Uso prolongado de cánula nasal de alto flujo en niños con problemas respiratorios / Prolonged use of high flow nasal cannula in children with respiratory problems

La cánula nasal de alto flujo (CNAF) es una modalidad ventilatoria no invasiva segura y efectiva, usada ampliamente en patología respiratoria aguda en adultos y niños. Objetivo: presentar casos clínicos pediátricos que utilizaron CNAF por tiempo prolongado por problemas respiratorios crónicos. Descripción de casos clínicos, revisión de fichas clínicas de 5 pacientes que utilizaron CNAF por más de 1 mes, entre los años 2017-2020 en el Complejo Asistencial Dr. Sótero del Río. Aprobado por Comité de Ética. Resultados: 5 pacientes varones de mediana 61 (44 a 212) días de edad al inicio del uso de CNAF. Diagnóstico de base: displasia broncopulmonar (2/5), síndrome de Treacher Collins (1/5), síndrome de cimitarra con hipoplasia pulmonar derecha (1/5) y traqueobroncomalacia severa (1/5). Todos requirieron previamente uso de ventilación invasiva o no invasiva con mediana de 59 (4 a 78) días. A todos se les realizó broncoscopia, saturometría contínua o poligrafía para diagnóstico y titulación de CNAF y oxígeno. Todos mejoraron clínicamente, la SpO2 y el número de apneas. Dos pacientes se enviaron a domicilio con uso de Airvo2 nocturno. La mediana de uso de CNAF fue 165 (34 a 445) días. Conclusiones: el uso prolongado de CNAF es útil en pacientes pediátricos seleccionados, bien tolerado y factible de utilizar en domicilio.

The high-flow nasal cannula (HFNC) is a safe and effective non-invasive ventilation support widely used in acute respiratory pathology in adults and children. Objective: To present pediatric clinical cases that used HFNC for an extended period due to chronic respiratory disease. Description of clinical cases, review of medical records of 5 patients who used HFNC for more than 1 month, between the years 2017-2020 at Complejo Asistencial Dr. Sótero del Río. Approved by the Ethics Committee. Results: 5 male patients with a median age of 61 (44 to 212) days at the start of HFNC use. Underlying diagnoses: bronchopulmonary dysplasia (2/5), Treacher Collins syndrome (1/5), Scimitar syndrome with right pulmonary hypoplasia (1/5), and severe tracheobronchomalacia (1/5). All of them previously required invasive or non-invasive ventilation for a median of 59 (4 to 78) days. All patients underwent bronchoscopy, continuous pulse oximetry or polygraphy for diagnosis and titration of HFNC and oxygen. All showed clinical improvement, including SpO2 levels and the number of apneas. Two patients were discharged with nocturnal use of Airvo 2 at home. The median duration of HFNC use was 165 (34 to 445) days. Conclusions: Prolonged use of HFNC is useful in selected pediatric patients, well tolerated, and feasible for home use.

Terapia con cánula nasal de alto flujo en pacientes pediátricos en domicilio / High flow nasal cannula therapy in pediatric patients at home

Se realiza comentario de estudio de Israel en el cual analizan 75 pacientes pediátricos que utilizaron cánula nasal de alto flujo (CNAF) en domicilio, evaluando la seguridad, las indicaciones, los parámetros de utilización, la duración del tratamiento, los resultados clínicos y la satisfacción de los padres. Se acompaña de una revisión de la literatura del tema.

A comment is made on a study conducted in Israel analyzing 75 pediatric patients who used high-flow nasal cannula at home, evaluating safety, indications, utilization parameters, treatment duration, clinical outcomes, and parental satisfaction. It is accompanied by a literature review on the topic.

Asociación e interacciones de la apnea obstructiva del sueño (AOS) y del síndrome de hipoventilación obesidad (SHO) / Metabolic associations of the obstructive sleep apnea (AOS) and hypoventilation obesity syndrome

La apnea obstructiva del sueño (AOS) y el síndrome hipoventilación-obesidad (SHO) son patologías que se encuentran estrechamente asociadas a la obesidad como principal factor de riesgo, hasta un 70% de los pacientes con AOS son obesos. Ambas patologías comparten procesos fisiopatológicos comunes, donde destaca la inflamación sistémica, lo que, sumado a la hipoxia crónica intermitente y la fragmentación del sueño característicos de la AOS, aumenta considerablemente el riesgo de presentar comorbilidades metabólicas como síndrome metabólico, alteraciones en el metabolismo de la glucosa (resistencia a la insulina y diabetes mellitus tipo 2), y hígado graso metabólico. En esta revisión narrativa, se describirán los mecanismos identificados en estas asociaciones, así como la prevalencia y la evidencia sobre el tratamiento de la AOS y del SHO

Obstructive sleep apnea (OSA) and obesity-hypoventilation syndrome (OHS) are pathologies that are closely associated with obesity as the main risk factor, up to 70% of patients with OSA are obese. Both pathologies share common pathophysiological processes, where systemic inflammation stands out, which, added to the intermittent chronic hypoxia and sleep fragmentation characteristic of OSA, considerably increases the risk of presenting metabolic comorbidities such as metabolic syndrome, alterations in the metabolism of the glucose (insulin resistance and type 2 diabetes mellitus), and metabolic fatty liver. In this narrative review, the mechanisms identified in these associations will be described, as well as the prevalence and evidence on the treatment of OSA and OHS

The Effect of Continuous Positive Airway Pressure on Basal Metabolism Rate in Patients with Severe Obstructive Sleep Apnoea Syndrome

ABSTRACT Objective: To assess the effect of the continuous positive airway pressure (CPAP) treatment on basal metabolism rate (BMR) in patients with severe obstructive sleep apnoea syndrome (OSAS). Methods: Demographic characteristics, body mass index (BMI), apnoea-hypopnoea index (AHI) and smoking history of the patients were recorded. Basal metabolism rate was measured via indirect calorimetry in the morning following nights of polysomnography and CPAP titration. Basal metabolism rate, oxygen consumption (VO2) and carbon dioxide output (VCO2) levels were compared before and after CPAP administration. Results: A total of 25 patients with a mean age of 51.4 ± 13.7 years were included in the study: 6 (24%) female and 19 (76%) male. A significant reduction in the BMR (p = 0.049), VO2 (p = 0.042) and VCO2 (p = 0.008) values were observed after a single night administration of CPAP as compared to before treatment. Furthermore, it was detected that this reduction provided by CPAP treatment was more significant in current smokers, patients with AHI > 60 and BMI ≥ 30. Conclusion: It is suggested that there is a correlation between BMR and the severity of OSAS, and it is possible to provide a significant reduction in BMR with single night administration of CPAP depending on the patient's smoking history, degree of obesity and disease severity.

Side effects of mandibular advancement splints for the treatment of snoring and obstructive sleep apnea: a systematic review

ABSTRACT Introduction: Occlusal side effects or development of pain and/or functional impairment of the temporomandibular complex are potential reasons for poor compliance or abandonment of mandibular advancement splints treatment for snoring and obstructive sleep apnea. Objective: This study aimed at providing a comprehensive review evaluating the craniofacial side effects of oral appliance therapy for snoring and obstructive sleep apnea. Methods: An electronic search was systematically conducted in PubMed and Virtual Health Library from their inception until October 2016. Only Randomized Controlled Trials whose primary aim was to measure objectively identified side effects on craniofacial complex of a custom-made oral appliance for treating primary snoring or obstructive sleep apnea were included. Studied patients should be aged 20 or older. The risk of bias in the trials was assessed in accordance with the recommendations of The Cochrane Risk of Bias criteria. Results: A total of 62 full-text articles were assessed for eligibility. After the review process, only 6 met all the inclusion criteria. All studies were rated as having a high risk of bias. The most uniformly reported mandibular advancement splint side effects were predominantly of dental nature and included a decrease in overjet and overbite. The risk of developing pain and function impairment of the temporomandibular complex appeared limited with long-term mandibular advancement splint use. Conclusion: The limited available evidence suggests that mandibular advancement splint therapy for snoring and obstructive sleep apnea results in changes in craniofacial morphology that are predominantly dental in nature, specially on a long-term basis. Considering the chronic nature of obstructive sleep apnea and that oral appliance use might be a lifelong treatment, a thorough customized follow-up should therefore be undertaken to detect possible side effects on craniofacial complex. It is also important to provide adequate information to the patients regarding these possible changes, especially to those in whom larger occlusal changes are to be expected or in whom they are unfavorable. Long-term assessments of adverse effects of oral appliance therapy, with larger study samples and recruitment of homogenous patient population are still required.

RESUMO Introdução: efeitos colaterais oclusais e o desenvolvimento de dor e/ou disfunção do complexo temporomandibular podem levar à baixa adesão ou ao abandono do tratamento do ronco e da apneia obstrutiva do sono com aparelhos de avanço mandibular. Objetivo: fornecer uma revisão abrangente da literatura sobre os efeitos colaterais craniofaciais do tratamento do ronco e da apneia obstrutiva do sono com aparelhos de avanço mandibular. Métodos: foram realizadas buscas eletrônicas sistematicamente no PubMed e na Biblioteca Virtual em Saúde até outubro de 2016. Foram incluídos apenas Ensaios Controlados Randomizados, com o objetivo primário de mensurar objetivamente os efeitos colaterais no complexo craniofacial associados ao uso de aparelhos de avanço mandibular no tratamento do ronco e da apneia obstrutiva do sono. Os pacientes estudados deveriam ter 20 anos de idade ou mais. A avaliação do risco de viés dos trabalhos selecionados seguiu as recomendações do The Cochrane Risk of Bias. Resultados: no total, 62 artigos completos foram avaliados em relação à elegibilidade. Após o processo de revisão, apenas 6 atenderam aos critérios de inclusão. Todos os estudos foram julgados como tendo alto risco de viés. Os efeitos colaterais mais frequentemente encontrados foram de natureza dentária e incluíram uma diminuição do overjet e do overbite. O risco de desenvolvimento de dor ou disfunção do complexo temporomandibular pareceu limitado na avaliação de longo prazo do uso do aparelho de avanço mandibular. Conclusão: as evidências disponíveis são limitadas e sugerem que o tratamento do ronco e da apneia obstrutiva do sono com aparelhos de avanço mandibular resulta em alterações craniofaciais predominantemente dentárias, especialmente nas avaliações de longo prazo. Considerando-se que a apneia obstrutiva do sono é crônica e que os aparelho intrabucais se constituem em uma forma de tratamento contínuo e por tempo indefinido, é necessário um acompanhamento individualizado para monitorar possíveis efeitos colaterais no complexo craniofacial. Também é importante informar aos pacientes sobre esses possíveis efeitos, especialmente àqueles nos quais são esperadas maiores alterações oclusais ou nos quais elas sejam desfavoráveis. Ainda são necessárias avaliações de longo prazo dos efeitos colaterais do tratamento com aparelhos intrabucais, com amostras maiores e mais homogêneas.

Síndrome de apneas del sueño: revisión de 25 años de experiencia / Sleep apnea syndrome: review of 25 years of experience / Síndrome da apnéia do sono: revisão de 25 anos de experiência

El conocimiento científico y clínico sobre los trastornos respiratorios del sueño se ha desarrollado de manera acelerada en las últimas décadas. El objetivo de este estudio es presentar la experiencia adquirida en nuestro país, en el diagnóstico y tratamiento del síndrome de apneas del sueño de tipo obstructivo, durante el desarrollo de una nueva disciplina en el ámbito de la neumología. Se revisaron los registros de 3109 pacientes; 447 con historias clínicas electrónicas y cuestionarios para cuantificación de síntomas y 1779 polisomnografías de pacientes con apneas de tipo obstructivo. Se presenta la evolución de la referencia de pacientes, las características demográficas (en especial el aumento de la prevalencia en jóvenes) y los hallazgos clínicos más frecuentes. Se destacan los factores de riesgo relevantes: obesidad y su relación con la severidad, enfermedades endocrinas y desplazamiento cefálico de fluidos. Se destaca el modo de acceso y la adherencia al tratamiento. La implementación de unidades clínicas de sueño permitió la referencia de pacientes para el diagnóstico y el tratamiento, dando lugar a una nueva disciplina de la neumología. La prevalencia de las apneas obstructivas del sueño es muy elevada, con progresivo y sostenido incremento. El tratamiento con aplicación de presión nasal no invasiva es factible. Aunque con distintos grados de accesibilidad y adherencia, ha permitido la corrección del trastorno respiratorio del sueño más relevante.

Scientific and clinical knowledge on sleep-disordered breathing has developed at an accelerated pace in the last decades. The objective of this study is to present the experience gained in our country in the diagnosis and treatment of obstructive sleep apnea syndrome during the development of a new discipline in the field of pneumology. Clinical records of 3109 patients were reviewed; 447 with electronic medical records and questionnaires for quantification of symptoms and 1779 polysomnographies of patients with obstructive apneas. The time evolution of the patient referral, the demographic characteristics (especially the increase in the prevalence in young people) and the most frequent clinical findings are presented. We highlight the relevant risk factors: obesity and its relationship with severity, endocrine diseases and cephalic fluid displacement. Access mode and adherence to treatment are highlighted. The implementation of sleep clinics allowed the referral of patients for diagnosis and treatment, giving rise to a new discipline of pneumology. The prevalence of obstructive sleep apnea is high, with progressive and sustained increase. Treatment with non-invasive nasal pressure application is feasible. Although with different degrees of accessibility and adherence, it has allowed the correction of the most relevant respiratory sleep disorder

O conhecimento científico e clínico sobre os transtornos respiratórios do sono desenvolveu-se rapidamente nas últimas décadas. O objetivo deste estudo é apresentar a experiência adquirida em nosso país no diagnóstico e tratamento da síndrome da apneia obstrutiva do sono durante o desenvolvimento de uma nova disciplina no campo da pneumologia. Os registros de 3109 pacientes foram revisados; 447 com registros médicos eletrônicos e questionários para quantificação de sintomas e 1779 polissonografias de pacientes com apnéia obstrutiva. Apresentamos a evolução da referência do paciente, as características demográficas (especialmente o aumento da prevalência em jovens) e os achados clínicos mais freqüentes. Destacamos os fatores de risco relevantes: obesidade e sua relação com severidade, doenças endócrinas e deslocamento do cefálico de fluídos. O modo de acesso e a adesão ao tratamento são destacados. A implementação de unidades de sono clínicas permitiu a referência de pacientes para diagnóstico e tratamento, dando origem a uma nova disciplina de pneumologia. A prevalência da apneia obstrutiva do sono é muito alta, com aumento progressivo e sustentado. O tratamento com pressão nasal não invasiva é viável. Embora com diferentes graus de acessibilidade e adesão, permitiu a correção do transtorno do sono respiratório mais relevante.

Predictors of success for mandibular repositioning appliance in obstructive sleep apnea syndrome

Abstract The characteristics of non-obese patients with mild to moderate Obstructive Sleep Apnea Syndrome (OSAS) who will present with a good response to Mandibular Repositioning Appliance (MRA) treatment have not yet been well established in the literature. The aim of this study is to assess whether polysomnographic (PSG), demographic, anthropometric, cephalometric, and otorhinolaryngological parameters predict MRA success in the treatment of OSAS. Forty (40) males with mild and moderate OSAS were assessed pretreatment and 2-months post-treatment after wearing an MRA. Demographic, anthropometric, otorhinolaryngological (ENT), cephalometric, and polysomnographic parameters, including continuous positive airway pressure (CPAP) titrated pressure, dental models, Epworth Sleepiness Scale, quality of life (Short Form SF-36), and mood state (Profile of Mood States – POMS), were assessed. The responders exhibited fewer oropharyngeal alterations, increased upper pharyngeal space, reduced lower airway space, and increased mandibular intercanine width, and they had milder disease. Nevertheless, no predictive factors of MRA success could be found. MRA was more successful among men with a more pervious airway, a larger interdental width and milder OSAS. However, a combined [1] functional and structural assessment is needed to successfully predict the [2] effectiveness of MRA treatment of OSA.

Impact of upper airway abnormalities on the success and adherence to mandibular advancement device treatment in patients with Obstructive Sleep Apnea Syndrome, / O impacto das alterações da via aérea superior na adesão e sucesso do tratamento com aparelho intraoral na Síndrome da Apneia Obstrutiva do Sono

ABSTRACT INTRODUCTION: The mandibular advancement device (MAD) is a option to treat patients with Obstructive Sleep Apnea Syndrome (OSAS). OBJECTIVE: To assess the influence of upper airway abnormalities on the success of and adherence to MAD in patients with OSAS. METHODS: Prospective study with 30 patients with mild to moderate OSAS and indications for MAD. The protocol included questionnaires addressing sleep and nasal complaints, polysomnography, and upper airway assessment. The analyzed parameters of patients who showed therapeutic success and failure and those who exhibited good and poor treatment adherence were compared. RESULTS: 28 patients completed the protocol; 64.3% responded successfully to treatment with MAD, and 60.7% exhibited good adherence to treatment. Factors associated with greater success rates were younger age (p = 0.02), smaller cervical circumference (p = 0.05), and lower AHI at baseline (p = 0.05). There was a predominance of patients without nasal abnormalities among patients treated successfully compared to those with treatment failure (p = 0.04), which was not observed in relation to adherence. Neither pharyngeal nor facial skeletal abnormalities were significantly associated with either therapeutic success or adherence. CONCLUSION: MAD treatment success was significantly lower among patients with nasal abnormalities; however, treatment adherence was not influenced by the presence of upper airway or facial skeletal abnormalities.

RESUMO INTRODUÇÃO: O Aparelho Intraoral (AIO) é uma opção para tratamento da Síndrome da Apneia Obstrutiva do Sono (SAOS). OBJETIVOS: Avaliar a influência das alterações da VAS e esqueléticas faciais através de uma avaliação clinica sistematizada no sucesso e adesão ao (AIO) em pacientes com (SAOS). MÉTODO: Estudo prospectivo em que foram avaliados 30 pacientes com SAOS leve a moderada e indicação de AIO. Protocolo incluiu questionários de sono e queixas nasais; polissonografia e avaliação da VAS por rinoscopia anterior e oroscopia. Os parâmetros analisados foram comparados entre pacientes com sucesso e insucesso, e com boa e má adesão à terapia. RESULTADOS: Completaram o protocolo 28 pacientes. O sucesso ao tratamento foi de 64,3% e a adesão 60,7%. Os fatores associados ao sucesso foram menor idade, menor circunferência cervical e menor IAH basal. Quanto à presença de alterações nasais, houve predomínio de pacientes sem alteração nasal entre os pacientes com sucesso comparados àqueles com insucesso (p = 0,04); o que não foi observado em relação à adesão. Quanto às alterações faríngeas e alterações esqueléticas faciais, não houve significância. CONCLUSÃO: O sucesso do tratamento com AIO foi significativamente menor nos pacientes com alterações nasais, porém a adesão não foi influenciada pela presença de alterações de VAS ou esqueléticas faciais.

Adesão de pacientes com síndrome da apneia obstrutiva do sono à pressão positiva contínua em via aérea em um serviço público / Adherence of obstructive sleep apnea syndrome patients to continuous positive airway pressure in a public service

Introdução: A terapia padrão para tratamento da síndrome da apneia obstrutiva do sono (SAOS) é o aparelho de pressão positiva contínua em via aérea (CPAP); todavia, seu uso correto e frequente é determinante para o controle da doença. Objetivo: Analisar a adesão ao CPAP entre pacientes com SAOS tratados em um ambulatório multidisciplinar em um hospital público. Métodos: Estudo retrospectivo avaliando 156 pacientes com SAOS que foram submetidos à polissonografia para titulação de CPAP de 2008 a 2011. Os pacientes foram divididos em dois grupos: os com boa e os com má adesão. Os grupos foram comparados entre si em relação aos seus dados: sexo, idade, IMC, doenças associadas, IAH à polissonografia diagnóstica e pressão em (cmH20) sugerida à polissonografia de titulação. Resultados: Foram analisados 125 pacientes, demonstrando que 82 dels (65%) tinham boa adesão, enquanto 43 (35%) eram maus usuários. A comparação entre os grupos mostrou que os pacientes com maior índice de apneia e hipopneias (IAH) eram os com melhor adesão ao tratamento com CPAP. Conclusões: A taxa de adesão ao CPAP entre os pacientes com SAOS monitorizados regularmente em um serviço público foi de 65%. Os pacientes com pior IAH foram os mais aderentes ao tratamento com CPAP. .

Introduction: The standard therapy for obstructive sleep apnea syndrome (OSAS) is continuous positive airway pressure (CPAP), but its correct and frequent use is essential to control the disease. Purpose: To analyze adherence to CPAP among patients with OSAS treated in a multidisciplinary outpatient clinic of a public tertiary hospital. Methods: This was a retrospective study evaluating 156 patients with OSAS who underwent polysomnography for CPAP titration from 2008 to 2011. The patients were divided into two groups, those with good adherence to CPAP (a mean use of four or more hours per night) and those with poor adherence. The groups were compared regarding the following data: gender, age, body mass index, associated diseases, AHI at diagnostic polysomnography, and pressure (cmH2O) suggested by titration polysomnography. Results: 125 patients were analyzed, and it was observed that 82 of the patients (65%) had good adherence, whereas 43 (35%) showed poor adherence. Comparison between groups revealed that patients with a higher apnea-hypopnea index (AHI) were those who better adhered to treatment with CPAP. Conclusions: the rate of adherence to CPAP among OSAS patients undergoing clinical monitoring at a public service was 65%. Patients with a higher AHI were those who adhered better to treatment with CPAP. .

¿Cómo abordar a un paciente con apnea del sueño? / How to treat sleep apnea patient?

El Síndrome de Apnea Hipoapnea Obstructiva del Sueño (SAHOS) es un trastorno frecuente, crónico y de evolución progresiva. Se asocia a mayor morbilidad cardiovascular, neurocognitiva y metabólica, riesgo de accidentes, mala calidad de vida y mortalidad aumentada (1). Por su alta prevalencia e identificación de factores de riesgo, se puede lograr un enfoque multidisciplinario encaminado a realizar una historia clínica completa, que incluya tanto una revisión exhaustiva de los antecedentes como un examen físico completo, los cuales lograrían garantizar un manejo y tratamiento adecuados. Este trastorno ha generado un gran impacto en salud pública, debido a los altos costos que genera y también por las múltiples patologías asociadas que lo acompañan. Recientes estudios lo consideran como parte de una enfermedad crónica, y por esto se ha despertado gran interés en el diagnóstico y tratamiento adecuado por parte de los profesionales de la salud, en este caso cardiólogos, neumólogos, neurólogos, otorrinolaringólogos y psiquiatras (3). El propósito de este artículo es realizar un enfoque práctico de cómo abordar a un paciente con apnea del sueño en nuestra consulta médica diaria, como especialistas basados en la evidencia actual de la medicina...

Obstructive Sleep Apnea Syndrome (OSAS) is a common chronic and progressive disorder. It has cardiovascular, neurocognitive and metabolic consequences. Also has increased risk of accident, poor quality of life and higher mortality. Because of its high prevalence and identification of risk factors it is possible to achieve a multidisciplinary approach aimed at performing a complete medical history that includes both an exhaustive review as a full physical examination, which would achieve a proper management and treatment. This condition has generated a large impact on public health due to the high costs it generates, as well as the many associated pathologies that accompany it. Recent studies considered it as part of a chronic disease, this has aroused great interest in the diagnosis and treatment by health professionals, in this case cardiologists, neumologists, neurologists, psychiatrists and otolaryngologists (3). The purpose of this article is to make a practical approach of how to approach a patient with sleep apnea in our daily medical practice as specialists based on current medical evidence...

Influence of obstructive sleep apnea on serum butyrylcholinesterase activity and ischemia-modified albumin levels

OBJECTIVE: To investigate the effect of obstructive sleep apnea and continuous positive airway pressure treatment on serum butyrylcholinesterase activity and ischemia-modified albumin levels. METHODS: Thirty-two patients with obstructive sleep apnea and 30 age- and sex-matched controls were enrolled and underwent a diagnostic polysomnogram. The serum butyrylcholinesterase activity, ischemia-modified albumin levels, metabolic parameters, and polysomnography scores were detected and evaluated. Nine patients were studied before and after treatment with continuous positive airway pressure. RESULTS: The serum ischemia-modified albumin levels were significantly higher and the butyrylcholinesterase activity was significantly lower in patients with obstructive sleep apnea than in the controls (p<0.001). The continuous positive airway pressure treatment decreased the modified albumin levels and elevated the buthrylcholinesterase activity (p = 0.019 and p = 0.023, respectively). The modified albumin levels were positively correlated with the apnea-hypopnea index (r = 0.462, p = 0.008) at baseline. Elevated ischemia-modified albumin levels can be more accurate than butyrylcholinesterase activity at reflecting the presence of obstructive sleep apnea. Receiver operating characteristic curves revealed a significant difference between the areas under the curve 0.916 for ischemia-modified albumin and 0.777 for butyrylcholinesterase (z = 2.154, p = 0.031). CONCLUSION: The elevated ischemia-modified albumin level was significantly associated with obstructive sleep apnea and was more sensitive than butyrylcholinesterase activity in reflecting obstructive sleep apnea. The continuous positive airway pressure treatment helped to ameliorate the imbalance. .

Apneia obstrutiva do sono: da suspeita diagnóstica ao tratamento / Obstructive sleep apnea: the suspected diagnosis to treatment

Dentre os diversos distúrbios do sono, a apneia obstrutiva é um dos mais prevalentes. Sua dinâmica causa o colapso transitório da faringe, impedindo o fluxo de ar entre o ambiete e os pulmões. Estes eventos costumam levar à redução da oxigenação do organismo e à fragmentação do sono. Com evolução insidiosa, a suspeita diagnóstica parte de queixas de sonolência diurna excessiva, roncos e apneia testemunhada. O atual padrão ouro para o diagnóstico é o exame de polissonografia. O tratamento inclui a higiene do sono e a perda ponderal. Existem três linhas de tratamento usuais: dispositivos intraorais, correções cirúrgicas ou aparelhos de pressão positiva. Por tratar-se de doença crônica, progressiva, deve ter acompanhamento, mesmo com o tratamento instituído

Among various sleep disorders, obstructive apnea is one of the most prevalent. Its dynamic causes the transient collapse of pharynx, avoiding the air flow between the environment and the lungs. These events often lead to low body oxygenation and sleep frangmentation. With insidious onset, it's possible to suspect when complains occurs: excessive daytime sleepiness, snoring and witnessed apnea. The current gold standard for diagnosis is polysomnography. Treatment of obstructive sleep apnea includes sleep hygiene and wight loss. There are three lines of treatment as usual: intraoral devices, surgical corrections or positive pressure devices. By being a chronic, progressive disease, even when treatment is instituted, the patients must have follow up

Oxidative stress and quality of life in elderly patients with obstructive sleep apnea syndrome: are there differences after six months of Continuous Positive Airway Pressure treatment?

OBJECTIVES: This study evaluated the effect of Continuous Positive Airway Pressure treatment on oxidative stress parameters and the quality of life of elderly patients with obstructive sleep apnea syndrome. METHODS: In total, 30 obstructive sleep apnea syndrome patients and 27 subjects without obstructive sleep apnea syndrome were included in this study. Both groups underwent quality of life and oxidative stress evaluations at baseline and after six months. Polysomnography was performed in both groups at baseline and a second time in the obstructive sleep apnea syndrome group after six months of Continuous Positive Airway Pressure treatment. All of the variables were compared between the control and obstructive sleep apnea syndrome groups in this prospective case-control study. RESULTS: The baseline concentrations of the antioxidant enzyme catalase were higher in the obstructive sleep apnea syndrome group than the control group. After Continuous Positive Airway Pressure treatment, the obstructive sleep apnea syndrome group exhibited a reduction in the level of oxidative stress, as indicated by a decrease in the level of lipid peroxidation measured by the malondialdehyde (MDA) concentration [pre: 2.7 nmol malondialdehyde/mL (95% 1.6-3.7) vs. post: 1.3 nmol MDA/mL (0.7-1.9), p<0.01]. Additionally, improvements were observed in two domains covered by the SF-36 questionnaire: functional capacity [pre: 77.4 (69.2-85.5) vs. post: 83.4 (76.9-89.9), p = 0.002] and pain [pre: 65.4 (52.8-78.1) vs. post: 77.8 (67.2-88.3), p = 0.004]. CONCLUSION: Our study demonstrated that the use of Continuous Positive Airway Pressure to treat obstructive sleep apnea syndrome in elderly patients reduced oxidative stress and improved the quality of life.

Apneia obstrutiva do sono em crianças / Obstructive sleep apnea in children

Em crianças, SAOS é caracterizada por episódios recorrentes de obstrução parcial ou completa das vias aéreas superiores durante o sono. Caracteriza-se por um continuum que vai desde o ronco primário (uma situação benigna de ronco sem alterações fisiológicas e complicações associadas), passando por resistência aumentada das vias aéreas, hipoventilação obstrutiva e, finalmente, SAOS. A prevalência de ronco é elevada e, dependendo da forma como ele é definido, varia entre 1,5 por cento e 15 por cento. O diagnóstico da SAOS, combinando questionários de relatos dos pais e exames complementares, apresenta uma prevalência de 1-4 por cento. A SAOS é mais frequente nos meninos, nas crianças com sobrepeso, de ascendência africana, com história de atopia e prematuridade. Ronco alto e frequente, apneias observadas pelos familiares e sono agitado são os sintomas mais frequentes. O exame físico deve identificar a situação ponderostatural do paciente, avaliar evidências de obstrução crônica das vias aéreas superiores e ainda verificar a presença de alterações craniofaciais. A polissonografia de noite inteira é o exame padrão tanto para o diagnóstico, como para a definição da pressão necessária em equipamentos de pressão positiva e também para a avaliação do tratamento cirúrgico. A hipóxia intermitente e os múltiplos despertares resultantes dos eventos obstrutivos contribuem para as consequências cardiovasculares, neurocognitivas e comportamentais bem descritos nesses pacientes. A adenoamigdalectomia é o principal tratamento para a SAOS em crianças. O uso da pressão positiva nas vias aéreas (CPAP ou Bilevel) é outra opção de uso crescente na população pediátrica.

Childhood obstructive sleep apnea syndrome (OSAS) is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep. The disease encompasses a continuum from primary snoring (a benign condition without physiological alterations or associated complications) to increased upper airway resistance, obstructive hypoventilation and OSAS. The prevalence of snoring is high, ranging from 1.5 percent to 15 percent, depending on how it is defined. Based on parent-reported questionnaires and complementary tests, the prevalence of OSAS is 1-4 percent. This syndrome is more common in boys, overweight children, of African ancestry, with a history of atopy and prematurity. The most common symptoms are snoring that is frequent and loud; family-reported apnea; and restless sleep. The physical examination should assess growth status, signs of chronic upper airway obstruction, and craniofacial malformations. Overnight polysomnography is the gold standard test for the diagnosis and for the determination of the appropriate positive pressure level, as well as for postsurgical treatment evaluation. Intermittent hypoxia and multiple arousals resulting from obstructive events contribute to the well-described cardiovascular, neurocognitive, and behavioral consequences in pediatric patients with OSAS. Although the main treatment for OSAS in children is adenotonsillectomy, treatment with CPAP or Bilevel is becoming more widely used in the pediatric population.

El manejo de la disfunción eréctil en pacientes con trastornos respiratorios durante el sueño y enfermedad pulmonar obstructiva crónica / The management of erectile dysfunction in patients with sleep-disordered breathing and chronic obstructive pulmonary disease

En hombres con apnea obstructiva del sueño y enfermedad pulmonar obstructiva crónica (síndrome superpuesto) la disfunción eréctil es un motivo de consulta frecuente. La evidencia señala una relación etiológica, por lo tanto el tratamiento de los trastornos respiratorios mejoraría la función eréctil. Cuarenta y ocho hombres con síndrome superpuesto y disfunción eréctil fueron tratados de manera convencional mediante presión continua positiva de las vías aéreas y broncodilatadores durante seis meses. El puntaje que medía la intensidad de la disfunción eréctil mejoró significativamente en toda la población en estudio. Cuando se utilizó el criterio clínico de mejoría de por lo menos 5 puntos de aumento en el puntaje de la intensidad de la disfunción eréctil sólo 12 pacientes (25%) lo lograron. Un porcentaje significativo de los pacientes sin respuesta, o que no estaban satisfechos con el manejo convencional respondieron a la ingesta de sildenafil a demanda. Si bien el mejoramiento de la función respiratoria generalmente se acompañaba de una mejora en la función eréctil, debería considerarse el tratamiento específico de la disfunción eréctil si la satisfacción del paciente es la meta del tratamiento.

In men with obstructive sleep apnea and chronic obstructive pulmonary disease (overlap syndrome), erectile dysfunction is a frequent complaint. Evidence suggests an etiologic link, and therefore treatment of breathing disorders would improve erectile function. Forty-eight men with overlap syndrome and erectiledysfunction were treated conventionally with continuous positive airway pressure and bronchodilators for 6 months. Erectile dysfunction intensity score improved significantly in the entire study population. When the clinical improvement criterion of at least a 5-point increase in erectile dysfunction intensity score was used only 12 patients (25%) responded. A significantpercentage of patients whose erectile dysfunction did not respond, or who were not satisfied with conventionalmanagement, responded to on-demand sildenafil. Even though improvements in respiratory function generally improve erectile function, specific ED treatment may be considered if patient satisfaction is the treatment goal.

Tratamento de ronco e síndrome da apnéia do sono com placa intrabucal ajustável / Snoring and obstructive sleep apnea syndrome treatment with adjustable intrabuccal appliance

O ronco e a apnéia obstrutiva do sono podem levar a diversos problemas de saúde. Hipertensão arterial e pulmonar, infarto, acidente vásculo-cerebral, impotência e depressão são alguns exemplos de doenças que se instalam mais facilmente quando ocorre a apnéia do sono. O cirurgião-dentista inserido em uma equipe multidisciplinar é um profissional altamente requisitado para o diagnóstico e tratamento destes distúrbios do sono. Dentre os tratamentos recomendados, a terapia com placas intrabucais se mostra uma excelente alternativa não-invasiva, alcançando ótimos resultados

Ventilación mecánica no invasiva / Non invasive artificial respiration

Durante los últimos diez años la ventilación mecánica no invasiva con presión positiva dentro de la vía aérea ha sido una de las maneras de enfrentar la falla respiratoria aguda, la evidencia ha demostrado que es útil en la falla respiratoria aguda hipercápnica de pacientes portadores de enfermedad pulmonar obstructiva crónica (EPOC), no se ha podido establecer claramente su indicación en la Falla Respiratoria Aguda Hipoxémica, y además se ha usado con éxito en la Falla Respiratoria posquirúrgica, en el destete temprano de ventilación mecánica tradicional y en el Edema Pulmonar Cardiogénico. Su indicación en pacientes portadores de Falla Respiratoria Crónica esta dada en neurológicos portadores de debilidad muscular con síndrome de hipoventilación, en alteraciones de la caja torácica (xifoescoliosis) en quienes la indicación de VMNI es una de las más prometedoras en cuanto a mejoría de calidad de vida y sobrevida y en EPOC estables retenedores de pCO2. El éxito de la VMNI está dado por la indicación adecuada y por un equipo entrenado en el manejo de la técnica

Asistencia ventilatoria no invasiva con sistemas generadores de flujo en pediatría: experiencia 1996-1999 / Non invasive mechanical ventilation with a flow generator device in pediatric patients: experience 1996-1999

La presión nasal positiva es un sistema de ventilación no invasivo que se indica en pacientes con apnea obstructiva del sueño, insuficiencia respiratoria crónica, hipoventilación central y rara vez en insuficiencia respiratoria aguda. Desde 1996 a 1999 diez pacientes que ingresaron a la guardia respiratoria pediátrica de nuestro hospital fueron incluídos en un programa de ventilación mecánica no invasiva. Las edades de los pacientes fluctuaron entre 1,5 y 14 años (promedio = 7 años). Cinco pacientes (50 por ciento) por presentar insuficiencia respiratoria aguda, tres por insuficiencia respiratoria crónica y dos por apnea obstructiva del sueño. Los diagnósticos al ingreso fueron los siguientes: infección respiratoria aguda baja (n=4) parálisis cerebral (n=3) miopatía congénita (n=2) y tumor torácico (n=1). Se utilizó BIPAP en siete pacientes y CPAP en tres, administrándose oxígeno suplementario en nueve pacientes. Resultados: seis pacientes mejoraron y cuatro de ellos fueron enviados a sus hogares con ventilación mecánica no invasiva. Un paciente con mucopolisacaridosis murió y tres no mejoraron, por lo que fueron manejados con ventilación mecánica. La única complicación observada fue edema nasal, que se presentó en dos pacientes. Conclusión: La asistencia ventilatoria no invasiva puede usarse en algunos pacientes con insuficiencia respiratoria aguda, esta eventual indicación podría agregarse a las convencionales. La aplicación de criterios estrictos de selección (mayores de 12 meses con vía aérea estable, hipercapnia pero con pH > 7,25, sin falla orgánica múltiple, inestabilidad hemodinámica o compromiso aguda de conciencia) podría evitar la ventilación mecánica en estos pacientes