Impact of Acute Changes in CPAP Flow Route in Sleep Apnea Treatment.

BACKGROUND: CPAP is the gold standard treatment for OSA and was conceived to be applied through a nasal interface. This study was designed to determine the acute effects of changing the nasal CPAP route to oronasal and oral in upper airway patency during sleep in patients with OSA. We hypothesized that the oronasal route may compromise CPAP's effectiveness in treating OSA. METHODS: Eighteen patients (mean ± SD age, 44 ± 9 years; BMI, 33.8 ± 4.7 kg/m2; apnea-hypopnea index, 49.0 ± 39.1 events/hour) slept with a customized oronasal mask with nasal and oral sealed compartments connected to a multidirectional valve. Sleep was monitored by using full polysomnography and induced by low doses of midazolam. Nasal CPAP was titrated up to holding pressure. Flow route was acutely changed to the oronasal (n = 18) and oral route (n = 16) during sleep. Retroglossal area was continuously observed by using nasoendoscopy. RESULTS: Nasal CPAP (14.8 ± 4.1 cm H2O) was able to stabilize breathing in all patients. In contrast, CPAP delivered by the oronasal and oral routes promoted obstructive events in 12 (66.7%) and 14 (87.5%) patients, respectively. Compared with stable breathing during the nasal route, there was a significant and progressive reduction in the distance between the epiglottis and tongue base and the retroglossal area when CPAP was delivered by the oronasal and oral routes. CONCLUSIONS: CPAP delivered through the oronasal route may compromise CPAP's effectiveness in treating OSA.

Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial.

BACKGROUND: Snoring is extremely common in the general population and may indicate OSA. However, snoring is not objectively measured during polysomnography, and no standard treatment is available for primary snoring or when snoring is associated with mild forms of OSA. This study determined the effects of oropharyngeal exercises on snoring in minimally symptomatic patients with a primary complaint of snoring and diagnosis of primary snoring or mild to moderate OSA. METHODS: Patients were randomized for 3 months of treatment with nasal dilator strips plus respiratory exercises (control) or daily oropharyngeal exercises (therapy). Patients were evaluated at study entry and end by sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index) and full polysomnography with objective measurements of snoring. RESULTS: We studied 39 patients (age, 46 ± 13 years; BMI, 28.2 ± 3.1 kg/m2; apnea-hypopnea index (AHI), 15.3 ± 9.3 events/h; Epworth Sleepiness Scale, 9.2 ± 4.9; Pittsburgh Sleep Quality Index, 6.4 ± 3.3). Control (n = 20) and therapy (n = 19) groups were similar at study entry. One patient from each group dropped out. Intention-to-treat analysis was used. No significant changes occurred in the control group. In contrast, patients randomized to therapy experienced a significant decrease in the snore index (snores > 36 dB/h), 99.5 (49.6-221.3) vs 48.2 (25.5-219.2); P = .017 and total snore index (total power of snore/h), 60.4 (21.8-220.6) vs 31.0 (10.1-146.5); P = .033. CONCLUSIONS: Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01636856; URL: www.clinicaltrials.gov.

Critical closing pressure during midazolam-induced sleep.

The critical closing pressure (Pcrit) is the airway pressure at which the airway collapses and reflects the anatomical contribution to the genesis of obstructive sleep apnea. Pcrit is usually determined during non-rapid eye movement sleep at night, but has been determined under midazolam sedation during the day in the absence of sleep stage monitoring. Indeed, little is known about the effects of midazolam on sleep architecture. Moreover, deeper sedation with midazolam can decrease upper airway muscle activity and increase collapsibility compared with natural sleep. Pcrit under sedation has not been systematically compared with the usual method performed during natural sleep. Therefore, this study aimed to test the hypothesis that Pcrit following low doses of midazolam during the day would be comparable to Pcrit measured during natural sleep in the same patient. Fifteen men (age 54 ± 10 yr, body mass index 30 ± 4 kg/m(2)) with obstructive sleep apnea underwent a baseline standard overnight polysomnogram (apnea-hypopnea index 38 ± 22 events/h, range: 8-66 events/h), and Pcrit was determined during natural sleep and following midazolam. Sleep induction was obtained with low doses of midazolam (2.4 mg, range 2.0-4.4 mg), and sleep architecture was comparable to natural sleep. Natural sleep and induced sleep Pcrit were similar (-0.82 ± -3.44 and -0.97 ± 3.21 cmH(2)O, P = 0.663) and closely associated (intraclass correlation coefficient = 0.92; 95% confidence interval, 0.78-0.97, P < 0.001). Natural and midazolam-induced Pcrit correlated with obstructive sleep apnea severity, indicating that both Pcrit measures provided meaningful physiological information. Pcrit determined during the day with sleep induction is similar to natural overnight sleep and is a valid alternative approach in which to determine Pcrit.

Comparison of full versus short induced-sleep polysomnography for the diagnosis of sleep apnea.

OBJECTIVES/HYPOTHESIS: Polysomnography (PSG) is the gold-standard method for diagnosing obstructive sleep apnea (OSA). However, the gap between demand and capacity in performing PSG is a major health-care problem. We sought to validate a short day-time induced sleep for the diagnosis of OSA. STUDY DESIGN: Prospective diagnostic method validation. METHODS: We studied 25 consecutive patients referred to the sleep laboratory and 15 healthy volunteers. All subjects were evaluated by means of full overnight PSG (Full-PSG) and short day-time induced-sleep PSG (Induced-PSG). Sleep was monitored during both procedures (Embla, 16 channels). Sleep was induced by slow intravenous drip infusion of midazolam. RESULTS: The population studied (N = 40) was 60% male (mean age, 42 ± 10 years; body mass index, 29 ± 6.5 kg/m(2)). Sleep was successfully induced in all subjects, and no complications were observed (midazolam doses, 6.2 ± 3.8 mg; time of induced sleep 41.5 ± 18.9 minutes). The apnea-hypopnea index (AHI) and minimal oxygen saturation during Full-PSG versus Induced-PSG were similar: median AHI (with 25%-75% interquartile range) was 13 (3-35) events per hour versus 17 (4-36) events per hour, and median oxygen saturation was 84% (75-90) versus 85% (76-92); P = .89 and P = .53, respectively. The majority of the respiratory events during induced sleep were obstructive and similar to those observed during Full-PSG. AHI and lowest oxygen saturation during Induced-PSG correlated significantly with Full-PSG (r = 0.67 and r = 0.77, respectively). Sensitivity and specificity for the diagnosis of OSA (AHI > 15 events per hour) by Induced-PSG were 0.83 and 0.72, respectively. CONCLUSIONS: Induced-PSG by midazolam during the day is safe and correlates with Full-PSG; it therefore is a promising alternative method in the diagnosis of OSA.

Tumor carcinóide: broncotomia como alternativa técnica / Carcinoid tumor: bronchotomy as a technical alternative

Geralmente, o tratamento para tumores carcinóides típicos em brônquio é a ressecçäo pulmonar econômica, com ou sem broncoplastia. Este éum relato de caso de uma paciente com tumor carcinóide típico no brônquio lobar inferior esquerdo, junto à carina lobar. Foi realizada broncotomia longitudinal, ressecçäo do tumor e sutura do brónquio, preservando o parênquima pulmonar. A paciente evoluiu bem e apresenta três anos de pós-operatório sem evidência de recidiva da doença nas broncoscopias de controle