The Prognostic Role of Obstructive Sleep Apnea at the Onset of Amyotrophic Lateral Sclerosis.

BACKGROUND/OBJECTIVE: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by the progressive loss of central and peripheral motor neurons. Some studies have found discordant data in the presence of sleep apnea in ALS patients. An obstructive component also occurs with upper airways hypotonia and muscle weakness that may result in an excessive reduction of airway lumen, leading to obstructive sleep apnea (OSA). The aim of this study was to assess the role of obstructive apneic events at disease onset in the ALS prognosis. METHODS: A longitudinal retrospective study was conducted on 42 clinically diagnosed ALS patients. The study population was divided into 2 groups according to their obstructive apnea/hypopnea index (AHIo): group 1 consisted of 20 patients with an AHIo ≥5 and group 2 consisted of 22 patients with an AHIo <5. Both groups were compared with regard to demographic, polygraphic, and respiratory function parameters as well as ALS characteristics (bulbar onset, time between onset and first check-up, time between diagnosis and first check-up, time between first check-up and death or tracheostomy). RESULTS: The mean survival in ALS patients with an AHIo ≥5 was significantly shorter than in ALS without OSA (p = 0.0237). The sniff nasal inspiratory pressure test was significantly correlated with AHIo, time of oxyhemoglobin saturation below 90% and the oxyhemoglobin desaturation index (p < 0.0001). CONCLUSIONS: Our study highlights the importance of an early diagnosis of OSA in ALS patients, allowing the identification of ALS patients with an OSA phenotype (AHIo ≥5), who are characterized by a worse prognosis.

Atrial flutter regression in HIV-associated pulmonary arterial hypertension after treatment with bosentan.

Pulmonary arterial hypertension (PAH) is a rare condition characterized by an increase in pulmonary arterial resistance leading to right heart failure and death. Arrhythmias are a growing problem in PAH; therefore, maintenance of sinus rhythm is considered to be an important treatment aim in these patients. We described the case of a 46-year-old woman with HIV-associated pulmonary arterial hypertension  who developed atrial flutter. After treatment with bosentan, it was observed a significant improvement in clinical and haemodynamic parameters. In addition, the AFL, which had previously persisted to both antiarrhythmic drug therapy and electrical stimulation, and had recurred after transthoracic electrical cardioversion, disappeared  in absence of any antiarrhythmic drug. Though the precise factors responsible for supraventricular arrhythmogenesis are still largely obscure, it is likely that initiation and maintenance of AFL may depend on all the conditions that can lead to increase in right atrial pressure, size, and wall stress, such as PAH. In our case, bosentan reduced both mean pulmonary artery pressure (mPAP) value and right heart chambers pressures. Therefore, it is conceivable that with the anatomical substrate needed for the maintenance of AFL being disappeared, sinus rhythm was restored.

Correlation between inflammatory markers of atherosclerosis and carotid intima-media thickness in Obstructive Sleep Apnea.

Obstructive Sleep Apnea (OSA) is a sleep-related breathing disorder associated with the development of cardiovascular diseases and atherosclerosis. Systemic inflammation plays an important role in the development of cardiovascular complications in OSA patients. The aim of the study was to evaluate the relationship between carotid intima-media thickness (cIMT) and inflammatory markers plasma levels in OSA patients. We enrolled 80 OSA patients and 40 controls matched for age and body mass index (BMI). The presence and severity of sleep apnea was determined by in-laboratory portable monitoring (PM). Demographic data, blood pressure, heart rate, and cIMT were measured. High-sensitive C-Reactive Protein (hsCRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α and pentraxin (PTX)-3 serum concentrations were detected. cIMT was higher in OSA patients than controls (0.89 ± 0.13 mm vs. 0.65 ± 0.1 mm, p < 0.01). Moderate-severe OSA patients (0.95 ± 0.09 mm) had significantly increased cIMT than mild OSA (0.76 ± 0.1 mm; p < 0.01) and control (0.65 ± 0.1 mm; p < 0.01). hsCRP, IL-6, TNF-α, and PTX-3 in patients with OSA (1.67 ± 0.66 mg/L, 2.86 ± 1.39 pg/mL, 20.09 ± 5.39 pg/mL, 2.1 ± 0.59 ng/mL, respectively) were significantly higher than in controls (1.08 ± 0.53 mg/L, p < 0.01; 1.5 ± 0.67 pg/mL, p < 0.01; 12.53 ± 3.48 pg/mL, p < 0.01; 1.45 ± 0.41 ng/mL, p < 0.01, respectively). Carotid IMT was significantly correlated to CRP (r = 0.44; p < 0.01), IL-6 (r = 0.42; p < 0.01), TNF-α (r = 0.53; p < 0.01), and PTX-3 (r = 0.49; p < 0.01). OSA patients showed increased cIMT, CRP, IL-6, TNF-α, and PTX-3 levels. Inflammatory markers levels are correlated to cIMT in OSA patients.

Titration effectiveness of two autoadjustable continuous positive airway pressure devices driven by different algorithms in patients with obstructive sleep apnoea.

BACKGROUND AND OBJECTIVE: Nocturnal application of continuous positive airway pressure (CPAP) is the standard treatment for patients with obstructive sleep apnoea (OSA). Determination of the therapeutic pressure (CPAP titration) is usually performed by a technician in the sleep laboratory during attended polysomnography. One possible alternative to manual titration is automated titration. Indeed, during the last 15 years, devices have been developed that deliver autoadjustable CPAP (A-CPAP). The aim of the present study was to compare the titration effectiveness of two A-CPAP devices using different flow-based algorithms in patients with OSA. METHODS: This is a randomized study; 79 subjects underwent two consecutive unattended home A-CPAP titration nights with two different devices (Autoset Resmed; Remstar Auto Respironics); during the third and the fourth night, patients underwent portable monitoring in the sleep laboratory during fixed CPAP at the A-CPAP recommended pressure. RESULTS: Bland Altman plots showed good agreement between the recommended median and maximal pressure levels obtained with the two devices. A significant improvement was observed in all the sleep parameters by both A-CPAP machines to a similar degree. CONCLUSIONS: It was observed that the two A-CPAP devices using different algorithms are equally effective in initial titration of CPAP.

Recurrent pulmonary embolism due to echinococcosis secondary to hepatic surgery for hydatid cysts.

We describe the case of a 53-year-old man with recurrent pulmonary embolism due to intra-arterial cysts from Echinococcus. Both the patient's medical history and the computed tomographic (CT) scan abnormalities led to the diagnosis. The CT scan, performed during hospitalization in our ward, showed cystic masses in the left main pulmonary artery and in the descending branch of the right pulmonary artery. Within cystic masses, thin septa were visible, giving a chambered appearance, which was suggestive of a group of daughter cysts. In the past, our patient underwent multiple operations for recurring echinococcal cysts of the liver. After the last intervention, 4 years earlier, his postoperative course was complicated by pulmonary embolism: a CT scan showed a filling defect in the descending branch of the right pulmonary artery, which was caused by the same cystic mass as 4 years later, although smaller. This mass, not properly treated, increased in diameter. Moreover, after 4 years, there has been a new episode of embolism, which involved the left main pulmonary artery. This is the first case in which there are repeated episodes of pulmonary embolism echinococcosis after hepatic surgery for removal of hydatid cysts.

Using PaCO2 values to grade obesity-hypoventilation syndrome severity: a retrospective study.

BACKGROUND: To date, an important aspect that has still not been clarified is the assessment of OHS severity. The purpose of this retrospective study was to evaluate whether grading OHS severity according to PaCO2 values may be useful in order to provide a more definite characterization and targeted management of patients. In this regard, baseline anthropometric and sleep polygraphic characteristics, treatment options, and follow up outcomes, were compared between OHS patients with different degree of severity (as assessed according to PaCO2 values). METHODS: Patients were classified into three groups, according to PaCO2 values: 1) mild (46 mmHg ≤ PaCO2 ≤ 50 mmHg), moderate (51 mmHg ≤ PaCO2 ≤ 55 mmHg), severe (PaCO2 ≥ 56 mmHg). Therefore, differences among the groups in terms of baseline anthropometric, and sleep polygraphic characteristics, treatment modalities and follow up outcomes were retrospectively evaluated. RESULTS: Patients with more severe degree of hypercapnia were assessed to have increased BMI and bicarbonate levels, worse diurnal and nocturnal hypoxemia, and a more severe impairment in pulmonary mechanics compared to milder OHS. CPAP responders rate significantly decreased from mild to severe OHS. After follow up, daytime sleepiness (as measure by the ESS), PaO2, and PaCO2 significantly improved with PAP therapy in all three groups. DISCUSSION AND CONCLUSIONS: Classification of OHS severity according to PaCO2 levels may be useful to provide a more defined characterization and, consequently, a more targeted management of OHS patients. Further studies are needed to confirm our findings.

Obstructive Sleep Apnea, Hypertension, and Their Additive Effects on Atherosclerosis.

Background and Aims. It is widely accepted that obstructive sleep apnea (OSA) is independently associated with atherosclerosis. Similar to OSA, hypertension (HTN) is a condition associated with atherosclerosis. However, to date, the impact of the simultaneous presence of OSA and HTN on the risk of atherosclerosis has not been extensively studied. The aim of this study was to evaluate the consequences of the coexistence of OSA and HTN on carotid intima-media thickness (IMT) and on inflammatory markers of atherosclerosis (such as interleukin- [IL-] 6 and pentraxin- [PTX-] 3). Methods. The study design allowed us to define 4 groups: (1) controls (n = 30); (2) OSA patients without HTN (n = 30); (3) HTN patients without OSA (n = 30); (4) patients with OSA and HTN (n = 30). In the morning after portable monitoring (between 7 am and 8 am), blood samples were collected, and carotid IMT was measured. Results. Carotid IMT, IL-6, and PTX-3 in OSA normotensive patients and in non-OSA HTN subjects were significantly higher compared to control subjects; in addition, in OSA hypertensive patients they were significantly increased compared to OSA normotensive, non-OSA HTN, or control subjects. Conclusions. OSA and HTN have an additive role in the progression of carotid atherosclerosis and in blood levels of inflammatory markers for atherosclerosis, such as interleukin-6 and pentraxin-3.

Polysomnograph chart view by patients: a new educational strategy to improve CPAP adherence in sleep apnea therapy.

BACKGROUND: CPAP is currently the treatment of choice for obstructive sleep apnea syndrome, but therapy adherence is poor. Many educational trials have been proposed to increase CPAP adherence. We tested the hypothesis that polysomnograph chart viewing by patients would improve CPAP adherence. METHODS: A controlled parallel group study was performed with 206 newly diagnosed obstructive sleep apnea syndrome patients, randomized into 2 groups (n = 103 each): standard support group, and educational support group. Each educational support group subject viewed 2 consecutive polysomnograms on the computer screen: the first recorded during a standard diagnostic overnight polysomnography, and the second during a full-night polysomnography with nasal CPAP. The subject's attention was drawn only to the flow and oxyhemoglobin saturation curves. Clinical outcomes were assessed via polysomnography at CPAP initiation and after 1, 3, and 12 months. RESULTS: After 12 months of CPAP, 76% of the educational support group and 52% of the standard support group returned for a follow-up visit (P < .001). Statistical significance had already been reached after 1 and 3 months. Moreover, CPAP use (measured as hours of use per night) was higher in the educational support group at each control visit. CONCLUSIONS: Polysomnograph chart viewing by obstructive sleep apnea patients can increase CPAP adherence, as evaluated by rate of return for the follow-up visit and mean nightly CPAP use.

The Epworth Sleepiness Scale: conventional self vs physician administration.

BACKGROUND: The Epworth Sleepiness Scale (ESS) is a simple, self-administered questionnaire that provides a measurement of the subject's level of daytime sleepiness, and is widely used for patients with obstructive sleep apnea (OSA). Some works undermined its accuracy. The aim of this study was to compare self-administered ESS scores to physician-administered scores in a sample of patients with suspicion of OSA. METHODS: Patients were randomly divided into two groups: group 1, or the self-administered group (n = 113); and group 2, or the physician-administered group (n = 112). Patients in group 1 were asked to complete the ESS in the traditional way; in group 2, the ESS was administered by a sleep-medicine physician. Subjects in both groups underwent diagnostic in-laboratory portable monitoring (PM) within 1 week's time. RESULTS: The percentage of questionnaires properly completed was significantly different between groups: 77% (87 of 113) in the group 1 vs 100% (112 of 112) in the group 2 (P = .00). Scores obtained when a physician administered the questionnaire (ESSp) were higher than those when the ESS was self administered (ESSs) (ESSp:12.09 ± 4.1 vs ESSs:10.37 ± 5.49; P = .01). The ESSp was more highly correlated with apnea-hypopnea index and oxygen desaturation index than the ESSs. CONCLUSIONS: Our results lead us to consider the physician-administered ESS to be more accurate than the traditional ESS; thus, our suggestion is to validate this new method of administration.

Home unattended portable monitoring and automatic CPAP titration in patients with high risk for moderate to severe obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea is a disorder characterized by recurrent obstruction of the upper airways during sleep. The high prevalence of this disease led to proposed new strategies based on the home evaluation and management of patients. OBJECTIVE: To compare home unattended portable monitoring and automatic CPAP titration with attended in-laboratory analysis, in a sample of patients with high risk for moderate to severe obstructive sleep apnea. METHODS: We enrolled 131 subjects, who were randomly divided into 2 groups: the home group (n = 66) was diagnosed and titrated at home; the laboratory group (n = 65) was analyzed in the sleep laboratory of our hospital. Diagnostic evaluations were carried out with portable monitoring at home, and with polysomnography in the sleep laboratory. Titration of CPAP was performed with the same automatic CPAP device in both groups. RESULTS: At the end of the study, 13 (19%) subjects had dropped out of the home group, and 9 (14%) of the laboratory group (P = .50). There were no significant differences among groups in both baseline and with-CPAP values of apnea-hypopnea index, oxygen desaturation index, and total sleep time with SpO2 below 90%. In the home group, the therapeutic pressure values reached at the end of each unattended home titration night were similar. CONCLUSIONS: A home diagnosis and titration approach should be considered in a subset of patients with obstructive sleep apnea. A single unattended titration night is sufficient to determine the therapeutic pressure.

Is there a correlation between OSAS duration/severity and carotid intima-media thickness?

BACKGROUND: Obstructive Sleep Apnea Syndrome (OSAS) is a common airways disease recognized as an independent cardiovascular risk factor. It is often associated with obesity, diabetes and dyslipidemia. Its pathophysiological consequences (hypoxia, hypercapnia, micro-arousals, sympathetic hyperactivity, oxidative stress, systemic inflammation and hyper-coagulability) are implicated in the development of hypertension, endothelial dysfunction and higher intima-media thickness (IMT) values, all elements known to lead to atherosclerosis. The study aim was to demonstrate a relationship between OSAS duration and IMT values and to confirm how OSAS severity could influence IMT (a marker of atherosclerosis). METHODS: We enrolled 156 patients (125 men, mean age: 60 ± 12 years) affected by OSAS of different severity: 111 (71%) were in CPAP therapy; some of the population were also affected by hypertension [102 (65%)], dyslipidemia [52 (33%)] and diabetes [38 (24%)]. Patients underwent evaluation of carotid artery IMT and answered a questionnaire investigating the time of onset (confirmed by a person aware of the patient's previous sleeping habits) and the duration of the disease. RESULTS: We found a statistically significant higher IMT value in patients with longer-lasting disease (OSAS duration in IMT < 0.9 mm: 120 (60-192) months versus OSAS duration in IMT ≥ 0.9 mm: 200 (120-310) months; p < 0.001). OSAS severity is positively related to IMT values. We found a positive relationship between IMT and OSAS duration [r = 0.34; p < 0.001] and between AHI and IMT [r = 0.51; p < 0.001]. CONCLUSIONS: Our study shows that the duration of OSAS and its severity are important factor related with higher values of IMT and hence with a higher risk of atherosclerosis.