Bases fisiopatológicas del tratamiento con CPAP/BIPAP nasal

La presión positiva continua por vía nasal (CPAP) es el tratamiento médico de elección del síndrome de apnea/hipopnea del sueño de tipo obstructivo. La efectividad de la CPAP parece ser multifactorial. Mantiene la permeabilidad de la vía aérea mediante la "separación neumática" de las paredes faríngeas. A pesar de su eficacia, en algunos pacientes persisten desaturaciones de oxigeno debidas a hipoventilación. La BIPAP supone un tratamiento efectivo de las apneas, hipopneas y de la hipoventilación nocturna; mejora significativamente las cifras de los gases sanguíneos en vigilia después de un período de tratamiento (AU)

Neurofisiología de la ventilación durante el sueño

En este artículo se exponen los mecanismos neurofisiológicos que controlan la respiración y los cambios que se producen en los mismos durante el sueño. La alternancia cíclica de los distintos estados de conciencia fisiológicos (vigilia, sueño No REM y sueño REM) se acompaña de variaciones en la función respiratoria. Mientras que en vigilia y en sueño REM la respiración está controlada por un doble mecanismo, automático y conductual, en sueño No REM el control es sólo automático. En los períodos de REM tónico el control es preferentemente automático y en los de REM fásico se activa el control conductual. Los centros de control automático se localizan en el tronco cerebral y dependen de factores homeostáticos; el control conductual se ejerce desde niveles corticales. Durante el sueño se producen diversas modificaciones en la ventilación, que son diferentes en sueño No REM y en sueño REM. La atonía de la musculatura esquelética de la vía aérea superior que se da durante el sueño provoca un aumento de la resistencia inspiratoria, que en los roncadores puede llegar a ser considerablemente superior a la de vigilia (AU)

Taquipnea neurógena ligada al sueño: una etiopatogenia no aclarada

La taquipnea neurógena ligada al sueño (TNLS) es un raro trastorno sobre el que existen muy pocas referencias en la literatura, y con una etiopatogenia no aclarada. Se define como un incremento sostenido de la frecuencia respiratoria durante el sueño, que se mantiene durante el mismo y revierte con el despertar. Algunos pacientes presentan excesiva somnolencia diurna como síntoma de consulta, y en otros es completamente asintomática. Se ha asociado a trastornos respiratorios (ronquido, apneas) y con diferentes patologías del SNC. Se presentan en este trabajo tres pacientes con TNLS estudiados en nuestra unidad, que presentaron características clínicas y polisomnográficas similares a las descritas. Con este motivo se realiza una discusión sobre las posibles causas de este trastorno, con especial énfasis en el papel de la formación reticular (AU)

Acreditación de unidades, centros y laboratorios de sueño

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[Arousal and its influence on vigilance]. / Arousal y su repercusión sobre la vigilia.

INTRODUCTION: The term arousal usually refers to transient, brief arousal during nocturnal sleep or to a state of vigilance which is maintained during the day. DEVELOPMENT AND CONCLUSION: In this review we consider the various accepted meanings and clinical disorders of 'arousal'. Insomnia (hyperarousal), parasomnias (partial arousal) and the sudden death syndrome of infancy are all attributed to disorders of arousal. It is concluded that diurnal hyperarousal leads to difficulty in getting off to sleep and staying asleep, whilst nocturnal arousal leads to excessive somnolence during the day, due to broken sleep during the night.

Periodic leg movements in sleep in essential hypertension.

The presence of periodic leg movements in sleep (PLMS) was assessed in 91 subjects diagnosed with essential hypertension. More than 18 per cent of the sample had PLMS, which is considerably higher than in normal controls. Also, the prevalence was significantly correlated with the severity of hypertension, as well as with age. Periodic leg movements in sleep were more frequent in the first few hours of the sleep period and during sleep stages 1 and 2. The arousing effect of PLMS was minimal, with only 17 per cent of all events related to an EEG arousal. Our results suggest that PLMS are common in people with essential hypertension, although they do not seem to be associated with any particular sleep disorder.

[Sleep apnea in arterial hypertension]. / Apnea del sueño en la hipertensión arterial.

BACKGROUND: The sleep apnea syndrome (SAS) and high blood pressure (HBP) present multiple relations. Apnea culminates with an increase in arterial pressure, and a high percentage of apneic patients have HBP. It has also been reported that SAS is more frequent among hypertensive patients than among the general population. METHODS: In the present study 91 essential hypertensive individuals were studied by a questionnaire and polygraphic study of night sleep, to establish the prevalence of SAS among hypertensive subjects and the predictive value of the clinical questionnaire. RESULTS: The prevalence of SAS in HBP was 8.8%. The greatest predictive value was found for the presence of respiratory pauses every night and throughout the night. The risk factor of greatest association was cigarette smoking and the greatest organic repercussion was observed in renal function. CONCLUSIONS: An increase in the prevalence of sleep apnea syndrome was found among essential hypertensive subjects, thus leading this syndrome to be suggested as a risk factor of high blood pressure. The question as to whether the patients present daily pauses between snores and throughout the entire night is suggestive and implies confirmation by polygraphic study of night sleep.

Changes in psychopathological symptoms in sleep apnea patients after treatment with nasal continuous positive airway pressure.

To evaluate the psychological disturbances associated with obstructive sleep apnea (OSA) and the effect of nasal continuous positive airway pressure (NCPAP) treatment on these alterations, personality patterns and psychosocial adjustment were assessed in patients hypnopolygraphically diagnosed with OSA before and after different periods of NCPAP therapy. Prior to treatment, MMPI results for 23 patients showed significant elevations (p < .01) on five clinical scales compared to those of 17 normal controls. Apneics' personality patterns were predominantly of a "neurotic-mixed" type, indicating an anxiety reaction with paranoid features. Depression, schizophrenia, and hypochondriasis were the highest scales. Most patients had severe psychosocial maladjustment. In the follow-up study during the NCPAP treatment, there was a progressive reduction of the psychopathological signs along with a generalized improvement in psychosocial adaptation. These changes were remarkably significant after about a year's treatment, in particular for depression (p < .01) and total adjustment degree (p < .01). It was concluded that severe OSA is associated with serious psychosocial alterations that improve gradually with NCPAP.

Hypnopolygraphic alterations in Attention Deficit Disorder (ADD) children.

The sleep pattern of 13 prepubertal children, nonmedicated, rigourously diagnosed as Attention Deficit Disorder (ADD) was recorded for two consecutive nights. Analyses of sleep pattern variables revealed a marked reduction of sleep onset latency (p less than .01), a great number of nocturnal awakenings (p less than .01), and a high increase of Delta sleep percentage (p less than .01) for the ADD children compared to normals. In addition, the two subtypes of the disorder--ADD with hyperactivity (ADD/H) and ADD without hyperactivity (ADD/WO) or ADD undifferentiated--showed distinct hypnopolygraphic correlates. Those ADD/H children had a greater sleep fragmentation and a lesser degree of sleep efficiency. These findings would support the hypothesis that ADD is related to a deficient control of arousal level and, on the other hand, suggest that ADD/H and ADD/WO are different clinical entities.

Rett's syndrome: a neurophysiological study.

Thirteen girls with Rett's syndrome were evaluated with wakefulness and sleep polygraphic records and EMG studies. The main EEG findings were paroxysmal activity during sleep, multifocal in younger and unifocal in older girls, and "pseudorhythmic flattening". In the opinion of the authors, the changes with age are related to evolution of the disease or maturational changes of CNS. The affectation of the peripheral nervous system was demonstrated in almost half the patients.

[Immediate effect of nasal continuous positive pressure in the treatment of obstructive sleep apnea]. / Efecto inmediato de la presión positiva continua por vía nasal en el tratamiento de la apnea obstructiva del sueño.

In 8 patients with severe sleep apnea syndrome we have studied the immediate effect of nasal continuous positive airway pressure. A good adaptation to the machine during their stay at the laboratory and the beneficial immediate effect on somnolence was observed. There was found a better efficiency of sleep, shortening of latency, decrease of stage 1, increase of REM and shortening of the latency of REM (rebound of REM sleep). Significant correlations were found between the needed pressure to eliminate apneas and the proportion of stage 1 (r = 0.83), of REM stage (r = 0.72) and stage 2 (r = -0.84) of basal night sleep.

[Rett's syndrome: study of 15 cases]. / Síndrome de Rett: estudio de 15 casos.

A multicentric study of 15 cases of Rett syndrome selected with the diagnostic criteria according HAG-BERG et al: female sex, normal pre and perinatal period, normal psychomotor development through the first months of life, early dementia between 1-3 years of age with autistic behaviour, loss of acquired purposeful hand skill, "washing hands" stereotypies, normal head circumference at birth with later deceleration of head growth and truncal ataxia with gait apraxia. Waking EEG showed unspecific abnormalities while sleep recording demonstrated extremely frequent multifocal spike and sharp waves mainly over the rolandic region and generalized, and also pseudo-periodic suppression of background activity. In 3 cases the EMG showed a peripheral axonal neuropathy. Only in one case we found hyperammonemia. Karyotypic studies performed in 12 cases demonstrated non specific fragile sites. CT scan was normal in almost all cases. The QD was extremely low.