Hipoxemia y el riesgo de hipertensión arterial en apnea obstructiva del sueño / Hypoxemia and the Hypertension Risk in Obstructive Sleep Apnea

Hay poca información sobre el rol de la hipoxemia como factor de riesgo de hipertensión arterial (HTA) en pacientes con apnea obstructiva del sueño. El objetivo de este estudio fue evaluar la hipoxemia como factor de riesgo independiente de HTA en un modelo de trabajo basado en pacientes reales examinados en una unidad de sueño. Métodos: estudio retrospectivo. Modelo predictivo mediante regresión logística múltiple para establecer la relación entre HTA y edad, sexo, índice de masa corporal (IMC), índice de apneas e hipopneas por hora de registro (IAH) y tiempo de saturación de oxígeno debajo de 90% (T90 > 3%). Resultados: incluimos 3854 pacientes (edad mediana 55 años), predominio varones (61.5%). Según el modelo, las variables asociadas con HTA fueron: edad (OR 3.27 ­ 3.29, IC95% 2.83 ­ 3.80, p < 0.0001), sexo masculino (OR 1.35, IC95% 1.17 ­ 1.56, p < 0.001), obesidad (OR 1.83, IC95% 1.59 ­ 2.11, p < 0.0001), IAH ≥ 15 eventos por hora (OR 1.22, IC95% 1.05 ­ 1.43, p < 0.01) y T90 ≥ 3% (OR 1.56 ­ 1.57, IC95% 1.32 ­ 1.84, p < 0.0001). Conclusiones: en una población clínica con sospecha de apnea obstructiva del sueño, la hipoxemia (T90 ≥ 3%) se asoció con hipertensión arterial. (AU);

There is limited information about the role of hypoxemia degree as a risk factor for hypertension (HTN) in patients with obstructive sleep apnea (OSA). The objective of this study is to assess hypoxemia as an independent risk factor for HTN in a work model based on real-life patients examined at sleep unit. Methods: this retrospective study consisted of a predictive model using multiple logistic regression to establish the relationship between HTN and age, sex, body mass index (BMI), apnea/hypopnea index (AHI) and time below SO2 ≤ 90% (T90 ≥ 3%). Results: we included 3.854 patients (median age: 55 years), mostly men (61.5%). According to the model, the variables that were significantly associated with HTN were: age (OR: 3.27 ­ 3.29, CI95% 2.83 ­ 3.80, p < 0.0001), male sex (OR 1.35, CI95% 1.17 ­ 1.56, p < 0.001), Obesity (OR 1.83, CI95% 1.59 ­ 2.11, p < 0.0001), AHI > 15 events per hour (OR 1.22, CI95% 1.05 ­ 1.43, p < 0.01) and T90 ≥ 3% (OR 1.56 ­ 1.57, CI95% 1.32 ­ 1.84, p < 0.0001). Conclusion: in a clinical population of subjects suspected of OSA, nocturnal hypoxemia measure as T90 ≥ 3% was associated with HTN. (AU);

Independent association between hypoxemia and night sweats in obstructive sleep apnea.

PURPOSE: To assess the relationship between hypoxemia during polysomnography (PSG) and patient-reported night sweats (NS). METHODS: This retrospective observational study included adult patients who completed a standardized sleep questionnaire and the Epworth Sleepiness Scale (ESS) before PSG. RESULTS: We included 1397 patients (41% women). The median age was 52 years, 80% had obstructive sleep apnea (OSA) defined as an apnea-hypopnea index (AHI) ≥ 5, and 35% were obese. A total of 245 patients (17.5%) reported NS. Their prevalence was higher among patients with OSA compared to controls (18.9% vs. 12.2%, p < 0.01). In the bivariate analysis, the variables associated with NS were BMI, AHI, hypoxemia (T90 ≥ 2.5% of total recording time plus minimum SO2 < 85%), frequent body movements or awakenings, nightmares, excessive daytime sleepiness (Epworth > 10), nocturia, cardiovascular events, and the use of sedatives or antidepressants. In the multivariate model, the independent predictors of NS were BMI (OR: 1.47, CI 95%: 1.07-2.01, p = 0.016), hypoxemia (OR: 1.87, CI 95%: 1.37-2.60, p = 0.0001), nightmares (OR: 2.60, CI 95%: 1.73-3.80, p < 0.0001), frequent body movements and awakenings (OR: 1.57, CI 95%: 1.16-2.11, p = 0.003 and OR: 1.54, CI 95%: 1.13-2.08, p = 0.005, respectively), and excessive daytime sleepiness (OR: 1.65, CI 95%: 1.24-2.20, p = 0.0007). CONCLUSIONS: In patients with OSA, night sweats were significantly and independently associated with a higher hypoxic burden.

A novel, simple, and accurate pulse oximetry indicator for screening adult obstructive sleep apnea.

OBJECTIVE: The objective of the study was to develop a multiparametric oximetry indicator (IMp-SpO2) to diagnose obstructive sleep apnea in adults. MATERIAL AND METHOD: This was an observational, retrospective study of diagnostic accuracy. We included adults who had had a diagnostic polysomnography with few artifacts and a total sleep time of at least 180 min in the sleep laboratory. Obstructive sleep apnea (OSA) was defined as an apnea-hypopnea index (AHI) ≥ 5. The database was randomly divided into an experimental (Exp-G) and validation (Val-G) group. The program calculated several parameters of oxygen saturation variability (Par-VarSpO2): (a) oxygen desaturation index (ODI ≥ 3, 4%) and (b) 90, 95, and 97.5 percentiles of both the number of oxygen desaturations ≥ 3 and 4% (P90-97.5 OD3/4 W5-60) and SpO2 standard deviations in moving windows from 5 to 60 min (P90-P97.5 SDSpO2 W5-10). Area under the ROC curve (AUC-ROC), sensitivity, specificity, positive/negative likelihood ratios, and accuracy were calculated. RESULTS: Of 1141 adults included in the study, experimental (571) and validation group (570) were similar (women 47% vs 45%, BMI 27.5 kg/m2 vs 27.2 kg/m2, and AHI 11.7 vs 12, p NS). The IMp-SpO2 developed in the experimental group consisted of a combination of 10 parameters of oxygen saturation variability. The presence of at least one IMp-SpO2 variable had a high diagnostic performance for OSA (sensitivity/specificity/accuracy: Exp-G: 92.8/94/93.2%; Val-G: 93/95.2/93.7%). The IMp-SpO2 AUC-ROC was higher (Exp-G 0.934, Val-G 0.941) than most of the Par-VarSpO2 (0.898-0.929, p < 0.05). CONCLUSION: The IMp-SpO2 showed a > 90% accuracy for OSA diagnosis in adults.

Contribution of pulse oximetry in relation to respiratory flow events in a home-based approach aimed at diagnosing obstructive sleep apnea.

OBJECTIVE: To compare pulse oximetry with manual analysis against all signals of respiratory polygraphy. MATERIAL AND METHODS: This retrospective study estimated sensitivity (S), specificity (Sp) and positive/negative likelihood ratio (LR+/-) of the oxygen desaturation index (ODI-test) and apnea-hypopnea index (AHI-reference). RESULTS: 3854 patients (61.5% men) were included. Age, BMI, Epworth sleepiness scale and AHI were: 55 years (44-65), 30.9kg/m2 (27-36), 7 points (4-11), and 14 events/hour (6-25), respectively. 18% showed an AHI <5 events/hour, 34% = 5 and <15, 27% = or > 15 and < 30, and 31% > 30. The S, Sp, and LR+/- of ODI for AHI = 5 events/hour was 93%, 92%, 12 and 0.08 with an accuracy of 93%. For AHI = 15 events/hour, the values were: S 94%, Sp 94%, LR+ 15 and LR- 0.06 and 94% accuracy (r(2) Spearman: 0.92). CONCLUSION: In a population at a high risk for OSA, home-based pulse oximetry had a diagnostic accuracy > 90% when is compared against all respiratory signals obtained from simplified home sleep testing.

[Lung cancer diagnosed by transesophageal ecoendoscopy and fine needle aspiration biopsy]. / Cáncer de pulmón diagnosticado mediante ecoendoscopía transesofágica y biopsia por punción con aguja fina.

Lung cancer is one of the leading causes of death worldwide. Pulmonary nodules located in the vicinity of the mediastinum, retrocardiac, near the aorta or pulmonary vessels, and in front of the spine, may be difficult to access through a percutaneous or bronchoscopic approach. Fine needle aspiration/biopsy guided by transesophageal echoendoscopy (EUS-FNA/FNB) is a minimally invasive method with low morbidity that could allow access to lesions in these places. We present the case of a patient with a solitary pulmonary nodule, in which the diagnosis of lung cancer was obtained by EUS-FNA/FNB.

El cáncer de pulmón es la principal causa de muerte por cáncer en todo el mundo. Los nódulos pulmonares ubicados en proximidad al mediastino, retrocardíacos, cercanos a grandes vasos o por delante de la columna vertebral pueden resultar de difícil acceso por vía percutánea o broncoscópica. La punción aspiración/biopsia con aguja fina guiada por ecoendoscopía transesofágica (EUS-FNA/FNB) es un método mini invasivo con baja morbilidad que permitiría acceder a estas localizaciones. Presentamos el caso de un paciente con nódulo pulmonar solitario, en el que se obtuvo el diagnóstico de cáncer de pulmón mediante EUS-FNA/FNB.

Cáncer de pulmón diagnosticado mediante ecoendoscopia transesofágica y biopsia por punción con aguja fina / Lung cancer diagnosed by transesophageal ecoendoscopy and fine needle aspiration biopsy

El cáncer de pulmón es la principal causa de muerte por cáncer en todo el mundo. Los nódulos pulmonares ubicados en proximidad al mediastino, retrocardíacos, cercanos a grandes vasos o por delante de la columna vertebral pueden resultar de difícil acceso por vía percutánea o broncoscópica. La punción aspiración/biopsia con aguja fina guiada por ecoendoscopía transesofágica (EUS-FNA/FNB) es un método mini invasivo con baja morbilidad que permitiría acceder a estas localizaciones. Presentamos el caso de un paciente con nódulo pulmonar solitario, en el que se obtuvo el diagnóstico de cáncer de pulmón mediante EUS-FNA/FNB.

Lung cancer is one of the leading causes of death worldwide. Pulmonary nodules located in the vicinity of the mediastinum, retrocardiac, near the aorta or pulmonary vessels, and in front of the spine, may be difficult to access through a percutaneous or bronchoscopic approach. Fine needle aspiration/biopsy guided by transesophageal echoendoscopy (EUS-FNA/FNB) is a minimally invasive method with low morbidity that could allow access to lesions in these places. We present the case of a patient with a solitary pulmonary nodule, in which the diagnosis of lung cancer was obtained by EUS-FNA/FNB.

Indication of CPAP without a sleep study in patients with high pretest probability of obstructive sleep apnea.

OBJECTIVE: To evaluate the performance of clinical criteria (CC) for diagnosis and initiation of empirical treatment with continuous positive airway pressure (CPAP) in patients with suspected obstructive sleep apnea (OSA) compared with the treatment decision based on sleep studies (polysomnography or respiratory polygraphy), guidelines, and experience of participating physicians. METHODS: This was a simulated intention-to-treat study in a retrospective (G1) and prospective (G2) cohort. Four observers (two per group) called CC1 and CC2 reviewed the sleep questionnaires and indicated CPAP if the patients presented snoring, frequent apneas (≥ 3-4/week), body mass index (BMI) > 25 kg/m2, sleepiness (Epworth > 11), or tiredness (at least 3-4 times per week) and some comorbidity (hypertension, coronary/cerebrovascular event, diabetes). Ten independent observers formed two groups of five (FD1 and FD2) and were blinded to each other's opinion. These observers in FD1 and FD2 decided CPAP treatment based on guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) or guidelines of the American Academy of Sleep Medicine (AASM) and factored in their own opinion. Sensitivity (S), specificity (Sp), and positive/negative likelihood ratios (LR+/-) were calculated with the test method: CC1/2, and the reference method: majority decision of FD1/2. RESULTS: A total of 653 patients (264 women, 40%) were studied. Median age was 54 years, BMI 28 kg/m2, and apnea hypopnea index (AHI) 16.5 events/h. S ranged from 21 to 25% (p 0.60), Sp 96.1 to 97.6% (p 0.39), and LR+ of clinical criteria 6.4 to 8.9 (p 0.52). CONCLUSION: CPAP indication without a previous sleep study showed a low sensitivity (≅ 22%) but a specificity greater than 95% in patients with high pretest probability for OSA (snoring, report of frequent apneas, BMI > 25 kg/m2 and sleepiness or tiredness plus comorbidity).

The influence of gender on symptoms associated with obstructive sleep apnea.

BACKGROUND: It has been reported that the clinical expression of obstructive sleep apnea (OSA) may differ in women and men. OBJECTIVE: The objective of this study was to evaluate the influence of gender on reported OSA-related symptoms in a large clinical population of patients. METHODS: The database from the sleep laboratory of a tertiary care center was examined. Adult patients who had undergone a diagnostic polysomnography and completed the Berlin questionnaire, a sleep questionnaire, and the Epworth sleepiness scale were selected. Multiple logistic regression analysis was performed to assess the relationship between OSA-associated symptoms and different potential explanatory variables. RESULTS: The study sample included 1084 patients, median age was 53 years, 46.5% (504) were women, 72.7% (788) had OSA (apnea/hypopnea index ≥ 5), and 31.2% were obese. After adjusting for age, body mass index, and apnea/hypopnea index, men were more likely to report snoring (OR 4.06, p < 0.001), habitual or loud snoring (OR 2.34, p < 0.001; 2.14, p < 0.001, respectively) and apneas (OR 2.44, p < 0.001), than women. After controlling for multiple variables, female gender was an independent predictive factor for reported tiredness (OR 0.57, p 0.001), sleep onset insomnia (OR 0.59, p 0.0035), and morning headaches (OR 0.32, p < 0.001). Reports of excessive daytime sleepiness, nocturia, midnight insomnia, and subjective cognitive complaints were not significantly associated with gender. CONCLUSION: Women with OSA were more likely to report tiredness, initial insomnia, and morning headaches, and less likely to complain of typical OSA symptoms (snoring, apneas) than men.

Tumor endobronquial… no todo es lo que parece / Endobronchial tumor ... not everything is what seems

Se trata de un paciente masculino de 43 años, con antecedentes de VIH/SIDA, 150 linfocitos CD4/mm3 y toxoplasmosis cerebral. Consultó por un cuadro de 20 días de evolución caracterizado por fiebre de hasta 40°C, tos con expectoración mucosa y diarrea. Habiendo recibido diferentes esquemas antibióticos, se internó con diagnóstico de neumonía de lenta resolución. Al examen físico presentaba: TA 120/85, temperatura 39.2 °C, FC 104/min, FR 28/min, saturación 97% respirando aire, hipoventilación en base pulmonar izquierda y crepitantes en campo medio izquierdo

The role of surveillance cultures in guiding ventilator-associated pneumonia therapy.

PURPOSE OF REVIEW: Ventilator-associated pneumonia (VAP) is the most frequent cause of death among the nosocomial infections acquired in the ICU. Routine surveillance endotracheal aspirate (ETA) cultures in patients on mechanical ventilation have been proposed to predict the cause of VAP. Our aim is to review the available experience regarding the role of surveillance ETA cultures in guiding VAP antimicrobial therapy. RECENT FINDINGS: Microorganisms arrive in the lower respiratory tract by aspiration from the oropharynx or gastric reflux, extension from a contiguous infection, air contamination or by hematogenous seeding. Bacterial colonization of the airway leads to the development of VAP and may result from the aspiration of oropharyngeal or gastric secretions. Recent studies have suggested that surveillance cultures could provide a rationale for prescribing appropriate antibiotics, while waiting for culture results, in up to 95% of patients in whom VAP is ultimately diagnosed by bronchoalveolar lavage fluid culture. However, some authors observed that guiding therapy with those routine surveillance cultures leads to unacceptably low coverage of the pathogens producing VAP. SUMMARY: This article describes the evidence supporting the use of routine ETA cultures to prescribe appropriate initial empirical therapy compared with the current practice dictated by guidelines.