[Sleep apneas, metabolic syndrome and cardiovascular risk: Data from the Pays de la Loire sleep cohort]. / Apnées du sommeil, syndrome métabolique et risque cardiovasculaire : données de la cohorte sommeil des Pays de la Loire.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a prevalent disease characterized by recurrent episodes of partial or complete obstruction of upper airway during sleep. Untreated moderate to severe OSAHS is recognized as a cardiovascular (CV) risk factor. Data from the Pays de la Loire sleep cohort and other clinic- or population-based cohorts demonstrate a strong association between OSAHS and the different components of the metabolic syndrome including systemic hypertension, diabetes and impaired lipid metabolism. Beside sleep-disordered breathing severity, these factors contribute to increase the risk of CV events in OSAHS patients. Continuous positive airway pressure (CPAP) therapy of OSAHS is associated with a modest but clinically significant blood pressure reduction. Conversely, there is no clear evidence in support of a metabolic impact of CPAP in OSAHS patients. Considering the multifactorial pathophysiology of CV risk in OSAHS patients and the beneficial impact of various lifestyle and pharmacologic interventions on blood pressure and metabolic dysfunction, combined modality therapy is a promising strategy to improve CV outcomes in individuals with OSAHS.

[Vascular dysfunction in obstructive sleep apnoea: Implication of microparticules]. / Atteinte vasculaire associée au syndrome d'apnées hypopnées obstructives du sommeil : rôle des microparticules.

Obstructive sleep apnea (OSA) is associated with increased cardiovascular diseases, including myocardial infarction and stroke and promotes cardiovascular risk factors including diabetes and hypertension. OSA has also been proposed to have a direct proatherogenic effects. Recent studies have investigated the role of microparticles (MPs) in the atherogenic process. MPs are small plasma membrane vesicles that can be released by a variety of vascular or blood cells and that contain membrane and cytosolic elements. Case-control studies have suggested that OSA is associated with an increase in circulating platelet-, endothelial- and leukocyte-derived MPs. MPs from OSA patients injected to mice have also been shown to induce vascular inflammation and endothelial dysfunction. In this article, we provide an overview of the main characteristics of MPs expressed in OSA and their potential role in the atherogenic process.

[Update on the respiratory management of patients with chronic neuromuscular disease]. / Mise au point dans la prise en charge respiratoire des maladies neuromusculaires chroniques.

BACKGROUND: Neuromuscular diseases include a wide range of conditions that may involve potentially life-threatening respiratory complications (infection, respiratory failure). SURVEILLANCE AND PULMONARY FUNCTION TESTS: For patients with neuromuscular diseases, clinical assessment of respiratory function and regular pulmonary function tests are needed to screen for nocturnal respiratory disorders, weakness of the diaphragm and potential restrictive disorders and/or chronic hypercapnic respiratory insufficiency, possibly with couch deficiency. MANAGEMENT OF NOCTURNAL RESPIRATORY DISORDERS AND CHRONIC RESPIRATORY FAILURE: Nocturnal respiratory assistance is an important phase of care for nocturnal respiratory disorders and chronic respiratory failure. This may involve continuous positive airway pressure, adaptative servo-ventilation or non-invasive ventilation with a facial or nasal mask. As needed, diurnal assistance may be proposed by mouthpiece ventilation. Should non-invasive ventilation prove insufficient, or if significant swallowing disorders or recurrent bronchial obstruction develop, or in case of prolonged intubation, tracheotomy may be required. LOWER AIRWAY OBSTRUCTION: In case of lower airway infection with ineffective cough, physical therapy, associated with air stacking, intermittent positive pressure breathing or mechanical in-exsufflation may be proposed. PATIENT-CENTERED MANAGEMENT: Care for swallowing disorders, nutritional counseling (cachexia, obesity), vaccinations and therapeutic education are integral elements of patient-centered management aiming to prevent the negative impact of infection and to manage respiratory failure of chronic neuromuscular disease.

[Practical aspects of the management of patients treated by continuous positive airway pressure]. / Le suivi pratique des patients sous pression positive continue.

The therapeutic follow-up is a decisive factor of the success of a long course treatment by continuous positive airway pressure (CPAP). The effectiveness of this treatment on both symptoms and complications must be regularly verified. Polysomnography with CPAP could be necessary in order to check out the efficacy of this treatment and/or to find an associated diagnosis when symptoms persist, particularly a diurnal drowsiness, which is the main therapeutic target in obstructive sleep apnea syndrome (OSAS). The secondary effects that are likely to compromise the compliance of CPAP treatment must be resolved, particularly the nasal intolerance, which are enhanced by mask leakages and often corrected by using heated humidity with CPAP delivery systems. The efficacy of CPAP on both diurnal drowsiness and hypertension is related to the compliance of this treatment which must be regularly verified, at the same time that the clinical evaluation. The data obtained from the device's memory give information concerning the number of hours day to day, in which the CPAP device was running at the prescribed pressure. The first months with CPAP are decisive to avoid a failure of the treatment at long term. This period must be closely monitored by both the physician and the home care provider. Patients should use the CPAP at least 3-4 h by night and all possible means should be used to obtain a maximal compliance. Therapeutic educational programs could help to reach this goal.

Titrated mandibular advancement versus positive airway pressure for sleep apnoea.

The aim of this study was to compare mandibular advancement device (MAd) therapy and continuous positive airway pressure (CPAP) for obstructive sleep apnoea/hypopnoea syndrome (OSAHS) after one-night polysomnographic (PSG) titration of both treatments. 59 OSAHS patients (apnoea/hypopnoea index (AHI): 34+/-13 events x h(-1); Epworth scale: 10.6+/-4.5) were included in a crossover trial of 8 weeks of MAd and 8 weeks of CPAP after effective titration. Outcome measurements included home sleep study, sleepiness, health-related quality of life (HRQoL), cognitive tests, side-effects, compliance and preference. The median (interquartile range) AHI was 2 (1-8) events x h(-1) with CPAP and 6 (3-14) events x h(-1) with MAd (p<0.001). Positive and negative predictive values of MAd titration PSG for treatment success were 85% and 45%, respectively. Both treatments significantly improved subjective and objective sleepiness, cognitive tests and HRQoL. The reported compliance was higher for MAd (p<0.001) with >70% of patients preferring this treatment. These results support titrated MAd as an effective therapy in moderately sleepy and overweight OSAHS patients. Although less effective than CPAP, successfully titrated MAd was very effective at reducing the AHI and was associated with a higher reported compliance. Both treatments improved functional outcomes to a similar degree. One-night titration of MAd had a low negative predictive value for treatment success.

[Prevalence of symptoms of sleep apnea syndrome. Study of a French middle-aged population]. / Prévalence des symptômes du syndrome d'apnées du sommeil. Etude dans une population française d'âge moyen.

OBJECTIVE: To study the prevalence of symptoms of sleep apnoea syndrome (SAS) in a large French middle-aged population and to establish what proportion have symptoms that justify further investigation with a sleep study. METHODS: We performed a cross-sectional study of 2,195 men and 2,247 women, 33 to 69 year old (DESIR. cohort) recording responses to a self-administered "sleep" questionnaire and a general questionnaire including socio-economic characteristics and lifestyle factors. RESULTS: The prevalence of symptoms in men and women were respectively: snoring frequently (28%, 14%), frequent daytime sleepiness (14%, 18%) and frequent apnoeas (5%, 2%). Overall, 8.5% of men and 6.3% of women reported a pattern of symptoms suggestive of OSA, as they snored and had daytime sleepiness and/or apnoeas. This pattern was associated, for both sexes, with age, body mass index and after adjustment on these two factors, to a mediocre self-reported health status and treatment with benzodiazepines or other sedatives. For men only, the OSA pattern of symptoms was also associated with, hypertension, alcohol consumption and smoking. CONCLUSION: Snoring, daytime hypersomnolence and witnessed apnoeas are symptoms frequently observed in the general population. Subjects with a combination of these abnormalities suggesting a high probability of sleep apnoea syndrome and in whom a sleep study is warranted represent 7.5% of the adult population.

Sleep-disordered breathing in patients with Chiari malformation: improvement after surgery.

Sixteen consecutive patients with Arnold-Chiari malformation type I and syringomyelia underwent full-night polysomnography (PSG). Sleep apnea syndrome (apnea-hypopnea index > 10) was diagnosed in 12 of 16 patients with 48% of central apneas. In six patients with sleep apnea syndrome, PSG was repeated an average of 203 days after decompression surgery. Postoperative PSG showed a decrease in the central apnea index from 14.9 +/- 5.5 to 1.3 +/- 0.6 (p = 0.03).

[Central apnea developing during treatment with a mandibular advancement device]. / Apnées centrales induites sous traitement par orthèse d'avancée mandibulaire.

INTRODUCTION: Mandibular advancement (MA) has emerged over the last decade as an alternative solution to nasal continuous airway pressure (nCPAP) for the treatment of obstructive sleep apnea syndrome (OSAS). OBSERVATION: We report the case of a patient with history of chronic atrial fibrillation and moderate supine-dependent OSAS in whom central sleep apneas developed during treatment by a bi-bloc MA device. Central apneas increased with the level of MA and preferentially occurred in the supine position. We hypothesized that mouth opening under excessive mandibular advancement in supine position may have led to pharyngeal narrowing at the base of the tongue and potentially unstable ventilation. Sleep fragmentation that enhanced during progressive MA may also have compromised ventilatory control stability in our patient. Finally, chronic atrial fibrillation may have predisposed to central sleep apneas. CONCLUSION: Our case report highlights the importance of follow-up nocturnal recordings during progressive MA.

[Long term use of nCPAP therapy in sleep apnoea patients]. / Acceptation a long terme du traitement par pression positive continue.

INTRODUCTION: Although obstructive sleep apnoea syndrome (OSAS) is usually a lifelong condition, little is known about compliance with nasal continuous positive airway pressure (nCPAP) over longer periods of follow up. METHODS: Long term acceptance of nCPAP was evaluated retrospectively using a survival analysis in 137 consecutive patients who started nCPAP therapy for OSAS between 1985 and 1993. RESULTS: During a mean follow-up of 9.2 +/- 4.7 years, 30 patients died, 5 were lost of follow-up and 30 patients stopped their treatment most of them during the first 5 years. In compliant patients, the median value of daily nCPAP use was 7.5 hours. Kaplan Meier analysis showed that 82% of patients were still using nCPAP at 5 years, 77% at 10 years and 61% at 15 years. Multivariate analysis showed that OSAS severity was an independent predictor of long-term nCPAP use. The rate of nCPAP acceptance at 10 years was 82% in patients with an apnoea-hypopnoea index (AHI) > or = 30 compared to 58% in patients with AHI < 30. CONCLUSION: nCPAP is a suitable long-term therapy for OSAS, particularly in patients with more severe disease, with more than 80% of patients continuing to be compliant with treatment at 10 years.

Economic arguments for the immediate management of moderate-to-severe obstructive sleep apnoea syndrome.

The objective of this study was to measure the impact of a 6-month delay in the diagnosis and treatment of patients with moderate obstructive sleep apnoea syndrome (OSAS) (apnoea/hypopnoea index (AHI) < 30) or severe OSAS (AHI > or = 30) on daytime sleepiness, cognitive functions, quality of life and healthcare expenditure (hospitalisations, medical visits, complementary tests, biological tests and drug prescriptions). In addition, this study aimed to analyse the incremental cost effectiveness ratios related to daytime sleepiness or quality of life following immediate introduction of treatment in these two populations. This study was conducted as a multicentre randomised controlled trial and carried out at two teaching hospitals in France. A total of 171 patients were followed for 6 months, with 82 patients randomised to group 1 "immediate polysomnography" and 89 in group 2 "polysomnography within 6 months". Patients with severe OSAS were deprived of a significant improvement of their daytime sleepiness (5.1 +/- 5.0 at the Epworth Sleepiness Scale score in group 1 versus 0.2 +/- 3.4 in group 2) and quality of life (12.4 +/- 13.3 at the Nottingham Health Profile score in group 1 versus 0.7 +/- 10.1 in group 2) during the waiting time. The impact of delayed management in subjects with less severe OSAS only concerned daytime sleepiness (1.1 +/- 3.3 in group 1 versus 0.3 +/- 4.3 in group 2). Delayed treatment did not affect cognitive functions or healthcare expenditure regardless of the severity of the disease. Incremental cost effectiveness ratios related to rapid introduction of treatment were significantly lower in the patients with more severe OSAS. These results provide fairly clear medical and economic arguments in favour of early management of patients with more severe forms of obstructive sleep apnoea syndrome.

Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome.

The aim of this cross-sectional study was to evaluate the frequency of type-2 diabetes and impaired glucose tolerance (IGT) in a large clinic-based male population presenting various degrees of obstructive sleep apnoea syndrome (OSAS) and to analyse the relationship between OSAS and glucose-insulin metabolism. Male patients (n=595) with suspected OSAS underwent both nocturnal polysomnography and a 2-h oral glucose-tolerance test with measurements of fasting and postload blood glucose and plasma insulin. Insulin sensitivity was evaluated by the ratio of fasting glucose to fasting insulin. OSAS was diagnosed in 494 patients, while 101 patients were nonapnoeic snorers. Type-2 diabetes was present in 30.1% of OSAS patients and 13.9% of nonapnoeic snorers. IGT was diagnosed in 20.0% of OSAS patients and 13.9% of nonapnoeic snorers. Fasting and postload blood glucose increased with severity of sleep apnoea. Insulin sensitivity decreased with increasing severity of sleep apnoea. In addition to body mass index and age, the apnoea/hypopnoea index independently influenced postload blood glucose and insulin sensitivity. The authors conclude that in a clinic-based sample of patients, obstructive sleep apnoea syndrome is associated with a high frequency of type-2 diabetes and impaired glucose tolerance. The relationship between sleep-disordered breathing and impaired glucose-insulin metabolism is independent of obesity and age.

[Obstructive sleep apnea syndrome and cardiovascular risk]. / Syndrome d'apnées obstructives du sommeil et risque cardio-vasculaire.

Numerous studies have shown that obstructive sleep apnea syndrome (OSAS) is associated with an increased cardiovascular morbidity and mortality. Obstructive sleep apnea syndrome and cardiovascular disorders are frequent diseases. They share several risk factors such as age, gender, obesity, smoking, and alcohol. Therefore it is difficult to demonstrate that OSAS is a cardiovascular risk factor, independent of previously known factors. Recent epidemiological studies and trials, consistent with the results of previous studies, have demonstrated a strong association between OSAS and systemic hypertension. They also suggest that there is a possible cause-effect relation between OSAS and coronary artery disease or cardiac arrhythmias. Studies demonstrating that early recognition and treatment of OSAS may be effective in reducing these cardiovascular complications are still needed.

[Profiles of 939 patients with obstructive sleep apnea syndrome treated with continuous positive pressure]. / Typologie de 939 patients traités par pression positive continue pour syndrome d'apnées obstructives du sommeil.

The aim of this study was to analyze the characteristics of patients on long-term continuous positive pressure therapy for obstructive sleep apnea in order to determine the efficacy, observance, tolerance, degree of patient satisfaction and patient quality of life using the Nottingham scale. A questionnaire was sent to 939 patients treated for at least six months in 11 centers. Factorial analysis of multiple correspondences and two classification analyses were used to establish patient profiles. Factorial analysis evidenced a relationship between patient satisfaction, reduced symptoms, observance and tolerance. The classification analyses distinguished three groups. Group A (n = 596) included primarily men (93%) who were satisfied with the treatment (99%) and showed good observance. Group B (n = 284) was characterized by patient satisfaction, observance, improved symptoms and lower quality of life than group A. Group C was composed of older patients who were satisfied with their treatment and showed good observance but who had no notable improvement in their symptoms. In conclusion, this study pointed out the difficulty in defining which patients with obstructive sleep apnea would benefit most from continuous positive pressure therapy. Good observance is not a sufficient criterion for therapeutic efficacy.

Simultaneous laboratory-based comparison of ResMed Autoset with polysomnography in the diagnosis of sleep apnoea/hypopnoea syndrome.

ResMed Autoset (AS) is a simplified diagnosis system for obstructive sleep apnoea/hypopnoea syndrome (OSAS) based on the respiratory flow/time relationship by pressure variation measured through simple nasal prongs. A multicentre prospective trial was used to compare AS and polysomnography (PSG) for diagnosing 95 patients, with suspected OSAS. Physicians gave a pretest probability of the patient having OSAS. The apnoea/hypopnoea index (AHI) was compared between the two methods of diagnosis for the whole population and for subgroups according to the pretest probability. Twenty-four patients had AHI < 15 events x h(-1) on PSG and 19 AHI 15-30, and 52 patients had AHI > or = 30. Correlation between AHI assessed by AS and PSG was r=0.87 for total sleep time (TST), p<0.0001. A Bland and Altman plot gave an agreement between the two methods of +/-40%. For a threshold of AHI > or = 15 events x h(-1) to diagnose OSAS, AS has a sensitivity of 92%, specificity of 79%, positive predictive value of 93% and negative predictive value of 76%. With a pretest probability > or = 80%, sensitivity and positive predictive value were 98 and 100% respectively. Of six false negative, four had a high pretest probability (> 80%) or Epworth score > or = 10. Using these parameters as a criterion for proceeding to PSG after a negative AS study would mean that two apnoeic patients (AHI 20 and 17 events x h(-1) by PSG) would escape detection. The Autoset is useful for the detection of obstructive sleep apnoea but with high pretest probability and a negative Autoset result polysomnography should be performed.

A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: benefits, tolerance, compliance and quality of life.

The aim of this study was to investigate in a large population of patients with obstructive sleep apnoea and on long-term treatment with continuous positive airway pressure (CPAP) the patients' perception of symptomatic improvement, side-effects and quality of life. Questionnaires were mailed via local respiratory homecare associations to 5,339 French patients who had been treated at home for at least 6 months with CPAP machines and who continued their treatment. In total, 3,225 questionnaires were analysable. More than 80% of the responding patients reported that CPAP treatment had greatly improved their symptoms. Despite discomfort related to nasal problems and excess noise from the blower, the mean rate of use for the whole population was 6 h 36 min+/-2 h 15 min. The perceived health evaluated by the Nottingham Health Profile was good (mean score <50) for at least 75% of the patients in each dimension explored. The perceived health was significantly related to the improvement in symptoms, the overall satisfaction and the objective compliance. This retrospective study indicates that patients who continued continuous positive airway pressure treatment for more than 6 months felt a great improvement in their symptoms, were satisfied with the treatment and had a relatively good perception of their health.