0.003). No other differences in anthropometric, hypnologic, or arterial blood gas values were found between the two groups. CONCLUSIONS: In clinical practice, all OSA patients should undergo a complete ENT exam, including assessment of swallowing, before CPAP therapy is started. This may predict the need for higher CPAP pressure settings to resolve apnoea episodes in the presence of dysphagia as well as guide the choice of CPAP interfaces (orofacial vs. nasal) in these patients.

Reduction of Sniff Nasal Inspiratory Pressure (SNIP) as an Early Indicator of the Need of Enteral Nutrition in Patients with Amyotrophic Lateral Sclerosis.

Percutaneous endoscopic gastrostomy (PEG) is the standard procedure for feeding severely dysphagic patients with amyotrophic lateral sclerosis (ALS). It is associated with prolonged survival and improvement in quality of life. Nasal inspiratory pressure during a sniff (SNIP) is a respiratory test used extensively in ALS for the assessment of inspiratory muscle strength. In this study, we aimed to investigate the role of SNIP at baseline to predict PEG placement in ALS. Data from a clinical incident cohort of 179 ALS cases attending the multidisciplinary ALS unit of the University of Bari between April 2006 and December 2012 were retrospectively analysed. At baseline, patients underwent detailed neurological, nutritional and respiratory assessments, including measurements of SNIP and forced vital capacity (FVC). Patients were therefore followed up approximately every three to six months until they were able to attend the centre. The censoring date for the survival analysis was 15 April 2014, with PEG placement as the main outcome. Cox proportional hazard regression models were used to examine the association between SNIP and PEG placement, adjusted for possible confounders. During the follow-up period, 75 participants (42%) received PEG implant. PEG placement was more frequent (57% vs. 31%; p = 0.001) and earlier (after 11.6 ± 14.0 months from the first visit, vs. 23.3 ± 15.5 months; p < 0.0001) in the group of patients with baseline SNIP ≤ 40 cm H2O. Baseline SNIP was a predictor of PEG placement even after correction for multiple potential confounders (HR 0.98; 95% CI: 0.96-0.99; p = 0.02). To conclude, the present study showed that SNIP at baseline is an early indicator of disease progression and therefore of the need for enteral nutrition in ALS.

Galectin-3 and neutrophil-to-lymphocyte ratio are indicative of heart remodelling and disease severity in patients with obstructive sleep apnoea.

BACKGROUND: Galectin-3, considered as a new inflammatory marker; it is increased in cardiovascular disease. We investigated Galectin-3 in relation to heart damage in patients with OSA and its role in inflammation, based on the Neutrophil-to-Lymphocyte Ratio (NLR). METHODS: Sixty-three consecutive patients (45 males, 18 females, 58.60 ± 12.28 years old) were studied. According to the Apnoea-Hypopnoea Index (AHI) patients were divided into Group 1 - non-severe (AHI <30) (17 males and 10 females, 59.89 ± 10.62 years old) and Group 2 - severe (AHI ≥30) (29 males and 6 females, aged 57.53 ± 13.30 years old) OSA. All patients underwent morning blood gas analysis, laboratory tests, nocturnal polygraphy, and echocardiography. RESULTS: Galectin-3 was significantly increased in Group 2 (p = 0.027) patients. Moreover, it was directly related to left ventricle (LV) mass, left ventricle hypertrophy and LV posterior wall diameter. Tissue Doppler septal velocity (e'), that measures wall motion, was inversely correlated to Galectin-3. Furthermore, a direct association to diastolic dysfunction, evaluated as E/e' ratio, was observed. In line with these data, a direct correlation between Galectin-3 and left atrium volume was also found. Galectin-3 and percentage of total registration time with nocturnal oxygen saturation <90% (TST90) were directly correlated (p = 0.0003), while Galectin-3 and mean nocturnal SpO2 were negatively correlated (p = 0.0045). We found a direct correlation between Galectin-3 and NLR (p = 0.011). Finally, Galectin-3 was able to predict 3-yr mortality with a specificity of 83.33% and a sensitivity of 91.84%. CONCLUSION: Galectin-3 showed a direct association to nocturnal respiratory indices and to cardiac remodelling in patients with OSA. OSA-induced inflammation may play an important role in the pathogenesis of heart damage.

Nocturnal Hypoventilation May Have a Protective Effect on Ischemic Heart Disease in Patients with Obesity Hypoventilation Syndrome.

The importance of nocturnal hypoventilation (nHyp) in the development of cardiovascular comorbidity (CVM) in patients with obesity hypoventilation syndrome (OHS) is controversial. We recently hypothesized that nHyp may have a protective effect on CVM in OHS. The aim of this study was to evaluate the link between nHyp and CVM in patients with OHS. We performed a retrospective analysis of the clinical records of 60 patients with OHS. The initial population was divided into two groups: (1) 31 subjects with OHS and nHyp (nhOHS); (2) 29 individuals with OHS without nHyp (wnhOHS). All patients had also obstructive sleep apnea. Anthropometric data, medical history, electrocardiogram, pulmonary function testing, arterial blood gas test, and sleep recordings were collected. Patients with nhOHS, compared with those wnhOHS, showed higher values of PaCO2 (48.75 ± 3.78 vs. 46.91 ± 2.09 mmHg; p = 0.023), lower percentage of ischemic heart disease (3.2% vs. 20.7%; p = 0.042), higher oxygen desaturation index (ODI; 55.10/h ± 28.76 vs. 38.51/h ± 23.21; p = 0.017), and higher total sleep time (TST90) with SpO2 <90% (53.58% ± 26.90 vs. 25.64% ± 21.67; p = 0.000). Moreover, individuals in the nhOHS group showed a significantly different (p = 0.031) distribution of the three ODI tertiles 0-32/h, 33-72/h, >72/h compared with those in wnhOHS group (19.4% vs. 37%, 41.9% vs. 51.7%, 38.7% vs. 10.3%, respectively). Subsequent discriminant analysis correctly classified nhOHS and wnhOHS in 66.7% of the cases. Ours is the first study analyzing the correlation between nHyp and CVM in patients with OHS. We showed that nHyp in OHS may have a protective effect on cardiovascular morbidity, in particular on ischemic cardiac disease.

Bilateral pulmonary nodules and acute respiratory failure in a 22-year-old man with dyspnoea and fever.

Can you diagnose the cause of this man's bilateral pulmonary nodules and acute respiratory failure? http://ow.ly/NfED30dDBzm.

Voluntary lung function screening to reveal new COPD cases in southern Italy.

BACKGROUND: Underdiagnosis of COPD is a relevant issue, and most frequently involves patients at early stages of the disease. Physicians do not routinely recommend smokers to undergo spirometry, unless they are symptomatic. AIMS: To investigate the effectiveness of voluntary lung function screening in bringing to light patients with previously unknown COPD and to evaluate the relationships among symptoms, smoking status, and airway obstruction. METHODS: A voluntary screening study for COPD was conducted during two editions of the annual Fiera del Levante (2014 and 2015), an international trade fair in Bari. Subjects were eligible for the study if they fulfilled the following inclusion criteria: age ≥35 years, smoker/ex-smoker ≥5 pack-years (PYs), or at least one chronic respiratory symptom (cough, sputum production, shortness of breath, and wheezing). A free post-ß2-agonist spirometry test was performed by trained physicians for each participant using portable spirometers. Post-ß2-agonist forced expiratory volume in 1 second (FEV1):forced vital capacity ratio <0.7 was chosen to establish the diagnosis of COPD. Sensitivity, specificity, and negative and positive predictive values (NPVs and PPVs) of symptoms for the presence of obstruction were calculated. RESULTS: A total of 1,920 individuals were eligible for the study; 188 subjects (9.8%) met COPD criteria. There was a 10.4% prevalence of COPD in subjects with one or more symptoms who had never smoked or smoked ≤5 PYs. Among COPD patients, prevalence of symptoms increased in the presence of FEV1 <80%. COPD smokers were more symptomatic than smokers without COPD. Sensitivity and specificity in all subjects with one or more symptoms were 87% and 32%, respectively, whereas in smoker subgroups, sensitivity and specificity were 71% and 41% (≥5 PYs) and 74% and 35% (≥10 PYs), respectively. In all subjects, the presence of at least one symptom was associated with a low PPV for COPD of 11%, but a very high NPV (96%). These data did not change if the analysis was limited to smokers. CONCLUSION: Voluntary public lung function screening programs in Italy are effective, and may detect a large number of undiagnosed subjects with COPD in early stages. In our population, COPD symptoms had low specificity and PPV, even considering smokers only.

An electronic nose may sniff out amyotrophic lateral sclerosis.

Amyothrophic lateral Sclerosis (ALS) is a neurodegenerative disease characterized by a progressive degeneration of the cortical and spinal motor neuron. Exhaled molecular profiles that have potential in the diagnosis of several respiratory and systemic diseases can be obtained by analyzing human breath with an electronic nose. We hypothesized that exhaled molecular profiling may discriminate well-characterized patients with ALS from controls. 20 ALS patients (age: 63.5±12.3), and 20 healthy controls (age: 58.1±4.4) participated in a cross-sectional study. A Tedlar bag was used to collect exhaled breath by using a validated method. Bags were then sampled by an electronic nose (Cyranose 320). Statistical analysis on sensor responses was performed off-line by principal component analysis, linear discriminant analysis and ROC curves. Breathprints from patients with ALS were discriminated from healthy controls (CVA: 75.0%; p=0.003; AUC 0.795). Based on our results, patients with ALS can be discriminated from healthy controls. This suggests that exhaled breath analysis has potential for screening and/or diagnosis of this neuromuscular disease.