Insomnia symptoms combined with nocturnal hypoxia associate with cardiovascular comorbidity in the European sleep apnea cohort (ESADA).

PURPOSE: The aim of the current study was to further investigate the concept of previously reported high occurrence of comorbidities in obstructive sleep patients (OSA) with insomnia-like symptoms. We hypothesized that this finding at least partly is mediated by nocturnal hypoxia. Moreover, we speculated that the spectrum of the clinical OSA phenotypes differs between European geographical regions. METHODS: Cohort of the European Sleep Apnea Database (n = 17,325; 29.9% females) was divided into five subcohorts according to geographical region (North, East, South, West, Central) and further into four clinical presentation phenotypes based on daytime symptoms (EDS) and characteristics suggestive of insomnia. RESULTS: The insomnia phenotype (alone or together with EDS) dominated in all European regions. Isolated insomnia, however, was less common in the West. Insomnia phenotype was associated with the highest proportion of cardiovascular comorbidity (51.7% in the insomnia vs. 43.9% in the EDS type). Measures of nocturnal hypoxemia were independently associated with cardiovascular comorbidity in phenotypes with insomnia-like symptoms. The burden of comorbidities was high across all geographical regions and clinical phenotypes. Regional differences were clinically relevant for age (48 vs. 54 years), BMI (29 vs. 34 kg/m2), and ODI (15 vs. 32/h). CONCLUSION: High prevalence of particularly cardiovascular comorbidity among patients with insomnia-like symptoms was linked to nocturnal hypoxemia. Considerable differences in clinical presentation were found among OSA patients across Europe. Our data underline that physicians should ask their patients with suspected OSA also for insomnia symptoms. It remains to be explored if a reduction of nocturnal hypoxemia predicts the improvement of insomnia symptoms.

Improved follow-up by peripheral arterial tonometry in CPAP-treated patients with obstructive sleep apnea and persistent excessive daytime sleepiness.

BACKGROUND: OSA-patients with persistent excessive daytime sleepiness (EDS) despite CPAP treatment are challenging in daily clinical life. To rule out residual sleep-disordered breathing (SDB), CPAP device-derived data are used in outpatient setting. In case of no pathological finding, a more intensive work-up with is necessary. 6-channel portable monitoring (6Ch-PM) is frequently used to exclude residual SDB. Peripheral arterial tonometry (PAT), as embodied in the WatchPAT device, represents an alternative technique for detecting SDB based on changes in autonomic tone. We wanted to investigate whether PAT might be a useful tool to improve diagnostic work-up in this specific patient group by better identifying residual SDB due to insufficient CPAP-adjustment. METHODS: Forty-nine OSA patients (39 male, 10 female) with sufficient CPAP treatment according to device-derived data were consecutively recruited. EDS was assessed by Epworth Sleepiness Scale (ESS). All patients underwent home-based CPAP therapy control by 6Ch-PM and portable monitoring using PAT technology on two consecutive nights. A sequence of both types of monitoring was randomized to prevent possible first night effect bias. RESULTS: Twelve out of 49 patients showed persistent EDS according to ESS (ESS > 10 points). 6Ch-PM showed a residually increased AHI under CPAP-treatment in 2 of those 12 subjects (positive predictive value, PPV = 16.7%). PAT-PM revealed 5 patients of those 12 with residual SDB (PPV = 41.7%). CONCLUSION: PAT could detect significantly more residual SDB under CPAP treatment than 6Ch-PM. Diagnostic work-up of CPAP-treated OSA patients with persistent EDS might be optimized, as insufficient pressure level adjustments could be recognized more precisely in time, possibly preventing more resource-consuming procedures, and potentially increased morbidity. CLINICAL TRIAL REGISTRATION: DRKS00007705.

[Lung Health Data of the Study of Health in Pomerania - a Review of Samples, Methods and First Results]. / Pneumologisch relevante Daten aus der "Study of Health in Pomerania" (SHIP) ­ eine Übersicht zu den Kohorten, Methoden und ersten Ergebnissen.

Investigating reasons for differing life expectancy and prevalence of cardiovascular risk factors between old and new states of the Federal Republic of Germany an epidemiological study in Western Pomerania - the population-based project Study of Health in Pomerania (SHIP) - was planned.Prevalence and incidence of common risk factors, subclinical disorders and clinical diseases have been assessed since 1997 in five-year intervals. The third follow up (SHIP-3) was assessed between 2014 and 2016. In addition, an independent representative population sample was investigated between 2008 - 2012 (SHIP-TREND). Recently, the first follow up of this cohort has been started (SHIP-TREND-1). This paper reports the methodological approaches for detecting pneumological relevant morbidities in this population-based study. It aims to offer insights for potential cooperation with interested research groups.

[Diagnosis of sleep disordered breathing using portable methods]. / Diagnostik schlafbezogener Atmungsstörungen mittels portabler Verfahren.

Portable monitoring of sleep disordered breathing is the first diagnostic method not only in Germany but today in other countries as well. The conditions under which portable monitoring can be done with reliable results are now well defined. The limitations for the use of portable monitoring are specified as well. The devices used for portable monitoring are classified in four categories according to the number and the kind of signals recorded. New technical developments in the field of portable monitoring (polygraphy) use an indirect assessment of sleep disordered breathing based on signals not directly recording respiration. The recording of ECG and deriving respiration, the analysis of the plethysmographically recorded pulse wave, the recording of jaw movements using magnets, and advanced analysis of respiratory sounds are recent approaches. These new methods are presented with few studies until now. More and larger clinical studies are needed in order to show which of these systems is useful in the diagnosis of sleep disordered breathing and which are the specific strengths and weaknesses.

[Sleep apnoea syndrome in the rehabilitation setting]. / Das Schlafapnoe-Syndrom in der Rehabilitation.

Sleep-related breathing disorders are a common finding in patients undergoing cardiological rehabilitation. Sleep apnoea is recognized as a major risk factor for cardiovascular disorders. The diagnosis of sleep-related breathing disorders begins with taking a thorough sleep medicine-related patient history and answering dedicated questionnaires. The second step involves portable monitoring to assess oxygen saturation, heart rate, respiratory flow and effort. Portable monitoring is able to detect the severity of the breathing disorder and forms the basis on which to refer the patient for further sleep laboratory diagnosis or, in the case of positive results, to initiate appropriate treatment. In order to exclude a sleep-related breathing disorder, to distinguish between obstructive and central sleep apnoea, or to diagnose other sleep disorders a cardiorespiratory polysomnography in a sleep laboratory is required. Polysomnography is also needed if comorbidities are present. Appropriate and prompt treatment of sleep-related breathing disorders can shorten cardiological rehabilitation and improve outcomes in this patient group.

[Portable sleep monitoring in patients with disorders in falling asleep or maintaining sleep]. / Erweiterte ambulante Polygraphie bei Patienten mit Ein- und/oder Durchschlafstörungen.

BACKGROUND: The most common diagnoses in sleep medicine are insomnia, sleep disordered breathing (SDB) and periodic leg movements (PLM). These disorders may coincide. This study examined the role of portable sleep monitoring in the diagnostic process and which sleep medicine diagnoses are additionally found in patients with disorders of initiating and maintaining sleep. METHODS: A total of 217 patients, including 103 men (47.5%) and 114 (52.5%) women aged 52.2 ± 13.6 years with disorders of initiating or maintaining sleep were included in the study. Patients with known SDB were excluded. Patients were investigated using a stepwise diagnostic procedure with clinical interviews, questionnaires, clinical examination and portable sleep recording with electromyography (EMG) of the tibialis anterior muscle to diagnose SDB and PLM. RESULTS: Of the patients 125 (57.6%) were diagnosed with insomnia according to the International Classification of Sleep Disorders (ICSD) and 70 (56%) had no other sleep disorder. Out of the 217 patients SDB was found in 107 (49.3%) patients, PLM in 90 patients (41.5%) and in 78 patients (35.9%) restless legs syndrome (RLS) was diagnosed. Among the 125 patients with insomnia 44 patients had RLS/PLMD and 35 had SDB in addition whereas SDB and RLS/PLMD were found in 33 subjects. All 3 disorders insomnia, RLS/PLMD and SDB were found in 24 subjects. CONCLUSIONS: Out of 217 patients with a complaint of non-restorative sleep only 125 were finally diagnosed with insomnia. As 25.3% of patients showed combinations of sleep disorders, 49.3% with SDB and 41.5% with RLS/PLMD portable monitoring with electromyography of the legs is recommended. The investigation with a portable sleep monitoring system including an EMG of the tibialis muscle is very useful in patients with insomnia in addition to a clinical interview and questionnaires.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

The European Sleep Apnoea Database (ESADA): report from 22 European sleep laboratories.

The European Sleep Apnoea Database (ESADA) reflects a network of 22 sleep disorder centres in Europe enabled by a COST action B26 programme. This ongoing project aims to describe differences in standard clinical care of patients with obstructive sleep apnoea (OSA) and to establish a resource for genetic research in this disorder. Patients with suspected OSA are consecutively included and followed up according to local clinical standards. Anthropometrics, medical history, medication, daytime symptoms and sleep data (polysomnography or cardiorespiratory polygraphy) are recorded in a structured web-based report form. 5,103 patients (1,426 females, mean±sd age 51.8±12.6 yrs, 79.4% with apnoea/hypopnoea index (AHI) ≥5 events·h(-1)) were included from March 15, 2007 to August 1, 2009. Morbid obesity (body mass index ≥35 kg·m(-2)) was present in 21.1% of males and 28.6% of females. Cardiovascular, metabolic and pulmonary comorbidities were frequent (49.1%, 32.9% and 14.2%, respectively). Patients investigated with a polygraphic method had a lower AHI than those undergoing polysomnography (23.2±23.5 versus 29.1±26.3 events·h(-1), p<0.0001). The ESADA is a rapidly growing multicentre patient cohort that enables unique outcome research opportunities and genotyping. The first cross-sectional analysis reveals a high prevalence of cardiovascular and metabolic morbidity in patients investigated for OSA.

[Sleep medicine services in Germany]. / Schlafmedizinische Versorgung in Deutschland.

The increase in sleep medicine services has paralleled the increased in nocturnal ventilation therapy in patients with sleep apnea. Even if the sleep medicine expertise did increase in the past, this is not sufficient to cover the increasing demand for sleep medicine services. To serve patients with nonrestorative sleep, a clinical algorithm showing the pathway from the clinical interview to sleep laboratory investigations is available. However, there is a gap in the services offered by family physicians, other medical specialists, and sleep medicine practitioners. For sleep apnea, the diagnostic process and therapy are established; however, for other sleep disorders such as insomnia, parasomnia, movement disorders, hypersomnia, and circadian rhythm disorders, this is not the case. A basic investigation for sleep disorders is attended cardiorespiratory polysomnography, which is not always essential. There is a network of qualified sleep centers for stationary and ambulatory care, but their work is becoming more difficult under increasing health care economic pressure. Sleep medicine needs a solid structural and financial basis to provide good coverage of high quality health care service. New sleep medicine service centers for ambulatory care with a better network structure linked with other medical specialties and with offers for preventive medicine can serve all patients with sleep disorders over long periods of time.

Effects of optimized heart failure medication on central sleep apnea with Cheyne-Stokes respiration pattern in chronic heart failure with reduced left-ventricular ejection fraction.

Central Sleep Apnea with Cheyne Stokes Respiration (CSA-CSR) is often diagnosed in patients with chronic heart failure (CHF). CSA-CSR displays a periodic breathing pattern with a typical waxing and waning breathing with central sleep apnea phases in between. Optimization of heart failure medication with Angiotensin receptor neprilysin inhibition (ARNi) can effect phenotypic traits of CSA-CSR indicating improvements of both, hemodynamic parameters and central chemosensitivity.

Medico-legal implications of sleep apnoea syndrome: driving license regulations in Europe.

BACKGROUND: Sleep apnoea syndrome (SAS), one of the main medical causes of excessive daytime sleepiness, has been shown to be a risk factor for traffic accidents. Treating SAS results in a normalized rate of traffic accidents. As part of the COST Action B-26, we looked at driving license regulations, and especially at its medical aspects in the European region. METHODS: We obtained data from Transport Authorities in 25 countries (Austria, AT; Belgium, BE; Czech Republic, CZ; Denmark, DK; Estonia, EE; Finland, FI; France, FR; Germany, DE; Greece, GR; Hungary, HU; Ireland, IE; Italy, IT; Lithuania, LT; Luxembourg, LU; Malta, MT; Netherlands, NL; Norway, EC; Poland, PL; Portugal, PT; Slovakia, SK; Slovenia, SI; Spain, ES; Sweden, SE; Switzerland, CH; United Kingdom, UK). RESULTS: Driving license regulations date from 1997 onwards. Excessive daytime sleepiness is mentioned in nine, whereas sleep apnoea syndrome is mentioned in 10 countries. A patient with untreated sleep apnoea is always considered unfit to drive. To recover the driving capacity, seven countries rely on a physician's medical certificate based on symptom control and compliance with therapy, whereas in two countries it is up to the patient to decide (on his doctor's advice) to drive again. Only FR requires a normalized electroencephalography (EEG)-based Maintenance of Wakefulness Test for professional drivers. Rare conditions (e.g., narcolepsy) are considered a driving safety risk more frequently than sleep apnoea syndrome. CONCLUSION: Despite the available scientific evidence, most countries in Europe do not include sleep apnoea syndrome or excessive daytime sleepiness among the specific medical conditions to be considered when judging whether or not a person is fit to drive. A unified European Directive seems desirable.

Snoring noise pollution--the need for objective quantification of annoyance, regulatory guidelines and mandatory therapy for snoring.

Habitual snoring without episodes of apnea or hypoventilation and without respiratory related arousals is considered to be annoying and without any need for treatment. However, studies seem to suggest an enormous psychosocial impact of annoyance for the bed partner. Apart from subjective questionnaires there still exists no generally accepted mode of measurement that can describe snoring objectively. We therefore adapted methods developed for environmental medicine and established a new snore score using psycho-acoustic parameters. For quantification of snoring noise we conducted nocturnal measurements in 19 habitual snorers. Free-field snore sounds were acquired with two low-cost non-contact microphones and transferred to a PC (sampling frequency 11 kHz). The data were recorded, analysed and stored automatically using a MATLAB script. Following the analysis of sound characteristics and levels, the score was computed from relevant parameters containing the rating level (L(R)), maximum level, two percentile levels for frequent maxima (L(5)S; L(1)) and snoring time. The determined values substantially exceeded the prescribed limits defined by WHO noise guidelines, and mainly affected the equivalent continuous sound exposure level, rating level and the immission standard values of brief noise peaks, whose maximum was exceeded by up to 32 dB(A). The Berlin snore score illustrated the objective acoustic annoyance on a scale from 0 to 100. It allows inter-individual comparison and objectifies the need for therapy. The clinical applicability of evaluating the reduction of snoring after surgical therapy is discussed exemplarily. The presented measuring method was found to be suitable for quantifying snoring noise and can be easily integrated into existing polysomnographic applications. In the case of habitual snoring with objective evidence of psychosocially disturbing acoustic annoyance, health fund providers should assume the costs of mandatory medical therapy.

[Are there alternative therapeutical options other than CPAP in the treatment of the obstructive sleep apnea syndrome]. / Gibt es Alternativen zum nCPAP-Verfahren in der Behandlung des obstruktiven Schlafapnoesyndroms?

Many patients with the obstructive sleep apnea syndrome (OSAS) look for alternative conservative or surgical therapies to avoid to be treated with continuous positive airway pressure. In view of the high prevalence and the relevant impairment of the patients lots of methods are offered which promise definitive cure or relevant improvement of OSAS. The working group "Apnea" in the German Society of Sleep Medicine and Research established a task force to evaluate the scientific literature on non-CPAP therapies in the treatment of OSAS according to the standards of evidence-based medicine. This paper summarizes the results of the task force. The data were unsatisfactorily for most of the methods. Sufficient data were available for intraoral appliances (IOA) and the maxillomandibular osteotomy (MMO). IOA's can reduce mild to moderate respiratory disturbances, MMO are efficient in the short and long term but are performed only in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment of OSAS. Most surgical procedures still lack sufficient data according to the criteria of evidence based medicine. Resections of muscular tissue within the soft palate have to be strictly avoided. But even success following gentle soft palate procedures is difficult to predict and often decreases after years. Results in other anatomical regions seem to be more stable over time. Today combined surgeries in the sense of multi-level surgery concepts are of increasing interest in the secondary treatment after failure of nasal ventilation therapy although more data from prospective controlled studies are needed. There is no evidence for any other treatment options.

Exposure to light and darkness and its influence on physiological measures of intensive care unit patients-a systematic literature review.

Sleep-wake patterns are often significantly disturbed in critically ill patients. This disturbance is closely linked to secondary brain dysfunctions in these patients. Sedation not only impairs sleep quality in ICU patients but also has detrimental effects on short- and long-term outcome. In other contexts, light therapy has been proven to be effective in maintaining and resynchronizing circadian rhythmicity in humans. The objective of this systematic review was to analyse studies that investigated the effect of exposure to light or darkness on physiological measures and clinical outcomes of adult ICU patients. Studies were systematically identified by searching electronic bibliographic databases (The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2002) and MEDLINE via PubMed). The search algorithm identified a total of 156 articles, 10 of which were taken into final review. These 10 selected articles included 3 were monocentric RCTs, five prospective cohort studies, one retrospective cohort study, and one manuscript that included a partial systematic review of the literature. Included trials were published between 2007 and 2015. Five of these studies used multiple intervention approaches while four trials used a single intervention approach. Among all studies, 1,278 patients were analysed (489 prospectively). There was a high heterogeneity among the studies in terms of applied intervention and outcome measures. The most frequent methodological limitations were a lack of precise definitions regarding the illuminance and the light spectrum utilised. The analyses indicate that further studies including clearly defined interventions with objective outcome measures, as these are currently lacking, would add significant knowledge to this new field of research.

Feasibility of noise reduction by a modification in ICU environment.

Noise is a proven cause of wakefulness and qualitative sleep disturbance in critically ill patients. A sound pressure level reduction can improve sleep quality, but there are no studies showing the feasibility of such a noise reduction in the intensive care unit (ICU) setting. Considering all available evidence, we redesigned two ICU rooms with the aim of investigating the physiological and clinical impact of a healing environment, including a noise reduction and day-night variations of sound level. Within an experimental design, we recorded 96 h of sound-pressure levels in standard ICU rooms and the modified ICU rooms. In addition, we performed a sound source observation by human observers. Our results show that we reduced A-weighted equivalent sound pressure levels and maximum sound pressure levels with our architectural interventions. During night-time, the modification led to a significant decrease in 50 dB threshold overruns from 65.5% to 39.9% (door side) and from 50% to 10.5% (window side). Sound peaks of more than 60 decibels were significantly reduced from 62.0% to 26.7% (door side) and 59.3% to 30.3% (window side). Time-series analysis of linear trends revealed a significantly more distinct day-night pattern in the modified rooms with lower sound levels during night-times. Observed sound sources during night revealed four times as many talking events in the standard room compared to the modified room. In summary, we show that it is feasible to reduce sound pressure levels using architectural modifications.

Value of bronchial artery embolisation with platinum coils in tumorous pulmonary bleeding.

We performed bronchial artery embolizations (BAE) using platinum coils with Dacron fibres in 30 consecutive patients with haemoptysis due to bronchial carcinoma. The aim of the study was to compare immediate results of bleeding cessation, recurrence and survival rates with a historical control group of 15 patients with tumorous pulmonary bleeding who were treated conservatively (non-BAE-group). Bronchial artery embolisation with platinum coils stopped active bleeding in all patients immediately. Comparing the BAE group and controls the cessation of first time haemoptysis (BAE 100% versus non-BAE 93%) and the rates of bleeding recurrence (BAE 50% versus non-BAE 47%) were similar in either group. In case of recurrent bleeding, repeated BAE led to a definite cessation of pulmonary haemorrhage in every case. In contrast, all patients with recurrent haemoptysis without a repeated BAE (8 patients, 27%) and all patients with bleeding recurrence in the non-BAE group died from pulmonary haemorrhage (8 patients, 53%). The mean survival time of the BAE group was significantly longer compared with the non-BAE group, 139 (range: 1-818) days versus 62 (range: 1-186) days (P<0.05). We conclude that consistent BAE proved beneficial in tumorous pulmonary bleeding, particularly with regard to the permanent arrest of haemorrhage in case of recurrence.

Respiratory arousals in mild obstructive sleep apnea syndrome.

The objective of the study is to identify patients with mild sleep apnea by counting not only apneas and hypopneas, but also mild respiratory events, which do not fulfill apnea or hypopnea criteria, but result in an arousal (Type-R arousal). Arousals related to body movements (Type-M arousal) were separately counted. The influence of nasal continuous positive airway pressure (nCPAP) on respiratory and movement arousals was analyzed. Daytime sleepiness before and after nCPAP and its relationship to arousal types was investigated using the Multiple Sleep Latency Test (MSLT) and a standardised questionnaire. Twenty-two patients with a mean age of 43.6 +/- 9.2 years underwent polysomnographic evaluation on a baseline night, and during three nights with nCPAP. On the baseline night, subjects presented with a mean RDI of 10.5 +/- 7.2/h, an apnea index (AI) of 1.2 +/- 1.5/h, a hypopnea index (HI) of 9.3 +/- 6.6/h, a R index of 5.2 +/- 5.9/h, and a M index of 9.7 +/- 5.6/h. Use of nCPAP lowered the RDI (p < 0.001) and the R index (p < 0.01). Mean sleep latency in the MSLT increased with nCPAP (p < 0.05) and the patient's subjective well being improved (p < 0.01). Correlation analysis revealed a relationship between Type-R arousals and RDI and HI (r = 0.5, p < 0.01) as well as between questionnaire scores and mean sleep latency. The decrease of Type-R indicates the positive effect of nCPAP. Arousal analysis and detection of mild respiratory events associated with arousals are helpful in investigating the sleep structure and in objectifying clinical symptoms and treatment success in patients with mild OSAS.

Circadian reactions to nCPAP treatment.

To determine possible effects of apnea attacks on the spontaneous behavior of the circadian system (body temperature, sleeping behavior, vigilance), 11 patients with obstructive sleep apnea (OSA) were observed before therapy over a 24 h period under a special constant routine (bed-rest study) and again during therapy with nCPAP (nasal continuous positive airway pressure). Clinical indicators (polysomnographical, subjective sleep quality, etc.) indicated successful therapy. During the bed-rest study with nCPAP therapy, the 24 h amplitude of core temperature was found to be greater than the amplitude measured before therapy. Also, therapy decreased sleep disturbances at night and reduced daytime sleeping times. Consequently, the level of subjective vigilance was higher during the daytime during therapy. OSA attacks do not only impair sleep; they disturb the whole circadian system. This may also impair recuperation and sleep. Further research should test whether measurements of the spontaneous circadian system could have additional diagnostic value and whether the stabilization of the circadian system has therapeutic value.

Severe prosthetic valve-related endocarditis following dental scaling: a case report.

There is a well-known correlation between surgical dental procedures and the risk of bacterial endocarditis in patients with prosthetic cardiac valves. A 43-year-old patient with prosthetic aortic and mitral valves, which already have been removed twice because of endocarditis, suffered from a prosthetic valve-related endocarditis following dental scaling, which was performed without any antibiotic prophylaxis. Invasive medical procedures in patients with prosthetic heart valves may lead to endocarditis. Antibiotic prophylaxis is recommended even for dental procedures considered to be "harmless," such as dental scaling.

[Complications of nasal CPAP therapy. Consequences for general practice]. / Komplikationen bei der nasalen CPAP-Therapie. Konsequenzen für die Praxis.

BACKGROUND: The prevalence of the obstructive sleep apnea syndrome is about 5% in the entire population. The amount of treatment-indications grows for this particular sleep-related breathing disorder due to the increasing usage of diagnostic screening tests. In most cases, the positive-pressure ventilation, PPV (nCPAP, nBiPAP) is considered as a highly effective form of treatment, in comparison to other treating methods. The residential polysomnographic supervised adjustment of the treatment is optimally applied to most of the patients. Due to the increasing number of the treated patients, the reports about the appearance of short-termed side effects during the adjustment of the PPV become more frequent. PATIENTS AND RESULTS: We report on 9 patients who showed complications during the initial stage of treatment. The most common one, during the nCPAP-therapy, was the increase of central apneas. Because of this complication, a rapid optimization of the respiratory pressure or a change to a nBiPAP-therapy was necessary in 5 of the patients. 2 of the patients showed cardiac arrhythmias, some of which were severe. One patient produced a remarkable central hypoventilation during the initial phase of a nCPAP-therapy. The nBiPAP-titration combined with right-heart-catheter monitoring could demonstrate in another patient a possible cardiac decompensation through an increased ventilatory pressure. CONCLUSION: The risk of a positive-pressure ventilation is higher in patients with accompanying cardiac, pulmonary, neuropsychiatric and/or otorhinolaryngologic disorders. Considering the various predisposing factors of the patients we suggest an intensive apparative monitoring as well as stuff-supervision during the introduction to a respiratory treatment. If complications appear, a rapid improvement of the ventilatory pressure or a change to another respiratory treatment is indicated.