[Healthy sleep: evidence and guidelines for action. Official document of the Spanish Sleep Society]. / Sueño saludable: evidencias y guias de actuacion. Documento oficial de la Sociedad Española de Sueño.

One of the main objectives of the Spanish Sleep Society is to promote healthy sleep in both the general population and in health professionals. This document aims to conduct a review of the current scientific literature on sleep habits that can serve as the basis on which to establish a set of general recommendations, regarding healthy sleep, for use by the general population in Spain as well as to identify the main challenges faced by research into sleep habits. The document has been developed by a multidisciplinary team made up of members of the Spanish Sleep Society who are experts in paediatric sleep medicine, clinical neurophysiology, pulmonology, neurology, chronobiology, physiology and psychology. The existing scientific literature dealing with sleep habits in the general population was reviewed, and the following aspects were addressed: the current state of sleep habits in the Spanish population; a generic review of the optimum number of hours of sleep; the impact of the environmental setting (noise, temperature, illumination, etc.), hours of sleep, diet and sport, together with several specific sections for children and teenagers, shift-workers and drivers of different vehicles. The conclusions from all the aspects addressed in this document have resulted in a set of final general recommendations that will serve as a guide for the general population and health professionals. Likewise, the principal environmental challenges and future lines of research are also discussed.

Trastornos respiratorios del sueño en Pediatría. Estado de la cuestión / Sleep respiratory disorders in Pediatrics. State of the question

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Effects of adenotonsillectomy on plasma inflammatory biomarkers in obese children with obstructive sleep apnea: A community-based study.

BACKGROUND: Obesity and obstructive sleep apnea syndrome (OSA) are highly prevalent and frequently overlapping conditions in children that lead to systemic inflammation, the latter being implicated in the various end-organ morbidities associated with these conditions. AIM: To examine the effects of adenotonsillectomy (T&A) on plasma levels of inflammatory markers in obese children with polysomnographically diagnosed OSA who were prospectively recruited from the community. METHODS: Obese children prospectively diagnosed with OSA, underwent T&A and a second overnight polysomnogram (PSG) after surgery. Plasma fasting morning samples obtained after each of the two PSGs were assayed for multiple inflammatory and metabolic markers including interleukin (IL)-6, IL-18, plasminogen activator inhibitor-1 (PAI-1), monocyte chemoattractant protein-1 (MCP-1), matrix metalloproteinase-9 (MMP-9), adiponectin, apelin C, leptin and osteocrin. RESULTS: Out of 122 potential candidates, 100 obese children with OSA completed the study with only one-third exhibiting normalization of their PSG after T&A (that is, apnea-hypopnea index (AHI) ≤1/hour total sleep time). However, overall significant decreases in MCP-1, PAI-1, MMP-9, IL-18 and IL-6, and increases in adropin and osteocrin plasma concentrations occurred after T&A. Several of the T&A-responsive biomarkers exhibited excellent sensitivity and moderate specificity to predict residual OSA (that is, AHI⩾5/hTST). CONCLUSIONS: A defined subset of systemic inflammatory and metabolic biomarkers is reversibly altered in the context of OSA among community-based obese children, further reinforcing the concept on the interactive pro-inflammatory effects of sleep disorders such as OSA and obesity contributing to downstream end-organ morbidities.

Eficacia de la adenoamigdalectomía en el síndrome de apneas-hipopneas durante el sueño valorada mediante poligrafía respiratoria / Evaluation of the efficacy of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome in children using respiratory polygraphy

Objetivo: Evaluar la eficacia del tratamiento quirúrgico mediante adenoamigdalectomía en el síndrome de apnea-hipopnea durante el sueño (SAHS) en la infancia mediante poligrafía respiratoria (PR). Material y métodos: Estudio prospectivo en niños menores de 14 años remitidos con la sospecha clínica de SAHS. A todos ellos se les realizó una historia clínica, examen físico general y otorrinolaringológico, así como PR previa a la adenoamigdalectomía y 6 meses después. Se excluyeron los síndromes cráneo-faciales, las alteraciones neuromusculares y la enfermedad concomitante grave. Resultados: Se estudiaron 150 casos (67,3% varones), con una edad media de 3,74±1,80 años y un percentil de IMC de 41,70±31,75, diagnosticados de SAHS, cuando el número total de eventos respiratorios, apneas más hipopneas, dividido por el tiempo total del estudio (IER) era mayor de 4,6, mediante PR previa a la cirugía. El IER medio fue de 15,18±11,11; del total, 58,7% (88) presentaba un SAHS grave (IER>10). Después de 6 meses tras la cirugía, mejoraron todos los parámetros clínicos y poligráficos. Persistió enfermedad (IER>4,6) en 21 pacientes (14%). Ninguno de ellos presentó IER>10 tras la cirugía. El IER preoperatorio se relacionó significativamente con la persistencia de enfermedad (p=0,042). Conclusiones: La PR es útil para monitorizar la eficacia del tratamiento quirúrgico mediante adenoamigdalectomía en el SAHS infantil (AU)

Objetive: To evaluate the effectiveness of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) in children by respiratory polygraphy (RP). Material and methods: Prospective study was conducted on children referred with clinical suspicion of OSAHS. A clinical history was taken and a general physical and ENT examination was performed on all patients. RP was performed before adenotonsillectomy and six months afterwards. Patients with craniofacial syndromes, neuromuscular disorders, and severe concomitant disease were excluded. Results: We studied 150 children (67. 8% male), with a mean age of 3.74±1.80 years and a BMI of 41.70±31.75. A diagnosis of OSAHS was made if the total number of respiratory events, apneas and hypopneas, divided by the total study time (RDI) was > 4.6, using RP before undergoing adenotonsillectomy. The mean respiratory disturbance index (RDI) was 15.18±11.11, with 58.7% (88) of with severe OSAHS (RDI>10). There was a significant improvement in all clinical and polygraphic variables six months after adenotonsillectomy. The residual OSAHS was 14%. The preoperative RDI was significantly associated with persistent disease (P=0.042). Conclusions: Respiratory polygraphy is useful for monitoring the efficacy of surgical treatment by adenotonsillectomy in children with OSAHS (AU)

[Evaluation of the efficacy of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome in children using respiratory polygraphy]. / Eficacia de la adenoamigdalectomía en el síndrome de apneas-hipopneas durante el sueño valorada mediante poligrafía respiratoria.

OBJECTIVE: To evaluate the effectiveness of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) in children by respiratory polygraphy (RP). MATERIAL AND METHODS: Prospective study was conducted on children referred with clinical suspicion of OSAHS. A clinical history was taken and a general physical and ENT examination was performed on all patients. RP was performed before adenotonsillectomy and six months afterwards. Patients with craniofacial syndromes, neuromuscular disorders, and severe concomitant disease were excluded. RESULTS: We studied 150 children (67. 8% male), with a mean age of 3.74±1.80 years and a BMI of 41.70±31.75. A diagnosis of OSAHS was made if the total number of respiratory events, apneas and hypopneas, divided by the total study time (RDI) was > 4.6, using RP before undergoing adenotonsillectomy. The mean respiratory disturbance index (RDI) was 15.18±11.11, with 58.7% (88) of with severe OSAHS (RDI>10). There was a significant improvement in all clinical and polygraphic variables six months after adenotonsillectomy. The residual OSAHS was 14%. The preoperative RDI was significantly associated with persistent disease (P=.042). CONCLUSIONS: Respiratory polygraphy is useful for monitoring the efficacy of surgical treatment by adenotonsillectomy in children with OSAHS.

Avances en el diagnóstico y tratamiento del síndrome de apneas del sueño (SAHS) / Advances in the diagnosis and treatment of sleep apnea syndrome (SAS)

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Diagnóstico precoz, seguimiento y control del paciente con síndrome de apneas-hipopneas durante el sueño / Early diagnosis, follow-up and control of patients suffering from sleep apnoea-hipoapnoea syndrome

El síndrome de apneas-hipopneas durante el sueño (SAHS) se define como un cuadro de somnolencia excesiva, trastornos cognitivo-conductuales, respiratorios, cardiacos, metabólicos o inflamatorios secundarios a episodios repetidos de obstrucción de la vía aérea superior (VAS) durante el sueño. Estos episodios se miden con el índice de alteraciones respiratorias (IAR), definido como número de apneas, hipopneas y ERAM (esfuerzos respiratorios asociados a microdespertares). Un IAR# 5 asociado a síntomas relacionados con la enfermedad y no explicados por otras causas, confirma el diagnóstico de SAHS. En la práctica el número de pacientes diagnosticados de SAHS depende de la disponibilidad de medios técnicos adecuados, del número de laboratorios de sueño y de la accesibilidad a los mismos. El papel del médico de atención primaria es fundamental tanto en el diagnóstico de sospecha como en el seguimiento y control de los pacientes con SAHS. El diagnóstico de sospecha de SAHS se realizará a partir de una historia clínica compatible y, aunque no existe ningún síntoma específico de SAHS, tres son los síntomas clave para establecer la sospecha diagnóstica: ronquidos entrecortados, pausas asficticas y excesiva somnolencia diurna o sueño no reparador. Los pacientes identificados en atención primaria con sospecha de SAHS deben ser remitidos a la Unidad de Sueño según unos criterios de derivación de forma preferente, urgente u ordinaria. Los médicos de atención primaria deben desempeñar un papel importante en el seguimiento de los pacientes diagnosticados de SAHS y deberían realizar vigilancia de las medidas higienicodietéticas, evaluar el grado de adhesión y eficacia del tratamiento con presión positiva continua sobre la vía aérea superior (CPAP), y la aparición de efectos secundarios (AU)

Sleep apnoea-hipoapnoea syndrome (SAHS) is defined by excessive daytime sleepiness, and cognitive-behavioural, respiratory, cardiac, metabolic or inflammatory disorders, secondary to repetitive episodes of upper airway collapse during sleep. These episodes are ass essed with the respiratory alteration index (RAI), defined by the number of apnoeas, hipoapnoeas and REAM (respiratory effort associated to microarousals). A RAI<=5, together with disease symptoms not explained by other causes, confirms the diagnosis of SAHS. In practice, the number of patients diagnosed of SAHS depends on appropriate technical resources availability, and on the number and accessibility to sleep laboratories. The role of primary care physicians is fundamental as much for the diagnosis as for the follow-up and control of patients suffering from SAHS. SAHS diagnosis starts with a compatible clinical history and, although there are not specific SAHS symptoms, there are 3 key symptoms to suppose the diagnosis: laboured snoring, asphyxiating breaks and excessive daytime sleepiness or no refreshing sleep. Patients identified in primary care suspicious of a SAHS diagnosis must be sent to a Sleep Unit following specific derivation criteria: preferential, urgent or ordinary. Primary care physicians should play an important role in the follow-up of SAHS patients. They should pay attention to hygienic-dietary measures and assess thedegree of both, performance and efficacy, of the treatment with continuous positive air pressure (CPAP) and the development of side effects (AU)

[Sleep apnea syndrome in children]. / Syndrome d'apnées hypopnées du sommeil chez l'enfant.

Obstructive sleep apnea is characterized by prolonged, generally partial, upper airways obstruction associated with hypoxemia and/or hypercapnia. Main etiological factors include hypertrophy of the tonsils and adenoids. Polysomnography is the gold standard for diagnosis. Diagnosis of obstructive sleep apnea must be established early in order to prevent complications. Adenotonsillectomy is an effective therapy.

Síndrome de resistencia aumentada de la vía aérea superior. ¿Una entidad específica? / Increased upper airway resistance syndrome: a specific diagnosis?

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[Situation in Spain of the diagnostic resources and of the treatment with continuous positive pressure respiration in sleep obstructive apnea-hypopnea syndrome]. / Situación en España de los recursos diagnósticos y de los tratamientos con presión positiva continua sobre la vía aérea, en el síndrome de apneas-hipopneas obstructivas del sueño.

Sleep apnea-hypopnea syndrome (SAHS) is a major health problem whose estimated prevalence is 2 to 4% of the population. The Respiratory Insufficiency and Sleep Disorders Task Force estimated in 1995 that over one million people suffer SAHS with clinical repercussions in Spain while the number of patients receiving treatment was 8,000; diagnostic resources were not widely available. The aim of this study was to analyze the current situation in Spain. A survey carried out nation-wide in the period from 1995 to 1997 revealed that approximately 28,000 individuals were receiving nighttime support ventilation, signifying a prevalence of 72 per 100,000 inhabitants for this type of treatment. This situation has come about in a context of insufficient availability of diagnostic tools, with nocturnal oxygen levels having been established for some 37% of patients. We conclude that a broad plan to diagnose and treat patients with SAHS is required. The plan should include: a) greater availability of diagnostic tools; b) protocols for coordination; c) programs for continuous training and updating of knowledge of this disease, and d) revision of systems for financing support ventilation.

Situación en España de los recursos diagnósticos y de los tratamientos con presión positiva continua sobre la vía aérea, en el síndrome de apneas-hipopneas obstructivas del sueño / Continuous positive airway pressure for obstructive sleep apnea syndrome: the current state of diagnostic resources and therapy in Spain

El síndrome de apneas-hipopneas del sueño (SAHS) constituye un problema de salud de primera magnitud con una prevalencia estimada del 2-4 por ciento de la población. En 1995, el grupo de trabajo del Área de Insuficiencia Respiratoria y Trastornos del Sueño estimó que en España había más de un millón de personas que sufrían de SAHS, con repercusión clínica, mientras que el número de pacientes en tratamiento entonces ascendía a 8.000, y se constataba una baja disponibilidad de métodos diagnósticos. El objetivo de este estudio es analizar la situación actual en nuestro país y para ello en el período 1995-1997 y mediante cuestionario, llevado a cabo en todo el territorio español, hemos constatado que a finales de 1997 aproximadamente 28.000 personas realizan tratamiento con soporte ventilatorio nocturno, lo que implica una prevalencia de estos tratamientos de 72/100.000 habitantes y todo ello con un nivel insuficiente en cuanto a recursos diagnósticos, que son establecidos hasta en un 37 por ciento de los casos con registro oximétrico nocturno. Concluimos que es precisa la elaboración de un plan global para el diagnóstico y tratamiento de pacientes con SAHS que incluya: a) incremento de recursos diagnósticos; b) protocolos de coordinación; c) programas de formación continuada en esta disciplina, y d) replanteamiento de las fórmulas de financiación de los sistemas de soporte ventilatorio. (AU)

[Validation of half-night polysomnography for sleep apnea/hypoapnea syndrome]. / Validación de estudios polisomnográficos de mitad de la noche en el síndrome de apneas/hipoapneas durante el sueño.

UNLABELLED: A diagnosis of sleep apnea/hypopnea syndrome (SAHS) is based on clinical signs and nighttime polysomnograms. Brief polysomnography has been proposed as an alternative to all-night recording. OBJECTIVES: The aim of this study was to determine whether a polysomnograms obtained during the first half of the night is sufficient for establishing a diagnosis of SAHS and to determine the correlation between polysomnographic variables recorded during the first four hours (half the study time) with those recorded over the full eight hours (full study time), as well as to determine diagnostic agreement. DESIGN: Thirty-five patients suspected of having SAHS were studied prospectively. Baseline polysomnograms were scored blindly by two independent observers following standard methods. A diagnosis of SAHS was made according to guidelines of the Spanish Society of Pneumology and Chest Surgery. During the first half of the night and up to the end of each recording period we gathered neurophysiological and respiratory variables and diagnostic impressions. RESULTS: The correlation between variables (sleep stage, overall AHI, REM-AHI, non-REM-AHI and sleep efficiency) recorded in the first half of the night and throughout the night was significant (p < 0.05) by both Pearson's correlation coefficient (r) and by the intraclass correlation coefficient (ICC). In 33 of 35 patients (94.3%) diagnostic agreement was achieved (95% CI 80.84-99.30); when SAHS was severe, agreement was 100%. CONCLUSION: Based on these results, we conclude that for patients with a diagnosis of severe SAHS during the first half of the night, data recorded during the second half can be considered supplementary.

Validación de estudios polisomnográficos de mitad de la noche en el síndrome de apneas/hipoapneas durante el sueño / Validation of half-night polysomnograms for sleep apnea syndrome

El diagnóstico del síndrome de apneas/hipoapneas del sueño (SAHS), se establece en función de manifestaciones clínicas y registros polisomnográficos (PSG) nocturnos. Como alternativa a la PSG nocturna completa, se han propuesto estudios nocturnos abreviados. Objetivos: Determinar si la corrección de la PSG de la primera mitad de la noche es suficiente para establecer el diagnóstico de SAHS y analizar la correlación existente entre las variables polisomnográficas de los registros de 4 h (mitad del estudio) frente a los de ocho horas de duración (estudio completo), así como determinar la coincidencia diagnóstica. Diseño: Se estudian de forma prospectiva 35 pacientes con sospecha clínica de SAHS, a los que se realiza un estudio polisomnográfico basal nocturno, corregido de forma ciega por dos observadores diferentes, según los métodos estándar. El diagnóstico de SAHS, se realiza según la normativa de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). En la primera mitad y al final del estudio PSG se recogen variables neurofisiológicas, respiratorias y la impresión diagnóstica. Resultados: La correlación encontrada entre las diferentes variables consideradas (estadios de sueño, índice de apnea/hipoapnea [IAH] global, IAH REM, IAH no REM y eficiencia del sueño) entre la mitad (MN) y el estudio PSG completo (TN) es significativa para un valor de p < 0,05, tanto al aplicar el coeficiente de correlación de Pearson (r) como al aplicar el coeficiente de correlación intraclase (CCI). La coincidencia diagnóstica se produjo en 33 de los 35 pacientes estudiados (94,3 por ciento; intervalo de confianza [IC] del 95 por ciento: 80,84-99,30), siendo del 100 por ciento en el caso de los SAHS severos. Conclusión: Sobre la base de los resultados obtenidos, concluimos que los pacientes con diagnóstico de SAHS severo en la primera mitad de la noche son subsidiarios de estudios de titulación en la segunda mitad de la noche. (AU)

[Efficacy of demand of positive airway pressure therapy for treating obstructive sleep apnea syndrome]. / Eficacia de la presión positiva a demanda en el tratamiento del síndrome de apnea obstructiva del sueño.

UNLABELLED: The treatment of choice for obstructive sleep apnea syndrome (OSAS) is nasal continuous positive airway pressure (nCPAP). The precise level of pressure is adjusted by polysomnography. Devices to deliver pressure on demand have recently been designed to adapt the level of pressure to each respiratory cycle according to flow modification. OBJECTIVE: To compare the manual titering nCPAP system with that of demand continuous positive airway pressure (nDPAP) in patients diagnosed of OSAS. PATIENTS AND METHODS: Eighteen consecutive patients whose OSAS was diagnosed by conventional polysomnography were enrolled with apnea-hypopnea indexes over 10/hour (AHI > 10) and clinical symptoms of daytime drowsiness and/or cardiovascular risk factors. Titering polysomnographs were performed for all patients with nCPAP and with nDPAP and analyzed blindly. RESULTS: No significant differences between nCPAP and nDPAP were found in neurophysiological variables analyzed (sleep architecture, arousals, sleep efficiency) or in respiratory variables (AHI, oxygen saturation) with the exception of minimum SatO2 during REM sleep, which was significantly better with nCPAP (p < 0.03). Mean end pressure with nCPAP and mean pressure with nDPAP were similar; it is also worth noting that mean pressure was lower with nDPAP than with titered nCPAP pressure a mean 65.7 +/- 22% of the time. CONCLUSION: Automatic nDPAP is as effective as titered nCPAP for treating patients with OSAS.

The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander.

BACKGROUND AND METHODS: Drowsiness and lack of concentration may contribute to traffic accidents. We conducted a case-control study of the relation between sleep apnea and the risk of traffic accidents. The case patients were 102 drivers who received emergency treatment at hospitals in Burgos or Santander, Spain, after highway traffic accidents between April and December 1995. The controls were 152 patients randomly selected from primary care centers in the same cities and matched with the case patients for age and sex. Respiratory polygraphy was used to screen the patients for sleep apnea at home, and conventional polysomnography was used to confirm the diagnosis. The apnea-hypopnea index (the total number of episodes of apnea and hypopnea divided by the number of hours of sleep) was calculated for each participant. RESULTS: The mean age of the participants was 44 years; 77 percent were men. As compared with those without sleep apnea, patients with an apnea-hypopnea index of 10 or higher had an odds ratio of 6.3 (95 percent confidence interval, 2.4 to 16.2) for having a traffic accident. This relation remained significant after adjustment for potential confounders, such as alcohol consumption, visual-refraction disorders, body-mass index, years of driving, age, history with respect to traffic accidents, use of medications causing drowsiness, and sleep schedule. Among subjects with an apnea-hypopnea index of 10 or more, the risk of an accident was higher among those who had consumed alcohol on the day of the accident than among those who had not. CONCLUSIONS: There is a strong association between sleep apnea, as measured by the apnea-hypopnea index, and the risk of traffic accidents.

[Level of compliance in the treatment of sleep obstructive apnea syndrome with nasal continuous positive pressure]. / Nivel de cumplimiento en el tratamiento del síndrome de apnea obstructiva del sueño con presión positiva continua nasal.

The therapy of the obstructive sleep apnea syndrome (OSAS) with nasal continuous positive airway pressure (CPAP) eliminates symptoms of OSAS and is currently the non-surgical therapy of choice. The present study was undertaken to evaluate the compliance with such therapy in our setting, the factors associated with it, and the secondary effects. A sample of 88 patients diagnosed with OSAS and undergoing CPAP followed for a period of 29 +/- 11 months was studied. The results showed that compliance among our patients, as measured by time counter, was 70% and was associated with drowsiness degree, apnea/hypopnea index, and mean pressure of CPAP. The subjective evaluation of compliance by patients overestimates the actual use of the CPAP device. There was a high satisfaction degree with therapy, and secondary effects were not a limiting factor for compliance. The therapeutical approach of the patient must be on an individual basis if a good acceptance level is to be achieved.

[Metastatic pulmonary fibrosarcoma: apropos a case and a review of the literature]. / Fibrosarcoma pulmonar metastásico: a propósito de un caso y revisión de la literatura.

Fibrosarcoma is a rare entity that affects soft tissues in a variety of locations, although it is most commonly found on the extremities. Local recurrence is frequent and metastasis usually takes place in pulmonary tissues early on, within a mean interval of 12 months. We present a case of pulmonary metastasis after fibrosarcoma of the leg that had been diagnosed and treated 14 years earlier.