Efficacy of oral appliance in UARS: randomized, parallel, placebo and controlled clinical trial

Introduction: Upper Airway Resistance Syndrome (UARS) is characterized by episodes of increased respiratory efforts during sleep that can cause sleep disruption, fatigue and excessive daytime sleepiness. There are few studies about UARS treatment and it is unclear what the best treatment for the condition is. Objective: To evaluate the effects of a mandibular advancement device (MAD) on fatigue, subjective and objective excessive daytime sleepiness, insomnia, cognition, mood and autonomic nervous system (ANS) response after autonomic challenges. Methods: Inclusion criteria consisted of both genders; body mass index ≤ 30Kg/m2 age ranging from 25 to 50 years of age. UARS diagnosis was presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea/hypopnea index (AHI) ≤ 5 and a respiratory disturbance index (RDI) > 5 events/hour of sleep, and/or flow limitation in more than 30% of total sleep time. Patients were randomized in two groups: placebo and MAD. The following evaluations were performed before and after 6 months and 1.5 year of treatment: sleep questionnaires, full-night polysomnography, Multiple Sleep Latency Test (MSLT), Psychomotor Vigilance Test (PVT), cognitive evaluation and ANS test (ANSAR). Results: RDI, number of Respiratory Effort Related Arousals (RERAs), percentage of total sleep time with flow limitation and arousal index significantly decreased after 1.5 year of MAD. Pittsburgh Sleep Quality Index (PSQI) total score improved, severity of depression symptoms decreased, alert and resistance stress phases in Lipp test improved and mean reaction time in the PVT, based on the first measurement taken at 8 a.m. significantly decreased after 1.5 year treatment. ANSAR test results in deep breath and stand position challenges showed maintenance of the parasympathetic tendency in the placebo group when compared to treatment group. Conclusion: Mandibular advancement device was effective in improving sleep quality, sustained attention and reducing the severity of depression and stress. Oral appliance had also decreased the objective sleep fragmentation and respiratory events in sleep studies and the parasympathetic reflex response during deep breath and stand up position challenges in ANSAR in UARS patients. Our results suggest that mandibular advancement device can be considered a good treatment option for UARS patients.Introdução: A Síndrome da Resistência da Via Aérea Superior (SRVAS) é um distúrbio respiratório do sono que se caracteriza pela ocorrência de episódios de esforço respiratório que produzem múltiplos despertares e consequentes fadiga e sonolência excessiva diurna. Atualmente, existem poucos estudos avaliando o impacto de tratamentos da SRVAS. Com efeito, não há, até o momento, um tratamento bem estabelecido para a doença. Objetivo: Avaliar a eficácia do tratamento com aparelho intraoral de avanço mandibular (AIO) em pacientes com SRVAS em relação à melhora da queixa de cansaço, da sonolência medida de forma subjetiva e objetiva, assim como das queixas de insônia, das alterações da cognição e do humor e da resposta do sistema nervoso autônomo (SNA) a desafios autonômicos. Métodos: Foram incluídos pacientes de ambos os sexos; com índice de massa corpórea ≤ 30Kg/m2; idade entre 25 e 50 anos. Todos apresentavam diagnóstico clínico e polissonográfico de SRVAS: queixa de sonolência excessiva diurna (Escala de Sonolência de Epworth ≥ 10) e/ou fadiga (Escala de Impacto da Fadiga – MFIS BR ≥ 38) associada à polissonografia (PSG) com índice apneia / hipopneia (IAH) ≤ 5 eventos por hora e índice de distúrbio respiratório (IDR) > 5 eventos por hora e / ou tempo em limitação do fluxo aéreo (LFA) > 30% do tempo total do sono. Os pacientes foram randomizados para tratamento com AIO ou placebo. Foram realizados na condição basal, após 6 meses e com 1,5 ano questionários de sono, PSG, teste múltiplo das latências do sono (TMLS), Teste de Vigilância Psicomotora (“Psychomotor Vigilance Test” - PVT), testes neurocognitivos e avaliação de SNA (ANSAR). Resultados: O IDR, o número de despertares relacionados ao esforço respiratório (RERA), a porcentagem do tempo total do sono em limitação ao fluxo aéreo e o índice de despertares diminuíram significativamente após 1,5 ano de tratamento com AIO. O resultado total do Índice de Qualidade do Sono de Pittsburgh (PSQI) melhorou, a gravidade dos sintomas de depressão diminuiu, os valores do teste de estresse de Lipp referente às fases de alerta e resistência melhoraram e o tempo médio de reação medido pelo PVT às 8 horas da manhã diminuiu após 1,5 ano de tratamento. O teste ANSAR nos desafios respiração profunda e posição ortostática demonstrou manutenção da tendência parassimpática no grupo placebo em relação ao grupo tratamento. Conclusão: O aparelho intraoral de avanço mandibular melhorou a qualidade do sono, a atenção sustentada e reduziu os sintomas depressivos bem como o estresse nas fases de alerta e resistência em pacientes com SRVAS.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Associação Fundo de Incentivo à Pesquisa (AFIP)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)FAPESP: 2013-22776-0Dados abertos - Sucupira - Teses e dissertações (2018

Accuracy of peripheral arterial tonometry in the diagnosis of obstructive sleep apnea

ABSTRACT INTRODUCTION: The use of handheld devices that assess peripheral arterial tonometry has emerged as an auxiliary method for assessment and diagnosis of obstructive sleep apnea syndrome. OBJECTIVE: To evaluate the accuracy of peripheral arterial tonometry in the diagnosis of obstructive sleep apnea. METHODS: Contemporary cohort cross-sectional study. Thirty patients with suspected obstructive sleep apnea underwent peripheral arterial tonometry and assisted nocturnal polysomnography concomitantly. RESULTS: The mean apnea/hypopnea index by peripheral arterial tonometry was significantly higher than that by polysomnography (p < 0.001), but the values of both sleep studies were significantly correlated (r = 0.762). There was a high correlation between variables: minimum oxygen saturation (r = 0.842,p < 0.001), oxygen saturation < 90% (r = 0.799, p < 0.001), and mean heart rate (r = 0.951, p < 0.001). Sensitivity and specificity were 60% and 96.2% (AUC: 0.727;p = 0.113), respectively, when at a threshold value of 5 events/h. In severe cases (≥30 events/h), the result was a sensitivity of 77.8% and a specificity of 86.4% (AUC: 0.846, p = 0.003). CONCLUSION: Peripheral arterial tonometry is a useful portable device for the diagnosis of obstructive sleep apnea; its accuracy is higher in moderate and severe cases

Upper Airway Resistance Syndrome Patients Have Worse Sleep Quality Compared to Mild Obstructive Sleep Apnea.

PURPOSE:To compare sleep quality and sustained attention of patients with Upper Airway Resistance Syndrome (UARS), mild Obstructive Sleep Apnea (OSA) and normal individuals. METHODS:UARS criteria were presence of excessive daytime sleepiness (Epworth Sleepiness Scale-ESS-≥ 10) and/or fatigue (Modified Fatigue Impact Scale-MFIS-≥ 38) associated to Apnea/hypopnea index (AHI) ≤ 5 and Respiratory Disturbance Index (RDI) > 5 events/hour of sleep or more than 30% of total sleep time with flow limitation. Mild OSA was considered if the presence of excessive daytime sleepiness (ESS ≥ 10) and/or fatigue (MFIS ≥ 38) associated to AHI ≥ 5 and ≤ 15 events/hour. "Control group" criteria were AHI < 5 events/hour and RDI ≤ 5 events/hour and ESS ≤ 9, without any sleep, clinical, neurological or psychiatric disorder. 115 individuals (34 UARS and 47 mild OSA patients and 34 individuals in "control group"), adjusted for age, gender, body mass index (BMI) and schooling years, performed sleep questionnaires and sustained attention evaluation. Psychomotor Vigilance Task (PVT) was performed five times (each two hours) from 8 a.m. to 4 p.m. RESULTS:UARS patients had worse sleep quality (Functional Outcomes of Sleep Questionnaire-FOSQ-and Pittsburgh Sleep Quality Index-PSQI: p < 0.05) and more fatigue than mild OSA patients (p = 0.003) and scored significantly higher in both Beck inventories than "control group" (p < 0.02). UARS patients had more lapses early in the morning (in time 1) compared to the results in the afternoon (time 5) than mild OSA (p = 0.02). Mild OSA patients had more lapses in times 2 than in time 5 compared to "control group" (p = 0.04). CONCLUSIONS:UARS patients have a worse sleep quality, more fatigue and a worse early morning sustained attention compared to mild OSA. These last had a worse sustained attention than controls

Polysomnographic variables.

<p>Polysomnographic variables.</p

Descriptive data.

<p>Descriptive data.</p

Questionnaires.

<p>Questionnaires.</p

Number of lapses of PVT repeated measures: mild OSA patients had more lapses at times 2 than at time 5 than “control group” (p = 0.044).

<p>UARS patients had more lapses at time 1 than at time 5 in comparison to mild OSA patients (p = 0.02).</p