Adel Bachour

Smoking and improvement after nasal surgery in snoring men.

Background The aim of this study was to compare subgroups of smokers and nonsmokers undergoing nasal surgery and to evaluate improvement of nasal stuffiness, snoring, and symptoms related to sleep-disordered breathing after nasal surgery. Methods A cross-sectional prospective study was performed. The study population included 40 consecutive snoring men scheduled for surgical treatment of nasal obstruction. The patients completed nasal and sleep questionnaires, an Epworth sleepiness scale, and a visual analog scale of snoring intensity. They underwent polysomnography, anterior rhinomanometry, acoustic rhinometry, and cephalometric analysis. Results The smokers were younger, they snored longer and louder, and they had higher nasal resistance with decongestion and longer soft palates than the nonsmokers. Nasal stuffiness improved well after surgery, but a decrease of nasal resistance was not related to improvement of subjective snoring. Conclusion Smoking was associated with increased snoring, nasal obstruction, and pharyngeal soft tissue volume. Expectations of patients may influence subjective assessment of snoring after nasal surgery.

Screening of snoring with an MP3 recorder

PurposeSnoring patients seeking medical assistance represent a wide range of clinical and sleep study findings from nonsleepy nonapneic snoring to severe obstructive sleep apnea syndrome. The prevalence of snoring is high and it significantly impacts quality of life. Its objective diagnosis usually requires a sleep study. We developed a system to analyze snoring sounds with a Moving Picture Experts Group Layer-3 Audio (MP3) recorder device and present its value in the screening of snoring.MethodsWe recorded snoring sounds during in-lab polysomnography (PSG) in 200 consecutive patients referred for a suspicion of obstructive sleep apnea. Snoring was recorded during the PSG with two microphones: one attached to the throat and the other to the ceiling; an MP3 device was attached to the patient’s collar. Snoring was confirmed when the MP3 acoustic signal exceeded twice the median value of the acoustic signal for the entire recording. Results of the MP3 snoring recording were compared to the snoring recordings from the PSG.ResultsMP3 recording proved technically successful for 87% of the patients. The Pearson correlation between PSG snoring and MP3 snoring was highly significant at 0.77 (p < 0.001). The MP3 recording device underestimated the snoring time by a mean ± SD of 32 ± 55 min.ConclusionsThe recording of snoring with an MP3 device provides reliable information about the patient’s snoring.

The Oxford Sleep Resistance test (OSLER) and the Multiple Unprepared Reaction Time Test (MURT) detect vigilance modifications in sleep apnea patients

STUDY OBJECTIVES The Oxford Sleep Resistance Test (OSLER) is a behavioral test that measures a subjects ability to maintain wakefulness and assesses daytime vigilance. The multiple unprepared reaction time (MURT) test measures a subjects reaction time in response to a series of visual or audible stimuli. METHODS We recruited 34 healthy controls in order to determine the normative data for MURT. Then we evaluated modifications in OSLER and MURT values in 192 patients who were referred for suspicion of sleep apnea. We performed OSLER (three 40-min sessions) and MURT (two 10-min sessions) tests at baseline. Of 173 treated OSA patients, 29 professional drivers were retested within six months of treatment. RESULTS MURT values above 250 ms can be considered abnormal. The OSLER error index (the number of all errors divided by the duration of the session in hours) correlated statistically significantly with sleep latency, MURT time, and ESS. Treatment improved OSLER sleep latency from 33 min 4 s to 36 min 48 s, OSLER error index from 66/h to 26/h, and MURT time from 278 ms to 224 ms; these differences were statistically significant. CONCLUSIONS OSLER and MURT tests are practical and reliable tools for measuring improvement in vigilance due to sleep apnea therapy in professional drivers.

Persistence of Upper-Airway Symptoms During CPAP Compromises Adherence at 1 Year

BACKGROUND: The most common adverse effects of CPAP are related to the upper airways. We evaluated upper-airway symptoms before and after a CPAP trial as well as their effect on CPAP adherence. We also evaluated the effect of humidification added to CPAP therapy on upper-airway symptoms. METHODS: We followed for 1 y 536 subjects with obstructive sleep apnea scheduled consecutively for CPAP initiation. Subjects completed visual analog questionnaires on nasal stuffiness, rhinorrhea, and mouth dryness (0 = no symptoms, 100 = severe symptoms). RESULTS: Before CPAP initiation, mean nasal stuffiness score was 29.6 ± 24.9, rhinorrhea score was 16.0 ± 21.7, and mouth dryness score was 43.8 ± 33.1. In subjects who quit CPAP treatment before the 1-y follow-up, the increase in rhinorrhea score during CPAP initiation was significant, 5.3 (95% CI 0.5–9.5, P = .02), and in those using CPAP at 1 y, nasal stuffiness score and mouth dryness score decreased significantly during initiation, −5.1 (95% CI −7.9 to −2.4, P < .001) and −21.2 (−25.5 to −17.4, P < .001). Mouth dryness score decreased significantly with CPAP regardless of humidification: change with humidification, −18.1 (95% CI −22.1 to −14.3), P < .001; change without, −10.5 (95% CI −16.9 to −4.1), P = .002. Humidification also prevented the aggravation of rhinorrhea (change, −0.4 [95% CI −2.6 to 1.9], P = .75) and alleviated nasal stuffiness (change −5.3 [95% CI −7.8 to −2.6], P < .001) with CPAP, whereas its absence induced a significant rise in symptom scores: change in rhinorrhea, 11.5 (95% CI 7.1–16.7), P < .001; change in nasal stuffiness, 8.5 (95% CI 3.9–13.5, P < .001). CONCLUSIONS: The severity of upper-airway symptoms before CPAP does not predict CPAP use at 1 y, whereas CPAP non-users at 1 y had smaller or no alleviation in symptom scores during initiation compared with those who continued CPAP treatment.

Bubbling test to recognize retrograde air escape via the nasolacrimal system during positive airway pressure therapy

Reports have identified dry eyes, epiphora and superficial punctate keratitis as side effects of CPAP therapy [1,2]. These symptoms have been attributed to direct air leak towards the eyes due to poor mask fit. However, in 2004, Singh et al. [3] reported CPAP-associated retrograde air escape via the nasolacrimal system (CRANS), causing dry eyes, epiphora and eyelid fluttering. This is a report of a video describing a bubbling test for the diagnosis of CRANS.

A detection dog for obstructive sleep apnea

PurposeWe sought to assess whether a dog can be trained to distinguish obstructive sleep apnea patients from healthy controls based on the olfactory detection of urine.MethodsUrine samples were collected from 23 adult male obstructive sleep apnea patients and from 20 voluntary adult male volunteers. Three dogs were trained through reinforced operant conditioning.ResultsTwo of the three dogs correctly detected two thirds of obstructive sleep apnea patients (p < 0.000194 and p < 0.000003, respectively).ConclusionsWe found that dogs can be trained to distinguish obstructive sleep apnea patients from healthy controls based on the smell of urine. Potentially, dogs could be utilized to identify novel biomarkers or possibly screen for obstructive sleep apnea.

Obstructive sleep apnoea and the risk for coronary heart disease and type 2 diabetes: a longitudinal population-based study in Finland

Objective To evaluate if obstructive sleep apnoea (OSA) modifies the risk of coronary heart disease, type 2 diabetes (T2D) and diabetic complications in a gender-specific fashion. Design and setting A longitudinal population-based study with up to 25-year follow-up data on 36 963 individuals (>500 000 person years) from three population-based cohorts: the FINRISK study, the Health 2000 Cohort Study and the Botnia Study. Main outcome measures Incident coronary heart disease, diabetic kidney disease, T2D and all-cause mortality from the Finnish National Hospital Discharge Register and the Finnish National Causes-of-Death Register. Results After adjustments for age, sex, region, high-density lipoprotein (HDL) and total cholesterol, current cigarette smoking, body mass index, hypertension, T2D baseline and family history of stroke or myocardial infarction, OSA increased the risk for coronary heart disease (HR=1.36, p=0.0014, 95% CI 1.12 to 1.64), particularly in women (HR=2.01, 95% CI 1.31 to 3.07, p=0.0012). T2D clustered with OSA independently of obesity (HR=1.48, 95% CI 1.26 to 1.73, p=9.11× 10 − 7 ). The risk of diabetic kidney disease increased 1.75-fold in patients with OSA (95% CI 1.13 to 2.71, p=0.013). OSA increased the risk for coronary heart disease similarly among patients with T2D and in general population (HR=1.36). All-cause mortality was increased by OSA in diabetic individuals (HR=1.35, 95% CI 1.06 to 1.71, p=0.016). Conclusion OSA is an independent risk factor for coronary heart disease, T2D and diabetic kidney disease. This effect is more pronounced even in women, who until now have received less attention in diagnosis and treatment of OSA than men.

The effect of CPAP treatment for obstructive sleep apnea on asthma control-study limitations-author's response.

Dear Editor, We thank colleagues Dr. Cravo, Dr. Pazarli, and Dr. Esquinas for their interest in our study and their comments. First, we agree that polygraphy has lower sensit ivity than polysomnography (PSG) especially in cases with a lower respiratory event index (REI) [1]. The mean REI in our study was 41; therefore, we do not believe that cases of false negative OSAwere included in our study population. Second, none of the patients included in the study had obesity hypoventilation syndrome and, thus, we focused on CPAP treatment [3]. Third, we have discussed in our paper that the retrospective study design is one of the study limitations and, indeed, includes the possibility of recall bias [2]. Finally, the medication of the patients was analyzed by self-reported use of rescue medication which is one the questions included in the asthma control test (ACT). However, as we have discussed in our paper, further analyses of asthmamedicationwould also include the possibility of bias since use of medication is reported by patients. Using information in medical records is a commonly employed technique in clinical studies. Unfortunately, patients often use their drugs (both tablets and inhalers) in a different way than they are prescribed and, thus, even medical record information on prescribed drugs is only an estimation [4]. Considering the concept of different phenotypes of asthma and results from other studies on CPAP treatment, we find it likely that CPAP is mostly beneficial for patients with both OSA and asthma. We believe that the benefit of CPAP on asthma is related to its effect on improving the acinar ventilation heterogeneity as well as reducing reflux. However, an important effect involves abolishing respiratory disturbances since we found similar results with the use of mandibular advancement devices [5]. A prospective study including sleep apnea patients, asthma patients, and patients with both disorders in a study design that includes PSG, lung function, inflammatory parameters, self-reported symptoms, medication and adherence to medication, and CPAP use would give further objective information on this issue. Thus, our real-life study results are important and valuable but need to be read with caution in view of the study limitations as outlined in our paper.

The Effect of mandible advancement splints in mild, moderate, and severe obstructive sleep apnea—the need for sleep registrations during follow up

Objective and design Our aim was to evaluate the effect of mandible advancement splint (MAS) in mild, moderate, and severe obstructive sleep apnea (OSA). We also determined, if and in which OSA-groups the adequate forward movement in MAS could be quantified without sleep registration for different OSA levels. A retrospective study. Settings The effect of MAS was measured with clinical methods and by sleep registration. Participants The series consisted of 103 patients, 75 males and 28 females (mean age 52 years) suffering from mild (32 per cent), moderate (32 per cent), or severe (36 per cent) OSA, who were treated with MAS at Helsinki University Hospital, Finland during the years 2011-2012. Seventy per cent of the patients had tried continuous positive airway pressure (CPAP) before MAS. Results The lower the body mass index (BMI) was the bigger the probability was to get apnea/hypopnea index (AHI) values <5 per hour with MAS (P < 0.01). The total AHI decreased significantly from the baseline with MAS: 23 per hour (range 5-89) to 6 per hour (range 0.3-54), (P < 0.001). The mean oxygen desaturation index (ODI4%) improved significantly from 16 per hour (range 1-76) to 5.3 per hour (range 0.2-49), (P < 0.01), and the minimum oxygen saturation improved significantly from 84 per cent (67-91) to 87 per cent (68-93), (P < 0.01). The reduction of AHI with MAS was significantly bigger in patients with a previous CPAP experience (73 per cent) than those who did not tried CPAP therapy. The positive correlation was found between the decrease in AHI and the increase of the protrusion in MAS. Conclusion Both sleep recordings and subjective indicators demonstrated that MAS therapy was successful in OSA based on ESS, total AHI, ODI4%, and minimum oxygen saturation values. It seems useful to increase the protrusion at its maximal clinical tolerance. An experienced dentist could make therapeutically decision concerning the follow up of MAS efficacy regardless of the result of sleep study. We suggest that MAS is a valuable treatment alternative for CPAP. However, the previous use of CPAP with MAS as well as lower baseline BMI seem to have a positive correlation with the success of MAS therapy.