Long-term evaluation of mental fatigue by Maastricht Questionnaire in patients with OSAS treated with CPAP.

BACKGROUND: Patients with obstructive sleep apnoea syndrome (OSAS) suffer from disrupted sleep. Impaired nightly sleep leads to increase physical and mental fatigue. The effect of long term continuous positive airway pressure (CPAP) on mental fatigue in OSAS patients, assessed by Maastricht Questionnaire (MQ), has not been investigated yet. METHODS: In order to evaluate the role of CPAP in improving mental fatigue of patients with OSAS, we studied 35 patients (26 males, age < 65 years at the time of the diagnosis) affected by OSAS, established by polysomnography (PSG). Patients were divided into two groups; 19 subjects (15 males), who refused CPAP therapy, and 16 patients (11 males) well matched for sex, age, body mass index (BMI), neck circumference, duration of follow up, and severity of disease, who had been treated with CPAP for at least two years. RESULTS: All patients had severe OSAS with Respiratory Disturbance Index (RDI), of 48 +/- 20.9 (range 22-90) and 61.48 +/- 18.6 (range 34-101) respectively, for group one (untreated patients) and group two (CPAP treatment). In addition, all patients had severe impairment of mental fatigue and of daytime sleepiness, demonstrated by high values of MQ score (32.17 +/- 15.33 and 37.36 +/- 12.4, respectively) and Epworth Sleepiness Scale (ESS) (14.21 +/- 4.77 and 15.06 +/- 6.07 respectively). There was no statistical significant difference in the group one at baseline and after follow-up, in terms of BMI, MQ score, ESS, and RDI. In the CPAP group (group two), the patients reported a significant improvement of the quality of their mental health (MQ 37.36 +/- 12.4 vs. 16.41 +/- 9.02; p < 0.0001) and sleepiness (ESS 15.06 +/- 6.07 vs. 4.13 +/- 3.93; p < 0.0001) with a stable BMI. There was significant correlation between the severity of sleep apnoea, expressed as RDI, and MQ at admission compared to at the end of follow-up (r = 0.4, p < 0.05). CONCLUSIONS: This study demonstrates an evident deterioration of mental fatigue in patients with OSAS, directly correlated to the severity of nocturnal disorder breathing; however supports the hypothesis that long-term CPAP therapy significantly improves sleepiness and mental fatigue.

Gender difference in sleep profile of severely obese patients with obstructive sleep apnea (OSA).

OBJECTIVES: Few papers addressed the gender difference in the polisomnographic features of obstructive sleep apnea (OSA). In this paper we investigated the sleep architecture and the nocturnal respiratory pattern in a group of severely obese women with OSA compared with a group of men with OSA matched by age and weight. DESIGN: A cross-sectional study. SETTING: Primary-care setting. SUBJECTS, MAIN OUTCOME MEASURES: Anthropometric parameters, respiratory function data and a full night polisomnography were evaluated in a group of 45 obese subjects, 20 females and 25 males, with a previous diagnosis of OSA. RESULTS: The group of the severely obese women with OSA presented greater disturbances of the sleep architecture than the group of the men does (wake time after sleep onset 92.6+/-52.4 vs 58.2+/-45.2 min, P<0.05; total wake time 104.8+/-51.4 vs 67.8+/-47.4, P<0.05; number of awakenings 15.5+/-3.6 vs 10.2+/-6.215, P<0.001; OSA that occurred almost exclusively during REM sleep (REM OSA) 35% vs 4%, P<0.05) and a reduced sleep efficiency (69.6+/-15.9 vs 80.3+/-14.0%, P<0.05). CONCLUSIONS: Severely obese women with OSA, even with milder OSA, present greater disturbances of the sleep architecture with a more severe sleep disruption and more frequently REM OSA in comparison with men matched by age and weight.

Prevalence and mechanisms of diurnal hypercapnia in a sample of morbidly obese subjects with obstructive sleep apnoea.

It is well known that obstructive sleep apnoea is especially frequent in the morbidly obese. In these subjects diurnal chronic hypercapnia, whose mechanism is still debated, may be present. Our study was performed to evaluate the prevalence and the mechanism of diurnal hypercapnia in the morbidly obese affected by obstructive sleep apnoea. From a population referred to our centre because of suspicion of sleep related breathing disorders, we selected 285 subjects without cardiopulmonary, neuromuscular or endocrinological diseases: 89 (36 M and 53 F, aged 46+/-13 years) had body mass index (BMI) > or = 40 kg m(-2) (MO group: morbidly obese subjects) and 196 (99 M and 97 F, aged 48+/-16 years) had BMI <40 kg m(-2) (NMO group: non-morbidly obese subjects). Then the MO group was divided into three subgroups: normocapnic subjects without obstructive sleep apnoea, normocapnic subjects with obstructive sleep apnoea, hypercapnic subjects with obstructive sleep apnoea; while we found no hypercapnic subject without obstructive sleep apnoea. All subjects underwent anthropometric evaluations and bioelectrical impedance analyses, respiratory function tests and arterial blood gas analysis, a modified version of the Sleep and Healthy questionnaire and a full night polysomnography. Our results showed that hypercapnia (PaCO2 > or = 45 mm Hg) associated with obstructive sleep apnoea [respiratory disturbance index (RDI) > or = 10 h(-1)] was found in 27% of the morbidly obese subjects, but only in 11% of the nonmorbidly obese ones (P<0.01). The comparison among the three subgroups, in which we divided the morbidly obese subjects, shows that those with hypercapnia and obstructive sleep apnoea had significantly more important ventilatory restrictive defects [forced vital capacity (FVC)% of pred 73.27+/-14 81 vs. 82.37+/-16.93 vs. 87.25+/-18.14 respectively; total lung capacity (TLC)% of pred 63.83+/-16.35 vs. 79.11+/-14.15 vs. 87.01+/-10.5], a significantly higher respiratory disturbance index (RDI 46.34+/-26.90 vs. 31.79+/-22.47 vs. 4.98+/-3.29) a longer total sleep time with oxyhaemoglobin saturation<90% [total sleeptime (TST)SaO2<90% 63.40+/-33.86 vs. 25.95+/-29.34 vs. 8.22+/-22.12] and a lower rapid eye movement (REM) stage (9.5+/-1.2 vs. 14.0+/-0.9 vs. 17.05+/-1.2) than normocapnic subjects with obstructive sleep apnoea or subjects without obstructive sleep apnoea. The best model to predict PaCO2 resulted from a combination of TSTSaO2<90% (r2 = 0.22, P<0.001), forced expiratory volume in 1 sec (FEV1)% of pred (r2 = 0.09, P<0.01), FVC % of pred (r2 = 0.075, P<0.01). In conclusion our study suggests that diurnal hypercapnia is frequently associated with obstructive sleep apnoea in the morbidly obese without chronic obstructive pulmonary disorder (COPD) and that ventilatory restriction and sleep related respiratory disturbances correlate to diurnal hypercapnia.

A randomized trial of cefepime and ceftazidime for the treatment of community-acquired pneumonia.

We compared the effectiveness and safety of ceftazidime and cefepime in hospitalized patients with community-acquired pneumonia. The 148 enrolled patients received 2 g ceftazidime three times daily or 2 g cefepime twice daily. The clinical success rate was the same for both drugs. Even the microbiological effectiveness was similar. Both drug regimens were well tolerated. We conclude that 2 g ceftazidime three times daily were as effective as 2 g cefepime twice daily for the treatment of community-acquired pneumonia in hospitalized patients. The cost of ceftazidime treatment was, however, higher than the cost of cefepime treatment.

Hypercapnia in obstructive sleep apnoea syndrome.

BACKGROUND: The reports on the prevalence of hypercapnia in Obstructive Sleep Apnoea Syndrome (OSAS) are conflicting. We studied the prevalence of hypercapnia in a population of OSAS patients referred to a Department of Respiratory Medicine and the mechanism of the respiratory failure in OSAS associated with Obesity Hypoventilation Syndrome (OHS) or with Chronic Obstructive Pulmonary Disease (COPD) (Overlap syndrome). METHODS: We studied 219 consecutive OSAS patients during a period of 3 years. We recorded age and anthropomorphic data and performed polysomnography and pulmonary function tests. In relation to the value of PaCO(2), the patients were divided in hypercapnic (PaCO(2)>45 mmHg) patients and normocapnic patients. They were also divided into three groups in relation to the presence of "simple" or "pure" OSAS, to the presence of OSAS associated with COPD, to the presence of OSAS associated with OHS. RESULTS: Seventeen per cent of the patients were hypercapnic. They were significantly heavier, had more severe lung function test abnormalities and more severe nocturnal oxyhemoglobin desaturations than the normocapnic ones, while Forced Expiratory Volume in one second as a percentage of Forced Vital Capacity (FEV1/FVC %) and Apnoea/Hypopnoea Index (AHI) were similar. OHS patients (13%) were significantly younger and heavier, had lower PaO(2) and higher PaCO(2) than "simple" OSAS patients (77%) and Overlap patients (10%) and had more severe restrictive defect. There was no difference in terms of AHI among the three groups, but nocturnal oxyhemoglobin desaturations were more severe in OHS group. In OHS group hypercapnia was correlated to FVC% of predicted and FEV1% of predicted and to the mean nocturnal oxyhemoglobin saturation; in Overlap patients PaCO(2) was correlated to Forced Expiratory Flow rate at low Vital Capacity. CONCLUSION: Seventeen per cent of OSAS patients referred to a Department of Respiratory Medicine were hypercapnic. Hypercapnia in OHS patients correlates to the restrictive ventilatory defect whereas in Overlap patients it seems to correlate to peripheral airways obstruction. The distinction between patients with "simple" or "pure" OSAS and patients affected by OSAS associated with OHS or COPD could be important not only for clinical and prognostic implications, but also for the consequences in terms of ventilatory treatment.

Early and late failure of noninvasive ventilation in chronic obstructive pulmonary disease with acute exacerbation.

BACKGROUND: Despite recent encouraging results, the use of noninvasive ventilation (NIV) in the management of acute exacerbations in chronic obstructive pulmonary disease (COPD), complicated by acute respiratory failure (ARF), is not always successful. Failure of NIV may require an immediate intubation after a few hours (usually 1-3) of ventilation ('early failure') or may result in clinical deterioration (one or more days later) after an initial improvement of blood gas tension and general conditions ('late failure'). MATERIALS AND METHODS: We enrolled 122 patients affected by COPD complicated by ARF, and treated with NIV. The schedule of NIV provided sessions of 2-6 h twice daily. RESULTS: Ninety-nine (81%) patients showed a progressive improvement of the clinical parameters and were discharged. Among the remaining 23 patients, 13 had an early failure and 10 had a late failure. In the 'success' group and 'late failure' groups we found after an increase of pH 2 h of NIV (from 7.31 +/- 0.05 to 7.38 +/- 0.04 P < 0.001 and from 7.29 +/- 0.03 to 7.36 +/- 0.02 P < 0.001, respectively) and a decrease of PaCO2 (from 80.93 +/- 9.79 to 66.48 +/- 5.95 P < 0.001 and from 85.96 +/- 10.77 to 76.41 +/- 11.02 P < 0.001, respectively). After 2 h of NIV in the 'late failure' group there were no significant changes in terms of pH (from 7.20 +/- 0.10 to 7.28 +/- 0.06) nor PaCO2 (from 92.86 +/- 35.49 to 93.68 +/- 23.68). The 'early failure' group had different characteristics and, owing to more severe conditions, the value of pH, of Glasgow Coma Score, and Apache II Score were the best predictors of the failure; while, among the complications on admission, metabolic alterations were the only independently significant predictor. CONCLUSIONS: Our study confirms that NIV may be useful to avoid intubation in approximately 80% of patients with COPD complicated by moderate-severe hypercapnic respiratory failure.

Measurement of nasal mucociliary clearance.

The saccharin test was carried out in a randomly selected sample of schoolchildren (142 boys and 153 girls, age range 11-14 years) to determine the variability and reproducibility of the test and to assess whether it could be used as a screening test for nasal mucociliary clearance. Nasal mucociliary clearance times were analysed according to clinical history (asthma, rhinitis, asthma with rhinitis, and acute upper respiratory tract infections), laboratory findings (positive skin test responses and bronchial hyper-reactivity assessed by methacholine challenge), and parental smoking. Nasal mucociliary clearance times showed a narrow coefficient of repeatability (six minutes) in 50 subjects and there was substantial agreement between the two tests. Nasal mucociliary clearance times were less than 40 minutes in all the children. Normal children had nasal mucociliary clearance times of less than 24 minutes while significantly impaired nasal mucociliary clearance was detected in those with positive skin reactions and a positive response to methacholine challenge. We were unable to show that passive smoking had any consistent effect on nasal mucociliary clearance. We suggest that a time response between 30-60 minutes should be checked again at least two weeks later, and that children in whom repeated saccharin tests show a nasal mucociliary clearance of greater than 30 minutes should have ciliary beat frequency estimated.

Prevalence of obstructive sleep apnoea in a sample of obese women: effect of menopause.

BACKGROUND: Obesity is a well known risk factor for obstructive sleep apnoea (OSA). Previous studies have investigated the prevalence of OSA among obese people, but a sample of women was rarely studied. OBJECTIVE: To describe the anthropometric and polysomnographic characteristics of a sample of obese women and investigate the effect of menopause on the prevalence of OSA. MATERIALS AND METHODS: Using a full-night polysomnography we studied a sample of 133 obese women with a body mass index (BMI) > or = 30 kg/m2. RESULTS: About 44% of our sample had a respiratory disturbance index (RDI) > or = 10. Neck circumference, BMI and age resulted the strongest predictors of RDI value. We also found that the prevalence of OSA was higher among post-menopausal women (67%) in comparison with pre-menopausal women (31%). Moreover, post-menopausal women had larger neck circumference and higher waist-to-hip circumference ratio (WHR). CONCLUSIONS: Among post-menopausal obese women the prevalence of OSA increases. We suggest that menopause could cause a different body fat distribution with an increase of fat in upper parts of the body and, consequently, with an increase of neck circumference.

Low sleep quality and daytime sleepiness in obese patients without obstructive sleep apnoea syndrome.

OBJECTIVES: To evaluate sleep quality, sleep-related symptoms, and degree of excessive daytime sleepiness (EDS) in severe obesity, independently of obstructive sleep apnoea syndrome (OSAS). DESIGN: A cross-sectional study. SETTING: Primary-care setting. SUBJECTS, MAIN OUTCOME MEASURES: Anthropometric parameters, respiratory function data and sleep related symptoms were evaluated in 78 severely obese patients (aged 16-75 years) without OSAS and in 40 healthy sex- and age-matched normal weight subjects, who underwent a full-night polysomnography. RESULTS: Obese patients and control subjects had similar sleep latency and rapid eye movement (REM) latency, but they showed lower percentage of REM (P < 0.01) and sleep efficiency (P < 0.05) than controls. All sleep-related symptoms (observed or reported apnoea, awakenings, choking and unrefreshing sleep) were significantly more frequent in obese patients than in control subjects. Loud snoring was present in 46.7% of the obese patients and in 8.1% of the control individuals (P < 0.01). Excess daytime sleepiness was reported by 34.7% of the obese patients and by 2.7% of the normal weight subjects (P < 0.01). The Epworth Sleepiness Scale (ESS) was higher in the obese group than in the control group (P < 0.01), whereas arousals were not different between the two groups. CONCLUSIONS: This study clearly shows that severe obesity, even in the absence of OSAS, is associated with sleep-related disorders and EDS. All these alterations may be partly responsible for a lower quality of life, a higher prevalence of medical complications, an increased risk of occupational injury, and both social and family problems characterizing obese patients, independently of the presence of OSAS.

Nocturnal oxygen desaturation in patients with congestive heart failure.

The aim of our study was to evaluate the modifications of the respiratory pattern during sleeping in patients with congestive heart failure (CHF) by a simple pulse-oxymetry. We studied 10 subjects (8M/2F), mean age 71.4 +/- 12.4 yrs, admitted to sub-intensive cardiological therapy unit, with diagnosis of CHF due to left ventricular insufficiency by ischemic, hypertensive or idiopathic cardiopathy, when in a stable clinical condition. All patients presented arterial blood gas values within normal limits. The ejection fraction of left ventricle showed a mean value of 30.4 +/- 8.2% (range 20%-45%). Nocturnal pulse-oxymetry was performed by pulse-oxymeter (PULSOX 7 Minolta) provided with a digital probe at a sliding speed 24 cm/h. Our data showed that all patients presented nocturnal desaturation episodes (mean oxygen desaturation index 15.7 +/- 18.4). In two patients, we found an "Overlap Syndrome" (obstructive sleep apnoea in presence of cardiopathy). In other patients pulse-oxymetry showed a typical sequence of "fall-rise" basal O2 saturation lasting from 36 to 72 seconds, collected in "wave trains" which were present from 14% to 70% of total sleep time compatible with periodic breathing. In conclusion, our study shows that patients affected by CHF, even if in stable condition and with a PaO2, within normal values, present more or less severe disturbances of nocturnal SaO2, with periodic and regular sequences of SaO2 fall-rise that may be referred to ventilatory troubles such as periodic breathing or Cheyne-Stokes breathing. In these patients the pulse-oxymetry may be considered an efficacious, simple, cheap and well tolerated method.

Sleep-related breathing disorders, loud snoring and excessive daytime sleepiness in obese subjects.

OBJECTIVE: To investigate the prevalence of sleep breathing disorders, loud snoring and excessive daytime sleepiness in a group of obese subjects, and to identify the predictors of obstructive sleep apnea (OSA) severity in these patients. SUBJECTS: A total of 161 consecutive obese patients (body mass index (BMI)> or =30.0 kg/m(2)), ranging between 30.0 and 67.3, represented by 57 men and 104 women, aged 16-75 y. Forty (15 men and 25 women) age-matched (20-70 y) nonobese (BMI<27 kg/m(2)) volunteers were also recruited for the study. MEASUREMENTS: Respiratory function parameters, nocturnal sleep quality (evaluated by a specific questionnaire), nocturnal hypoventilation and OSA (evaluated by night polysomnography) were examined in all subjects. Anthropometric parameters (neck circumference, waist circumference, waist-to-hip ratio) were also investigated. RESULTS: Eighty-three obese patients (51.5% of the obese group) had a respiratory disturbance index (RDI)> or =10, corresponding to a moderate or severe sleep apnea. In particular, 24.8% (40/161), ie a quarter of all obese patients, were affected by severe OSA and this alteration was present in 42.1% of obese men (24/57) and in 15.4% (16/104) of obese women. When a stepwise multiple regression analysis was performed, neck circumference in men and BMI in women were shown to be the strongest predictors of sleep apnea. Twenty-nine percent of all obese subjects (40.3% of men and 23.1% of women) showed nocturnal hypoventilation; however, it was present as a unique breathing alteration in only 5% of the obese population. The percentage of patients having excessive daytime sleepiness was significantly higher than in nonobese subjects, even when only nonapneic obese patients were considered (P<0.001). CONCLUSION: This study shows that OSA is present in more than 50% of a population of obese patients with a mean BMI higher than 40.0, this percentage being much higher than that commonly reported in previous studies, particularly in women. Neck circumference in men and BMI in women seem to be the strongest predictors of the severity of OSA in obese patients. Nocturnal hypoventilation seems to be present in more than 29% of a severe obese population. Moreover, this study indicates that morbid obesity can be associated with excessive daytime sleepiness even in the absence of sleep apnea.