Mandibular Advancement Devices in Obstructive Sleep Apnea Patients Intolerant to Continuous Positive Airway Pressure Treatment

Obstructive sleep apnea (OSA) is defined as episodes of upper airway obstruction occurring during sleep. Conservative treatment of OSA consists of continuous positive airway pressure (CPAP). An alternative treatment in mild-to-moderate OSA could be the use of intraoral mandibular advancement devices (MAD). The aim of this study was to evaluate therapeutic efficacy of MAD in OSA patients intolerant to CPAP. The study group included 8 patients, who fulfilled specific inclusion criteria during a dental examination, out of the 30 CPAP intolerant patients who were referred for the possible use of MAD. The selected patients used MAD for 30 days and then switched to CPAP for 10 days to compare the effectiveness of both treatment methods. They had 3 polysomnographic (PSG) examination: baseline before treatment, and at the end of MAD and CPAP. We found that either treatment method resulted in comparable symptomatic improvements in OSA patients. In detail, the apnea-hypopnea index decreased, along with the overall number of obstructive, central, and mixed apneic episodes during sleep time. The mean arterial oxygen saturation (SaO₂) improved and the minimum SaO₂ level noted during night time got enhanced. Differences in the sleep apnea indices after MAD and CPAP treatments were insignificant, but there was a consistent impression that CPAP was superior to MAD as it tended to improve symptoms to a somehow greater extent. We conclude that MAD is a sufficiently effective treatment alternative for OSA patients who are intolerant to CPAP or in whom CPAP therapy fails.

Therapeutic Efficacy of Mandibular Advancement Devices in Patients with Severe Sleep Apnea: A Preliminary Report

Obstructive sleep apnea (OSA) is defined as episodes of upper airway obstructions during sleep. The method of choice in conservative treatment of OSA is the use of devices that produce positive airway pressure (CPAP). In patients with mild-moderate form of OSA, intraoral mandibular advancement devices (MAD) are applied. The aim of the study was to evaluate the therapeutic efficacy of MAD in patients with severe OSA who were unable to use CPAP. In this preliminary study three patients from a group of 25 severe OSA sufferers who failed to use CPAP, were included. The three patients underwent a triple polysomnographic (PSG) investigation: on CPAP, before MAD treatment, and during MAD. The patients completed the Epworth Sleepiness Scale questionnaire twice. We found significant improvements of subjective symptoms and PSG-evaluated variables after application of MAD in all three patients in comparison with both baseline and CPAP-recorded data. We conclude that MAD can be an alternative treatment option for severe OSA patients who are non-compliant with CPAP therapy.

Pilot program on distance training in spirometry testing - the technology feasibility study

INTRODUCTION

Office spirometry has been widely used in recent years by general practitioners in primary care setting, thus the need for stricter monitoring of the quality of spirometry has been recognized.

MATERIAL AND METHODS

A spirometry counseling network of outpatients clinics was created in Poland using portable spirometer Spirotel. The spirometry data were transferred to counseling centre once a week. The tests sent to the counseling centre were analyzed by doctors experienced in the analysis of spirometric data. In justified cases they sent their remarks concerning performed tests to the centres via e-mail.

RESULTS

We received 878 records of spirometry tests in total. Data transmission via the telephone was 100% effective. The quality of spirometry tests performed by outpatients clinics was variable.

CONCLUSIONS

The use of spirometers with data transfer for training purposes seems to be advisable. There is a need to proper face-to-face training of spirometry operators before an implementation of any telemedicine technology.

Factors associated with diastolic dysfunction in patients with resistant hypertension: resist-POL study

BACKGROUND

Diastolic dysfunction has been shown to be an independent factor of cardiovascular diseases in patients with hypertension. Very often, obstructive sleep apnea (OSA) and metabolic syndrome (MS) coexist with resistant hypertension (RHTN) and may lead to diastolic dysfunction. Thus, the purpose of this study was to investigate whether OSA and MS are associated with diastolic dysfunction in patients with RHTN independently from other factors, including age, left ventricular mass index (LVMI), and blood pressure (BP).

METHODS

Data from 155 patients (n = 92 men and 63 women) were analyzed. All patients underwent thorough examination, including biochemical evaluations, ambulatory blood pressure monitoring, polysomnography with assessment of apnea/hypopnea index (AHI), and echocardiography. LVMI and diastolic function parameters were obtained.

RESULTS

Patients were divided into 2 groups based on the presence or absence of diastolic dysfunction: group 1 (E' < 10cm/second; n=87) and group 2 (E' > 10cm/second; n = 68). AHI, LVMI, and 24-hour systolic BP/diastolic BP values were higher in group 1. E' correlated with AHI (r = -0.25; P < 0.001), LVMI (r = -0.36; P < 0.0001), 24-h systolic BP/24-h diastolic BP (r = -0.28, P < 0.001; r = -0.30, P < 0.001, respectively), glucose level (r = -0.26; P < 0.01), and abdominal obesity (r = -0.28; P < 0.0001). In multivariable models decreased E' was independently related to the presence of MS or abdominal obesity when separate components of MS were included in the model. Age and 24-hour systolic BP were independently associated with decreased E'. However, the relationship of decreased E' with 24-hour systolic BP was nonsignificant if LVMI was included in the multivariable model.

CONCLUSIONS

MS and abdominal obesity were independently associated with diastolic dysfunction in patients with RHTN. OSA was not confirmed to be an independent factor of diastolic dysfunction.

Relationship between primary aldosteronism and obstructive sleep apnoea, metabolic abnormalities and cardiac structure in patients with resistant hypertension

INTRODUCTION

The aim of this study was to evaluate in patients with resistant hypertension (RHTN) enrolled in the RESIST-POL study the relationship between primary aldosteronism (PA) and obstructive sleep apnoea (OSA) and their effect on metabolic abnormalities and cardiac structure.

MATERIAL AND METHODS

We included 204 patients (123 M, 81 F, mean age 48.4 yrs) with true RHTN, eGFR > 60 mL/min/1,73 m(2) and no known diabetes. OSA was defined as an apnoea/hypopnoea index of 15/h or more. Metabolic syndrome components were assessed. On echocardiography, left ventricular hypertrophy (LVH), concentric remodelling (RWT > 0.45), E' velocity, E/E' index and global strain (GLS) were evaluated.

RESULTS

PA was diagnosed in 32 patients (15.7%). OSA occurred more frequently in patients with PA (59.4 v. 42.4%; p = 0.058). Patients were divided into four groups: PA+ OSA+ , PA+ OSA-, PA-OSA+ and PA-OSA-. Newly diagnosed diabetes, impaired glucose tolerance and increased fasting glucose were most frequent in the PA+ OSA+ group compared to other groups. The presence of OSA was associated with concentric remodelling, and the presence of PA was associated with higher left ventricular mass and higher frequency of left ventricular hypertrophy. In the PA+ OSA+ and PA+ OSA- groups, the most frequent geometry patterns were concentric hypertrophy (68.4%) and eccentric hypertrophy (54.5%) respectively. E' velocity was lowest and E/E' was highest in PA+ OSA+ compared to other groups. GLS was lower in patients with OSA compared to those without OSA.

CONCLUSIONS

Both metabolic abnormalities and target organ damage are more pronounced in patients with RHTN, PA and OSA. OSA and PA influence differently left ventricular geometry.

Effects of renal sympathetic denervation on blood pressure, sleep apnea course, and glycemic control in patients with resistant hypertension and sleep apnea

Percutaneous renal sympathetic denervation by radiofrequency energy has been reported to reduce blood pressure (BP) by the reduction of renal sympathetic efferent and afferent signaling. We evaluated the effects of this procedure on BP and sleep apnea severity in patients with resistant hypertension and sleep apnea. We studied 10 patients with refractory hypertension and sleep apnea (7 men and 3 women; median age: 49.5 years) who underwent renal denervation and completed 3-month and 6-month follow-up evaluations, including polysomnography and selected blood chemistries, and BP measurements. Antihypertensive regimens were not changed during the 6 months of follow-up. Three and 6 months after the denervation, decreases in office systolic and diastolic BPs were observed (median: -34/-13 mm Hg for systolic and diastolic BPs at 6 months; both P<0.01). Significant decreases were also observed in plasma glucose concentration 2 hours after glucose administration (median: 7.0 versus 6.4 mmol/L; P=0.05) and in hemoglobin A1C level (median: 6.1% versus 5.6%; P<0.05) at 6 months, as well as a decrease in apnea-hypopnea index at 6 months after renal denervation (median: 16.3 versus 4.5 events per hour; P=0.059). In conclusion, catheter-based renal sympathetic denervation lowered BP in patients with refractory hypertension and obstructive sleep apnea, which was accompanied by improvement of sleep apnea severity. Interestingly, there are also accompanying improvements in glucose tolerance. Renal sympathetic denervation may conceivably be a potentially useful option for patients with comorbid refractory hypertension, glucose intolerance, and obstructive sleep apnea, although further studies are needed to confirm these proof-of-concept data.

Relationship between Age and Cardiovascular Complications in Obstructive Sleep Apnoea

Introduction: Obstructive sleep apnoea (OSA) is a risk factor for cardiovascular morbidity and mortality. The aim of this study was to assess relations between cardiovascular diseases (CVD) and age in OSA subjects. Material and Methods: 10, Epworth score > 9 points) were evaluated. The chest X-ray, spirometry, arterial blood gases, ECG, blood morphology and biochemistry were performed during trial treatment with autoCPAP. Results: We studied 533 consecutive OSA patients, mean age 55.6 ± 10.3 years (range 24–81), with obesity (BMI 34.4 ± 6.6 kg/m²) and severe OSA (AHI/RDI 37.8 ± 21.8). To evaluate relations between CVD and age, patients were divided into three groups. Group 1 < 50 years (123 subjects, 23.1%), Group 2 aged 50–60 years (250 subjects, 46.9%) and Group 3 > 60 years (160 subjects, 30%). Subjects < 50 years were more obese and had higher AHI/RDI when compared to older groups. Incidence of arterial hypertension, coronary artery disease, atrial fibrillation, heart failure and stroke increased with age (higher in subjects > 60 years). Conclusions: Cardiovascular diseases were prevalent in OSA patients > 60 years. However the youngest group presented with more severe obesity and higher AHI/RDI.

[Relationship between age and cardiovascular complications in obstructive sleep apnoea]

INTRODUCTION

Obstructive sleep apnoea (OSA) is a risk factor for cardiovascular morbidity and mortality. The aim of this study was to assess relations between cardiovascular diseases (CVD) and age in OSA subjects.

MATERIAL AND METHODS

Consecutive OSA subjects (AHI/RDI > 10, Epworth score > 9 points) were evaluated. The chest X-ray, spirometry, arterial blood gases, ECG, blood morphology and biochemistry were performed during trial treatment with autoCPAP.

RESULTS

We studied 533 consecutive OSA patients, mean age 55.6 +/- 10.3 years (range 24-81), with obesity (BMI 34.4 +/- 6.6 kg/m(2)) and severe OSA (AHI/RDI 37.8 +/- 21.8). To evaluate relations between CVD and age, patients were divided into three groups. Group 1 < 50 years (123 subjects, 23.1%), Group 2 aged 50-60 years (250 subjects, 46.9%) and Group 3 > 60 years (160 subjects, 30%). Subjects < 50 years were more obese and had higher AHI/RDI when compared to older groups. Incidence of arterial hypertension, coronary artery disease, atrial fibrillation, heart failure and stroke increased with age (higher in subjects > 60 years).

CONCLUSIONS

Cardiovascular diseases were prevalent in OSA patients > 60 years. However the youngest group presented with more severe obesity and higher AHI/RDI.

Metabolic Abnormalities in Obstructive Sleep Apnea Patients

Introduction: OSA is a well-recognized risk factor of cardiovascular disorders and is related to metabolic syndrome. The aim of this study was to evaluate the effect of BMI and AHI/RDI on metabolic disturbances in patients suspected of OSA. Material and methods: Ninety-nine patients referred with suspected OSA underwent standard polysomnography or limited sleep study. AHI/RDI ≥ 10/h was considered relevant for OSA diagnosis. Subjects with AHI/RDI < 10 were considered as controls. We assessed apnea-hypopnea index or respiratory disturbances index (AHI/RDI), Epworth sleepiness scale (ESS), body mass index (BMI), C-reactive protein (CRP, mg/L), glycosylated haemoglobin (HbA1c, %), fasting serum total cholesterol, HDL-, LDL-cholesterol, triglycerides (TG), glucose (G), insulin (INS, IU/mL) and HOMA index. Results: Data are presented as mean ± SD or median (interquartile range) for parametric and nonparametric data respectively. Twenty-two patients were included as controls (age 51.8 ± 10 vs. 55 ± 11 in OSA; p = NS). AHI/RDI in the OSA group was 23 (16–31.3) and 7 (3.8–8.1) in controls (p < 0.001). BMI in OSA 32.2 ± 5.8 vs. 30.4 ± 4.6 in controls (p = NS). Patients with OSA had higher TG (160 ± 75.9 vs. 130.2 ± 51.9 mg/dL, p = 0.046), G (5.04 ± 0.6 vs. 4.47 ± 0.6, p = 0.0037), HOMA (2.31 ± 1.5 vs. 1.85 ± 1.7, p = 0.046). G correlated best with AHI/RDI (p < 0.001, r = 0.41). Significant differences were observed in OSA patients between obese (51 pts, BMI 35.2 ± 4.8) and non-obese (26 pts, BMI 26.61 ± 1.9) pts in: HDL-cholesterol (50.8 ± 13.2 vs. 60.9 ± 18.4 mg/dL; p = 0.02), TG (178.7 ± 69.9 vs. 124 ± 75.3 mg/dL, p < 0.001), G (5.15 ± 0.7 vs. 4.8 ± 0.5 mmol/L, p = 0.01), INS (11.7 ± 5.9 vs. 6.57 ± 4.7, p < 0.001), HOMA (2.7 ± 1.4 vs. 1.4 ± 1.2, p < 0.001), HbA1c (5.89 ± 0.9 vs. 5.4 ± 0.8, p = 0.03), CRP (2.2 ± 2.9 vs. 1.09 ± 1.2, p = 0.01). Conclusions: Our findings support the results of previous studies showing the influence of OSA alone on metabolic disturbances. However, BMI has major impact on metabolic variables.

Influence of Neck Circumference and Body Mass Index on Obstructive Sleep Apnoea Severity in Males

Introduction: Obesity and male gender are the main risk factors for the development of obstructive sleep apnoea (OSA); however, some epidemiological data has shown that neck circumference (NC) ≥ 43 cm is a better predictor of obstructive event frequency than body mass index (BMI). The aim of this study was to assess the relation between NC and BMI on OSA severity in males. Material and methods: The subjects completed a sleep questionnaire and Epworth sleepiness scale before the sleep study (full polysomnography or PolyMesam study). We studied 133 consecutive males with confirmed OSA (AHI/RDI > 10, Epworth score > 9 points). Chest X-ray, spirometry, arterial blood gases, ECG, blood morphology and biochemistry were performed during treatment trial with autoCPAP. Results: Subjects presented with obesity—BMI = 35.8 ± 6.1 kg/m2, NC = 46 ± 3.4 cm and severe disease—AHI/RDI = 45.3 ± 23.6. Mean age was 52.7 ± 11.3 years. The majority of subjects had NC ≥ 43 cm (116 pts, 87.2%—group 1), 17 pts (12.8%—group 2) had NC < 43 cm had 17 pts. Comparison of both groups showed significant differences only for BMI (gr. 1—36.8 ± 5.7, gr. 2—28.6 ± 3.7; p < 0.0001). Linear regression analysis revealed significant correlation between NC and AHI/RDI (R2 = 0.07, r = 0.26; p = 0.003); however, the correlation between BMI and AHI/RDI was stronger (R2 = 0.14, r = 0.37; p < 0.0001). In multiple linear regression analysis we found significant correlation between AHI/RDI and age (β = –0.31, p = 0.003) and BMI (β = 0.34, p = 0.02). Conclusions: The strongest correlation between AHI/RDI, younger age and BMI was found in males with OSA. Correlation between neck circumference and AHI/RDI was significant but less when compared to BMI.

Six-Minute Walk Test in Obstructive Sleep Apnoea

Introduction: The aim of this study was to assess results of 6MWT in non-selected group of obstructive sleep apnoea (OSA) patients. In healthy adult subjects 6-minute walking distance (6MWD) range from 400 to 700 m. Obesity, the main symptom of OSA, is one of the factors associated with reduction of 6MWD (another common factors: older age, shorter height, female sex, pulmonary, cardiovascular and musculoskeletal diseases). Material and methods: Subjects completed sleep questionnaire and Epworth sleepiness scale before sleep studies (full polysomnography [PSG] or PolyMesam study [PM]). Consecutive OSA subjects (AHI/RDI >10, Epworth score > 9 points) were evaluated. The 6MWT, chest X-ray, spirometry, arterial blood gases, ECG, blood morphology and biochemistry were performed during trial treatment with autoCPAP. Results: We studied 151 subjects (119 males—78.8% and 32 females—21.2%), mean age 53.4 ± 10.5 years. Subjects were obese—BMI = 35.7 ± 6.2 kg/m2 and presented severe OSA—AHI/RDI = 42.4 ± 23.2. To assess relations between 6MWD and AHI/RDI, BMI, age and concomitant diseases we divided subjects in two groups: 1st with 6MWD ≥ lower limit of normal (LLN) (123 pts; 81.5%) and 2nd with 6MWD < LLN (28 pts; 18.5%). Significant differences between groups were found for BMI, FVC (% of predicted) and Borg dyspnea scale before and after 6MWT. In multiple linear regression analysis we found significant correlation between 6MWD and BMI (β = 0.41, p < 0.0001) and arterial hypertension (β = –0.16, p = 0.04). Females had significantly shorter 6MWD than males (401.1 ± 83.6 m and 451.8 ± 107 m, respectively; p = 0.01). Difference was significant after adjustment for BMI and age (analysis of covariance)—R = 0.61, R2 = 0.38 (p < 0.0001). Conclusions: BMI, female sex, arterial hypertension and lower FVC (% of predicted) were related to shorter 6-minute walking distance in OSA patients.

[Influence of neck circumference and body mass index on obstructive sleep apnoea severity in males]

INTRODUCTION

Obesity and male gender are the main risk factors for the development of obstructive sleep apnoea (OSA); however, some epidemiological data has shown that neck circumference (NC) > or = 43 cm is a better predictor of obstructive event frequency than body mass index (BMI). The aim of this study was to assess the relation between NC and BMI on OSA severity in males.

MATERIAL AND METHODS

The subjects completed a sleep questionnaire and Epworth sleepiness scale before the sleep study (full polysomnography or PolyMesam study). Authors studied 133 consecutive males with confirmed OSA (AHI/RDI > 10, Epworth score > 9 points). Chest X-ray, spirometry, arterial blood gases, ECG, blood morphology and biochemistry were performed during treatment trial with autoCPAP.

RESULTS

Subjects presented with obesity--BMI = 35.8 +/- 6.1 kg/m2, NC = 46 +/- 3.4 cm and severe disease--AHI/RDI = 45.3 +/- 23.6. Mean age was 52.7 +/- 11.3 years. The majority of subjects had NC > or = 43 cm (116 pts, 87.2% - group 1), 17 pts (12.8% - group 2) had NC < 43 cm had 17 pts. Comparison of both groups showed significant differences only for BMI (group 1 - 36.8 +/- 5.7, group 2 - 28.6 +/- 3.7; p < 0.0001). Linear regression analysis revealed significant correlation between NC and AHI/RDI (R2 = 0.07, r = 0.26; p = 0.003); however, the correlation between BMI and AHI/RDI was stronger (R2 = 0.14, r = 0.37; p < 0.0001). In multiple linear regression analysis we found significant correlation between AHI/RDI and age (beta = -0.31, p = 0.003) and BMI (beta = 0.34, p = 0.02).

CONCLUSIONS

The strongest correlation between AHI/RDI, younger age and BMI. Correlation between neck circumference and AHI/RDI was significant but less when compared to BMI.

[Metabolic abnormalities in obstructive sleep apnea patients]

INTRODUCTION

Obstructive sleep apnea (OSA) is a well-recognized risk factor of cardiovascular disorders and is related to metabolic syndrome. The aim of this study was to evaluate the effect of BMI and AHI/RDI on metabolic disturbances in patients suspected of OSA.

MATERIAL AND METHODS

Ninety-nine patients referred with suspected OSA underwent standard polysomnography or limited sleep study. AHI/RDI > or = 10/hour was considered relevant for OSA diagnosis. Subjects with AHI/RDI < 10 were considered as controls. We assessed apnea-hypopnea index or respiratory disturbances index (AHI/RDI), Epworth sleepiness scale (ESS), body mass index (BMI), C-reactive protein (CRP, mg/l), glycosylated haemoglobin (HbA1c, %), fasting serum total cholesterol, HDL-, LDL-cholesterol, triglycerides (TG), glucose (G), insulin (INS, IU/ml) and HOMA index.

RESULTS

Data are presented as mean +/- SD or median (interquartile range) for parametric and nonparametric data respectively. Twenty-two patients were included as controls (age 51.8 +/- 10 vs. 55 +/- 11 in OSA; p = NS). AHI/RDI in the OSA group was 23 (16-31.3) and 7 (3.8-8.1) in controls (p < 0.001). BMI in OSA 32.2 +/- 5.8 vs. 30.4 +/- 4.6 in controls (p = NS). Patients with OSA had higher TG (160 +/- 75.9 vs. 130.2 +/- 51.9 mg/dl, p = 0.046), G (5.04 +/- 0.6 vs. 4.47 +/- 0.6, p = 0.0037), HOMA (2.31 +/- 1.5 vs. 1.85 +/- 1.7, p = 0.046). G correlated best with AHI/RDI (p < 0.001, r = 0.41). Significant differences were observed in OSA patients between obese (51 pts, BMI 35.2 +/- 4.8) and non-obese (26 pts, BMI 26.61 +/- 1.9) pts in: HDL-cholesterol (50.8 +/- 13.2 vs. 60.9 +/- 18.4 mg/dl; p = 0.02), TG (178.7 +/- 69.9 vs. 124 +/- 75.3 mg/dl, p < 0.001), G (5.15 +/- 0.7 vs. 4.8 +/- 0.5 mmol/l, p = 0.01), INS (11.7 +/- 5.9 vs. 6.57 +/- 4.7, p < 0.001), HOMA (2.7 +/- 1.4 vs. 1.4 +/- 1.2, p < 0.001), HbA(1c) (5.89 +/- 0.9 vs. 5.4 +/- 0.8, p = 0.03), CRP (2.2 +/- 2.9 vs. 1.09 +/- 1.2, p = 0.01).

CONCLUSIONS

Our findings support the results of previous studies showing the influence of OSA alone on metabolic disturbances. However, BMI has major impact on metabolic variables.

[Six-minute walk test in obstructive sleep apnoea]

INTRODUCTION

The aim of this study was to assess results of 6MWT in non-selected group of obstructive sleep apnoea (OSA) patients. In healthy adult subjects 6-minute walking distance (6MWD) range from 400 to 700 m. Obesity, the main symptom of OSA, is one of the factors associated with reduction of 6MWD (another common factors: older age, shorter height, female sex, pulmonary, cardiovascular and musculoskeletal diseases).

MATERIAL AND METHODS

Subjects completed sleep questionnaire and Epworth sleepiness scale before sleep studies (full polysomnography [PSG] or PolyMesam study [PM]). Consecutive OSA subjects (AHI/RDI >10, Epworth score > 9 points) were evaluated. The 6MWT, chest X-ray, spirometry, arterial blood gases, ECG, blood morphology and biochemistry were performed during trial treatment with autoCPAP.

RESULTS

We studied 151 subjects (119 males - 78.8% and 32 females - 21.2%), mean age 53.4 +/- 10.5 years. Subjects were obese - BMI = 35.7 +/- 6.2 kg/m(2) and presented severe OSA - AHI/RDI = 42.4 +/- 23.2. To assess relations between 6MWD and AHI/RDI, BMI, age and concomitant diseases we divided subjects in two groups: 1(st) with 6MWD > or = lower limit of normal (LLN) (123 pts; 81.5%) and 2(nd) with 6MWD < LLN (28 pts; 18.5%). Significant differences between groups were found for BMI, FVC (% of predicted) and Borg dyspnea scale before and after 6MWT. In multiple linear regression analysis we found significant correlation between 6MWD and BMI (beta = 0.41, p < 0.0001) and arterial hypertension (beta = -0.16, p = 0.04). Females had significantly shorter 6MWD than males (401.1 +/- 83.6 m and 451.8 +/- 107 m, respectively; p = 0.01). Difference was significant after adjustment for BMI and age (analysis of covariance) - R = 0.61, R2 = 0.38 (p < 0.0001).

CONCLUSIONS

BMI, female sex, arterial hypertension and lower FVC (% of predicted) were related to shorter 6-minute walking distance in OSA patients.

Community-Acquired Pneumonia Complications in a Patient with Hereditary Glucose-6-Phosphate Dehydrogenase Deficiency

Severe complications of lower respiratory tract infection in a patient with hereditary glucose-6-phosphate dehydrogenase (G-6-PD) deficiency may occur. The case of a 68-year-old man with hereditary glucose-6-phosphate dehydrogenase (G6PD) deficiency who developed severe haemolysis after community-acquired pneumonia is presented. G6PD deficiency in our patient was diagnosed during childhood. We observed complications of community-acquired pneumonia: empyema, haemolytic crisis and renal failure. Videopleuroscopy and pleural drainage were successfully performed. Community-acquired streptococcal pneumonia may also lead to haemolysis in G6PD deficient patients. Acute haemolysis, severe anaemia and renal insufficiency secondary to haemoglobinuria can be observed. Severe purulent complications of pneumonia in G6PD deficient patients may suggest granulocyte function impairment.

Nykturia u chorych na obturacyjny bezdech senny (OBS)

Wstęp: Nykturia (≥2 epizodów oddawania moczu w nocy) jest częstym objawem obturacyjnego bezdechu sennego (OBS). Wzrost ciśnienia w jamie brzusznej w czasie bezdechów, zwiększone wydzielanie przedsionkowego peptydu sodopędnego (ANP), stosowanie leków moczopędnych, współistnienie cukrzycy, nadmierne przyjmowanie płynów oraz przebudzenia w czasie snu powodują częstsze oddawanie moczu w nocy. Celem pracy była ocena częstości występowania nykturii u chorych z umiarkowanym i ciężkim OBS. Materiał i metody: Zbadano 171 otyłych (BMI—35.8 ± 6.3 kg/m²) chorych (135 mężczyzn i 36 kobiet) w średnim wieku 53.6 ± 10.8 lat z zaawansowanymi postaciami choroby (AHI/RDI—43.6 ± 23.2). Wyniki: W celu oceny relacji między nykturią oraz AHI/RDI (apnea hypopnea index/respiratory disturbance index), utlenowaniem w czasie snu, BMI (body mass index) i sennością dzienną badanych podzielono na 2 grupy: pierwszą bez nykturii (60 badanych; 35.1%—grupa N−) i drugą z nykturią (111 badanych; 64.9%—grupa N+). Grupa N+ miała znamiennie wyższy wskaźnik AHI/RDI, 48 ± 22.8 vs. 35.4 ± 21.7 (p = 0.0006), wyższy BMI, 36.8 ± 6.5 vs. 34 ± 5.5 kg/m² (p = 0.004), niższe średnie wysycenie krwi tętniczej tlenem w nocy (SaO₂), 88.6 ± 5.6 vs. 90.4 ± 4.3% (p = 0.03) oraz wyższą punktację w skali Epworth, 14.4 ± 5.1 vs. 11.3 ± 5.5 (p = 0.0002). W analizie regresji wielokrotnej ujawniono znamienne korelacje między nykturią oraz wynikami skali senności Epworth (β = 0.26, p < 0.0009), współistnieniem choroby wieńcowej, (β = 0.23, p = 0.004) i wskaźnikiem AHI/RDI (β = 0.21, p = 0.04). Wnioski: Nykturia jest częstym objawem u chorych na OBS (64.9%). Nocne oddawanie moczu wiązało się z ciężkością choroby, objawami senności dziennej i występowaniem choroby niedokrwiennej serca.

Wpływ menopauzy na nasilenie obturacyjnego bezdechu sennego (OBS) u kobiet

Wstęp: U kobiet obturacyjny bezdech senny (OBS) najczęściej występuje po menopauzie. Celem pracy było porównanie zaawansowania OBS u kobiet po menopauzie (grupa E−) oraz u kobiet z zachowaną aktywnością estrogenową (kobiety przed menopauzą lub stosujące hormonalna terapię zastępczą—grupa E+). Materiał i metody: Zbadano 147 kobiet chorych na OBS w średnim wieku 58.1 ± 9.4 roku. Badane kobiety charakteryzowały się otyłością (BMI = 34 ± 7.9 kg/m²) oraz umiarkowanym lub ciężkim OBS (AHI/RDI = 35.9 ± 20.9), średnie SaO₂ wynosiło 89.4 ± 5.8%. Grupa E− składała się z 116 chorych (75.5%), a grupa E+—z 36 (24.5%). Wyniki: Nasilenie choroby było większe w grupie E+ (AHI/RDI = 42 ± 26.6; BMI = 37.6 ± 10.1 kg/m²) w porównaniu z grupą E− (AHI/RDI = 33.9 ± 18.4; p = 0.04 i BMI = 32.8 ± 6.7 kg/m²; p = 0.001). Analiza regresji wielokrotnej ujawniła znamienną ujemną korelację między AHI/RDI i wiekiem (β = −0.29; p = 0.03). Po wyłączeniu wpływu wieku i BMI (analiza kowariancji) badane grupy nadal się różniły wartościami AHI/RDI (R = 0.24; p = 0.03). Wnioski: Większość kobiet chorych na OBS, które zakwalifikowano do leczenia CPAP, było w okresie menopauzy (75.5%). Nasilenie OBS (AHI/RDI) po wyłączeniu wpływu wieku i masy ciała było większe w grupie z zachowaną aktywnością estrogenową.

Influence of Treatment with Continuous Positive Airway Pressure on Respiratory Muscle Function and Physical Fitness in Patients with Obstructive Sleep Apnoea and Overlap Syndrome

Introduction: The aim of this study was to evaluate the effect of CPAP treatment on respiratory muscle strength and exercise tolerance in patients with obstructive sleep apnoea (OSA) and overlap syndrome (OS). Material and methods: 9 patients with OSA and 9 patients with OS were studied. Respiratory muscle assessment, 6 minute walking distance (6MWD) and cycloergometry exercise test were performed before and after six month period of CPAP treatment. Results: In OSA group exercise tolerance did not change after the treatment. Mean 6MWD was 571.8 ± 76.6 m before and 554.0 ± 125.5 m after treatment, mean Wmax was 142 ± 41 W before and 139 ± 38 W after treatment. PImax in OSA group did not change significantly, 140.4 ± 32.0 cm H2O before and 155.9 ± 31.5 after treatment (p = 0.14). PEmax improved from 170.5 ± 49.2 cm H2O, to 199.9 ± 27.6 cm H2O (p = 0.067). Handgrip force in OSA group improved from 50.5 ± 16.5 kg to 61.0 ± 17.0 kg (left hand) (p = 0.05) and from 53.3 ± 14.2 to 58.9 ± 15.9 (right hand) (p < 0.05). In OS group exercise tolerance improved by 17% after CPAP treatment from Wmax = 81 ± 33 W before to 95 ± 38 W after. Mean 6MWD was at the same level before (504 ± 144 m) and after treatment (492 ± 108 m). PImax in OS group improved from 89.2 ± 35.7 cm H2O to 106.3 ± 31.4 cm H2O (p < 0.05). PEmax in OS group did not change significantly, 159.9 ± 45.8 cm H2O before and 184.2 ± 45.0 cm H2O after treatment (NS). Handgrip force in OS group improved from 38.1 ± 15.9 kg to 46.9 ± 11.1 kg (left hand) (p < 0.05) and did not change in right hand (44.5 ± 17.7 kg vs. 47.9 ± 10.4 kg) (NS). Data analysis of the whole group (18 pts) showed clear tendency to improve strength of respiratory muscles in patients treated with CPAP. Mean PImax improved from 123 to 133 cm H2O (p = 0.006) and PEmax improved from 168.1 to 192 cm H2O (p = 0.02). Conclusions: CPAP treatment improved strentgh of respiratory and skeletal muscles in patients with OSA and OS and improved exercise tolerance in patients with OS.

[Influence of treatment with continuous positive airway pressure on respiratory muscle function and physical fitness in patients with obstructive sleep apnoea and overlap syndrome]

INTRODUCTION

The aim of this study was to evaluate the effect of CPAP treatment on respiratory muscle strength and exercise tolerance in patients with obstructive sleep apnoea (OSA) and overlap syndrome (OS).

MATERIAL AND METHODS

9 patients with OSA and 9 patients with OS were studied. Respiratory muscle assessment, 6 minute walking distance (6MWD) and cycloergometry exercise test were performed before and after six month period of CPAP treatment.

RESULTS

In OSA group exercise tolerance did not change after the treatment. Mean 6MWD was 571.8 +/- 76.6 m before and 554.0 +/- 125.5 m after treatment, mean W(max) was 142 +/- 41 W before and 139 +/- 38 W after treatment. PI(max) in OSA group did not change significantly, 140.4 +/- 32.0 cm H(2)O before and 155.9 +/- 31.5 after treatment (p = 0.14). PE(max) improved from 170.5 +/- 49.2 cm H(2)O, to 199.9 +/- 27.6 cm H(2)O (p = 0.067). Handgrip force in OSA group improved from 50.5 +/- 16.5 kg to 61.0 +/- 17.0 kg (left hand) (p = 0.05) and from 53.3 +/- 14.2 to 58.9 +/- 15.9 (right hand) (p < 0.05). In OS group exercise tolerance improved by 17% after CPAP treatment from W(max) = 81 +/- 33 W before to 95 +/- 38 W after. Mean 6MWD was at the same level before (504 +/- 144 m) and after treatment (492 +/- 108 m). PI(max) in OS group improved from 89.2 +/- 35.7 cm H(2)O to 106.3 +/- 31.4 cm H(2)O (p < 0.05). PE(max) in OS group did not change significantly, 159.9 +/- 45.8 cm H(2)O before and 184.2 +/- 45.0 cm H(2)O after treatment (NS). Handgrip force in OS group improved from 38.1 +/- 15.9 kg to 46.9 +/- 11.1 kg (left hand) (p < 0.05) and did not change in right hand (44.5 +/- 17.7 kg vs. 47.9 +/- 10.4 kg) (NS). Data analysis of the whole group (18 pts) showed clear tendency to improve strength of respiratory muscles in patients treated with CPAP. Mean PI(max) improved from 123 to 133 cm H(2)O (p = 0.006) and PE(max) improved from 168.1 to 192 cm H(2)O (p = 0.02).

CONCLUSIONS

CPAP treatment improved strentgh of respiratory and skeletal muscles in patients with OSA and OS and improved exercise tolerance in patients with OS.

Community-acquired pneumonia complications in a patient with hereditary glucose-6-phosphate dehydrogenase deficiency

Severe complications of lower respiratory tract infection in a patient with hereditary glucose-6-phosphate dehydrogenase (G-6-PD) deficiency may occur. The case of a 68-year-old man with hereditary glucose-6-phosphate dehydrogenase (G6PD) deficiency who developed severe haemolysis after community-acquired pneumonia is presented. G6PD deficiency in our patient was diagnosed during childhood. We observed complications of community-acquired pneumonia: empyema, haemolytic crisis and renal failure. Videopleuroscopy and pleural drainage were successfully performed. Community-acquired streptococcal pneumonia may also lead to haemolysis in G6PD deficient patients. Acute haemolysis, severe anaemia and renal insufficiency secondary to haemoglobinuria can be observed. Severe purulent complications of pneumonia in G6PD deficient patients may suggest granulocyte function impairment.

[Nocturia in obstructive sleep apnoea (OSA)]

INTRODUCTION

Nocturia (two or more urinations per night) is a common symptom in OSA subjects. Higher secretion of atrial natriuretic peptide, increased intra-abdominal pressure, diuretics, diabetes, excessive fluid intake, awakenings are responsible for nocturnal urination. The aim of this study was to evaluate incidence of nocturia in moderate and severe OSA.

MATERIAL AND METHODS

We studied 171 consecutive OSA patients (135 males and 36 females) - means: age - 53.6 +/- +/- 10.8 years, AHI/RDI - 43.6 +/- 23.2, BMI - 35.8 +/- 6.3 kg/m(2).

RESULTS

To assess relations between nocturia and AHI/RDI, overnight saturation, BMI and daytime sleepiness we divided subjects in two groups: 1(st) - without nocturia - 60 pts; 35.1% (group N-) and 2(nd) - with nocturia - 111 pts; 64.9% (group N+). Group N+ presented with higher AHI/RDI, 48 +/- 22.8 vs. 35.4 +/- 21.7 (p = 0.0006), higher BMI, 36.8 +/- 6.5 vs. 34 +/- 5.5 kg/m(2) (p = 0.004), lower mean overnight SaO(2), 88.6 +/- 5.6 vs. 90.4 +/- 4.3% (p = 0.03) and daytime sleepiness, Epworth score - 14.4 +/- 5.1 vs. 11.3 +/- 5.5 points (p = 0.0002). Multiple linear regression analysis revealed significant correlation between nocturia and Epworth sleepiness score (beta = 0.26, p = 0.0009), coronary artery disease (beta = 0.23, p = 0.004) and AHI/RDI (beta = 0.21, p = 0.04).

CONCLUSIONS

Nocturia is frequent in OSA patients (64.9%). Nocturnal urination was related to severity of OSA, excessive daytime sleepiness and coronary artery disease.

[Menopausal status and severity of obstructive sleep apnoea (OSA) in females]

INTRODUCTION

Prevalence of obstructive sleep apnoea (OSA) is higher in postmenopausal females. The aim of this study was to compare OSA severity in postmenopausal females (group E-) and females with preserved estrogen activity (premenopausal or on hormonal replacement therapy - group E+).

MATERIAL AND METHODS

We studied 147 OSA females in mean age 58.1 +/- 9.4 years. Subjects presented obesity (BMI = 34 +/- +/- 7.9 kg/m2) and moderate or severe disease (AHI = 35.9 +/- 20.9), SaO(2) mean - 89.4 +/- 5.8%. Group (E-) consisted of 116 pts (75.5%) and group (E+) of 36 pts (24.5%).

RESULTS

Group (E+) presented more severe OSA (AHI/RDI = 42 +/- 26.6) and obesity (BMI = 37.6 +/- 10.1 kg/m(2)) when compared to group E- (AHI/RDI = 33.9 +/- 18.4; p = 0.04 and BMI - 32.8 +/- 6.7 kg/m(2); p = 0.001). In multiple linear regression analysis we found significant negative correlation between AHI and age (beta = -0.29, p = 0.03). After adjustment for BMI and age (analysis of covariance) significant difference was still present between both groups (R = 0.24, p = 0.03).

CONCLUSIONS

Majority of OSA females qualified to CPAP therapy were postmenopausal (75.5%). Severity of OSA (AHI/RDI) after adjustment for age and BMI was higher in group (E+).

Central Sleep Apnoea (CSA) in Male with Heart Failure

We studied 44-year old man with heart failure (ejection fraction −25%). Obesity, arterial hypertension, snoring and excessive daytime sleepiness suggested concomitant obstructive sleep apnoea. Limited polysomnography with Polymesam revealed typical Cheyne-Stokes respiration with mainly central apnoeas (RDI = 48/hour). We did not fi nd any obstructive episodes during sleep study. Patient responded to CPAP therapy and apnoea hypo-pnoe index decreased to 12/hour on 8 mbar pressure.

[Central sleep apnoea (CSA) in male with heart failure]

We studied 44-year old man with heart failure (ejection fraction -25%). Obesity, arterial hypertension, snoring and excessive daytime sleepiness suggested concomitant obstructive sleep apnoea. Limited polysomnography with Polymesam revealed typical Cheyne-Stokes respiration with mainly central apnoeas (RDI=48/hour). We did not find any obstructive episodes during sleep study. Patient responded to CPAP therapy and apnoea hypopnoe index decreased to 12/hour on 8 mbar pressure.

[The variability of clinical presentation of chronic obstructive pulmonary disease in patients with hereditary alpha-1 antitrypsin deficiency]

Four patients with alpha-1 antitrypsin (alpha-1 AT) deficiency are presented: one woman with severe (phenotype PiZ) and 3 men with moderate (phenotype PiMZ) deficiency of alpha-1 AT. The variability of clinical presentation of hereditary emphysema is described. In all patients tobacco smoking history, spirometric and 6-minutes walking tests as well as HRCT of the lung were performed and compared. The influence of smoking on the functional status is underlined.

[Role of expiratory muscles in COPD patients]

Expiratory muscle recruitment is common in stable COPD patients. However, physiological significance of expiratory muscle recruitment in COPD remains unclear. The purpose of this study was to assess the effect of expiratory muscle contraction on force generating ability of the diaphragm in COPD patients breathing at rest. The force generating ability of the diaphragm was evaluated from its pressure swing (Pdi) for a given diaphragm electrical activity (Edi), where Edi was normalized as % of its maximal value [Pdi/(Edi/Edimax)]. Phasic expiratory muscle contraction was measured as the total expiratory rise in gastric pressure (Pgaexp.rise). Nineteen patients with severe COPD, participated in the study but only 10 exhibited phasic rise in Pga during expiration with a mean Pgaexp.rise of 1.91 +/- 0.89 cmH2O. Patients were divided into passive expiration (PE) and active expiration (AE) groups. There was no significant difference in lung function and breathing pattern parameters between the two groups. Pdi/(Edi/Edimax) was 0.63 +/- 0.07 and 0.54 +/- 0.07 cm cmH2O/% in PE and AE groups, respectively, and was not significantly different between each other. Compared with PE group, AE group not only recruited expiratory muscles, but also preferentially recruited inspiratory rib cage muscles and derecruited the diaphragm. In conclusion phasic contraction of expiratory muscles at rest in COPD patients do not improve the force-generating ability of the diaphragm.

[Diaphragm electrical activation in COPD patients]

Several studies have demonstrated relatively moderate increase in Pdi during exhaustive exercise in COPD patients. The present study was designed to determine whether the small increase in Pdi is due to a central inhibition of respiratory drive, or an inability of the diaphragm to develop pressure. Diaphragm electrical activation (Edi) and transdiaphragmatic (Pdi) pressure were measured in 19 patients with severe COPD using an esophageal catheter. End-expiratory lung volume (EELV) was assessed by inspiratory capacity (IC) maneuvers. Maximal voluntary Edi (Edimax) was obtained during these maneuvers. EELV increased during exercise (p < 0.001) causing end-inspiratory lung volume to attain 98 +/- 5% of TLC at end-exercise. Pdi at rest was 8.4 +/- 2.6 cm H2O. Edi was 19 +/- 4% of Edimax at rest and increased progressively during exercise (p < 0.001) to reach 78 +/- 3% of Edimax at end-exercise. In conclusion, dynamic hyperinflation during exhaustive exercise in patients with COPD, reduces diaphragm pressure generating capacity, promoting near maximal levels of diaphragm activation without evidence of central inhibition.

[Predictors of success in smoking cessation among participants of spirometric screening for COPD]

The aim of the study was to evaluate factors that could predict smoking cessation after a minimal antismoking counseling during spirometric screening for COPD. Every subject filled-in a simple questionnaire on clinical signs of COPD and tobacco habit, had a spirometry performed according to ATS standards and received a short antitobacco counseling together with a booklet on how to quit smoking. Out of 800 smokers over 40 years of age, smoking history of more than 10 packyears, screened for COPD in 1999, four hundred were invited a year later for a follow-up spirometry and evaluation of anti-smoking intervention. Of 383 patients, who responded to the invitation (208 M and 175 F, mean age 56.6 +/- 10.7 yrs), 52 (13.6%) quit smoking for one year and another 48 (12.5%) quit smoking temporarily and than resumed smoking. Smokers who permanently succeeded in quitting smoking were older (60.5 vs 55.9 years p < 0.01), started smoking later (age at starting smoking 22 vs 19.5 years p < 0.001), had a shorter tobacco exposition (28.8 vs 34.3 packyears p < 0.05), had lower lung function (FEV1%pred 80.5 vs 89.2% p < 0.05) and were less nicotine dependent (FTQ score 1 vs 4.8 p < 0.00001).

[Respiratory failure during the course of congenital myopathy effectively treated with nocturnal noninvasive nasal positive pressure ventilation]

Respiratory muscle weakness in myopathy may result in respiratory failure. 41 year old male with congenital myopathy was successfully treated with nocturnal noninvasive nasal positive pressure ventilation. NPPV resulted in improvement of arterial blood gases and allowed to close tracheostomy. Patient was able to return to full time employment.

[Noninvasive intermittent positive pressure ventilation in treatment of chronic respiratory disease exacerbation]

Noninvasive intermittent positive pressure ventilation (NIPPV) via nasal mask became a routine method of treatment of severe exacerbations of chronic respiratory failure. The aim of the study was to apply NIPPV in patients with COPD admitted to hospital due to exacerbation of the disease who on standard treatment developed progressing respiratory acidosis (pH < 7.30). Fourteen COPD patients were treated with NIPPV. Arterial blood gases at the beginning of treatment were: PaO2 41 +/- 9 mmHg, PaCO2 = 87 +/- 17 mmHg, pH = 7.30 +/- 0.05. In 10 patients NIPPV applied quasi continuously resulted in clinical improvement and an amelioration of arterial blood gases. PaO2 rose from 41 +/- 9 mmHg to 56 +/- 12 mmHg, PaCO2 fell from 85 +/- 17 to 57 +/- 9 mmHg and pH rose from 7.30 +/- 0.05 to 7.41 +/- 0.04. In 4 patients NIPPV did not prevent further progression of respiratory acidosis. They were intubated and mechanically ventilated. Three patients survived and were discharged home. One patient died from septic shock. We conclude that NIPPV is an effective method to treat respiratory acidosis developing during exacerbation of severe COPD.

[Noninvasive positive pressure ventilation in COPD patients with hypercapnic respiratory failure]

The effects of noninvasive positive pressure ventilation (NIPPV) in COPD patients (pts) with hypercapnic respiratory failure were evaluated. The study group consisted of 19 COPD pts (16M, 3F, mean age 60 +/- 8 years) on LTOT for at least 6 month before study. Patients were enrolled in random order to group I, which continued LTOT and to group II, which started nocturnal NIPPV and continued LTOT. There were 12 pts in group 1 and 7 pts in group II. Two pts from the group did not tolerate NIPPV and were transferred to group I. To ventilate the pts we used portable, volume ventilators. Mean time of follow-up in group I was 23 +/- 13 months and 16 +/- 10 months in group II. During that time died 5 pts from 1 and 4 pts from group II. Differences between functional variables (FEV1, FVC, FEV1/VC, PaO2, PaCO2, pH, PEmax, 6MWD), dyspnea, number of hospitalizations and mortality in both groups were not statistically significant. In both groups progression of the disease (decrease of FEV1, worsening of hypoxaemia and increase of hypercapnia) was observed. NIPPV did not slow down progression of the disease.

[Respiratory failure in mitochondrial myopathy treated with noninvasive mechanical ventilation]

Young man suffering from mitochondrial myopathy was admitted to our Institute due to severe hypercapnic respiratory failure. Noninvasive mechanical ventilation (NWM) during sleep using nasal mask was instituted with positive results. Diurnal blood gases breathing air also ameliorated suggesting improvement of respiratory muscles function.