Decision making in obstructive sleep-disordered breathing. Putting it all together

Correlation of clinical profiles with obstructive sleep apnea and metabolic syndrome

BACKGROUND

Obstructive sleep apnea (OSA) is a common condition being increasingly recognized and is associated with many diseases. Few data are available for Indian patients and public health hazard of the condition continues to be seriously underestimated in this country. The objective of this study was to evaluate the prevalence of obesity, hypertension, diabetes mellitus, and hyperlipidemia (HLP) in a South Indian population with proven OSA.

METHODS

A retrospective analysis of data accrued in patients undergoing polysomnography (PSG) was undertaken. Two hundred thirty-four patients of either sex in the age of 54 ± 11 years who tested positive for OSA were compared with control group. An apnea-hypopnea index (AHI) of >5 in the presence of snoring and daytime somnolence was taken to define sleep apnea.

RESULTS

The mean AHI among the study group with OSA was 31.3 ± 18.6 as compared with 1.2 ± 0.5 in the control group. The BMI among patients with OSA was 36 ± 6 as compared with 29 ± 4 in comparison group (p < 0.001). Among the patients with OSA, 31% were having HLP, 59% were diabetics, and 86% were hypertensive. Subjects with PSG-proven OSA had significant levels of day time sleepiness, lack of concentration, changes in mood, morning headache, and dry mouth. Nonrestorative sleep, awakening with choking, nocturnal dyspnea, insomnia with frequent awakenings, nocturia, and diaphoresis were observed in (>80%) patients. A significant difference in the sleep efficiency (16%), sleep onset (14%), and mean saturation (9%) was observed in the study group as compared to the control group.

CONCLUSIONS

The risk of obesity, hypertension, diabetes mellitus, and HLP in OSA syndrome patients was almost three times more than that of the comparing group.

Obesity hypoventilation syndrome

Obesity is becoming a major medical concern in several parts of the world, with huge economic impacts on health- care systems, resulting mainly from increased cardiovascular risks. At the same time, obesity leads to a number of sleep-disordered breathing patterns like obstructive sleep apnea and obesity hypoventilation syndrome (OHS), leading to increased morbidity and mortality with reduced quality of life. OHS is distinct from other sleep- related breathing disorders although overlap may exist. OHS patients may have obstructive sleep apnea/hypopnea with hypercapnia and sleep hypoventilation, or an isolated sleep hypoventilation. Despite its major impact on health, this disorder is under-recognized and under-diagnosed. Available management options include aggressive weight reduction, oxygen therapy and using positive airway pressure techniques. In this review, we will go over the epidemiology, pathophysiology, presentation and diagnosis and management of OHS.

Physiologic Pacing in Patients With Obstructive Sleep Apnea

OBJECTIVES

This study was designed to assess the impact of prevention of bradycardia with physiologic pacing on the severity of obstructive sleep apnea.

BACKGROUND

Apneic episodes during sleep are associated with slowing of the heart rate during apnea and tachycardia with subsequent arousal. Patients with permanent pacemakers may have reduced episodes of sleep apnea when their pacemaker rate is set faster than their spontaneous nocturnal heart rate.

METHODS

We conducted a prospective, randomized, single-blind crossover trial of temporary atrial pacing in obstructive sleep apnea to reduce the apnea hypopnea index (AHI). Fifteen patients (age 60 +/- 13 years, 12 men) with moderate to severe obstructive sleep apnea (AHI 34 +/- 14) underwent insertion of an externalized atrial permanent pacing system via the left subclavian vein. Patients underwent overnight respiratory sleep studies in hospital, during atrial pacing at 75 beats/min, and with pacing turned off. The order of pacing mode was randomized, with crossover the subsequent night to the other mode. Patients were blinded to pacing mode, and the analysis of sleep recordings was blind to pacing mode.

RESULTS

Pacing was tolerated without complications in all patients. Overnight physiologic pacing did not affect the AHI (pacing 39 +/- 21/h vs. control 42 +/- 21/h, p = 0.23, 95% confidence interval -9.3 to 2.5 for difference), desaturation time (pacing 3.8 +/- 6.0% vs. control 3.5 +/- 4.3%, p = 0.70), or the minimum SaO(2) (pacing 75 +/- 10% vs. control 77 +/- 11%, p = 0.38). There was a borderline significant reduction in circulatory time with pacing (pacing 23.4 +/- 3.2 s vs. control 25.5 +/- 4.4 s, p = 0.09).

CONCLUSIONS

Temporary atrial pacing does not appear to improve respiratory manifestations of obstructive sleep apnea. Permanent atrial pacing in this patient population does not appear to be justified.

Sleep apnoea: Finnish National guidelines for prevention and treatment 2002-2012

(1) After negotiations with the Finnish Ministry of Social Affairs and Health, a national programme to promote prevention, treatment and rehabilitation of sleep apnoea for the years 2002-2012 has been prepared by the Finnish Lung Health Association on the basis of extensive collaboration. The programme needs to be revised as necessary, because of the rapid development in medical knowledge, and in appliance therapy in particular. (2) Sleep apnoea deteriorates slowly. Its typical features are snoring, interruptions of breathing during sleep and daytime tiredness. Sleep apnoea affects roughly 3% of middle-aged men and 2% of women. In Finland, there are approx. 150,000 sleep apnea patients, of which 15,000 patients have a severe disease, 50,000 patients are moderate and 85,000 have a mild form of the disease. Children are also affected by sleep apnea. A typical sleep apnea patient is a middle-aged man or a postmenopausal woman. (3) The obstruction of upper airways is essential in the occurrence of sleep apnoea. The obstruction can be caused by structural and/or functional factors. As for structural factors, there are various methods of intervention, such as to secure children's nasal respiration, to remove redundant soft tissue, as well as to correct malocclusions. It is possible to have an effect on the functional factors by treating well diseases predisposing to sleep apnoea, by reducing smoking, the consumption of alcohol and the use of medicines impairing the central nervous system. The most important single risk factor for sleep apnoea is obesity. (4) Untreated sleep apnoea leads to an increase morbidity and mortality through heart circulatory diseases and through accidents by tiredness. Untreated or undertreated sleep apnoea deteriorates a person's quality of life and working capacity. (5) The goals of the Programme for the prevention and treatment of sleep apnoea are as follows: (1) to decrease the incidence of sleep apnoea, (2) to ensure that as many patients as possible with sleep apnoea recover, (3) to maintain capacity for work and functional capacity of patients with sleep apnoea, (4) to reduce the percentage of patients with severe sleep apnoea, (5) to decrease the number of sleep apnoea patients requiring hospitalisation and (6) to improve cost effectiveness of prevention and treatment of sleep apnoea. (6) The following means are suggested for achieving the goals: (1) to promote prevention of obesity, weight loss and weight control; (2) to promote securing of nasal respiration in child patients and removal of obstructing redundant soft tissues; (3) to promote the correction of children's malocclusions, (4) to enhance knowledge about risk factors and treatment of sleep apnoea in key groups, (5) to promote early diagnosis and active treatment, (6) to commence rehabilitation early and individually as a part of treatment and (7) to encourage scientific research. (7) On the national level, the occurrence of sleep apnoea can be prevented, for example, by encouraging weight control. The programme gives examples of such measures and appeals to various authorities and voluntary organisations to reinforce their collaboration. Preventive measures should be individualised, and based on due consideration. (8) The efficacy of diagnosing sleep apnoea should be increased. Attention should be paid to the symptoms of risk group patients at different units of the primary and occupational health care. Even mild forms of the disease should be treated appropriately. Diagnosis and treatment of the disease involve cooperation between the primary and specialised health-care sectors. Methods of treatment are (1) treatment of obesity, (2) positional therapy, (3) reduction of the use of medicines impairing the central nervous system, (4) reduction of smoking and the consumption of alcohol, (5) devices affecting the position of the tongue and lower jaw, (6) treatment with Continuous Positive Airway Pressure (CPAP-treatment), (7) surgical methods of treatment and (8) rehabilitation. (9) The hierarchy of referrals in the prevention and treatment of sleep apnoea should be revised to accord a greater role to the primary health-care sector. Good exchanges of information and cooperation between the primary health care and specialised medical-care sectors should be developed. Hospitals districts in cooperation with provincial governments and municipalities should ensure that different levels of the health-care system are capable of fulfilling the tasks assigned to them appropriately. (10) Rehabilitation of sleep apnoea should be goal-orientated and cover all forms of rehabilitation: medical, occupational and social. Rehabilitation should prevent the effects caused by the disease. Thus, it is possible to support self-care, increase the patient's resources and improve quality of life. (11) Information and training should be directed primarily towards health-care personnel, patients and their families. Organisations should produce materials for health and patient education as well as organising training events. To support the activities. financing will be needed from organisations such as Finland's Slot Machine Association. The Social Insurance Institution should disseminate information about questions of social security. Regional direction and training will mainly be the responsibilities of hospital districts, provincial governments and local health centres. The media will play an important role in the dissemination in-depth information about prevention and treatment of sleep apnoea.

Obstructive sleep apnea: recognition and management considerations for the aged patient

Sleep-disordered breathing (SDB) problems are estimated to affect between 2% to 4% of Americans with an even higher incidence occurring as one ages. This article focuses on obstructive sleep apnea (OSA) as a risk to safety and a leading contributor to interrupted sleep and disease morbidity in the aged population. Obstructive sleep apnea is caused by interruption in upper airway airflow during sleep that leads to oxygen desaturations and disruptions in sleep continuity. The symptoms, diagnosis, and initial management of OSA are discussed that provide direction for the advanced practice nurse who encounters patients with this disease.

Diagnosis and management of sleep apnea syndrome

Sleep apnea is the cessation of breathing during sleep. These episodes result in hypoxemia and sleep disruption; thus the consequences are both cardiorespiratory and neural. Sleep apnea syndrome is defined by a constellation of signs and symptoms, with the main presenting symptom being excessive daytime sleepiness. A diagnosis requires documentation of episodes of abnormal breathing during sleep. This disorder, once thought to be very rare, is so common that it is unlikely that any busy clinician has not encountered a case. Facilities for the evaluation of sleep breathing disorders are now available in most communities. With the introduction of continuous positive airway pressure and other treatments, most patients have complete resolution of their disabling symptoms.

Comparison of respiratory polysomnographic parameters in matched cohorts of upper airway resistance and obstructive sleep apnea syndrome patients

OBJECTIVE

To compare respiratory nocturnal polysomnography (NPSG) characteristics between matched cohorts of upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS) patients.

METHODS

All patients received 13-channel NPSG, including esophageal pressure (Pes) manometry. By definition, OSAS patients had an apnea-hypopnea index (AHI, number of apneas/hypopneas per hour total sleep time) > or = 15, and UARS patients had an AHI < 5. Respiratory effort-related arousal (RERA) was defined as the absence of apnea/hypopnea with > or = 10 s duration of progressive negative Pes, culminating in an arousal or microarousal. UARS patients, by definition, had > or = 15 RERAs per hour. Fifteen consecutively diagnosed UARS patients were matched with OSAS patients on the basis of body mass index (BMI) and gender.

RESULTS

Respiratory disturbance index (sum of the AHI and RERA per hour) was the same for both cohorts: UARS, 36+/-4; OSAS, 42+/-6 (p = 0.34). There were no differences between cohorts for mean inspiratory Pes nadirs for each 30-s epoch of sleep compared for each sleep stage over an entire night. For randomly selected breaths from supine stage 2 sleep, the mean inspiratory Pes nadir was the same for the cohorts: UARS, -16.6+/-2 cm H2O; OSAS, -16.1+/-3 cm H2O (p = 0.30). Differences between cohorts for each parameter fell within respective 95% confidence intervals.

CONCLUSION

With the exception of AHI, respiratory NPSG parameters were the same for UARS and OSAS patients when BMI and gender were controlled for.

Medical management of obstructive sleep apnea

The last 20 years have seen remarkable gains in our understanding of the pathophysiology of sleep-disordered breathing. The rapid growth in both scientific and clinical knowledge has been fueled by the development of nonsurgical therapies for obstructive sleep apnea (OSA). These medical therapies have provided the avenue for public acceptance of the diagnosis and treatment of this common medical condition. However, medical therapy requires active patient participation, to achieve the desired outcomes of improved sleep continuity, daytime functioning, and quality of life. Conservative therapies, such as weight loss and patient positioning; and pharmacological therapies, have been disappointing. Positive pressure therapy has become the treatment of choice for the vast majority of OSA patients. Oral appliances offer an acceptable treatment alternative for select patients. Present research indicates that these mechanical approaches can produce significant decreases in the frequency and severity of sleep-disordered breathing and nocturnal oxyhemoglobin desaturation. Preliminary data from ongoing studies suggest that these interventions will reduce long-term morbidity and possibly mortality.