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

Repercussions of a sleep medicine outreach program

Despite the high prevalence of sleep disorders, many healthcare professionals and lay people have little knowledge of Sleep Medicine. Mindful of such a reality, in 2001 the Sleep Institute of the Associação Fundo de Incentivo à Psicofarmacologia launched a campaign to increase Sleep Medicine awareness. Media features, exhibitions, inserts, and classes were used to reach 2,000,000 people and 55,000 healthcare professionals during the period from 2001 to 2004. To evaluate this program, we compared data for polysomnography referrals to the Institute in 2000 and in 2004. A total of 8805 referrals were evaluated (2000: 2164; 2004: 6641). Over the 4 years of the program, the number of beds increased by 43%; more women were referred (31 vs 37%; P < 0.001), mainly with a diagnostic hypothesis of sleep-disorder breathing (SDB). SDB was the most frequent diagnostic hypothesis in 2000 and 2004. In 2004 there were fewer referrals without a diagnostic hypothesis (27 vs 21%; P < 0.001) and for controlling surgically treated SDB (2.3 vs 1.6%; P < 0.05), and an increase in the following diagnostic hypotheses: non-invasive treatment of SDB (8.3 vs 12.3%; P < 0.001) and insomnia (3.5 vs 6.5%; P < 0.001). Insomnia diagnostic hypothesis was better correlated with SDB on referral documents in 2004 and less with a diagnostic hypothesis of limb movement disturbance. The program helped increase polysomnography referrals, particularly among women. Healthcare professionals appear to have a more developed understanding of sleep disorders.Universidade Federal de São Paulo (UNIFESP) Departamento de PsicobiologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de FarmacologiaUNIFESP, Depto. de PsicobiologiaUNIFESP, Depto. de FarmacologiaSciEL

Application of the Kushida morphometric model in patients with sleep-disordered breathing

The morphometric model is a useful screening test to investigate the possibility of OSAS in patients during initial office visits. AIM: To evaluate the clinical applicability of the Kushida morphometric model in a sample of patients with sleep-disordered breathing, and to define a cutoff value to differentiate patients with mild, moderate and severe apnea. METHOD: A sample of 80 patients with sleep respisratory disorder was studied. Patients were aged between 18 and 75 years, of both genders and had been submitted previously to polysomnography. The model cutoff value to distinguish between patients with or without apnea is 70. RESULTS: In this sample, the model cutoff value in all four groups was less than 70. It was impossible to establish a cutoff value according to the gravity of the condition, due to the proximity and the nonlinear increase in the values presented by the nonapneic group and those with mild and moderate apnea. CONCLUSION: The Kushida morphometric model can be applied in clinical practice to a selected sample and it was impossible to establish a cutoff value to separate patients with obstructive sleep apnea-hypopnea syndrome according to severity.O modelo proposto serve para triar os pacientes com alto risco para síndrome da apnéia e hipopnéia obstrutiva do sono. OBJETIVO: Avaliar a aplicabilidade clínica do modelo morfométrico de Kushida em uma amostra de pacientes com distúrbios respiratórios do sono e definir um valor de corte para discriminar os pacientes com apnéia leve, moderada e grave. FORMA DE ESTUDO: Coorte contemporânea longitudinal. MÉTODO: Foram estudados 80 pacientes com distúrbios respiratórios obstrutivos do sono, com idade entre 18 e 75 anos, de ambos os sexos e realizaram polissonografia prévia. O valor de corte do modelo morfométrico para distinguir os pacientes sem e com apnéia é de 70. RESULTADO: Na amostra estudada, os valores do modelo nos quatro grupos foram menores que 70. Não foi possível estabelecer um valor de corte de acordo com a gravidade da doença, devido à proximidade e ao aumento não-linear dos valores entre os pacientes não-apnéicos, com apnéia leve e moderada. CONCLUSÃO: O modelo morfométrico de Kushida é aplicável na prática clínica para a amostra selecionada e não foi possível estabelecer um valor de corte para separar os pacientes com síndrome da apnéia e hipopnéia do sono conforme sua gravidade.UNIFESPFMABCUNIFESP Departamento de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUNIFESP, Depto. de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoSciEL

Relationship between the quality of life and the severity of obstructive sleep apnea syndrome

The effects of sleep disorders on the quality of life (QOL) have been documented in the literature. Excessive sleepiness and altered circadian rhythms may negatively affect ability to learn, employment, and interpersonal relations, and directly degrade QOL. The objective of the present study was to evaluate the impact of obstructive sleep apnea syndrome of varying severity on QOL. The study was conducted on 1892 patients aged 18 years or older referred by a physician to the Sleep Institute, São Paulo, with complaints related to apnea (snoring, excessive daytime sleepiness, hyperarousal, and fatigue). They were submitted to overnight polysomnography for the diagnosis of sleep disorders from August 2005 through April 2006. The patients completed the Epworth Sleepiness Scale and QOL SF-36 sleep questionnaires. They were classified as non-physically active and physically active and not-sleepy and sleepy and the results of polysomnography were analyzed on the basis of the apnea hypopnea index (AHI). The apneic subjects showed a reduction in QOL which was proportional to severity. There was a significant decrease in all domains (physical functioning, role physical problems, bodily pain, general health perceptions, vitality, social functioning, emotional problems, general mental health) for apneics with AHI >30, who generally were sleepy and did not participate in physical activities (P < 0.05). The present study provides evidence that the impact of sleep disorders on QOL in apneics is not limited to excessive daytime sleepiness and that physical activity can contribute to reducing the symptoms. Thus, exercise should be considered as an adjunct interventional strategy in the management of obstructive sleep apnea syndrome.Universidade Federal de São Paulo (UNIFESP) Departamento de PsicobiologiaUniversidade Federal de São Paulo (UNIFESP) Centro de Estudos em Psicobiologia e ExercícioInstituto do SonoUNIFESP, Depto. de PsicobiologiaUNIFESP, Centro de Estudos em Psicobiologia e ExercícioSciEL

Apolipoprotein E polymorphisms and sleep quality in Obstructive Sleep Apnea Syndrome

Background: the purpose of this study was to evaluate the influence of polymorphism on sleep parameters of Obstructive Sleep Apnea Syndrome (OSAS) patients.Methods: Patients were genotyped after a full-night polysomnography using the large Epidemiologic Sleep Study of São Paulo population-based sample.Results: Individuals who carry the APOE epsilon 2 allele showed longer sleep latency, lower sleep efficiency and higher numbers of arousals/hour, when compared to epsilon 3 allele homozygous and carriers of epsilon 4 allele (p<0.05). These findings remained significant even after correction for potential confounders, such as sex, age and African genetic ancestry.Conclusion: the APOE polymorphisms may modulate the effects of intermittent hypoxia and sleep fragmentation in the sleep architecture of OSAS patients, and that the presence of the epsilon 2 allele may serve as a biological marker for the identification of a subgroup of patients who are more likely to suffer with OSAS detrimental effects on sleep, impacting not only the daily functioning, but also their quality of life. (C) 2011 Elsevier B.V. All rights reserved.Associacao Fundo de Incentivo a Psicofarmacologia (AFIP)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Universidade Federal de São Paulo, Dept Psicobiol, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Psicobiol, São Paulo, BrazilFAPESP: 07/50525-1FAPESP: 98/14303-3Web of Scienc

Sleep disturbance prevalence in postmenopausal women

PURPOSE: to evaluate the prevalence of reported sleep disturbances through polysomnographic recording (PSG) in a sample of postmenopausal women. METHODS: thirty-three postmenopausal women with a mean age of 56 years, a mean body mass index (BMI) of 27 kg/m², with 7.7 years of recognized postmenopausal period, and a mean Kupperman index of 17, were selected. The inclusion criteria were: age range from 50 to 65 years, at least one year of amenorrhea and an FSH which equaled or exceeded 30 mU/ml; they should not be undergoing hormone therapy, and should display normal laboratory test results. The patients with severe clinical diseases and/or decompensated were excluded; also the ones with suspicion of carcinoma of endometrium and/or breast cancer, a BMI over 30 kg/m² and those who ingested hypnotic drugs. The patients followed a routine climacteric check-up, answered a questionnaire about sleep and underwent an all-night PSG recording. Frequencies in percentage of emerging sleep complaints based on the questionnaire and those pertaining to PSG diagnosis were then calculated separately. RESULTS: the subjective prevalence of insomnia was 61% against 83% in the PSG recordings. The prevalence of apnea reported was 23% against 27% in the PSG. The subjective restless legs syndrome prevalence was 45%, and the objective, 27%. CONCLUSION: there was a high prevalence of sleep disturbances in postmenopausal patients, specially insomnia, apnea and restless legs.OBJETIVO: avaliar a prevalência das queixas de distúrbios do sono pela polissonografia em amostra de mulheres na pós-menopausa. MÉTODOS: foram selecionadas 33 mulheres na pós-menopausa com média de idade de 56 anos, índice de massa corporal médio de 27, tempo de pós-menopausa de 7,7 anos e índice de Kupperman de 17. Adotaram-se os seguintes critérios de inclusão: idade entre 50 e 65anos, no mínimo um ano de amenorréia e FSH plasmático superior ou igual a 30 mU/mL, sem uso de terapia hormonal prévia e exames laboratoriais normais. Foram excluídas as pacientes com doenças clínicas graves e/ou descompensadas, suspeita de câncer de endométrio e/ou mama; índice de massa corporal maior ou igual a 30 e uso de hipnóticos. As pacientes responderam a questionário específico contendo perguntas sobre as características do sono e foram submetidas a polissonografia completa durante uma noite inteira. Foram calculadas separadamente as freqüências em porcentagens das queixas de sono e dos diagnósticos polissonográficos. RESULTADOS: a prevalência de insônia subjetiva foi 61%, sendo que na polissonografia foi de 83%. A queixa de apnéia foi registrada em 23% e, na polissonografia, em 27%. A prevalência subjetiva de movimentos periódicos de pernas foi de 45% e a objetiva foi de 27%. CONCLUSÃO: houve alta prevalência de distúrbios do sono na pós-menopausa, em especial de insônia, apnéia e de movimentos periódicos das pernas. Nesta fase da vida, ocorre piora da qualidade do sono.Universidade Federal de São Paulo (UNIFESP) Departamento de Ginecologia ambulatório de Distúrbios do SonoUniversidade Federal de São Paulo (UNIFESP) Departamento de Psicobiologia Medicina e Biologia do SonoUNIFESP, Depto. de Ginecologia ambulatório de Distúrbios do SonoUNIFESP, Depto. de Psicobiologia Medicina e Biologia do SonoSciEL

Eszopiclone versus zopiclone in the treatment of insomnia

OBJECTIVE: To determine the therapeutic effects of two selective GABA-A agonists, zopiclone and eszopiclone, in the treatment of insomnia. METHODS: This study comprised a phase III, single-center, randomized, double-blind, double-dummy, parallel-group, non-inferiority trial. Patients were randomized to receive zopiclone 7.5 mg or eszopiclone 3 mg, both orally, for four weeks. In total, 199 patients were evaluated during two visits and then followed for at least six weeks. The primary endpoint was the Insomnia Severity Index after four weeks of treatment. Secondary endpoints were obtained through polysomnography data, including total sleep time, sleep latency and sleep efficiency. The frequency of adverse events was also analyzed. ClinicalTrials.gov: NCT01100164. RESULTS: The primary efficacy analysis demonstrated the non-inferiority of eszopiclone over zopiclone. Analysis of objective parameters assessed by polysomnography showed that eszopiclone increased total sleep time and also improved sleep efficiency. The safety profile of both study treatments was similar and the most common events reported in both groups were dysgeusia, headache, dizziness, irritability and nausea. Adverse events were observed in 223 patients, 109 (85.2%) in the eszopiclone group and 114 (87.7%) in the zopiclone group. CONCLUSION: Based on the Insomnia Severity Index at the end of four weeks of treatment, eszopiclone demonstrated efficacy comparable to that of zopiclone in the treatment of insomnia, increasing total sleep time as well as sleep efficiency according to polysomnography