Nasal cannula use during polysomnography in children aged under three with suspected sleep apnea.

OBJECTIVE: Early diagnosis of obstructive sleep apnea (OSA) in children is important. The use of a nasal cannula as an airflow sensor during polysomnography has not been evaluated in younger children. The study aims to evaluate the use of nasal cannula in detecting respiratory events in children under three with suspected OSA during daytime nap studies. METHODS: A total of 185 patients were prospectively included. Respiratory events were scored using nasal cannula alone, thermistor alone, and both methods simultaneously as the airflow sensor. Agreement and diagnostic accuracy were assessed. RESULTS: One hundred and seventy-two children were finally analyzed and 110 (64.0%) presented OSA. Total sleep time with an uninterpretable signal was longer with the nasal cannula than with the thermistor (17.8% vs 1.9%; p < 0.001), and was associated with poor sensor tolerance and adenotonsillar hypertrophy. In the estimation of the apnea-hypopnea index, the nasal cannula showed lower agreement than the thermistor with the joint use of the two sensors (intraclass correlation coefficient: 0.79 vs 0.996 with thermistor). Compared with the thermistor, the nasal cannula presented lower sensitivity for detecting OSA (82.7% vs 95.5%) and a lower negative predictive value (76.5% vs 92.4%). Overall, fewer children were diagnosed with severe OSA with the nasal cannula (19.8% vs 30.8% with the thermistor, and 32.6% with both). CONCLUSIONS: In children under the age of three, the ability of the nasal cannula to detect obstructive events was relatively low. Therefore, other non-invasive measurements for identifying respiratory events during sleep may be of additional value.

Predictors of respiratory complications in patients with C5-T5 spinal cord injuries.

STUDY DESIGN: Retrospective chart audit. OBJECTIVES: Describing the respiratory complications and their predictive factors in patients with acute traumatic spinal cord injuries at C5-T5 level during the initial hospitalization. SETTING: Hospital Vall d'Hebron, Barcelona. METHODS: Data from patients admitted in a reference unit with acute traumatic injuries involving levels C5-T5. Respiratory complications were defined as: acute respiratory failure, respiratory infection, atelectasis, non-hemothorax pleural effusion, pulmonary embolism or haemoptysis. Candidate predictors of these complications were demographic data, comorbidity, smoking, history of respiratory disease, the spinal cord injury characteristics (level and ASIA Impairment Scale) and thoracic trauma. A logistic regression model was created to determine associations between potential predictors and respiratory complications. RESULTS: We studied 174 patients with an age of 47.9 (19.7) years, mostly men (87%), with low comorbidity. Coexistent thoracic trauma was found in 24 (19%) patients with cervical and 35 (75%) with thoracic injuries (p < 0.001). Respiratory complications were frequent (53%) and were associated to longer hospital stay: 83.1 (61.3) and 45.3 (28.1) days in patients with and without respiratory complications (p < 0.001). The strongest predictors of respiratory complications were: previous respiratory disease (OR 5.4, 95% CI: 1.5-19.2), complete motor function impairment (AIS A-B) (OR 4.7, 95% CI: 2.4-9.5) and concurrent chest trauma (OR 3.73, 95% CI: 1.8-7.9). CONCLUSIONS: Respiratory complications are common in traumatic spinal cord injuries between C5-T5. We identified previous respiratory disease, complete motor function impairment and the coexistence of thoracic trauma as predictors of respiratory complications. Identification of patients at risk might help clinicians to implement preventive strategies.

Primary care and sleep unit agreement in management decisions for sleep apnea: a prospective study in Spain.

STUDY OBJECTIVES: Involvement of primary care teams in the care of patients with OSA is a focus of interest. The study objective was to compare diagnostic and therapeutic agreement between decisions taken by primary care professionals and sleep unit specialists. METHODS: This was a prospective multicenter study conducted at primary care and specialized care centers in the urban area of Barcelona, Spain. Men and women aged 18-75 years who visited the participating primary care centers for any reason were recruited. Both primary care physicians and sleep specialists made a diagnostic and therapeutic decision with clinical data and results of a home sleep apnea test. All patients were finally assessed with respiratory polygraphy or polysomnography as a gold-standard test. RESULTS: A total of 229 patients underwent a home sleep apnea test and were evaluated at the primary care centers and the sleep units. Diagnostic agreement using the same tools and excluding indeterminate decisions was 69.8% (Cohen's kappa = 0.64; 95% confidence interval, 0.56-0.72). Agreement for therapeutic decisions (PAP vs conservative treatment) was obtained in 82.5% of patients (Cohen's kappa = 0.62; 95% confidence interval, 0.51-0.73), increasing to 92.5% (Cohen's kappa = 0.49, 95% confidence interval, 0.40-0.58) when indeterminate options were excluded. As compared with the final therapeutic decisions made at the sleep unit with respiratory polygraphy/polysomnography, primary care physicians agreed regarding 83.3% (Cohen's kappa = 0.62; 95% confidence interval, 0.49-0.74) of patients. CONCLUSIONS: Primary care professionals may assume an important role in the management of OSA in coordination with sleep centers, identifying patients who require specific treatment and should be referred to specialized care. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979; Identifier: NCT02591979.

Coordinated program between primary care and sleep unit for the management of obstructive sleep apnea.

The purpose of this study is to develop and validate a work model in the primary health-care setting for identifying patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) based on clinical variables and an ambulatory sleep monitoring study. After screening, patients with mild-moderate OSAHS could be managed by primary care physicians, whereas those identified with severe OSAHS would be referred to specialists from sleep units for starting specific treatment. The proposed model does not move the entire health-care process to a generally overburdened primary care level and favors the coordinated work and the necessary flexibility to adapt the model to challenges and perspectives of OSAHS.

Clinical Practice Guideline recommendations on examination of the upper airway for adults with suspected obstructive sleep apnoea-hypopnoea syndrome. / Recomendaciones de la Guía de Práctica Clínica de la exploración de la vía aérea superior para pacientes adultos con sospecha de síndrome de apnea-hipoapnea obstructiva del sueño (versión reducida).

In November 2014 the Spanish Society of Otolaryngology, the Spanish Sleep Society and the Spanish Society of Maxillofacial Surgery proposed and endorsed the development of a Clinical Practice Guideline on the physical examination of the upper airway in patients with obstructive sleep apnoea. The Guideline strictly followed the recommendations of the manual for the preparation of clinical practice guidelines of the National Health System 2007 and 2009 and the manual of the Scottish Intercollegiate Guidelines Network (SIGN) 2015. The final document could be highly useful for the purposes that were originally proposed: to act as a reference to unify the regions that should be explored in patients with obstructive sleep apnoea-hypopnoea syndrome, the type of examination and how to grade it, and specific to all the care areas to which these patients have access. The conclusions and recommendations are based on a thorough and up-to-date review of the literature with a high level of evidence, as well as the experience and knowledge demonstrated by all the members of the drafting group. This group was formed bearing in mind at all times the transversality of the project, and, therefore, specialists from all the involved areas participated (maxillofacial surgery, family medicine, pneumology, clinical neurophysiology, odontology and otolaryngology). The external reviewers of the final text were selected along the same lines.

Effect of continuous positive airway pressure and upper airway surgery on exhaled breath condensate and serum biomarkers in patients with sleep apnea.

INTRODUCTION: Studies on inflammation biomarkers in serum and in exhaled breath condensate (EBC) in obstructive sleep apnea (OSA) have shown conflicting results. The objective of this study is to assess EBC and serum biomarkers in OSA patients at baseline and after continuous positive airway pressure (CPAP) or upper airway surgery (UAS). PATIENTS AND METHODS: Nine OSA patients referred for UAS were matched for anthropometric characteristics and apnea-hypopnea index with 20 patients receiving CPAP. pH, nitrite (NO2(-)), nitrate and interleukin 6 in EBC and NO2(-), nitrate, leukotriene B4 and interleukin 6 in serum were determined. EBC and serum samples were collected at baseline and 3 months after CPAP or UAS. RESULTS: Patients' mean body mass index was 30 (range 24.9-40) kg/m(2). EBC biomarker levels at baseline were within normal range and did not differ significantly after CPAP or UAS. No significant changes were observed in the serum concentration of the biomarkers determined after CPAP but the serum concentration of NO2(-) increased significantly at 3 months after UAS (P=.0078). CONCLUSION: In mildly obese OSA patients, EBC biomarkers of inflammation or oxidative stress were normal at baseline and remained unchanged 3 months after UAS or CPAP. Although UAS was not effective in terms of reducing OSA severity, it was associated with an increase in serum NO2(-).

[Sleep-apnea syndrome, mechanical ventilation and critical care in Archivos de Bronconeumología (December 2009-December 2010)]. / El síndrome de apnea del sueño, la ventilación mecánica y los cuidados críticos en Archivos de Bronconeumología (diciembre 2009-diciembre 2010).

The present study aims to review all the major articles on respiratory sleep disorders, mechanical ventilation, and respiratory critical care published in the last year in Archivos de bronconeumología. Between December 2009 and November 2010, 15 studies on these topics were published in Archivos de bronconeumología. Ten of these studies dealt with respiratory sleep disorders, consisting of six original articles, one special article, one review article, one letter to the editor and one supplement on chronic obstructive pulmonary disease and its association with sleep apneas. Five articles were published on non-invasive mechanical ventilation: one editorial, one special article, one article in a supplement and two original articles. As in previous years, there was a marked difference in the number of articles published on non-invasive mechanical ventilation and sleep-apnea syndrome, with a greater number of articles being published on the latter. Although some articles highlight the importance of the place where ventilation is commenced, no study specifically dealing with intermediate care units was published in Archivos de bronconeumología in 2010. This absence could be interpreted as a result of the low implantation of this type of unit in Spain, contrasting with the high activity undertaken in this field by pneumology services.

Insulin resistance is related to impaired lung function in morbidly obese women: a case-control study.

BACKGROUND: There is growing evidence suggesting an association between type 2 diabetes and impaired pulmonary function. However, the role of insulin resistance itself remains to be elucidated. The aim of the study is to determine whether obese patients with insulin resistance without diabetes have reduced pulmonary function in comparison with non-diabetic obese subjects without insulin resistance. METHODS: Seventy-five morbidly obese non-diabetic women [50 with an insulin resistance index (homeostasis model assessment, HOMA-IR) ≥ 3.8-cases-and 25 with HOMA-IR < 3.8-controls-] with a history of not smoking and without prior cardiovascular or respiratory disease were prospectively recruited in the outpatient Obesity Unit of a university hospital. Both groups were closely matched by age, body mass index and waist circumference. Pulmonary function test included a forced spirometry and static pulmonary volume measurements. RESULTS: Patients with HOMA-IR ≥ 3.8 showed lower forced expiratory volume at 1 s [mean difference - 7.6% of predicted (95% confidence interval - 14.2 to - 0.9); p = 0.025], and also a lower maximum midexpiratory flow [mean difference - 16.4% of predicted (95% confidence interval - 30.9 to - 2.0); p = 0.026] in comparison with those with HOMA-IR < 3.8. Significant negative correlations between HOMA-IR and forced expiratory volume at 1 s, maximum midexpiratory flow and forced vital capacity were detected. Multiple linear regression analysis showed that HOMA-IR (ß = - 0.323, p = 0.002) and total lung capacity (ß = 0.468, p < 0.001) were independently associated with forced expiratory volume at 1 s (r(2) = 0.358). CONCLUSIONS: Insulin resistance is related to respiratory function impairment in morbidly obese women. Our results strongly suggest that the metabolic pathways related to insulin resistance are crucial in initiating lung abnormalities previously described in type 2 diabetic patients. Copyright © 2010 John Wiley & Sons, Ltd.

Asymptomatic sleep-disordered breathing in premenopausal women awaiting bariatric surgery.

BACKGROUND: There is a strong association between sleep-disordered breathing (SDB) and obesity. However, there are no studies addressed to determining the prevalence of SDB in morbidly obese premenopausal women, the most frequent group of patients requiring bariatric surgery. To evaluate the prevalence and characteristics of sleep apnea-hypopnea syndrome (SAHS) and obesity hypoventilation syndrome (OHS) in morbidly obese pre-menopausal women included in a program of bariatric surgery. METHODS: A total of 88 consecutive morbidly obese pre-menopausal women (38.3 +/- 8.1 years, body mass index (BMI) 48.0 +/- 6.7 kg/m(2)) being evaluated for bariatric surgery at the outpatient obesity unit of a university hospital were prospectively recruited. SDB examinations included a non-attended respiratory polygraphy, pulmonary function testing, and an awake arterial gasometry. SAHS was defined as an apnea-hypopnea index (AHI) >or=10 events per hour and patients were divided in non-SAHS (AHI <10), mild (AHI: 10-20), moderate (AHI: 21-30), and severe (AHI >30). OHS was defined as the presence of hypercapnia (PaCO(2) > 45). Somnolence was evaluated using the Epworth sleepiness scale. RESULTS: A total of 66 (75.0%) obese patients had SAHS: 25 (28.4%) mild, 14 (15.9%) moderate, and 27 (30.6%) severe. Seven (7.9%) obese patients presented OHS. Excessive daily somnolence was recorded in only 11 (16.6%) of the obese women with SAHS. In multiple regression analysis, BMI was the only variable independently associated with SAHS severity. CONCLUSIONS: Due to its high prevalence and severity, it should be recommended to investigate SDB in all morbidly obese pre-menopausal women awaiting bariatric surgery even in the absence of excessive daytime sleepiness.

Diabetes is an independent risk factor for severe nocturnal hypoxemia in obese patients. A case-control study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and obesity have become two of the main threats to public health in the Western world. In addition, obesity is the most important determinant of the sleep apnea-hypopnea syndrome (SAHS), a condition that adversely affects glucose metabolism. However, it is unknown whether patients with diabetes have more severe SAHS than non-diabetic subjects. The aim of this cross-sectional case-control study was to evaluate whether obese patients with T2DM are more prone to severe SAHS than obese non-diabetic subjects. METHODOLOGY/PRINCIPAL FINDINGS: Thirty obese T2DM and 60 non-diabetic women closely matched by age, body mass index, waist circumference, and smoking status were recruited from the outpatient Obesity Unit of a university hospital. The exclusion criteria included chronic respiratory disease, smoking habit, neuromuscular and cerebrovascular disease, alcohol abuse, use of sedatives, and pregnancy. Examinations included a non-attended respiratory polygraphy, pulmonary function testing, and an awake arterial gasometry. Oxygen saturation measures included the percentage of time spent at saturations below 90% (CT90). A high prevalence of SAHS was found in both groups (T2DM:80%, nondiabetic:78.3%). No differences in the number of sleep apnea-hypopnea events between diabetic and non-diabetic patients were observed. However, in diabetic patients, a significantly increase in the CT90 was detected (20.2+/-30.2% vs. 6.8+/-13,5%; p = 0.027). In addition, residual volume (RV) was significantly higher in T2DM (percentage of predicted: 79.7+/-18.1 vs. 100.1+/-22.8; p<0.001). Multiple linear regression analyses showed that T2DM but not RV was independently associated with CT90. CONCLUSIONS/SIGNIFICANCE: T2DM adversely affects breathing during sleep, becoming an independent risk factor for severe nocturnal hypoxemia in obese patients. Given that SAHS is a risk factor of cardiovascular disease, the screening for SAHS in T2DM patients seems mandatory.

Delayed cutaneous hypersensitivity tests and lymphopenia as activity markers in sarcoidosis.

STUDY OBJECTIVES: To evaluate new and already known biological markers of activity in patients with sarcoidosis. DESIGN: A 10-year prospective clinical evaluation, including a battery of delayed cutaneous hypersensitivity tests (DCHTs) and other markers of activity. SETTING: Outpatient department of a university teaching hospital. PATIENTS: Forty patients with biopsy-proven sarcoidosis were prospectively evaluated every 6 months. In this study, only the visits that fulfilled the situation of active period (AcP) or of asymptomatic period (AsP) were taken into account. Twenty-one visits were considered to be in the AcP, and 26 were considered to be in the AsP. Seven patients were studied both in the AcP and the AsP. INTERVENTIONS: DCHTs and blood sample extraction every 6 months. MEASUREMENTS AND RESULTS: The mean diameter of the cutaneous wheal for each antigen (AG) was lower in the AcP group than in the AsP group (candidine, p < 0.0001; tuberculin, p < 0.0009; trichophytin, p < 0.02; streptokinase-streptodornase, p < 0.001). Also, the mean (+/- SD) diameter for the four AGs taken together was lower in the AcP group (2.3 +/- 4.2 mm) than in the AsP group (16.8 +/- 9.3 mm; p < 0.0001). The mean serum angiotensin-converting enzyme (S-ACE) value was higher in the AcP group than in the AsP group (p < 0.02). A low lymphocyte count and a percentage of the lymphocyte count (< 20%) also were detected more frequently in the AcP group than in the AsP group (p < 0.02 and p < 0.0001, respectively). CONCLUSIONS: DCHTs appear to be a simple, reliable, and easily performed marker of inflammatory activity in sarcoidosis patients. Furthermore, serum total and differential lymphocyte count and the S-ACE level proved to be useful inflammatory markers in this study.