Indication of CPAP without a sleep study in patients with high pretest probability of obstructive sleep apnea.

OBJECTIVE: To evaluate the performance of clinical criteria (CC) for diagnosis and initiation of empirical treatment with continuous positive airway pressure (CPAP) in patients with suspected obstructive sleep apnea (OSA) compared with the treatment decision based on sleep studies (polysomnography or respiratory polygraphy), guidelines, and experience of participating physicians. METHODS: This was a simulated intention-to-treat study in a retrospective (G1) and prospective (G2) cohort. Four observers (two per group) called CC1 and CC2 reviewed the sleep questionnaires and indicated CPAP if the patients presented snoring, frequent apneas (≥ 3-4/week), body mass index (BMI) > 25 kg/m2, sleepiness (Epworth > 11), or tiredness (at least 3-4 times per week) and some comorbidity (hypertension, coronary/cerebrovascular event, diabetes). Ten independent observers formed two groups of five (FD1 and FD2) and were blinded to each other's opinion. These observers in FD1 and FD2 decided CPAP treatment based on guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) or guidelines of the American Academy of Sleep Medicine (AASM) and factored in their own opinion. Sensitivity (S), specificity (Sp), and positive/negative likelihood ratios (LR+/-) were calculated with the test method: CC1/2, and the reference method: majority decision of FD1/2. RESULTS: A total of 653 patients (264 women, 40%) were studied. Median age was 54 years, BMI 28 kg/m2, and apnea hypopnea index (AHI) 16.5 events/h. S ranged from 21 to 25% (p 0.60), Sp 96.1 to 97.6% (p 0.39), and LR+ of clinical criteria 6.4 to 8.9 (p 0.52). CONCLUSION: CPAP indication without a previous sleep study showed a low sensitivity (≅ 22%) but a specificity greater than 95% in patients with high pretest probability for OSA (snoring, report of frequent apneas, BMI > 25 kg/m2 and sleepiness or tiredness plus comorbidity).

The influence of gender on symptoms associated with obstructive sleep apnea.

BACKGROUND: It has been reported that the clinical expression of obstructive sleep apnea (OSA) may differ in women and men. OBJECTIVE: The objective of this study was to evaluate the influence of gender on reported OSA-related symptoms in a large clinical population of patients. METHODS: The database from the sleep laboratory of a tertiary care center was examined. Adult patients who had undergone a diagnostic polysomnography and completed the Berlin questionnaire, a sleep questionnaire, and the Epworth sleepiness scale were selected. Multiple logistic regression analysis was performed to assess the relationship between OSA-associated symptoms and different potential explanatory variables. RESULTS: The study sample included 1084 patients, median age was 53 years, 46.5% (504) were women, 72.7% (788) had OSA (apnea/hypopnea index ≥ 5), and 31.2% were obese. After adjusting for age, body mass index, and apnea/hypopnea index, men were more likely to report snoring (OR 4.06, p < 0.001), habitual or loud snoring (OR 2.34, p < 0.001; 2.14, p < 0.001, respectively) and apneas (OR 2.44, p < 0.001), than women. After controlling for multiple variables, female gender was an independent predictive factor for reported tiredness (OR 0.57, p 0.001), sleep onset insomnia (OR 0.59, p 0.0035), and morning headaches (OR 0.32, p < 0.001). Reports of excessive daytime sleepiness, nocturia, midnight insomnia, and subjective cognitive complaints were not significantly associated with gender. CONCLUSION: Women with OSA were more likely to report tiredness, initial insomnia, and morning headaches, and less likely to complain of typical OSA symptoms (snoring, apneas) than men.

Utility of the STOP-BANG components to identify sleep apnea using home respiratory polygraphy.

BACKGROUND: Utility of questionnaires to estimate the probability of obstructive sleep apneas (OSA) is varying, and it is challenging to know the performance of STOP (Snore, Tired, Observed apnea, and Pressure)-BANG (BMI, Age, Neck and Gender) with simplified methods. To assess the performance of STOP-BANG and its ability to predict sleep apnea in patients with high pre-test like-hood to present OSA referred for a home respiratory polygraphy (RP) were studied. METHOD: A cross-sectional study of patients recruited over 26 months was performed. They were asked to complete the STOP-BANG questionnaire during evaluation prior to RP and were evaluated according to different apnea-hypopnea index (AHI) cut-offs. Areas under receiver operating characteristic (ROC) curves and multiple logistic regression models were calculated. RESULTS: Eight hundred sixty-nine patients were studied; 557 were male (64.1 %) with a median age of 52.82 ± 14.43 years, a body mass index (BMI) of 32.88 ± 8.51, and Epworth Sleepiness Scale (ESS) score of 7.95 ± 5.17. The performance for AHI ≥5/h (ROC area) was: STOP 0.62, BANG 0.66, and STOP-BANG 0.69. The best sensitivity (S)-specificity (Sp) relationship for AHI ≥5/h was found with 5 components in any combination (S 56.02 %; Sp 70 %). For AHI ≥30/h, STOP was 0.68, BANG 0.66 and STOP-BANG 0.73 and the best S-Sp relationship was obtained with 5 components (S 68 %; Sp 63.6 %). Six variables (snoring, observed apneas, high blood pressure (HBP), BMI >35, neck perimeter >40 cm, and male gender) showed the best performance for AHI >30/h; ROC area 0.76. CONCLUSION: STOP-BANG shows different discrimination power for AHI >5 and ≥30/h using RP. Five components in any combination have acceptable diagnostic S to identify patients with severe OSA. STOP-BANG performed best to identify AHI ≥30/h.

Validation of ApneaLink Ox™ for the diagnosis of obstructive sleep apnea.

OBJECTIVE: The aim of the study was to validate the automatic and manual analysis of ApneaLink Ox™ (ALOX) in patients with suspected obstructive sleep apnea (OSA). METHODS: All patients with suspected OSA had a polysomnography (PSG) and an ALOX performed in the sleep laboratory. For automatic analysis, hypopnea was defined as a decrease in airflow ≥30 % of baseline for at least 10 s plus oxygen desaturation ≥3 or 4 %. While for the manual analysis, hypopnoea was considered when a reduction of airflow ≥30 % of ≥10 s plus oxygen desaturation ≥3 % or increase in cardiac rate ≥5 beats/min were identified or, when only a reduction of airflow ≥50 % was observed. OSA was defined as a respiratory disturbance index (RDI) ≥5. The apnea/hypopnea automatic index (AHI3-a, AHI4-a) and manual index were estimated. Receiver operating characteristics (ROC) analysis and the agreement between ALOX and PSG were performed. RESULTS: Fifty-five patients were included (38 men; mean age, 48.2; median, RDI 15.1; median BMI, 30 Kg/m(2)). The automatic analysis of ALOX under-estimated the RDI from PSG, mainly for the criterion of oxygen desaturation ≥4 % (AHI3-a-RDI, -3.6 ± 10.1; AHI4-a-RDI, -6.5 ± 10.9, p < 0.05). The autoscoring from ALOX device showed a better performance when it was set up to identify hypopneas with an oxygen desaturation criterion of ≥3 % than when it was configured with an oxygen desaturation criterion of ≥4 % (area under the receiver operator curves, 0.87 vs. 0.84). Also, the manual analysis was found to be better than the autoscoring set up with an oxygen desaturation of ≥3 % (0.923 vs. 0.87). The manual analysis showed a good interobserver agreement for the classification of patients with or without OSA (k = 0.81). CONCLUSION: The AHI obtained automatically from the ApneaLink Ox™ using oxygen desaturation ≥3 % as a criterion of hypopnea had a good performance to diagnose OSA. The manual scoring from ApneaLink Ox™ was better than the automatic scoring to discriminate patients with OSA.

[Practical guidelines for the diagnosis and treatment of obstructive sleep apnea syndrome]. / Guías prácticas de diagnóstico y tratamiento del síndrome de apneas e hipopneas obstructivas del sueño.

Obstructive sleep apnoea syndrome (OSAS) is one of the most relevant chronic respiratory pathologies due to its high prevalence and impact in morbidity and mortality. In 2001, the Asociación Argentina de Medicina Respiratoria (AAMR) published the first Argentinean Consensus on Sleep-Related breathing Disorders. Since then, wide new scientific evidence has emerged, increasing significantly the knowledge about this pathology. According to this, the Sleep-Related breathing Disorders and Oxygen Therapy Section of the AAMR, decided to update its Consensus, developing this Practical Guidelines on Management of patients with OSAS. A working group was created with members belonging to the section, experts in OSAS. They extensively reviewed the literature and wrote these guidelines, orientated to practical resolution of clinical problems and giving answers to questions emerged from dealing with patients who suffer from this syndrome. The document defines OSAS and describes the diagnosis and severity criteria, as well as the risk factors, ways of presentation and epidemiology. Clinical consequences, mainly on cognition, cardiovascular system and metabolism are pointed out. Different diagnostic methods, with their indications and technical aspects for validation and interpretation are detailed. Finally, we describe therapeutic alternatives, as well as practical aspects of their implementation. The authors' aim was to generate an accessible tool for teaching and spreading the knowledge on these disorders, which have a great impact in public health.

[Compliance with CPAP treatment in patients with obstructive sleep apneas during the COVID-19 pandemic in two hospitals in the Federal Capital] / Cumplimiento del tratamiento con CPAP en pacientes con apneas obstructivas del sueño durante la pandemia COVID-19 en dos hospitales de Capital Federal.

Introduction: CPAP therapy is the first line treatment for sleep apnea and its effectiveness depends on adherence. Face to face control and follow-up was limited due to the fact that our country was immersed in social isolation due to the COVID-19 pandemic as of March 2020. In order to assess whether CPAP adherence was maintained in patients with obstructive sleep apnea (OSA), in two hospitals during the COVID-19 pandemic and compare it with the pre-pandemic situation on a historical control basis in the city of Buenos Aires. Methods: Observational and retrospective study based on systematic data collection of adherence to CPAP and residual apnea-hypopnea index (AHI). For comparison, a historical control corresponding to the specular period (May to December of each year between 2016 and 2019) was used as a reference. Patients over 18 years ago with OSA on CPAP therapy more than 30 days of treatment were included. Patients with other chronic respiratory diseases requiring ventilation therapy (Bi-level, servo ventilation, volume-assured ventilation) were excluded. Results: 151 pre-pandemic patients and 127 from the pandemic period, respectively, were evaluated. Men 98 (65%) vs. 50 (60.3%) p: 0.9, age: 65.4 ± 11.9 vs. 63.6 ± 12.6 p: 0.22, body mass index 31.5 ± 5.0 vs. 31.2 ± 5.3 kg/m2 p: 0.6, respectively. In both centers, the most used treatment was fixed CPAP; 90 (59.6%) vs. 96 (75.6%) p: 0.005. There was an increase in compliance with it compared to the pre-pandemic period in minutes/night [341.4 95% CI 292.4 - 340.6 vs. 274.3 95% CI 208.5 - 267.4, p: 0.001] and residual AHI reduction [3.3 IC 95% 2.0 - 3.05 vs. 6.3 IC 95% 2.6 - 4.3 p: 0.006]. Conclusions: In the period of the COVID-19 pandemic, greater adherence to CPAP treatment was observed in patients with sleep apnea.

Introducción: La terapia con CPAP es el tratamiento de primera línea para la apnea del sueño y su eficacia depende de la adherencia. El control y seguimiento de forma presencial fue limitado debido a que nuestro país se vio inmerso en aislamiento social debido a la pandemia por COVID-19 a partir de marzo del 2020. Con el objeto de evaluar si se mantuvo la adherencia de la CPAP en pacientes con apnea obstructiva del sueño (AOS), en dos hospitales durante la pandemia COVID-19 y compararlo con la situación prepandemia sobre una base de control histórico de la ciudad de Buenos Aires. Métodos: Estudio observacional y retrospectivo basado en datos de recolección sistemática de adherencia a la CPAP e índice de apnea-hipopnea (IAH) residual. Para la comparación, se utilizó como referencia un control histórico correspondiente al periodo especular (mayo a diciembre de cada año entre el 2016 y 2019). Se incluyeron pacientes de más de 18 años de edad, con AOS con terapia con CPAP de más de 30 días de tratamiento. Se excluyeron pacientes con otras patologías respiratorias crónicas que requerían de terapias de ventilación (Bi-level, servo ventilación, ventilación con volumen asegurado). Resultados: Fueron evaluados 151 pacientes prepandemia y 127 del periodo pandemia respectivamente. Hombres 98 (65%) vs. 50 (60.3%) p: 0.9, edad de 65.4± 11.9 vs 63.6 ± 12.6 p: 0.22, índice de masa corporal 31.5 ± 5.0 vs. 31.2 ± 5.3 kg/m2 p: 0.6, respectivamente En ambos centros, el tratamiento más utilizado fue CPAP fijo; 90 (59.6%) vs. 96 (75.6%) p: 0.005. Existió un aumento en el cumplimiento del mismo en comparación al periodo prepandémico en minutos/noche [341.4 IC 95% 292.4 - 340.6 vs. 274.3 IC 95% 208.5 - 267.4, p: 0.001] y reducción del IAH residual [3.3 IC 95% 2.0 - 3.05 vs. 6.3 IC 95% 2.6 - 4.3 p: 0.006]. Conclusiones: En el periodo de pandemia COVID-19 se observó mayor adherencia al tratamiento con CPAP en pacientes con apneas del sueño.

CPAP indication based on clinical data and oximetry for patients with suspicion of obstructive sleep apnea: A multicenter trial.

BACKGROUND AND OBJECTIVE: The usefulness of pulse oximetry for the management of obstructive sleep apnea is controversial. The aim of this study was to assess the accuracy for indication of Continuous Positive Airway Pressure (CPAP) treatment in patients with suspected obstructive sleep apnea (OSA) based on clinical and oximetry data as compared to polysomnography (PSG). METHODS: This multicenter observational study involved seven sleep laboratories. Patients with suspicion of OSA who completed a standardized sleep questionnaire and a diagnostic PSG were enrolled. Eight observers logged on to a website independently and blindly. Seven observers only accessed the clinical data, curve and pulse oximetry results (Os-SO2-test method), while the eighth observer had full access to all indicators of PSG (O-PSG-reference method). Once observers assessed the information available on the website, they had to choose between three CPAP treatment options (yes/no/do not know) based on their knowledge and criteria. RESULTS: 411 subjects (228 men), median age 54 years, were available for evaluation. Os-SO2 had lower sensitivity (S), greater specificity (Sp) and positive likelihood ratio (PLR) to prescribe CPAP in patients more symptomatic (Epworth Sleepiness Scale-ESS > 10 or comorbidities) than those with fewer symptoms (ESS < 11 without comorbidities) (S 45-75% versus 45-91%, p 0.028); Sp 93.8-100% versus 68.5-96.6%, p 0.004; PLR > 10 versus 2.9-17, p<0.01). CONCLUSIONS: Due to its low false positive rate, a strategy based on pulse oximetry and clinical data was a consistent tool to indicate CPAP treatment in most symptomatic patients with a suspicion of OSA.

Apnea-hypopnea index in sleep studies and the risk of over-simplification.

According to recent reports, sleep disorders affect 30% of the adult population and 5-10% of children. Obstructive Sleep Apnea Hypopnea Syndrome (OSA) has a considerable epidemiological impact and demand for consultation is growing in our community. Therefore, it is necessary to know the principles of interpretation of diagnostic methods. A suspicion of OSA requires confirmation. According to the guidelines of the Argentine Association of Respiratory Medicine, polysomnography (PSG) is the gold standard for OSA diagnosis, while home sleep testing (HST) can be accepted as a comparatively effective method depending on the clinical situation of the patient. This article questions the use of AHI (apnea-hypopnea index) as the only measurement needed to diagnose OSA and assess its severity. In fact, it is surprising that, despite the large mass of data analyzed during sleep studies, current practices only focus on AHI. More than four decades have passed since OSA was first described. Our tendency to oversimplify complex conditions may prevent us from gaining a deeper and more thorough understanding of OSA. The development and validation of OSA severity scoring systems based on multiple parameters is still a pending issue.

Patients' preferences and the efficacy of a hybrid model of a minimal contact nasal mask in patients with sleep apnea treated with CPAP.

OBJECTIVES: To evaluate patient's satisfaction, efficacy and adherence to CPAP with a hybrid nasal mask (DW) we tested patients with OSA in unattended setting under real-life conditions. MATERIAL AND METHODS: Prospective, comparative study using DW mask 7 days against habitual mask in patients adapted to CPAP therapy. RESULTS: We analyzed 52 patients: 35 men (67%) with IAH mean; 24.3±12.3 events/hour. At baseline mean compliance of 5.42±1.83 hours/night. After using DW mask, patients reported fewer marks, more comfort, greater partners acceptance, easier to use and was ranked higher to preventing leaks; p<0.05, and adherence (1 more hour per night, p>0.0042).Differences were not found in pressure 90th-95th percentile (9.6±9.2 cm of H2O, p<0.5), leaks (19.8±17 liters/min. p<0.37) or residual AHI (3.38±3.05 events/hour. p<0.93). CONCLUSION: In an uncontrolled non-randomized study, patients can use DW mask with similar leak level and better adherence as compared to conventional masks.

Cierre dinámico y toxina botulínica: una alternativa novedosa para el cierre definitivo del abdomen abierto y contenido / Dynamic closure system and botulinum toxin: a novel alternative for definitive closure of open abdomen

RESUMEN Se presenta el caso de un paciente masculino de 54 años que, cursando internación por neumonía- COVID-19, intercurrió con shock séptico por diverticulitis aguda Hinchey IV, por lo que se realizó cirugía de Hartmann. Evolucionó con isquemia colónica, se realizó colectomía total y abdomen abierto y contenido (AAyC). El manejo del AAyC se realizó con sistema de vacío (VAC) durante 7 semanas, resultando un AAyC tipo IIIa (Björck) con un gap de 16 cm. Se decidió iniciar, una vez dadas las condiciones clínicas del paciente, el cierre dinámico (CD) con tracción fascial con malla de polipropileno asociado a inyección de toxina botulínica (TB). Esta estrategia permitió el cierre fascial primario (CFP) de la pared abdominal en la quinta semana de comenzado el tratamiento, evitando de esta manera la morbilidad de un cierre por segunda intención.

ABSTRACT We report the case of a 54-year-old male patient hospitalized for COVID-19 pneumonia who developed septic shock due to acute Hinchey IV diverticulitis and required Hartmann's surgery. The patient evolved with colonic ischemia and underwent total colectomy and open abdomen (OA) with temporary abdominal closure (TAC) that was managed with a vacuum-assisted wound closure (VAWC) system for 7 weeks, resulting in a Björck grade 3A OA with a 16-cm gap. As he had a favorable clinic course, dynamic closure with mesh-mediated fascial traction was decided, associated with botulinum toxin (BT) injection. This strategy allowed primary fascial closure (PFC) of the abdominal wall 5 weeks after treatment was initiated, thus avoiding the complications of healing by secondary intention.

Evaluación respiratoria y manejo de pacientes con obesidad candidatos a procedimientos quirúrgicos y cirugía bariátrica / Respiratory evaluation and management of obese patients who are candidates for surgical procedures and bariatric surgery

En el seno de la Sección de Sueño, Oxigenoterapia y Asistencia Ventilatoria de la Asociación Argentina de Medicina Respiratoria, se planteó el desarrollo de sugerencias para la exploración respiratoria del paciente con obesidad y definiciones sobre el manejo perioperatorio en cirugía bariátrica y procedimientos quirúrgicos electivos (cirugía no bariátrica). Esta iniciativa se basó en la necesidad de contar con lineamientos adaptados a la realidad local y discutida por expertos que se desempeñan en la realidad coyuntural cotidiana de nuestro país. La agenda se inició en agosto de 2020 en un grupo de revisión de la bibliografía y redacción. Revisores de diferentes provincias argentinas efectuaron una extensa valoración de la evidencia. Luego, un comité editorial realizo una revisión crítica del documento. Finalmente, todo el grupo debatió las sugerencias que se exponen como puntos clave. Este documento exhorta a cirujanos y clínicos a trabajar junto a especialistas respiratorios en la evaluación del riesgo, definición de la aptitud operatoria y corrección de trastornos funcionales y apneas del sueño. La cirugía en individuos con obesidad y la cirugía bariátrica, son procedimientos a los que se arriba luego de una evaluación exhaustiva de la situación clínica y funcional. La tarea multidisciplinaria y el tratamiento de las anormalidades detectadas pueden disminuir los riesgos perioperatorios. Pacientes con obesidad que requieren cirugía electiva con anestesia general deben ser evaluados mediante pruebas objetivas para confirmar la presencia de apneas del sueño y estar adecuadamente tratados con CPAP.

Within the Sleep, Oxygen Therapy and Ventilatory Assistance Section of the Argentine Association of Respiratory Medicine, we de velopment of recommendations for the respiratory exploration of patients with obesity and definitions on perioperative management in bariatric surgery and elective surgical procedures (surgery non bariatric). This initiative was based on the need to have guidelines adapted to the local reality and discussed by experts who work in the daily conjunctural reality of our country. The schedule was started in August 2020 in a literature review group. Reviewers from different Argentine provinces carried out an extensive assessment of the evidence. Then, an editorial committee performed a critical review of the document. Finally, the whole group discussed the suggestions that are presented as key points. This document encourages surgeons and clinicians to work close to respiratory specialists in assessing risk, defining operative competence, and revise functional disorders and sleep apnea. Surgery in obese individuals and bariatric surgery are procedures that are reached after a detailed evaluation about clinical and functional situation. The multidisciplinary team and the treatment of detected abnormalities can reduce perioperative risks. Obese patients who require elective surgery with general anesthesia should be evaluated by objective tests to confirm the presence of sleep apnea and be adequately treated with CPAP.

Comparative Study between Sequential Automatic and Manual Home Respiratory Polygraphy Scoring Using a Three-Channel Device: Impact of the Manual Editing of Events to Identify Severe Obstructive Sleep Apnea.

Objective. According to current guidelines, autoscoring of respiratory events in respiratory polygraphy requires manual scoring. The aim of this study was to evaluate the agreement between automatic analysis and manual scoring to identify patients with suspected OSA. Methods. This retrospective study analyzed 791 records from respiratory polygraphy (RP) performed at home. The association grade between automatic scoring and manual scoring was evaluated using Kappa coefficient and the agreement using Bland and Altman test and intraclass correlation coefficient (CCI). To determine the accuracy in the identification of AHI ≥ 30 eV/h, the ROC curve analysis was used. Results. The population analyzed consisted of 493 male (62.3%) and 298 female patients, with an average age of 54.7 ± 14.20 years and BMI of 32.7 ± 8.21 kg/m(2). There was no significant difference between automatic and manual apnea/hypopnea indexes (aAHI, mAHI): aAHI 17.25 (SD: 17.42) versus mAHI 21.20 ± 7.96 (p; NS). The agreement between mAHI and aAHI to AHI ≥ 30 was 94%, with a Kappa coefficient of 0.83 (p < 0.001) and a CCI of 0.83. The AUC-ROC, sensitivity, and specificity were 0.99 (CI 95%: 0.98-0.99, p < 0.001), 86% (CI 95%: 78.7-91.4), and 97% (CI 95%: 96-98.3), respectively. Conclusions. We observed good agreement between automatic scoring and sequential manual scoring to identify subjects with AHI ≥ 30 eV/h.

Impacto de la infección por SARS-CoV-2 (COVID-19) en el tratamiento de una lesión duodenal por arma de fuego / Impact of SARS-CoV-2 infection (COVID-19) in the treatment of duodenal gunshot injury

RESUMEN Se presenta el caso clínico de un paciente con traumatismo abdominal por herida de arma de fuego (HAF). En otra institución se realizó cirugía de exclusión pilórica y hepatorrafia por lesión hepatoduo denal. Fue derivado a nuestra institución a las 12 horas posoperatorias. Intercurre en el posoperatorio con neumonía grave por COVID-19 y complicaciones de su cirugía ini cial. La presentación severa de la enfermedad nos inclina por el manejo no operatorio. La utilización de drenajes percutáneos permitió el manejo de colecciones evitando una cirugía mayor inicial. La recuperación pulmonar facilitó la cirugía definitiva. La neumonía severa por COVID-19 en un paciente con lesión duodenal grave por HAF condiciona la toma de decisiones.

ABSTRACT We report the case of a patient with an abdominal gunshot trauma with liver and duodenal injury who underwent pyloric exclusion and liver repair in another institution. The patient was transferred to our institution 12 hours after surgery. During hospitalization, severe pneumonia due to COVID-19 and complications of the initial surgery developed. Non-surgical management was decided due to the severity of the disease. Percutaneous drainage allowed for the management of the collections avoiding a major initial surgery. Once he recovered from the pneumonia, the definite surgery was performed. Severe COVID-19 pneumonia in a patient with serious duodenal shotgun injury is a determining factor for decision-making of treatment options.

Guías prácticas de diagnóstico y tratamiento del síndrome de apneas e hipopneas obstructivas del sueño: Actualización 2019: Sección Sueño, Oxigenoterapia y Tratamientos Crónicos Domiciliarios. Asociación Argentina de Medicina Respiratoria / Practical guides for diagnosis and treatment of obstructive sleep apneas and hypopneas syndrome: 2019 update. Sleep, Oxygen Therapy and Chronic Home Treatments Section. Argentine Association of Respiratory Medicine

Las apneas del sueño constituyen uno de los trastornos respiratorios crónicos de mayor relevancia en la población general, por su prevalencia, los efectos que produce en los pacientes que las padecen y su impacto en la salud pública. En el año 2013 se publicaron las primeras Guías Prácticas de diagnóstico y tratamiento del síndrome de apneas e hipopneas obstructivas del sueño de la AAMR. Desde entonces se ha generado un volumen significativo de evidencia científica sobre estos trastornos, lo que ha motivado la actualización de estas Guías Prácticas. Un grupo de trabajo, conformado por profesionales entrenados y con experiencia en trastornos respiratorios del sueño, revisó la bibliografía y actualizó los conceptos vertidos en las guías 2013. En su desarrollo se define el cuadro, los criterios diagnósticos y de gravedad, los factores de riesgo, las formas de presentación y sus consecuencias. Se detalla la metodología diagnóstica, sus distintas variables e indicaciones y los requisitos técnicos para su validación e interpretación. Por último se desarrollan las alternativas terapéuticas, así como también aspectos prácticos de su implementación. El objetivo central fue generar una herramienta de divulgación científica, que determine pautas claras que sirvan de referencia para la formación de profesionales, la atención de pacientes con esta enfermedad y la generación de políticas públicas.

Sleep apnea is one of the most relevant chronic respiratory disorders in the general population, given its prevalence, the effects it produces in patients and their impact on public health. In 2013, the first Practical Guidelines for diagnosis and treatment of obstructive sleep apnea syndrome of the AAMR were published. Since then, a significant volume of scientific evidence on these disorders has been generated, which has motivated the updating of these Practical Guidelines. A working group of trained professionals with experience in sleep breathing disorders reviewed the literature and updated the concepts included in the 2013 guidelines. Clinical aspects, diagnostic and severity criteria, risk factors, consequences and diagnostic strategy are addressed, as well as therapeutic alternatives and practical aspects of their implementation. The main objective was to generate practical guidelines that constitute a reference for the training of professionals, the care of patients with this disease and the generation of public policies.

Tratamiento con presión positiva de la Apnea Obstructiva del Sueño. Posición de la Asociación Argentina de Medicina Respiratoria / Treatment of Obstructive Sleep Apnea with Positive Pressure. Position of the Argentinian Association of Respiratory Medicine

La Sección de Sueño, Oxigenoterapia y Otros Tratamientos Crónicos Domiciliarios, de la Asociación Argentina de Medicina Respiratoria (AAMR) se planteó desarrollar en nuestro país un documento formal que exponga la base científica y costo económica de la cobertura del tratamiento del síndrome de apneas e hipopneas obstructivas durante el sueño (SAHOS). Esta iniciativa se basó en la necesidad de analizar la visión de expertos locales que se desempeñan en la realidad coyuntural cotidiana de nuestro país, para elaborar un documento informativo para miembros del equipo de salud. A su vez, exhorta a los diferentes actores del sistema a determinar pautas claras que sirvan de referencia para la generación de políticas públicas. La agenda se inició en septiembre de 2018 en un grupo de redacción. Luego, revisores de cinco provincias argentinas efectuaron una extensa valoración de la evidencia publicada. Para la edición final se realizó una reunión presencial de discusión y generación de consenso. Se plantearon como objetivos; actualizar la base científica que define al SAHOS como problema de salud de proporciones epidémicas con consecuencias demostrables en la salud, analizar los datos de costo-efectividad del tratamiento con CPAP para las formas moderadas a severas y leves con síntomas y unificar conceptos en relación con la calidad mínima necesaria en los tratamientos que se ofrecen. Finalmente, se analiza la situación en la Argentina sobre la base a datos publicados y se presenta una propuesta de mejora en tres niveles: social y económico, logístico-administrativo y clínico

The Sleep, Oxygen Therapy and Other Home Chronic Treatments Section of the Argentinian Association of Respiratory Medicine (AAMR, for its acronym in Spanish) proposed the development in our country of a formal document exposing the scientific and cost-economical foundation of the coverage for the treatment of obstructive sleep apnea and hypopnea syndrome (OSAHS). This initiative was based on the need to analyze the vision of local experts who work in the daily current reality of our country, in order to create an informative document for the members of the medical staff. In turn, it encourages the different members of the system to determine clear guidelines that could be used as reference for generating public policies. The agenda began in September, 2018 within a writing staff. Then, editors from five Argentinian provinces made a thorough assessment of published evidence. For the final edition, a face-to-face meeting was arranged to discuss and reach a consensus. The suggested objectives were: to update the scientific base that defines the OSAHS as a health problem of epidemic proportions with health consequences; to analyze cost-efficacy data of CPAP treatment for moderate to severe and mild-with-symptoms forms of the disease and to unify concepts in relation to the minimum necessary quality of treatments to be offered. Finally, the situation in Argentina is analyzed basing on published data, and a proposal is presented for improvement in three levels: social and economic, logistic-administrative and clinical.

Indicadores de los estudios de diagnóstico de los trastornos respiratorios vinculados al sueño y el riesgo de la simplificación / Indicators of diagnostic studies of sleep-related respiratory disorders and the risk of simplification

Datos recientes indican que los trastornos respiratorios del sueño afectan 15 a 20% de la población adulta y 5 a 10% de los niños. El Síndrome de apneas e hipopneas obstructivas del sueño (SAHOS) constituye una entidad de alto impacto epidemiológico con una creciente demanda en nuestro medio. Para comenzar a resolver el problema es necesario conocer los fundamentos básicos en la interpretación de los métodos diagnósticos. La confirmación es requerida ante la sospecha de SAHOS. Las guías de la Asociación Argentina de Medicina Respiratoria establecen que la polisomnografía (PSG) es el método diagnóstico estándar y acepta la poligrafía respiratoria (PR) como método equiparable considerando el contexto clínico del enfermo. Este artículo aborda el dilema del uso del índice de apnea e hipopnea (IAH) e índice de perturbación respiratoria (IPR) que definen la enfermedad y son usados para establecer su severidad. Resulta sorprendente que a pesar de la cantidad de datos que son analizados en un estudio del sueño, la atención se centre en este valor. Más de cuatro décadas han transcurrido desde la descripción original y nuestra capacidad de simplificación podría poner en riesgo las posibilidades de un entendimiento integral del SAHOS.

The latest data indicate that respiratory sleep disorders affect 15 to 20% of adults and 5 to 10% of children. Obstructive sleep apnea (OSA) means a high impact epidemiologic entity with a growing demand in our daily clinical practice. To begin to solve this problem it is necessary to know the basic fundaments in the interpretation of diagnostic methods. Confirmation is required in suspected OSA. Guidelines from Argentinian Respiratory Medicine Society recognize polysomnography (PSG) as the standard diagnostic method and respiratory polygraphy (RP) as comparable method considering the clinical context of the patient. This article summarizes the dilemma of using apnea and hypopnea index (AHI) that defines the disease and is used to assess the severity. It is surprising that despite the amount of data being analyzed in a sleep study, attention is focused on this value. More than four decades have passed since the original description and our ability to simplification could put on risk the chances of a comprehensive understanding of OSA.

Indication of CPAP in Patients with Suspected Obstructive Sleep Apnea, Based on Clinical Parameters and a Novel Two-Channel Recording Device (ApneaLink): A Pilot Study.

Objective. To evaluate the accuracy and reliability of the medical decision based on the results of the hand scoring from a two-channel recording device (ApneaLink) plus clinical data for the prescription of a CPAP assay in patients with suspected OSA. Methods. 39 subjects were assessed in the sleep laboratory with polysomnography and ApneaLink. The patients completed the Epworth sleepiness scale and a clinical history. Two blinded independent observers decided to prescribe CPAP according to the results of the PSG (gold standard, observer A), ApneaLink (alternative method, observer B), and the clinical parameters. Sensitivity and specificity of observer B on the indication of CPAP were calculated. The interobserver agreement for the indication of CPAP was assessed using kappa statistics. Results. 38 subjects were included (26 men, mean age 47.5, mean RDI 28.7, mean BMI 31.4 kg/m(2)). The prevalence of OSA was 84%. The sensitivity and specificity of observer B to initiate a CPAP trial were 90.6% and 100%, respectively. The interrater agreement for the prescription of CPAP was good (kappa: 0.75). Conclusion. This study has shown that the use of ApneaLink plus clinical data has made it possible to indicate CPAP reliably in most patients with high-clinical pretest for OSA.

Guías prácticas de diagnóstico y tratamiento del síndrome de apneas e hipopneas obstructivas del sueño / [Practical guidelines for the diagnosis and treatment of obstructive sleep apnea syndrome].

Obstructive sleep apnoea syndrome (OSAS) is one of the most relevant chronic respiratory pathologies due to its high prevalence and impact in morbidity and mortality. In 2001, the Asociación Argentina de Medicina Respiratoria (AAMR) published the first Argentinean Consensus on Sleep-Related breathing Disorders. Since then, wide new scientific evidence has emerged, increasing significantly the knowledge about this pathology. According to this, the Sleep-Related breathing Disorders and Oxygen Therapy Section of the AAMR, decided to update its Consensus, developing this Practical Guidelines on Management of patients with OSAS. A working group was created with members belonging to the section, experts in OSAS. They extensively reviewed the literature and wrote these guidelines, orientated to practical resolution of clinical problems and giving answers to questions emerged from dealing with patients who suffer from this syndrome. The document defines OSAS and describes the diagnosis and severity criteria, as well as the risk factors, ways of presentation and epidemiology. Clinical consequences, mainly on cognition, cardiovascular system and metabolism are pointed out. Different diagnostic methods, with their indications and technical aspects for validation and interpretation are detailed. Finally, we describe therapeutic alternatives, as well as practical aspects of their implementation. The authors’ aim was to generate an accessible tool for teaching and spreading the knowledge on these disorders, which have a great impact in public health.

¿Qué pasa con los pacientes luego de que ses diagnostica Apneas del Sueño? / What happens with patients after they have been diagnosed Sleep Apnea?

Numerosos pacientes con diagnóstico de SAHOS moderado severo no reciben finalmente tratamiento efectivo. El objetivo del estudio es evaluar el grado de utilización de las medidas terapéuticas necesarias entre estos enfermos y los motivos de no tratamiento o tratamiento insuficiente. Métodos: Muestra consecutiva de pacientes derivados al Laboratoriode Sueño del IADIN entre agosto y diciembre de 2006 con solicitud de Polisomnografía por síntomas de apneas del sueño, la que diagnosticó SAHOS moderado severo. Durante julio de 2007 se les realizó una encuesta telefónica. Resultados: 100 pacientes encuestados, 85 varones, IPR 51.9±30.9ev/h, edad 52,38±12.2, IMC 34.1±10.6.47 pacientes no hicieron tratamiento alguno. 52 comenzaron tratamiento con CPAP, pero 12 lo suspendieron. 2 pacientes fueron sometidos a tratamiento quirúrgico. 90 pacientespresentaban un IMC mayor de 25, 64p > 30 y 32p > 35. 30 consultaron un nutricionista, 21 pacientes bajaron de peso, solo 3 lograron bajar más del 20% del basal. Los pacientesno tratados presentaron un IPR menor (p 0.02). Conclusiones: Si bien se ha incrementado el nivel de conciencia y alerta acerca de las implicancias del SAHOS entre los médicos y en la población general, lo que acrecentó la pesquisa de estos cuadros, se detectanconsiderables fallas en la aplicación de los tratamientos necesarios para revertir el cuadro y prevenir las consecuencias que se le atribuyen.

Many patients with confirmed diagnosis of moderate to severe Sleep Apnea don’t receive efective treatment. The objective of this study is to evaluate the use of specific therapeutic measures in those subjects and to detect the posible reasons of ineffective treatment.Methods: consecutive sample of patients who attended to our Sleep Lab between August and December of 2006 for a PSG because of symptoms of sleep apneas, which diagnosed moderate to severe SAS. During july of 2007 a telephonic survey was performed. Results:100 patients surveyed, 85 males, AHI 51.9±30.9ev/h, age 52,38±12.2, BMI 34.1±10.6. 47 patients don’t received any treatament. 52 began nCPAP therapy, but 12 discontinued it later. 2 subjects received surgical treatment. 90 patients had a BMI >25, 64p >30 and32p >35. 30 visited a nutricionist; 21 patients were able to lose weight, but only 3 lost more than 20% from baseline. Untreated patients presented a smaller AHI (p 0.02). Conclusions: Although there is more consciusness and awareness regarding SAS and its consecuences between physicians and general population, we detected considerable failures in the onset of necesary treatment to revert the symptoms and prevent itsconsequences.