Predictors of anxiety and depression in patients with obstructive sleep apnea

AbstractBackground and objectiveSeveral studies have investigated the association of obstructive sleep apnea syndrome (OSAS) with depression and anxiety; however, the relationship is still poorly understood. Therefore, we aimed to assess anxious and depressive symptoms in OSA, and evaluate their association with potentially related variables of OSAS.Subjects and methodsThis study included 72 patients newly diagnosed with obstructive sleep apnea and 30 controls. Patients underwent an overnight polysomnography and were assessed using the Epworth sleepiness scale (ESS) for excessive daytime sleepiness (EDS), hospital anxiety and depression scale (HAD) for anxious and depressive symptoms, and Maugeri obstructive sleep apnea syndrome (MOSAS) questionnaire for quality of life (QOL).Results72 OSA patients (60 men and 12 women) whose mean age was 48.8±11.73yr and mean apnea and hypopnea index (AHI) was 64±21.86, were compared with 30 controls according to their HAD scores. We found that the HAD score for anxiety and depression was higher in OSA patients than in the control group (p=0.001 and 0.002 respectively). Moreover, the prevalence of symptoms of anxiety in patients with OSA was 33% while that of depression was 51%. Linear regression analysis revealed that daytime sleepiness and reduced QOL were strong predictors of depressive symptoms in OSA patients (P=0.001 and 0.002 respectively), while reduced QOL was the only predictor of anxious symptoms (p=0.035). No significant relations were found between severity of psychological symptoms and AHI or nocturnal hypoxemia in OSA patients.ConclusionAnxious and depressive symptoms are highly prevalent in patients with moderate to severe untreated OSAS. The severity of depressive symptoms maybe more related to excessive daytime sleepiness than to nocturnal hypoxemia. The reduced QOL is a strong predictor of psychiatric symptoms in OSAS patients. Therefore, patients with OSAS should be routinely screened for psychiatric symptoms to improve QOL and optimize diagnosis and therapy in these patients

Hypogonadism in patients with chronic obstructive pulmonary disease: relationship with airflow limitation, muscle weakness and systemic inflammation

AbstractObjectivesTo determine the prevalence of hypogonadism in male patients with Chronic obstructive pulmonary diseases (COPD), and to study its impact on skeletal muscle dysfunction and assess the effect of systemic markers of inflammation on testosterone level and muscle function. The study included 50 stable male COPD patients and 30 controls.MethodsBoth groups were subjected to the following measurements; inflammatory markers levels (high-sensitivity C-reactive protein (hs-CRP) and interleukin – 6 (IL-6)), sex hormones including; serum total (T) and free testosterone (FT), sex hormone binding globulins (SHBG), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and 17β estradiol levels (E2), the exercise capacity (6-minute walk distance (6MWT)) and quadriceps muscle force (One repetition maximum (1RM) and EMG). COPD patients underwent spirometry.ResultsThere was a higher prevalence of hypogonadism in COPD patients than the controls (62% versus 17%). There was a significant negative correlation between serum testosterone levels (T and FT) and the severity of airway obstruction. Quadriceps muscle force and the exercise capacity were significantly lower in COPD patients than controls but they showed no correlation with the testosterone level. Inflammatory markers were significantly higher in COPD patients compared to controls and showed a significant correlation with the severity of airflow obstruction. The higher inflammatory markers levels were related to more muscle weakness as hs-CRP was inversely correlated with the quadriceps strength and exercise capacity, while IL-6 was inversely correlated to quadriceps strength only.ConclusionHypogonadism is highly prevalent in clinically stable COPD patients and is particularly related to the severity of the airway obstruction. Systemic inflammation is present in stable COPD patients and its intensity is related to the severity of the underlying disease and it predisposes to skeletal muscle weakness and exercise intolerance. However, we failed to find a significant association between hypogonadism and muscle weakness or systemic inflammation

Sleep apnea in kidney transplant patients: Clinical correlates and comparison with pretransplant patients

AbstractBackgroundSleep disordered breathing (SDB) is a prevalent, but forgotten, cardiovascular (CV) risk factor in end-stage renal disease patients. Studies of SDB in renal transplant patients are few with mixed results.ObjectivesTo assess the prevalence and clinical correlates of SA in patients who received a kidney transplant, and to compare the prevalence of SA between waiting list and transplant patients.Subjects and methodsOur study included 40 clinically stable renal transplant patients and 15 patients awaiting transplantation. Patients with morbid obesity, diabetes, pulmonary disease or symptomatic heart failure were excluded from the study. All patients underwent overnight polysomnography, demographic and clinical data were also collected.ResultsWe found that the prevalence of SA was high in both the transplant and the waiting list groups (38% vs 47%). The severity of SA didn’t show significant difference in both groups (AHI=9.6 vs 16.2). Moreover, we found a significant association between impaired renal function and the AHI in Tx patients. Also, SA was associated with difficult-to-treat hypertension in Tx patients as we found a significant association between the AHI and the systolic blood pressure as well as the number of prescribed antihypertensive drugs.ConclusionSA is as highly prevalent in Tx as in WL patients. Moreover, this high prevalence in the transplant patients could be a consequence of declining renal function. In addition, we propose that sleep apnea is a new risk factor for hypertension and cardiovascular events in kidney-transplanted patients

Overlap of obstructive sleep apnea and bronchial asthma: Effect on asthma control

Obstructive sleep apnea (OSA) and asthma are highly prevalent respiratory disorders that share several risk factors and are frequently comorbid. Multiple mechanisms have been postulated to explain this frequent coexistence, which is recently referred to as the “alternative overlap syndrome”. Moreover, OSA is generally linked to worse asthma outcomes. Objectives: First, to assess the prevalence of OSA in a group of asthmatics. Second, to evaluate the potential risk factors underlying the development of OSA in these patients. Third, to determine the effect of this overlap on asthma control. Methods: Polysomnography was done for 30 asthmatics and 12 controls. Demographics, spirometry, comorbidities and clinical data were collected. Asthma control was assessed according to the latest GINA guidelines. Results: OSA defined by an AHI of ⩾5 events/h was present in 18 (60%) asthmatics and 2 (17%) controls. Regression analysis revealed that high body mass index (BMI), coexistent gastroesophageal reflux disease (GERD) and asthma severity (FEV1%) are significant independent predictors for the development of OSA in asthmatics (p = 0.03, 0.034, and <0.001 respectively). Moreover, the presence of OSA in asthmatic patients was significantly associated with worse asthma control (p < 0.001). Conclusion: A high index of suspicion is warranted for the overlap of OSA and asthma, particularly in the presence of obesity, GERD, and in patients with severe asthma. Individualized therapy addressing these moderating factors is warranted for optimal health outcomes. Recognition and treatment of OSA in asthmatics is an important element in improving asthma control

Sleep-related breathing disorders in patients with schistosomal cor-pulmonale

Schistosmiasis has long been an endemic disease in Egypt and an important cause of pulmonary hypertension. Objectives: We aimed to investigate the clinical and polysomnographic features of sleep-related breathing disorders (SRBD) in patients with schistosomal cor-pulmonale and to evaluate their effects on pulmonary hemodynamics. Patients and methods: We studied 10 stable patients diagnosed with schistosomal pulmonary hypertension (7 males and 3 females their mean age was 43.7 ± 8.04) and 10 healthy volunteers matched for age, sex and BMI. Patients’ exclusion criteria were: smoking, morbid obesity, other secondary causes of pulmonary hypertension, systemic hypertension, ischemic or rheumatic heart disease or left heart failure. All patients underwent overnight polysomnography or ambulatory cardiorespiratory sleep studies, spirometry, ECG and echocardiography. Daytime sleepiness was also assessed using the Epworth sleepiness scale (ESS). Results: The mean AHI in patients group was 20.0 ± 11.34/h while in the control group it was 2.3 ± 1.16/h. 80% of the patients were found to have an AHI > 10/h and 60% had moderate to severe sleep apnea (AHI ⩾ 15/h). In addition, the majority of the patients (80%) spent > 30% of the night with an arterial oxygen saturation <90%. SRBD were not correlated with anthropometric measures, spirometry nor with the typical symptoms of SA such as excessive sleepiness as assessed by ESS. More importantly, SRBD were significantly associated with measures of pulmonary hypertension severity, and patients with moderate to severe SA had more impaired cardiovascular function as indicated by more severe right ventricular dilatation (p = 0.036) than patients with mild sleep apnea. Conclusion: SRBD are highly prevalent in patients with schistosomal pulmonary hypertension (PH). Also, the SA severity was correlated with more advanced PH and more severe cardiovascular impairment. Therefore in the evaluation of patients with schistosomal PH, polysomnography or an ambulatory cardiorespiratory sleep study seems justified to identify potentially treatable SRBD that may additionally challenge the already compromised cardiovascular system in these patients

Relevance of chest sonography in the diagnosis of acute respiratory failure: Comparison with current diagnostic tools in intensive care units

Objectives: This study compares chest ultrasonography to current diagnostic tools for diagnosing the etiology of acute respiratory failure (ARF) in the ICU. Methods: The final etiology of ARF was diagnosed in 100 patients (excluding non-respiratory causes and multiple diagnoses) using conventional diagnostic tools (excluding ultrasound). They were pneumonia (49%), chronic obstructive pulmonary disease (COPD) (16%), acute respiratory distress syndrome (ARDS) (10%), pulmonary embolism (PE) (5%), empyema (5%), bronchial asthma (BA) (5%), pneumothorax (5%), idiopathic pulmonary fibrosis (IPF) (3%) and lung contusions (2%). Thoracic ultrasound was done on admission and the obtained profiles were compared to underling etiologies obtained by conventional methods. Characteristic ultrasound profiles that produced specificities >90% were considered diagnostic. Results: The main diagnostic profiles were: AB profile (asymmetric anterior interstitial syndrome) and C profile (anterior consolidation) indicated pneumonia. The B profile (diffuse anterior interstitial syndrome with lung sliding) indicated ARDS or IPF. Also the B + PLAPS profile (anterior interstitial syndrome with posterior and/or lateral alveolar and/or pleural syndrome) indicated ARDS. The A profile (normal) indicated COPD or bronchial asthma (21%). The A profile (normal) plus DVT indicated pulmonary embolism (5%). The lung point and loss of lung sliding (A′ profile) indicated pneumothorax (5%). Considering CT chest as the radiological gold standard, chest ultrasound produced 90% sensitivity and 100% specificity. Conclusions: Lung ultrasound provided an immediate diagnosis of the underlying etiology of acute respiratory failure in most cases; it can therefore be added to the armamentarium of ICU where urgent decisions are needed for rapid diagnosis and management of patients with ARF

Medical thoracoscopy versus image-guided pleural biopsy for diagnosing pleural diseases

Background The diagnostic role of medical thoracoscopy and image-guided pleural biopsy in patients with undiagnosed exudative pleural effusion has increased over the last few years. Objective The aim was to compare the efficacy and safety of medical thoracoscopy versus image-guided [ultrasound (US) and computed tomography] pleural biopsy in the diagnosis of pleural lesions. Patients and methods A total of 40 patients with undiagnosed pleural lesions were divided into two groups. After full investigations, pleural biopsies were taken by medical thoracoscopy and the image-guided technique in groups I and II, respectively. Results In group I, the results of 19 (95%) patients yielded a positive diagnosis, whereas in group II, the results of 17 (85%) patients yielded a positive diagnosis (where results were positive in 80% of US-guided biopsies and 90% in computed tomography-guided biopsies), with no significant difference in the diagnostic yield of the two groups. The US-guided biopsy showed significantly the least duration (P=0.001). Complications were significantly fewer in the image-guided biopsy group (P=0.008). The mean duration of hospital stay was significantly less in the image-guided group than in the medical thoracoscopy group (P=0.001). In conclusion, the overall diagnostic yield is comparably high for medical thoracoscopy and image-guided pleural biopsies, and both are complementary techniques used in different clinical situations. Each diagnostic procedure has its own advantages and disadvantages. Image-guided biopsy is less invasive and can be carried out as an outpatient procedure, whereas medical thoracoscopy provides diagnostic and therapeutic capabilities in one setting

Effect of comorbidities on response to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

Background and objective: Patients with chronic obstructive pulmonary disease (COPD) typically manifest with worsening dyspnea, poor exercise tolerance and diminished quality of life. In addition, comorbidities are commonly reported in these patients, complicating management strategies. Pulmonary rehabilitation (PR) is an evidence-based multimodality therapy increasingly prescribed for symptomatic COPD patients. This study aimed to assess the impact of comorbidities on achieving proper response to PR in patients with COPD. Methods: Forty patients with COPD were enrolled in PR program of upper and lower extremity exercise, and were prospectively followed. The minimal clinically important difference (MCID) was used as a cut-off to determine response in six-minute walk distance (6MWD), modified Medical Research Council (mMRC) dyspnea scale, Saint George Respiratory Questionnaire (SGRQ) and estimated maximum oxygen consumption (VO2max). According to comorbidities patients were divided into three groups: patients without comorbidities, patients with one comorbidity and patients with more than one comorbidity. Results: Comorbidities were diagnosed in 34 patients (85%). Patients with one or more comorbidity had significantly worse baseline mMRC, 6MWD, SGRQ score and VO2max but not FEV1%. Thirty-two patients (80%) showed improvements beyond the MCID. Factors that predicted better response included higher arterial PaCO2, presence of osteoporosis, and lower baseline 6MWD, mMRC and VO2max. Conclusions: Pulmonary rehabilitation can be offered to COPD patients from different severity stages. Comorbidities occur very commonly in patients with COPD and their presence worsens the baseline functional status in these patients which makes them more liable to achieve larger benefits from PR

Prevalence of chronic hepatitis C virus (HCV) infection in patients with idiopathic pulmonary fibrosis

Introduction: Pathogenic sequences leading to the development of idiopathic pulmonary fibrosis (IPF) are unclear; but one theory is that, in a genetically susceptible host, there is a “triggering agent or event inducing an inflammatory reaction in the lung that perpetuates itself and causes parenchymal fibrosis”. One potential source for a self-perpetuating triggering event could be a chronic viral infection. For this reason, evidence for an association between IPF and chronic viral infection has been sought by many investigators for several different viruses, including HCV. Objective: To estimate the prevalence of chronic hepatitis C virus infection in patients with idiopathic pulmonary fibrosis via detection of HCV antibodies in selected patients in comparison to the control group. Patients and methods: In this study we evaluated 30 patients diagnosed with idiopathic pulmonary fibrosis according to diagnostic criteria of American Thoracic Society (ATS) in comparison to 60 healthy control subjects. All enrolled subjects underwent a serologic test for HCV infection by detecting hepatitis C surface antigen (HCVsAg) by a third-generation enzyme-linked immunosorbent assay (ELISA) test. All patients had undergone dyspnea severity assessment by the mMRC score, routine laboratory testing including arterial blood gases (ABGs), pulmonary function testing (PFTs), chest-X-ray, high resolution CT scan (HRCT), liver ultrasonography and bronchoscopy (when needed). Results: 9 IPF patients were positive for HCV (30%), while 17 control subjects were positive for HCV (28.3%) (p = 0.869). In HCV positive IPF patients there were more severe dyspnea as assessed by the mMRC score (p = 0.042∗), lower FVC (p = 0.011∗), SaO2% and PaO2 were significantly lower (p ⩽ 0.001∗ for both parameters), and more severe HRCT scanning score (p = 0.012∗), in comparison to HCV negative IPF patients. There was significant negative correlation between the HRCT score and FVC (p = 0.011∗) in HCV positive IPF patients, there was significant negative correlation between liver cirrhosis and PaO2 (p = 0.023∗), PaCO2 (p = 0.002∗) in HCV positive IPF patients. Conclusion: Despite the fact that we couldn’t confirm the hypothesis that HCV can be a causative agent in the development of IPF, however, we have shown that HCV can be a predisposing factor for the development of a more severe form of IPF. Therefore screening IPF patients for the presence of underlying HCV infection can have important therapeutic and prognostic implications in those patients