Comparing CPAP masks during initial titration for Obstructive Sleep Apnea Syndrome: one-year experience

Abstract Objective: Continuous Positive Airway Pressure (CPAP) is the gold standard treatment for OSA. A wide variety of masks are used during CPAP therapy. The aim of the study is to compare polysomnography outcomes during titration for different types of masks (oronasal, nasal and pillow) and assess the impact on PAP titration. Methods: We retrospectively analyzed all CPAP titration polysomnography for one year. Anthropometric data and baseline apnea severity were documented. Results: A total of 497 patients were evaluated. Nasal masks were used in 82.3% (n = 409), pillow in 14.1% (n = 70) and oronasal in 3.6% (n = 18). There was no difference according to body mass index and baseline apnea-hypopnea index among the groups. The oronasal group was older and had higher titrated CPAP pressure, higher residual apnea-hypopnea index, lower sleep efficiency, more superficial N1 sleep and longer wake time after sleep onset. All other polysomnography outcomes were similar among the groups. The mean CPAP level was 11.6 ± 2.1 cm H2O for the oronasal mask, 10.1 ± 2.1 cm H2O for the nasal mask and 9.8 ± 2.2 cm H2O for the pillow. The residual apnea-hypopnea index was 10.4 ± 7.9 for the oronasal mask, 5.49 ± 5.34 events/h for the nasal mask and 4.98 ± 5.48 events/h for the pillow. The baseline apnea-hypopnea index was correlated with of a higher CPAP pressure for all the groups (p< 0.001 for the nasal group, p = 0.001 for the pillow group and p = 0.049 for the oronasal group). Body mass index and residual AHI were correlated with of a higher CPAP pressure for the nasal and pillow groups only (p < 0.001). Conclusion: The interface can have a significant impact on the effectiveness of PAP titration. Patients with oronasal masks have higher CPAP pressure, higher residual apnea-hypopnea index, lower sleep efficiency and higher wake time after sleep onset. Oronasal masks should not be recommended as the first choice for apnea patients. Level of evidence: Level 3.

Impact of CPAP treatment for a short period in moderate-to-severe OSAS patients: a randomized double-blind clinical trial / Impacto do tratamento com CPAP por um curto período em pacientes com SAOS moderada a grave: um estudo clínico duplo-cego randomizado

Abstract Introduction: Obesity is the most frequent reversible agravating factor of obstructive sleep apnea syndrome, with physical activity very important for its control. Continuous positive air pressure during sleep is the ‟gold standard" treatment for obstructive sleep apnea syndrome. Objective: we aimed to investigate if the use of continuous positive air pressure for a short period (7 days), would improve sleep quality, daytime sleepiness, and the disposition for physical activity. Methods: Eighty obstructive sleep apnea syndrome patients were randomly assigned as follows: group I - continuous positive air pressure with a steady pressure of 4cm H2O; group II - ideal therapeutic pressure. After filling out the questionnaires related to the studied variables (International physical activity questionnaire long-form, Epworth sleepiness scale, Pittsburgh sleep quality index), patients underwent a baseline pulmonary function test and continuous positive air pressure titration. After continuous positive air pressure therapy for 4> hours a night for 7 consecutive days, patients returned and filled out new (International physical activity questionnaire long-form, Epworth sleepiness scale, Pittsburgh sleep quality index) forms. New spirometry was carried out. Results: 39 patients completed the study. The mean age was 52 ±11 years old and 28 patients (71.79%) were obese. Both groups were similar for all variables studied at baseline. After Continuous positive air pressure use, patients of group II presented more significant improvements (p< 0.05) for sleep quality and diurnal sleepiness. Time spent with physical activities did not change. Spirometric data were at normal range at baseline. Solely the variable FEF 25%-75% was significantly enhanced (p< 0.05) in group II. Conclusion: Continuous positive air pressure therapy for 1 week, with ideal pressure, improves daytime sleepiness and sleep quality, enhances pulmonary function, but does not change the mean time spent with physical activities.

Resumo Introdução: A obesidade é o fator causal reversível mais frequente da síndrome da apneia obstrutiva do sono, a atividade física é muito importante para o seu controle. A pressão positiva contínua na via aérea, CPAP, durante o sono é o tratamento padrão ouro para essa condição clínica. Objetivo: Avaliar se o uso do CPAP na síndrome da apneia obstrutiva do sono por um curto período (7 dias) melhoraria a qualidade do sono, a sonolência diurna e a disposição para a prática de atividades físicas, além da função pulmonar. Método: Oitenta pacientes com síndrome da apneia obstrutiva do sono foram distribuídos aleatoriamente da seguinte forma: grupo I - CPAP com pressão constante de 4cm H2O; grupo II - pressão terapêutica ideal. Após o preenchimento dos questionários relacionados ao estudo das variáveis (PSQI, ESS e IPAQ-L), os pacientes foram submetidos a teste de função pulmonar basal e titulação da CPAP. Após terapia com CPAP por ≥ 4 horas por noite durante sete dias consecutivos, os pacientes retornaram e preencheram novos questionários PSQI, ESS e IPAQ-L. Nova espirometria foi feita. Resultados: Apenas 39 pacientes completaram o estudo. A média de idade foi de 52 ± 11 anos e 28 pacientes (71,79%) eram obesos. Ambos os grupos eram semelhantes quanto às variáveis avaliadas no início do estudo. Após o uso de CPAP, os pacientes do grupo II apresentaram melhorias mais significantes (p < 0,05) para qualidade do sono e sonolência diurna. O tempo gasto com atividades físicas não mudou. Os dados espirométricos estavam na faixa normal no início do estudo. Apenas a variável FEF 25%-75% aumentou significantemente (p < 0,05) no grupo II. Conclusão: A terapia com CPAP por uma semana, com pressão ideal, melhora a sonolência diurna e a qualidade do sono, melhora a função pulmonar, mas não altera o tempo médio despendido com atividades físicas.

A Case of Obstructive Sleep Apnea Successfully Treated with Kampo Medicine and Western Medicine / 日本東洋医学雑誌

We report a case of obstructive sleep apnea improved with the treatment both of Kampo medicine and Western medicine. The patient aged 52 years old was struggling with daytime drowsiness. Through the sleep test, he was diagnosed as severe obstructive sleep apnea (OSA) and was received a continuous positive airway pressure therapy (CPAP). Generally, positive air from CPAP applies through the nose and usage reports were recorded in the device. If having nasal congestion, it may be hard to continue CPAP. In this case he had a severe nasal congestion, and he nearly became CPAP failure. It was clear from the poor usage reports. Using Eppikajutsuto for nasal congestion, he felt decrease of nasal congestion. By switching to Shoseiryuto or kakkontokasenkyusin’i from Eppikajutsuto with reference to CPAP usage and nasal CT images, CPAP was continued effectively. Eventually, his daytime sleepiness disappeared.To continue CPAP, which is one of Western medicine, Kampo medicine was useful. On the other hand, to evaluate the effectiveness of Kampo medicine, Western medicine was necessary. CPAP reports and nasal CT images, which are Western medicine, contributed to the switch to Kampo medicine. This case showed the worth of the combined therapy of Kampo medicine with Western medicine.

Impact of the use of surfactant and Nasal CPAP in the reduction of mortality among very low birth weight preterm babies in Ile-Ife, south western Nigeria

Background: Respiratory distress syndrome causes significant morbidity and death especially among very low birth weight babies. Though the use of CPAP and surfactant have been shown to improve survival, these interventions were scarcely available in the past. This study aimed at comparing the clinical outcomes of preterm babies with RDS delivered at the Ife Hospital Unit of the Obafemi Awolowo University Teaching Hospitals Complex at two different periods. Objective: To compare the birth weight specific mortality rates and overall mortality rates of preterm babies with RDS between two periods in the neonatal ward of the Ife Hospital Unit of OAUTHC. Methods: A retrospective study comparing outcomes of 92 babies with RDS at GA 26 to 33+6 weeks between January 2015 and May 2016 and managed with intranasal oxygen alone to 104 babies of same gestational age characteristics between January 2019 and May 2020 who were managed withCPAP/surfactant. Results: The mean weight and gestational age of the babies respectively were 1.36 (±0.37) kg and 31.14 (±2.3) weeks in 2015/2016 and 1.35 (±0.322) kg and 30.95 (±2.24) weeks in 2019/2020. The overall case fatality rate and birth-weight specific mortality rates for ELBW, VLBW and LBW were 33.7%, 62.5%, 35.2% and 9.1% in 2015/2016 and 18.3%, 58.3%, 15.5% and 9.7% respectively in 2019/2020. Conclusion: While the use of CPAP and the administration of surfactant clearly show improved survival among very low birth weight babies who are at increased risk of death from RDS, this was not the case for extreme low birth weight babies.

Evaluación respiratoria y manejo de pacientes con obesidad candidatos a procedimientos quirúrgicos y cirugía bariátrica / Respiratory evaluation and management of obese patients who are candidates for surgical procedures and bariatric surgery

En el seno de la Sección de Sueño, Oxigenoterapia y Asistencia Ventilatoria de la Asociación Argentina de Medicina Respiratoria, se planteó el desarrollo de sugerencias para la exploración respiratoria del paciente con obesidad y definiciones sobre el manejo perioperatorio en cirugía bariátrica y procedimientos quirúrgicos electivos (cirugía no bariátrica). Esta iniciativa se basó en la necesidad de contar con lineamientos adaptados a la realidad local y discutida por expertos que se desempeñan en la realidad coyuntural cotidiana de nuestro país. La agenda se inició en agosto de 2020 en un grupo de revisión de la bibliografía y redacción. Revisores de diferentes provincias argentinas efectuaron una extensa valoración de la evidencia. Luego, un comité editorial realizo una revisión crítica del documento. Finalmente, todo el grupo debatió las sugerencias que se exponen como puntos clave. Este documento exhorta a cirujanos y clínicos a trabajar junto a especialistas respiratorios en la evaluación del riesgo, definición de la aptitud operatoria y corrección de trastornos funcionales y apneas del sueño. La cirugía en individuos con obesidad y la cirugía bariátrica, son procedimientos a los que se arriba luego de una evaluación exhaustiva de la situación clínica y funcional. La tarea multidisciplinaria y el tratamiento de las anormalidades detectadas pueden disminuir los riesgos perioperatorios. Pacientes con obesidad que requieren cirugía electiva con anestesia general deben ser evaluados mediante pruebas objetivas para confirmar la presencia de apneas del sueño y estar adecuadamente tratados con CPAP.

Within the Sleep, Oxygen Therapy and Ventilatory Assistance Section of the Argentine Association of Respiratory Medicine, we de velopment of recommendations for the respiratory exploration of patients with obesity and definitions on perioperative management in bariatric surgery and elective surgical procedures (surgery non bariatric). This initiative was based on the need to have guidelines adapted to the local reality and discussed by experts who work in the daily conjunctural reality of our country. The schedule was started in August 2020 in a literature review group. Reviewers from different Argentine provinces carried out an extensive assessment of the evidence. Then, an editorial committee performed a critical review of the document. Finally, the whole group discussed the suggestions that are presented as key points. This document encourages surgeons and clinicians to work close to respiratory specialists in assessing risk, defining operative competence, and revise functional disorders and sleep apnea. Surgery in obese individuals and bariatric surgery are procedures that are reached after a detailed evaluation about clinical and functional situation. The multidisciplinary team and the treatment of detected abnormalities can reduce perioperative risks. Obese patients who require elective surgery with general anesthesia should be evaluated by objective tests to confirm the presence of sleep apnea and be adequately treated with CPAP.

Cumplimiento e intolerancias durante el tratamiento con presión positiva en las vías aéreas Perfil de consultas externas en una unidad de sueño

Resumen Introducción: El tratamiento con presión positiva puede generar efectos adversos. Para conocer el perfil de cumplimiento e intole rancias analizamos conductas instituidas por kinesiólogos de una Unidad de Sueño. Material y Métodos: Estudio retrospectivo, trasversal y observacional. Se incluyeron pacientes > 18 años con presión positiva derivados a la consulta kinésica. Resultados: Durante cuatro años se evaluaron 244 pacientes; 165 hombres (67%), edad; 65.7 ± 11.6 años, IMC (kg/m2) 31.0 ± 5.4, de los cuales 61% utilizaba CPAP fija, 29% autoajustable, 8% dispositivos binivelados, máscaras nasales 147 (60%), oronasales 52 (21%); almohadillas 37 (15%) y termohumidificador 92 (36%). Los motivos de consultas fueron; control de la terapia (239; 61%), intolerancias (67; 17%) y calibración (51; 13%). El cumplimiento (horas/noche) fue de 4.61 ± 2.1 con un % de noches > 4 horas de 67 ± 36 %. No hallamos diferencias de cumplimiento entre primer y segundo año (4.5 vs. 5.0 horas/noche) p > 0.13, aunque este fue mayor a partir de 600 días de uso de la terapia (p < 0.05). 141 pacientes (57%) presentaban dificultades siendo más frecuentes las fugas (19%) o intolerancias a la máscara (10%). Un (97%) de los pacientes resolvieron intolerancias con 194 conductas; demostración de máscaras (94; 48%), calibración (44; 22%), educación (45; 23%), titulación (13; 6%) y derivación al neumonólogo (14; 7%). Conclusiones: Dos terceras partes de los pacientes cumplen el tratamiento con presión positiva y la mitad presenta intolerancias. La consulta kinésica especializada puede contribuir a la identificación y resolución de dificultades durante la terapia.

Patient Intolerance and Compliance with Positive Airway Pressure Treatment Outpatient Consultations Profile in a Sleep Unit

Abstract Introduction: Treatment with positive pressure may cause adverse effects. In order to know the compliance and intolerance profile, we analyzed the behaviors established by physiotherapists of a Sleep Unit. Materials and Methods: Observational, retrospective, cross-sectional study. We included patients older than 18 years with positive pressure referred to the kinesiological consultation. Results: 244 patients were evaluated during four years: 165 men (67%), age 65.7 ± 11.6 years, BMI (Body Mass Index) 31.0 ± 5.4 (kg/m2), 61% of which used fixed CPAP (Continuous Positive Airway Pressure), 29% auto-adjusting CPAP, 8% bilevel devices, 147 (60%) nasal masks, 52 (21%) oronasal masks; 37 pads (15%), and 92 (36%) thermohumidifiers. Reasons for consultation were: therapy control, 239 (61%); intolerance, 67 (17%), and calibration, 51 (13%). Compliance (hours/night) was 4.61 ± 2.1, with a percentage of nights > 4 hours of 67 ± 36%. We didn't find any difference in the com pliance of the first and the second year (4.5 vs. 5.0 hours/night) p > 0.13, but the value was higher after 600 days of therapy (p < 0.05). 141 patients (57%) showed some complications, the most frequent being leaks (19%) or intolerance to the masks (10%). 97% of the patients resolved the intolerance with 194 behaviors: explanation of how to use the mask, 94 (48%); calibration, 44 (22%); information, 45 (23%); titration, 13 (6%), and referral to the pulmonologist, 14 (7%). Conclusions: Two thirds of the patients complied with the positive pressure treatment and half of the patients showed intolerance. The specialized kinesiological consultation can contribute to the identification and resolution of difficulties that may arise during therapy.

Effect of topical corticosteroids on nasal patency after acute positive airway pressure exposure / Efeito dos corticosteroides tópicos na patência nasal após exposição aguda à pressão positiva nas vias aéreas

Abstract Introduction Nasal congestion and obstruction are reported in the majority of continuous positive airway pressure users and are frequently cited as reasons for noncompliance. Baseline inflammation due to allergic rhinitis could increase or exacerbate the inflammatory effect of high airflow in the nasal cavity as the result of continuous positive airway pressure and lead to greater continuous positive airway pressure intolerance. In this setting, intranasal steroids would be expected to counteract the nasal inflammation caused by allergic rhinitis and/or continuous positive airway pressure. Objective The aim of the present study is to evaluate the effects of topical corticosteroid use on nasal patency after acute exposure to positive pressure. Methods Ten individuals with allergic rhinitis were exposed to 1 h of continuous airway pressure (15 cm H2O) in the nasal cavity, delivered by a continuous positive airway pressure device. Visual analog scale, nasal obstruction symptom evaluation scale, acoustic rhinometry and peak nasal inspiratory flow were performed before and after the intervention. After 4 weeks topical nasal steroid (budesonide) application, positive pressure exposure was repeated as well as the first assessments. Results Patients reported a statistically significant improvement both on the visual analog (p = 0.013) and obstruction symptom evaluation scales (p < 0.01). Furthermore, objective measurements were improved as well, with increased nasal cavity volume on acoustic rhinometry (p = 0.02) and increased peak nasal inspiratory flow (p = 0.012), after corticosteroid treatment. Conclusion In patients with allergic rhinitis, intranasal corticosteroid therapy improved objective and subjective parameters of nasal patency after acute exposure of the nasal cavity to positive pressure.

Resumo Introdução Congestão e obstrução nasais são relatadas na maioria dos usuários de pressão positiva contínua nas vias aéreas e são frequentemente mencionadas como razões para a falta de aderência. A inflamação basal devida à rinite alérgica pode aumentar ou agravar o efeito inflamatório do alto fluxo de ar na cavidade nasal como resultado da pressão positiva contínua nas vias aéreas e aumentar a intolerância à mesma. Nesse cenário, espera-se que os esteróides intranasais neutralizem a inflamação nasal causada pela rinite alérgica e/ou pela pressão positiva contínua nas vias aéreas. Objetivo Avaliar os efeitos do uso tópico de corticosteroides na patência nasal após exposição aguda à pressão positiva. Métodos Dez indivíduos com rinite alérgica foram expostos a uma hora de pressão contínua nas vias aéreas (15 cm H2O) na cavidade nasal, fornecida por um dispositivo de pressão positiva contínua nas vias aéreas. A escala visual analógica, a escala Nasal Obstruction Symptom Evaluation, rinometria acústica e pico de fluxo inspiratório nasal foram aplicados antes e após a intervenção. Após 4 semanas de aplicação tópica de esteroide nasal (budesonida), a exposição positiva à pressão foi repetida, bem como as primeiras avaliações. Resultados Os pacientes relataram uma melhoria estatisticamente significante tanto na escala visual analógica (p = 0,013) quanto na escala Nasal Obstruction Symptom Evaluation (p < 0,01). Além disso, as medidas objetivas também foram melhoradas, com aumento do volume da cavidade nasal na rinometria acústica (p = 0,02) e aumento do pico de fluxo inspiratório nasal (p = 0,012), após o tratamento com corticosteroide. Conclusão Em pacientes com rinite alérgica, a terapia com corticosteroide intranasal melhorou os parâmetros objetivos e subjetivos da patência nasal após exposição aguda da cavidade nasal à pressão positiva.

The effect of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea and uncontrolled hypertension - Study design and challenges during the COVID-19 pandemic

OBJECTIVES: To describe the MORPHEOS (Morbidity in patients with uncontrolled HTN and OSA) trial, and describe the challenges imposed by the COVID-19 pandemic. METHODS: MORPHEOS is a multicenter (n=6) randomized controlled trial designed to evaluate the blood pressure (BP) lowering effects of treatment with continuous positive airway pressure (CPAP) or placebo (nasal strips) for 6 months in adult patients with uncontrolled hypertension (HTN) and moderate-to-severe obstructive sleep apnea (OSA). Patients using at least one antihypertensive medication were included. Uncontrolled HTN was confirmed by at least one abnormal parameter in the 24-hour ABPM and ≥80% medication adherence evaluated by pill counting after the run-in period. OSA was defined by an apnea-hypopnea index ≥15 events/hours. The co-primary endpoints are brachial BP (office and ambulatory BP monitoring, ABPM) and central BP. Secondary outcomes include hypertension-mediated organ damage (HMOD) to heart, aorta, eye, and kidney. We pre-specified several sub-studies from this investigation. Visits occur once a week in the first month and once a month thereafter. The programmed sample size was 176 patients but the pandemic prevented this final target. A post-hoc power analysis will be calculated from the final sample. ClinicalTrials.gov: NCT02270658. RESULTS: The first 100 patients are predominantly males (n=69), age: 52±10 years, body mass index: 32.7±3.9 kg/m2 with frequent co-morbidities. CONCLUSIONS: The MORPHEOS trial has a unique study design including a run-in period; pill counting, and detailed analysis of hypertension-mediated organ damage in patients with uncontrolled HTN that will allow clarification of the impact of OSA treatment with CPAP.

Effect of continuous positive airway pressure associated to exercise on the breathing pattern and heart rate variability of patients undergoing coronary artery bypass grafting surgery: a randomized controlled trial

Continuous positive airway pressure (CPAP) has been used to improve gas exchange and diaphragmatic function, among others benefits. Moreover, it can be used to increase exercise tolerance and positively influence ventilatory function and breathing pattern (BP) during exercise. However, there is no information about the long-term effects of CPAP, as an adjunct to an inpatient cardiac rehabilitation (CR) program, on BP and heart rate variability (HRV) of patients after coronary artery bypass grafting surgery (CABG). Twenty patients were allocated to receive, after randomization, standard inpatient CR without CPAP (control group - CG) or CR with CPAP between 10 to 12 cmH2O (CPAP group - CPG) associated with the exercises. Participants were assessed preoperatively and on the discharge day, in the sitting rest position. Outcome measurements included BP variables, collected by respiratory inductive plethysmography, and HRV, collected by polar precision performance. The CPG presented lower values of percent rib cage inspiratory and expiratory contributions to tidal volume (%RCi and %RCe) at discharge time, compared to CG. No statistical differences between groups were observed for HRV variables and both groups presented lower values of these indices, compared to preoperative ones. In this context, the patients who received CPAP throughout the whole rehabilitation program were discharged with a better BP, which could indicate more synchronized breathing. CPAP did not influence cardiac autonomic modulation in the long term.

Apnea central del sueño y respiración periódica / Central Sleep Apnea and Periodic Breathing

La apnea central del sueño es causada por una falla temporal del centro ponto-medular que es el responsable de generar una respiración rítmica. Puede ser un hallazgo fisiológico durante la transición vigilia-sueño o estar presente por múltiples causas. La enfermedad cardiovascular o cerebro-vascular, el síndrome de apneas e hipopneas obstructivas durante el sueño, el uso de opioides y el tratamiento con CPAP son las más frecuentes en la práctica clínica, mientras que en sujetos sanos las apneas centrales se relacionan con la altura durante la exposición recreacional. Este trabajo revisa la fisiopatología de las apneas centrales, su clasificación, las normas para su identificación en los estudios de sueño y un enfoque práctico sobre las opciones terapéuticas disponibles.

Central sleep apnea is caused by a temporary failure of the ponto-medullary center that is responsible for generating rhythmic breathing. It can be a physiological finding during the sleep-wake transition or be present for multiple causes. Cardiovascular or cerebrovascular disease, obstructive sleep apnea/hypopnea syndrome, use of opioids and treatment with CPAP (Continuous Positive Airway Pressure) are the most frequent in clinical practice, while in healthy subjects central apneas are related to high altitude during recreational exposure. This study reviews the physiopathology of central apneas, their classification, the current rules for their identification in sleep studies and a practical approach to the therapeutic options available.

Effect of AMPK pathway on apoptosis of human thyroid papillary cancer B-CPAP cells under low glucose and hypoxia conditions through CPT1c regulated by PPARα / 中国肿瘤生物治疗杂志

@#[Abstract] Objective: To investigate the mechanisms of carnitine palmitoyltransferase 1c (CPT1c) expression to affect the proliferation and apoptosis of human thyroid papillary cancer B-CPAP cells through the AMP-dependent/activated protein kinase (AMPK) pathway in the low glucose and hypoxic conditions. Methods: Firstly,humanthyroidpapillarycarcinomaB-CPAP cells were cultured under normal condition or low glucose and hypoxic condition respectively, followed with the treatment of AMPK inhibitor compound C. Western blotting was used to detect the expressions of AMPK, p-AMPK, peroxisome proliferator-activated receptor α (PPARα) and CPT1c; the proliferation and apoptosis were detected by CCK-8 and Flow cytometry, respectively. Then PPARα-siRNA was synthesized and transfected into B-CPAP cells to knock down PPARα, and then the cells were cultured under normal or low glucose and hypoxic condition respectively.Above indicators were also detected to verify the regulation of PPARα on CPT1c. Finally, the human luciferase reporter plasmid containing CPT1c gene promoter was constructed, and the effect of PPARα on the activity of CPT1c promoter luciferase activity was observed by immunofluorescence. Results: The expressions ofAMPK, p-AMPK, PPARα and CPT1c were significantly increased in B-CPAP cells under low glucose and hypoxia condition (P<0.05 or P<0.01), while cell proliferation and apoptosis rate did not change significantly (P>0.05). After the treatment of AMPK inhibitor compound C, the expressions of p-AMPK, PPARα and CPT1c in low glucose and hypoxia group were significantly decreased (P<0.05 or P<0.01), the inhibitory rate on cell proliferation and apoptosis rate were significantly increased (P<0.05). However, the change range was smaller than that in the normal culture + compound C group (P<0.05).After PPARα knockdown, the expressions ofAMPK, p-AMPK, PPARα and CPT1c in cancer cells cultured under normal conditions were significantly decreased (P<0.05 or P<0.01), and the inhibitory rate on cell proliferation and apoptosis rate were significantly increased (P<0.05). While under low glucose and hypoxia condition, the expression of CPT1c in cells after transfection was significantly decreased (P<0.05), and the inhibition rate on cell proliferation and the apoptosis rate were significantly increased (P<0.05); However, the change range was still lower than that of normal condition group after transfection (P<0.05).After PPARα overexpression, the ratio of fluorescence in the empty vector group was not significantly different from that of the blank group (P>0.05), and the ratio of fluorescence was significantly increased in PPARα over-expression group (P<0.05). Conclusions: AMPK can increase the expression of PPARα to promote the expression of CPT1c in thyroid cancer B-CPAP cells under low glucose and hypoxia conditions, thereby inhibiting cell apoptosis and maintaining cell proliferation ability.

Nasal Continuous Positive Airway Pressure for Carcinomatous Lymphangitis in End-stage Malignant Soft Tissue Sarcoma: A Case Report

Background: In the end stage of malignant bone and soft tissue tumors with lung metastasis, it is often necessary to relieve symptoms of dyspnea due to tumor enlargement and carcinomatous lymphangitis. We report a case in which nasal continuous positive airway pressure (nasal CPAP) was effective as a palliative treatment. Case: A 66-year-old male underwent wide resection with a diagnosis soft tissue sarcoma of right femur. Four years after surgery, he was hospitalized for hilar lymph node metastasis, multiple bone metastases, and carcinomatous lymphangitis. He was treated with nasal CPAP for dyspnea, and communication was possible until the day before his death. Discussion: For end-stage respiratory symptoms, medication therapy such as morphine or steroids is often used for palliation, but often symptoms are not sufficiently improved. Nasal CPAP might be a useful treatment for palliation for rapidly progressing respiratory failure.

The study of the effect of C-PAP therapy in type-II diabetic patients with obesity and obstructive sleep apnea

Type II diabetes mellitus (T2DM) is closely associated with Obstructive sleep apnea (OSA) and obesity. Type 2 diabetes and OSA may be pathophysiologically independent conditions although the joint association with obesity or visceral adiposity. There is a consistent relationship between obesity and OSA, which has been reported in 60-90% of OSA patients. The prevalence of obesity increases with a parallel increase in the prevalence of OSA. Continuous positive airway pressure (CPAP) therapy is an effective choice of treatment for OSA, an overnight test, or titration some patients may reduce apnea events by minimizes airway collapse by CPAP. Several studies showed that the effect of drug treatment with 3 months of C-PAP in patients with type 2 diabetes. In the present study, we include 300 patients in different groups, out of the 100 patients undergoing treatment of CPAP therapy minimum for three months. Blood sugar, HbA1c, and lipid profile were measured and an overnight sleep study was done. The obtained data shows the significant effect of therapy on physiological and biochemical parameters. AHI and BMI were highly significant in group II and Group III when compared to group I. FBS, HbA1C, and Lipid profile parameters also gave significance results (p-value <0.001) in group II and group III when compared with healthy subjects (group I).

Tratamiento con presión positiva de la Apnea Obstructiva del Sueño. Posición de la Asociación Argentina de Medicina Respiratoria / Treatment of Obstructive Sleep Apnea with Positive Pressure. Position of the Argentinian Association of Respiratory Medicine

La Sección de Sueño, Oxigenoterapia y Otros Tratamientos Crónicos Domiciliarios, de la Asociación Argentina de Medicina Respiratoria (AAMR) se planteó desarrollar en nuestro país un documento formal que exponga la base científica y costo económica de la cobertura del tratamiento del síndrome de apneas e hipopneas obstructivas durante el sueño (SAHOS). Esta iniciativa se basó en la necesidad de analizar la visión de expertos locales que se desempeñan en la realidad coyuntural cotidiana de nuestro país, para elaborar un documento informativo para miembros del equipo de salud. A su vez, exhorta a los diferentes actores del sistema a determinar pautas claras que sirvan de referencia para la generación de políticas públicas. La agenda se inició en septiembre de 2018 en un grupo de redacción. Luego, revisores de cinco provincias argentinas efectuaron una extensa valoración de la evidencia publicada. Para la edición final se realizó una reunión presencial de discusión y generación de consenso. Se plantearon como objetivos; actualizar la base científica que define al SAHOS como problema de salud de proporciones epidémicas con consecuencias demostrables en la salud, analizar los datos de costo-efectividad del tratamiento con CPAP para las formas moderadas a severas y leves con síntomas y unificar conceptos en relación con la calidad mínima necesaria en los tratamientos que se ofrecen. Finalmente, se analiza la situación en la Argentina sobre la base a datos publicados y se presenta una propuesta de mejora en tres niveles: social y económico, logístico-administrativo y clínico

The Sleep, Oxygen Therapy and Other Home Chronic Treatments Section of the Argentinian Association of Respiratory Medicine (AAMR, for its acronym in Spanish) proposed the development in our country of a formal document exposing the scientific and cost-economical foundation of the coverage for the treatment of obstructive sleep apnea and hypopnea syndrome (OSAHS). This initiative was based on the need to analyze the vision of local experts who work in the daily current reality of our country, in order to create an informative document for the members of the medical staff. In turn, it encourages the different members of the system to determine clear guidelines that could be used as reference for generating public policies. The agenda began in September, 2018 within a writing staff. Then, editors from five Argentinian provinces made a thorough assessment of published evidence. For the final edition, a face-to-face meeting was arranged to discuss and reach a consensus. The suggested objectives were: to update the scientific base that defines the OSAHS as a health problem of epidemic proportions with health consequences; to analyze cost-efficacy data of CPAP treatment for moderate to severe and mild-with-symptoms forms of the disease and to unify concepts in relation to the minimum necessary quality of treatments to be offered. Finally, the situation in Argentina is analyzed basing on published data, and a proposal is presented for improvement in three levels: social and economic, logistic-administrative and clinical.

Study on therapeutic effectiveness of continuous positive airway pressure compared to mechanical ventilation in preterm babies with respiratory distress

Background: Previously mechanical ventilation was primary modality of treatment in preterm neonates with respiratory distress. With the introduction of continuous positive airway pressure (CPAP), the need of mechanical ventilation is reduced. The present study was done to know the therapeutic effects of CPAP as compared to mechanical ventilation in preterm neonates with respiratory distress. To study the duration of oxygen requirement and duration of hospitalisation in preterm neonates treated with CPAP compared to invasive mechanical ventilationMethods: Hospital based prospective study was conducted from November 2013 to November 2014 in Dr. B. R. Ambedkar medical college, Bangalore. All the preterm babies admitted in neonatal intensive care unit with respiratory distress requiring CPAP or mechanical ventilation during study period were included. Total 50 cases were included, out of which 20 (40%) were on CPAP treatment and 30 (60%) were on mechanical ventilation. Outcome was assessed by reduction of respiratory distress with SpO2 more than 88% with FiO2 of 21%.Results: Out of 50 preterm neonates studied, 20 (40%) were on CPAP treatment and 30 (60%) were on mechanical ventilation. Mean duration of oxygen treatment was less in neonates on CPAP (4.8'0.9 days) compared to mechanical ventilated neonates (7.12'0.8days) and it is statistically significant (p value<0.05). Mean duration of hospitalisation was less in neonates on CPAP (19.3'0.76 days) compared to mechanical ventilated neonates (21'1.2 days) but it was statistically not significant (P value >0.05).Conclusions: CPAP as a mode of treatment for preterm babies with respiratory distress reduces the duration of oxygen dependency compared to invasive mechanical ventilation. Difference in duration of hospital stay was statistically not significant in these neonates treated with CPAP and mechanical ventilation.

Bubble continuous positive airway pressure therapy for neonatal respiratory distress at birth in level III newborn unit in Chengalpattu Medical College Hospital: a prospective observational study

Background: Bubble continuous positive airway pressure (bCPAP), a non-invasive respiratory device provides continuous pressure that helps recruitment of more alveoli, increases the lungs, functional residual capacity and decreases the work of breathing in newborns admitted with respiratory distress. Bubble continuous positive airway pressure (bCPAP) is the most important respiratory support in different types of respiratory conditions in level III. In this observational study, author reported this research using bCPAP therapy as the primary respiratory support in level III unit in tertiary care centre in Chengalpattu, Tamil Nadu, India. Despite reporting their indications, duration of use and adverse effects we tried to search for further improvement in other areas of CPAP therapy in level III newborn unit.Methods: This prospective observational study included 250 babies delivered in obstetric unit and admitted with respiratory distress within 6 hours of birth at level III care. They were treated according to level III newborn unit protocol. Those data were collected and entered in the proforma. Newborns were followed up till discharge.Results: A total of 250 babies satisfying the inclusion criteria delivered in Chengalpattu Medical College Hospital, Tamil Nadu, India (mean gestational age 36'2 weeks, mean birth weight 2.5'1.2 kg were included. All newborns were given bCPAP as the primary support. The most common underlying cause of respiratory distress was transient tachypnea of newborn (44%), followed by respiratory distress syndrome (24%) and prolonged respiratory transition (18%). The therapy success rate was 86%. Only 35 newborns failed to respond to CPAP. The most common adverse effect was eye puffiness (19%).Conclusions: Bubble continuous positive airway pressure (b CPAP) therapy use is being well established in level III unit for various respiratory conditions with minimal failure and adverse effects. Its use in extreme preterms and initiation after 6 hours is controversial.

Autoeficacia percibida y adherencia al CPAP (presión positiva continua en la vía aérea) en personas con apnea del sueño / Perceived self-efficacy and adherence to CPAP (continuous positive airway pressure) in people with sleep apnea

Objetivo: Determinar la relación entre la autoeficacia percibida y la adherencia objetiva al CPAP en una población de pacientes con SAHOS de una institución especializada en cuidado respiratorio de la ciudad de Bogotá. Método: Se utilizó un diseño de corte transversal con abordaje cuantitativo - correlacional, a partir de una corte de pacientes con Síndrome de Apnea Obstructiva del Sueño (SAHOS) moderado o severo. Entre los meses de septiembre y noviembre de 2018, se incluyeron de forma consecutiva 136 pacientes, hombres y mujeres, mayores de edad, que usaban CPAP y asistieron a consulta de neumología, sueño, rehabilitación y exámenes diagnósticos. Se obtuvo información demográfica y clínica. Cada participante diligenció el instrumento SEMSA para evaluar la autoeficacia y se obtuvo lectura de tarjeta del dispositivo, para evaluar adherencia objetiva. Se analizaron los datos por medio de un modelo de regresión logística. Resultados y conclusiones: La correlación entre la autoeficacia y la adherencia objetiva al CPAP, mostró un coeficiente de Sperman -,076. En el análisis discriminado, la dimensión autoeficacia de la escala de autoeficacia, mostró una correlación débil (Rho Sperman=0.17) estadísticamente significativa (p=0.048), lo cual concuerda con lo reportado en algunas publicaciones hechas en poblaciones diferentes a la estudiada. La puntuación de la dimensión de autoeficacia (3,4/4) fue superior a lo informado en la literatura, y la de expectativas de riesgo (1,85/4) fue inferior a lo reportado. Los pacientes jóvenes tuvieron una mayor autoeficacia que las personas mayores. La adherencia objetiva al CPAP (uso de CPAP > a 4 horas/noche por más del 70% de las noches) fue del 66,9 % con un promedio de horas de uso por noche de 5,54, valores más altos que los reportados a nivel mundial y local. Otras variables no tuvieron asociación con la adherencia.

Objective: To determine the relationship between perceived self-efficacy and objective adherence to CPAP in a population of patients with OSAHS from an institution specialized in respiratory care in the city of Bogotá. Method: This is a cross-sectional design with a quantitative-correlational approach, based on a cut-off of patients with moderate or severe obstructive sleep apnea OSAHS. Between the months of September and November of 2018, 136 patients were included; both gender male and female, which were above legal age 18 years old, users of CPAP machine and who attended to the pulmonology consultation, sleep, rehabilitation and diagnostic tests. Demographic and clinical information was obtained. Each participant completed the instrument in order to evaluate self-efficacy. Also, to evaluate objective adherence, card reading of the CPAP device, was obtained. The data was analyzed by logistic regression model. Results and conclusions: The correlation between self-efficacy and objective adherence to CPAP showed a Sperman coefficient of -,076. In the discriminated analysis, the selfefficacy dimension of the self-efficacy scale showed a weak correlation (Rho Spermean = 0.17) statistically significant (p = 0.048), in the sense that the information is relevant. The score of the dimension of self-efficacy (3.4 / 4) was higher and reported in the literature, but lower in the domain of risk expectations (1.85 / 4). Young patients had greater self-efficacy than older patients. Objective adherence to CPAP (use of CPAP> at 4 hours / night for more than 70% of the nights) was 66.9% with an average nighttime usage of 5.54, higher values than those reported Globally and locally. Other variables had no association with adherence.

Síndrome de Apnea del Sueño (SAS) ­ Síndrome de Apnea ­ Síndrome Hipoapnea del Sueño (SAHS) / Sleep Apnea Syndrome (SAS)

La apnea (a-pnoe = sin respiración) consiste en la aparición de episodios recurrentes de limitación al paso del aire durante el sueño, como consecuencia de una alteración anatómicofuncional de la vía aérea superior, con descenso de la saturación de oxihemoglobina (SaO2) y microdespertares que dan lugar a un sueño no reparador, somnolencia diurna, trastornos neuropsiquiátricos, respiratorios y cardíacos. La prevalencia es mayor en hombres (24%) que en mujeres (9%) y afecta a todos los grupos etarios. La Organización Mundial de la Salud estima que la apnea del sueño afecta a 100 millones de personas en todo el mundo, llamándolo "el trastorno orgánico del sueño más común". El diagnóstico y tratamiento interdisciplinario incrementan las tasas de éxito y optimizan la calidad de vida del paciente, comprendiendo que la ciencia y las terapéuticas avanzan para brindar alternativas menos invasivas y eficaces (AU)

Apnea (a-pnoe = without breathing) consists of the appearance of recurrent episodes of limitation to the passage of air during sleep, as a consequence of an anatomical-functional alteration of the upper airway, with a decrease in oxyhemoglobin saturation (SaO2 ) and micro-awakenings that lead to restless sleep, daytime sleepiness, neuropsychiatric, respiratory and cardiac disorders. The prevalence is higher in men (24%) than women (9%) and affects all age groups. The World Health Organization estimates that sleep apnea affects 100 million people worldwide, calling it "the most common organic sleep disorder." Diagnosis and interdisciplinary treatment increase success rates and optimize the patient's quality of life, understanding that science and therapeutics advance to provide less invasive and effective alternatives (AU)

Use Of Early Labour Room Bubble Cpap In Preterms Born At 28-32 Weeks Of Gestation

Objective: To study the use of early labour room Bubble CPAP in preterm neonates born at 28–32 weeks of gestation and to analyse the outcome in relation to need for mechanical ventilation, duration of hospital stay and mortality at the Neonatal Intensive Care Unit (NICU), Tertiary Care Teaching Government Hospital Kurnool, Andhra Pradesh for a period of 1 Year. Methods : Facility Based Interventional Studied (Randomised Control Study) Participants : Study sample of 109 preterm babies of age 28–32 weeks of gestation Cases : 54 cases, neonates with respiratory distress who were started on CPAP in the labour room within 15 minutes of life. Controls : 55 babies, neonates with respiratory distress who were started on CPAP after 15 minutes to 6 hours of life. In the present study, both the groups(cases and controls) were monitored till they were discharged and the need for mechanical ventilation was noted. Clinical diagnosis of RDS was made based on the time of onset of respiratory distress and clinical examination and respiratory scoring(Silverman Anderson Score) . Chest X–ray and routine investigations were done in all neonates. Duration of CPAP and difference in mortality between the two groups was analysed. Outcome : In the present study, preterm neonates born at 28–32 weeks of gestation who were started on early labour room CPAP vs control group outcome is assessed in relation to need for mechanical ventilation and duration of hospital stay and mortality. Results: It is observed that 16 (29.63%) cases required mechanical ventilation whereas 28 (50.91%) preterm neonatesin the control group needed mechanical ventilation. There was a statistically significant difference between the two groups (p < 0.05). The duration of stay in NICU in neonates with early CPAP was significantly less when compared to the controlled group. 30(76.9%) neonates were discharged within 14 days among cases and 16 (48.48%) neonates among control group. There is no difference in mortality between the 2 groups. Conclusions : The following conclusions could be drawn out of the present study on preterm neonates. 1. The early administration of CPAP in the delivery room in preterm neonates developing respiratory distress decreases the need for mechanical ventilation. 2. The duration of stay in NICU in neonates with early CPAP was significantly less. 3. There is no difference in mortality between the two groups.