Diagnostic criteria and treatment for sleep-disordered breathing: obstructive sleep apnea syndrome

In this chapter, the principal approaches to the diagnosis and treatment of patients with obstructive sleep apnea syndrome (OSAS) are presented. The diagnosis should be carried out by the taking of a thorough clinical history and by physical examination. For diagnostic confirmation, it is necessary to perform supervised overnight polysomnography. For patients in whom clinical suspicion is high, a simplified home study can be an alternative. The treatment of OSAS requires general measures and the use of positive pressure devices. In moderate and severe cases, CPAP is the method of choice, whereas oral appliances can be used in mild cases. Surgical procedures are recommended when anatomical alterations are evident or as an auxiliary method in combination with other types of treatment.Neste capítulo são apresentadas as principais abordagens para o diagnóstico e tratamento dos pacientes com SAOS. O diagnóstico deve ser realizado através de uma minuciosa história clínica e exame físico. Para a confirmação diagnóstica, é necessária a realização da polissonografia completa de noite inteira sob supervisão, sendo que em pacientes cuja suspeita clínica é alta, registros simplificados domiciliares podem ser uma alternativa. O tratamento da SAOS requer medidas gerais e o uso de aparelhos de pressão positiva. Em casos moderados e graves, CPAP é o mais indicado, enquanto aparelhos intraorais são indicados em casos leves. Os procedimentos cirúrgicos são indicados quando alterações anatômicas são evidentes ou como auxílio aos demais tratamentos.Universidade Federal de São Paulo (UNIFESP)Faculdade de Ciências Médicas de Minas GeraisUNIFESPSciEL

Assessment of daytime symptoms in snoring subjects and obstructive sleep apnea patients

El síndrome de apnea obstructiva del sueño (SAOS) es un trastorno de la respiración que se produce durante el sueño, caracterizado por episodios repetidos de apnea (cese total del flujo aéreo) o hipopnea (cese parcial) con una duración mínima de 10 segundos. La sintomatología asociada al trastorno es muy variada. La mayoría de los pacientes se queja de problemas cognitivos, dificultades dificultades de concentración, excesiva somnolencia diurna, despertares frecuentes y aumento de la actividad motora durante el sueño, así como de cambios en el estado de humor y en el carácter. De todos los síntomas observados en el trastorno, el ronquido es el rasgo más universal de la apnea del sueño y una de las causas más comunes de referencia para la evaluación del trastorno. Hoy en día se estima que aproximadamente 70% de los pacientes que acude a los laboratorios de sueño padece ronquido, siendo en este grupo además bastante alta la sospecha de un posible diagnóstico de SAOS. Algunos estudios han centrado su interés en evaluar si las personas que manifiestan ronquido crónico muestran algún tipo de sintomatología que pueda utilizarse como medida preventiva para el posterior desarrollo de la apnea del sueño. Aunque los resultados de estos estudios no son muy concluyentes, lo que sí parece confirmarse es que en muchos casos el ronquido puede llegar a producir consecuencias clínicas importantes. Por ello, y con base en la bibliografía revisada, el objetivo de la presente investigación es evaluar si hay o no diferencias en somnolencia diurna, tiempo de reacción, memoria a corto plazo, depresión, ansiedad estadorasgo y neuroticismo entre un grupo de pacientes con SAOS y un grupo de pacientes roncadores crónicos.The obstructive sleep apnea syndrome (OSAS) is a type of sleep disorder that has called the attention of many researchers because of its widespread distribution among middle-aged subjects. The OSAS is a respiratory problem characterized by the existence of apneas, defined as 10 second minimum intervals during which no aerial flux exchange takes place through the upper airways and the hypopneas not characterized by an arrest, but by a reduction of aerial flux through the upper airways. The most widespread index used in the diagnosis of the OSAS severity has been the apnea/hypopnea index (AHI). There is little consensus based on the apnea/hypopnea index regarding the clinical definition of the sleep apnea syndrome, as there is not a single criterion for the categorization of sleep apnea patients into severity levels. Nowadays, it is estimated that about 70% of the patients referred to sleep laboratories suffer from snoring, and it is suspected that they might also suffer from sleep apnea. Obstructive sleep apnea patients may suffer from memory and cognitive problems, excessive daytime sleepiness, as well as mood disturbance, among other symptoms. Additionally, this disorder has severe medical and social consequences. One of the most characteristic symptoms in sleep apnea is snoring. Although snoring is one of the symptoms of sleep apnea, it should be remembered it is a typical phenomenon among population in general. There is a primary kind of snoring, the most frequent type in less severe cases, which even occurs among the normal population. In this case, the noise accompanying inspiration is made with almost every breath. Secondly, there is another kind of snoring that is either intermittent or cyclic, and snoring does not come with every breath but silent periods are also frequent. The latter indicates apnea. A considerable number of epidemiological studies regarding snoring have been produced of late. Several of them have concluded that snoring may have severe clinical consequences. Most patients suffering from obstructive sleep apnea start having simple snores. In the last decade there has been a marked increase of patients who manifest respiratory disorders related to sleep who do not fall into the category of apnea patients. Nevertheless, the morbidity of these clinical disorders is not yet known, a circumstance that makes treatment more difficult. Only a reduced number of studies have tried to find out whether snorers show any kind of symptoms that could be used as a preventive measure against the development of sleep apnea. For all the previous reasons, the aim of this study is to assess whether there are any differences in daytime sleepiness, reaction time, short-term memory, depression, trait anxiety, state anxiety and neuroticism between a group of patients with obstructive sleep apnea and a group of snoring individuals who had not been diagnosed as suffering from OSAS

Nocturnal release of leukocyte-derived microparticles in males with obstructive sleep apnoea

Multiple pathophysiological mechanisms have been proposed to contribute to the increased cardiovascular morbidity in obstructive sleep apnoea (OSA), including autonomic dysfunction, inflammation, oxidative stress and endothelial dysfunction 1. Microparticles (MPs) are small membrane vesicles that are shed from circulating cells or from the components of the vessel wall in response to activation and apoptosis. There is growing evidence in support of a potential role of MPs in the field of cardiovascular diseases. Increased levels of MPs derived from various cell types are found in patients at risk of cardiovascular diseases 2. By modulating inflammation, coagulation, vasomotor reactivity and angiogenesis, MPs might directly contribute to cardiovascular diseases 2. Recent case–control studies suggest a potential involvement of MPs in OSA-associated cardiovascular morbidity 3–6. An increase in morning levels of MPs derived from activated leukocytes has been demonstrated in otherwise healthy male OSA patients with marked nocturnal desaturations 5. In vitro, nitric oxide (NO) production by endothelial cells incubated with MPs from OSA patients correlates negatively with circulating levels of activated leukocyte-derived MPs 5. Ex vivo, mice previously injected with MPs from OSA patients display endothelial dysfunction, reduced endothelial NO release and increased adhesion molecule expression 5

Circulating microparticles from patients with obstructive sleep apnea enhance vascular contraction: mandatory role of the endothelium

Obstructive sleep apnea (OSA) is characterized by repetitive apnea-hypopnea cycles during sleep associated with oxygen desaturation and sleep disruption. We evaluated the role of circulating microparticles (MPs) from patients with OSA in the regulation of vascular function. MPs from whole blood from patients with OSA or control subjects were injected i.v. into mice. Injection of MPs from patients with OSA induced ex vivo vascular hyperreactivity in aortas with functional endothelium but, in contrast, hyporeactivity in vessels without functional endothelium. Vascular hyperreactivity was blunted in the presence of a nitric oxide synthase inhibitor alone or combined with the cyclooxygenase inhibitor indomethacin. MPs from patients with OSA reduced endothelial nitric oxide synthase activity and nitric oxide production, increased aortic cyclooxygenase-1 and cyclooxygenase-2 expression, and increased thromboxane A(2) and prostacyclin production. Blockade of thromboxane A(2) receptor did not affect the serotonin response in arteries from OSA MP-treated mice. A superoxide dismutase mimetic reduced the vascular hyperreactivity induced by MPs from patients with OSA but had no effect on contraction in vessels from control and non-OSA MP-treated mice. These data provide evidence that circulating MPs from patients with OSA induce ex vivo vascular hyperreactivity with the obligatory role of the endothelium and subtle interactions between the nitric oxide and cyclooxygenase pathways and metabolites. These results highlight the participation of MPs in vascular dysfunction associated with OSA

Efficacy of a mandibular advancement intraoral appliance (MOA) for the treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients : a pilot-study

To evaluate the treatment efficacy of a mandibular advancement intraoral appliance (MOA) for treatment of obstructive sleep apnea syndrome (OSAS) in pediatric patients. Eighteen patients (mean=8.39 years old, women=44.4%) were selected. Sleep disorders, sleep bruxism, and temporomandibular disorders were assessed by the Sleep Disturbance Scale for Children (SDSC), the BiteStrip® (portable SB device), and the Research Diagnostic Criteria for Temporomandibular Disorders, respectively. The clinical diagnosis of OSAS was confirmed with a type 3 portable monitor device (ApneaLinkTM Plus). A silicon-based material MOA was used by patients for 60 days, and the results were compared to baseline. The median RDI was significantly reduced from 10 to 4.5 events/hour. Nadir SpO2 significantly increased from 82.6% to 88.9%. Total snoring events/hour have also significantly decreased from 205.5 to 91.5. Signs and symptoms of TMD remained unaltered. There was also a reduction from moderate to absence of SB in 12 patients. Similarly, all variables measured by the SDSC have had very significant reductions: disorders of initiating and maintaining sleep, sleep disordered breathing, disorders of arousal, nightmares, sleep wake transition disorders, disorders of excessive somnolence, and sleep hyperhidrosis. In selected cases, OA maybe considered as an alternative for the OSAS treatment

Feasibility study of determing a risk assessment model for obstructive sleep apnea in children based on local findings and clinical indicators

Objective: To test a feasible and reliable model for diagnosing obstructive sleep apnea (OSA) in children, based on clinically relevant parameters, in comparison to a polysomnography. Methods: A total of 94 children with the suspected underlying OSA were included in the analyses. An association between clinical parameters (modified Mallampati score, tonsil size, adenoid size, age, gender, and body mass index) and apnea-hypopnea index (AHI) obtained following an overnight polysomnography was assessed, and significant variables were incorporated in the logistic regression model. Also, the sensitivity and specificity calculations of the model with the inclusion of ROC curve analysis were performed. Results: All three local clinical parameters were significantly associated with AHI (p<0.001). The most significant correlation with AHI was shown with the modified Mallampati score (r=0.723), following with tonsil size (r=0.673), and adenoid size (r=0.502). The sensitivity of the tested model was 84%, and specificity was 74%. Conclusion: This study derived a model based on the local clinical findings that significantly overlapped with the results of an overnight polysomnography, in diagnosing OSA in children

Is surgery effective for reducing symptoms in adults with obstructive sleep apnea?

Current evidence is insufficient to recommend surgery for symptom relief for patients with obstructive sleep apnea. More convincing evidence exists supporting the use of Continuous Positive Airway Pressure (CPAP) or dental appliances for reducing symptoms of sleep apnea