Documento internacional de consenso sobre apnea obstructiva del sueño / International Consensus Document on Obstructive Sleep Apnea

El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del documento internacional de consenso. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte). Palabras clave: Apnea obstructiva del sueño Diagnóstico Tratamiento

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents). Keywords: Obstructive sleep apnea Diagnosis Treatment

Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study).

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) has been associated with cardiovascular events (CVEs), although recent randomized controlled trials have not demonstrated that long-term continuous positive airway pressure (CPAP) prevents CVEs. Our objective was to determine the effect of CPAP on older adults with moderate OSA regarding CVE reduction. METHODS: An observational and multicenter study of a cohort of older adults (> 70 years of age) diagnosed with moderate OSA (apnea-hypopnea index 15.0-29.9 events/h) was conducted. Two groups were formed: (1) CPAP treatment and (2) standard of care. The primary endpoint was CVE occurrence after OSA diagnosis. Association with CPAP treatment was assessed by propensity score matching and inverse weighting probability. Secondary endpoints were incidence of CVE separately and time to first CVE. RESULTS: A total of 614 patients were included. After matching, 236 older adults (111 men, mean age 75.9 ± 4.7 years) with a follow-up of 47 months (interquartile range: 29.6-64.0 months) were considered for primary and secondary endpoint evaluations. Forty-one patients presented at least 1 CVE (17.4%): 20 were in the standard-of-care group (16.9%) and 21 were in the CPAP group (17.8%), with a relative risk of 1.05 (95% confidence interval [CI], 0.60-1.83; P = .43) for CPAP treatment. Inverse probability weighting of the initial 614 patients determined an adjusted relative risk of 1.24 (95% CI, 0.79-1.96; P = .35) for CPAP treatment. No statistical differences were found in secondary endpoint analyses. CONCLUSIONS: CPAP should not be prescribed to reduce CVE probability in older adults with moderate OSA. CITATION: López-Padilla D, Terán-Tinedo J, Cerezo-Lajas A, et al. Moderate obstructive sleep apnea and cardiovascular outcomes in older adults: a propensity score-matched multicenter study (CPAGE-MODE study). J Clin Sleep Med. 2022;18(2):553-561.

Diagnostic accuracy of nasal cannula versus microphone for detection of snoring.

OBJECTIVE: Snoring is a common reason for referral to a sleep unit. Although there are several instruments to measure snoring, there is no gold standard for this purpose. In this study, we determine the diagnostic accuracy of the cannula as compared with the microphone, which are the two most commonly used tools. STUDY DESIGN: We performed a cross-sectional study of 75 patients who underwent baseline home sleep apnea testing for any reason. METHODS: Snore intensity and percentage were assessed during Home sleep-apnea testing via nasal cannula and microphone in all patients. We performed a complete diagnostic accuracy analysis, assuming the microphone to be the reference instrument use in order to compare it with the cannula. RESULTS: The intra-class correlation coefficient between the cannula and microphone for the percentage of snoring was 0.25. The Bland Bland-Altman analysis to determine the agreement regarding the percentage of snoring showed a lower limit of -57.73 and an upper limit of 20.30. A linear regression analysis of the differences produced a negative slope of -0.86. The receiver operating characteristic curve for severe snoring using the cannula produced an area under the curve of 0.67 (P = 0.019). The cannula showed a sensitivity of 57.89 and a specificity of 73.21. CONCLUSION: The nasal cannula showed poor reliability and accuracy for measuring snoring. LEVEL OF EVIDENCE: 2b. Laryngoscope, 127:2886-2890, 2017.

Terapias ventilatorias domiciliarias en el síndrome de apnea-hipopnea del sueño / Home Ventilation Therapy in Obstructive Sleep Apnea-Hypopnea Syndrome

El síndrome de apnea-hipopnea del sueño es una enfermedad muy prevalente, con tasas altas de infradiagnóstico en el momento actual, que conlleva un elevado impacto sanitario, económico y social, y consume gran parte de los recursos destinados a las terapias respiratorias domiciliarias. Con motivo del Año SEPAR 2014 del paciente crónico y las terapias respiratorias domiciliarias, patrocinado por la Sociedad Española de Neumología y Cirugía Torácica, en este artículo se revisa la literatura más reciente publicada sobre las indicaciones del tratamiento de la apnea del sueño y sus controversias, las últimas evidencias de las indicaciones de los distintos dispositivos de presión positiva, así como los modos de ajuste, desde el uso de fórmulas empíricas o estimaciones matemáticas, a los modernos equipos de auto-CPAP, pasando porla titulación manual como «gold standard». Además, se hace hincapié en la necesidad de seguimiento que los pacientes precisan para asegurar la adherencia y cumplimiento de la terapia. Por último, se comentan someramente otros tratamientos, que no son el objetivo del artículo

Obstructive sleep apnea-hypopnea is a highly prevalent disease that is often underdiagnosed at present. It has a significant economic and social welfare impact, accounting for a large part of the resources assigned to home respiratory therapies. As part of the 2014 SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care sponsored by the Spanish Society of Pulmonology and Thoracic Surgery, this article reviews the most recent publications on the indications and controversial issues in the treatment of sleep apnea, the latest evidence for indication of various positive pressure devices, and adjustment modes, ranging from the use of empirical formulae or mathematical estimations to modern auto-CPAP equipment, while not forgetting the gold standard of manual titration. Emphasis is placed on the need for monitoring required by patients to ensure treatment adherence and compliance. Finally, other therapies that are not the object of this article are briefly reviewed

Home ventilation therapy in obstructive sleep apnea-hypopnea syndrome.

Obstructive sleep apnea-hypopnea is a highly prevalent disease that is often underdiagnosed at present. It has a significant economic and social welfare impact, accounting for a large part of the resources assigned to home respiratory therapies. As part of the 2014 SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care sponsored by the Spanish Society of Pulmonology and Thoracic Surgery, this article reviews the most recent publications on the indications and controversial issues in the treatment of sleep apnea, the latest evidence for indication of various positive pressure devices, and adjustment modes, ranging from the use of empirical formulae or mathematical estimations to modern auto-CPAP equipment, while not forgetting the gold standard of manual titration. Emphasis is placed on the need for monitoring required by patients to ensure treatment adherence and compliance. Finally, other therapies that are not the object of this article are briefly reviewed.

¿Puede ser el tiempo de tránsito de pulso útil para detectar hipertensión arterial en pacientes remitidos a la unidad de sueño? / Can Pulse Transit Time Be Useful for Detecting Hypertension in Patients in a Sleep Unit?

Introducción: La relación causal entre el síndrome de apneas e hipopneas de sueño (SAHS) y la hipertensión arterial (HTA) es un hecho establecido en la literatura. El tiempo de tránsito de pulso (PTT) representa el tiempo que tarda el pulso en viajar entre 2 puntos arteriales diferentes, y puede ser útil en la estimación de la presión arterial (PA). Con este estudio se pretende valorar la utilidad del PTT en la estimación de la PA, ya que además de ser una técnica no invasiva y exenta de coste adicional, ofrece la ventaja de evitar arousals, como sucede con la monitorización ambulatoria de la PA (MAPA). Métodos: Estudio prospectivo y observacional realizado en una unidad multidisciplinar de sueño con la colaboración del servicio de Nefrología. Se reclutaron 30 pacientes consecutivos que acuden a consulta de sueño por sospecha de SAHS a los que se les realiza una polisomnografía (PSG) basal seguida de MAPA al día siguiente. Se calcula la PA sistólica (PAS) y la diastólica (PAD) media por PTT en la PSG y se compara con los resultados de la MAPA. Se diagnosticaron como pacientes con hipertensión arterial aquellos con cifras medias de MAPA durante la noche iguales o superiores a 120/70 mmHg, siguiendo normativas internacionales. Resultados: Edad media de 60 años (66% varones). El 80% eran SAHS (36% SAHS grave). La validez diagnóstica de HTA del PTT con respecto a la MAPA considerada como técnica de referencia fue: sensibilidad, 85%; especificidad, 88%; valor predictivo positivo, 85%, y valor predictivo negativo, 88%. El coeficiente de correlación lineal (R) entre la PAS media medida por MAPA durante la noche (desde las 24:00 h del día siguiente hasta las 6:00 h) y por PTT fue de 0,88, con un coeficiente de correlación intraclase de 0,88 (intervalo de confianza: 0,76-0,94), observándose una distribución de todos los sujetos entre ± 15 mmHg de diferencia entre las pruebas. Conclusiones: Existe una correlación positiva entre el PTT y la MAPA en la HTA sistólica. El PTT podría ser una alternativa capaz de ofrecer una medición continua y no invasiva de cribado de HTA no conocida o mal controlada

Introduction: Pulse transit time (PTT) is the time that a pulse wave takes to travel between two different arterial points, and may be useful in estimating blood pressure. This noninvasive technique, which does not add any cost to the procedure, offers the advantage of avoiding ‘arousals’ during sleep measurement as it occurs with ambulatory blood pressure monitoring (ABPM). We aim to confirm the usefulness of PTT for the detection of hypertension, and to study the correlation between both the measurements. Methods: Prospective observational study in a multidisciplinary sleep unit. We recruited 30 consecutive patients attending a sleep clinic and ran a baseline polysomnography followed by an ABPM the following day. Average systolic and diastolic blood pressure (SBP, DBP) by PTT were calculated and compared with ABMP results. In accordance with international guidelines, patients with mean nocturnal ABMP≥120/70 mmHg were diagnosed as having arterial hypertension. Results: Mean age was of 60 years; 66% were male, of whom 80% suffered from sleep apnoea (OSAS). Taking the ABPM as the reference technique, we found that the diagnostic sensitivity of PTT is 85% with a specificity of 88% in the case of SBP, with a positive predictive value of 85% and negative predictive value of 88%. By studying the relationship between mean SBP measured by ABPM and PTT, we found a linear correlation coefficient (R) of 0.88, showing a distribution of all subjects with a difference of ±15 mmHg between the tests. There is also a positive correlation between mean DBP measured for the two tests and with a weaker linear correlation. Conclusions: Pulse transit time shows a strong correlation with blood pressure (measured by ABPM). PTT provides continuous, non-invasive, cuffless blood pressure monitoring free of additional cost and could be an alternative for screening hypertension

Can pulse transit time be useful for detecting hypertension in patients in a sleep unit?

INTRODUCTION: Pulse transit time (PTT) is the time that a pulse wave takes to travel between two different arterial points, and may be useful in estimating blood pressure. This noninvasive technique, which does not add any cost to the procedure, offers the advantage of avoiding 'arousals' during sleep measurement as occurs with ambulatory blood pressure monitoring (ABPM). We aim to confirm the usefulness of PTT for the detection of hypertension, and to study the correlation between both measurements. METHODS: Prospective observational study in a multidisciplinary sleep unit. We recruited 30consecutive patients attending a sleep clinic and ran a baseline polysomnography followed by an ABPM the following day. Average systolic and diastolic blood pressure (SBP, DBP) by PTT were calculated and compared with ABMP results. In accordance with international guidelines, patients with mean nocturnal ABMP ≥ 120/70 mmHg were diagnosed as having arterial hypertension. RESULTS: Mean age of 60years; 66% male, 80% suffered from sleep apnoea (OSAS). Taking the ABPM as the reference technique, we found that the diagnostic sensitivity of PTT is 85% with a specificity of 88% in the case of SBP, with a positive predictive value of 85% and negative predictive value of 88%. By studying the relationship between mean SBP measured by ABPM and PTT, we found a linear correlation coefficient (R) of 0.88, showing a distribution of all subjects with a difference of between ±15mmHg between tests. There is also a positive correlation between mean DBP measured for the two tests, with a weaker linear correlation. CONCLUSIONS: Pulse transit time shows a strong correlation with blood pressure (measured by ABPM). PTT provides continuous, non-invasive, cuffless blood pressure monitoring free of additional cost and could be an alternative for screening hypertension.