Alberto Braghiroli

Sleep and Exertional Periodic Breathing in Chronic Heart Failure Prognostic Importance and Interdependence

Background— Sleep and exertional periodic breathing are proverbial in chronic heart failure (CHF), and each alone indicates poor prognosis. Whether these conditions are associated and whether excess risk may be attributed to respiratory disorders in general, rather than specifically during sleep or exercise, is unknown. Methods and Results— We studied 133 CHF patients with left ventricular ejection fraction (LVEF) ≤40%. During 1170±631 days of follow-up, 31 patients (23%) died. Nonsurvivors had higher New York Heart Association class, ventilatory response (&OV0312;e/&OV0312;co2 slope), and apnea-hypopnea index (AHI) and lower peak &OV0312;o2 (all P<0.01); lower LVEF and prescription of &bgr;-blockers, and shorter transmitral deceleration time (all P<0.05). Exertional oscillatory ventilation (EOV), established by cyclic fluctuations in minute ventilation that persisted for ≥60% of exercise duration with an amplitude ≥15% of the average resting value, was significantly more frequent in nonsurvivors (42% versus 15%, P<0.01). Multivariable analysis selected AHI (hazard ratio [HR] 5.66, 95% CI 2.3 to 19.9, P<0.01), peak &OV0312;o2 (HR 0.93, 95% CI 0.90 to 0.97, P<0.01), and &bgr;-blocker prescription (HR 0.34, 95% CI 0.13 to 0.87, P<0.05) as predictors of cardiac events. The best cutoff for AHI was >30/h. EOV was significantly related to AHI >30/h (&khgr;2 14.6, P<0.01): 78% of EOV patients showed AHI >30/h. Multivariable analysis, including breathing disorders alone (EOV, AHI >30/h) or in combination (EOV plus AHI >30/h), selected combined disorders as the strongest predictor of events (HR 6.65, 95% CI 2.6 to 17.1, P<0.01). Conclusions— In CHF, EOV is significantly associated with AHI >30/h. Although each breathing disorder alone is linked to total mortality, their combination has a crucial prognostic burden.

General Characteristics and Risk Factors of Cardiovascular Disease among Interstate Bus Drivers

Workers in the transportation industry are at greater risk of an incorrect diet and sedentary behavior. The aim of our study was to characterize a population of professional bus drivers with regard to clinical and demographic variables, lipid profile, and the presence of cardiovascular risk factors. Data from 659 interstate bus drivers collected retrospectively, including anthropometric characteristics, systolic and diastolic blood pressure, lipid profile, fasting blood glucose, meatoscopy, and audiometry. All participants were male, with a mean age of 41.7 ± 6.9 years, weight of 81.4 ± 3.3 kg, and BMI 27.2 ± 3.3 Kg/m2; the mean abdominal and neck circumferences were 94.4 ± 8.6 cm and 38.9 ± 2.2  cm; 38.2% of the sample was considered hypertensive; mean HDL cholesterol was 47.9 ± 9.5 mg/dL, mean triglyceride level was 146.3 ± 87.9 mg/dL, and fasting glucose was above 100 mg/dL in 249 subjects (39.1%). Drivers exhibited reduced audiometric hearing at 4–8 kHz, being all sensorineural hearing loss. The clinical characterization of a young male population of interstate bus drivers revealed a high frequency of cardiovascular risk factors, as obesity, hypertension, hyperlipidemia, and hyperglycemia, as well as contributing functional characteristics, such as a low-intensity activity, sedentary behavior, long duration in a sitting position, and high-calorie diet, which lead to excessive weight gain and associated comorbidities.

Observational study on efficacy of negative expiratory pressure test proposed as screening for obstructive sleep apnea syndrome among commercial interstate bus drivers - protocol study

BackgroundObstructive sleep apnea (OSA) is a respiratory disease characterized by the collapse of the extrathoracic airway and has important social implications related to accidents and cardiovascular risk. The main objective of the present study was to investigate whether the drop in expiratory flow and the volume expired in 0.2 s during the application of negative expiratory pressure (NEP) are associated with the presence and severity of OSA in a population of professional interstate bus drivers who travel medium and long distances.Methods/DesignAn observational, analytic study will be carried out involving adult male subjects of an interstate bus company. Those who agree to participate will undergo a detailed patient history, physical examination involving determination of blood pressure, anthropometric data, circumference measurements (hips, waist and neck), tonsils and Mallampati index. Moreover, specific questionnaires addressing sleep apnea and excessive daytime sleepiness will be administered. Data acquisition will be completely anonymous. Following the medical examination, the participants will perform a spirometry, NEP test and standard overnight polysomnography. The NEP test is performed through the administration of negative pressure at the mouth during expiration. This is a practical test performed while awake and requires little cooperation from the subject. In the absence of expiratory flow limitation, the increase in the pressure gradient between the alveoli and open upper airway caused by NEP results in an increase in expiratory flow.DiscussionDespite the abundance of scientific evidence, OSA is still underdiagnosed in the general population. In addition, diagnostic procedures are expensive, and predictive criteria are still unsatisfactory. Because increased upper airway collapsibility is one of the main determinants of OSA, the response to the application of NEP could be a predictor of this disorder. With the enrollment of this study protocol, the expectation is to encounter predictive NEP values for different degrees of OSA in order to contribute toward an early diagnosis of this condition and reduce its impact and complications among commercial interstate bus drivers.Trial registrationRegistro Brasileiro de Ensaios Clinicos (local acronym RBEC) [Internet]: Rio de Janeiro (RJ): Instituto de Informaçao Cientifica e Tecnologica em Saude (Brazil); 2010 - Identifier RBR-7dq5xx. Cross-sectional study on efficacy of negative expiratory pressure test proposed as screening for obstructive sleep apnea syndrome among commercial interstate bus drivers; 2011 May 31 [7 pages]. Available from http://www.ensaiosclinicos.gov.br/rg/RBR-7dq5xx/.

Long-term oxygen therapy in patients with diagnoses other than COPD

Long-term O2 prescription in chronic non-COPD hypoxic lung disease is, at present, based largely on physiological rather than on clinical studies. Controlled long-term studies in this field are difficult to perform. The cooperation of many centers is necessary to obtain a large and homogeneous population as the incidence of these diseases is significantly lower than COPD.

European position paper on drug-induced sleep endoscopy: 2017 Update

The first edition of the European position paper (EPP) on drug‐induced sleep endoscopy (DISE) was published in 2014 with the aim to standardise the procedure, to provide an in‐depth insight into the main aspects of this technique and to have a basis for future research. Since 2014, new studies have been published concerning new sedative agents or new insights into the pattern/levels of the obstruction depending on the depth of sedation. Therefore, an enlarged group of European experts in the field of sleep breathing disorders (SBD), including the most of the first DISE EPP main authors, has decided to publish an update of the European position paper on DISE, in order to include new evidence and to find a common language useful for reporting the findings of this endoscopic evaluation in adult population affected by SBD.

Auto-CPAP: saving money as a single tool for OSA

Dear Editor: We read with interest the paper by Nigro and coworkers [1] suggesting a possible clinical approach and an autoCPAP single night test to save money and decrease the burden of waiting lists. The model proposed is surely interesting, but there are some points we think should be elucidated. First, formal polysomnography is costly and has been replaced by cardiorespiratory monitoring in the majority of sleep labs, allowing a cheaper home diagnosis and decreasing money saving in the model proposed in this study [2–5]. Second, although false-positive cases are less than 5 %, they would anyway be inappropriately treated. Auto-CPAP does not discriminate between intermittent and continuous flow limitation caused by snoring, and the result is the definition of a therapeutic pressure and a CPAP prescription. Without mentioning the ethic concern, this is an additional cost not considered in the paper. Additionally, in mild and moderate OSA, CPAP is just one of the therapeutic options: the clinical criteria do not predict the severity of OSA and a fundamental piece of information for therapeutic choice is missing [3, 4].. Third, the retrospective nature of the study masks the difficulty of application in real life. Although authors excluded subjects with suspected restless legs syndrome, narcolepsy, and heart failure, just the association of snoring and insomnia would probably increase the figures of false-positive cases. Fourth, a single night on auto-CPAP would probably cause central events in about 10 % of patients. However, how could we discriminate patients with central apnea without a baseline sleep study? Would not a further sleep study be necessary? Obese patients with hypoventilation would miss an important part of the diagnosis without the baseline sleep study (high bicarbonate level was not an exclusion criterion). We consider that the study does not consider indirect costs, a major part of social costs of the disease. Every additional test or visit would increase also this part of the balance, further reducing the benefits of a simplified approach. Since two thirds of patients are not diagnosed properly with the simple clinical approach and a single night auto-CPAP, this study stimulates to test alternative diagnostic paths joining the clinical approach with a simplified, low-cost technology to substitute, not erase, the baseline diagnostic test in patients with suspected OSA. * Alberto Braghiroli alberto.braghiroli@fsm.it

Recurrent acute myocardial infarction and CPAP effect in mild-severe OSA: Is an independent risk factor?

Identifying and treating obstructive sleep apnea (OSA) may have important implications in the long-term prognosis of patients with post myocardial infarction (MI). Currently, 42% of the patients admitted with ST-segment elevation myocardial infarction (STEMI) have undiagnosed severe OSAwhich bears a negative prognostic impact [1]. Therefore we read with interest the important study by Garcia-Rio F et al. [2] which analyze the effects of continuous positive airway pressure (CPAP) in patientswithOSA andMI. This paper shows a dose-dependent risk ofMI at the increase of apnea–hypopnea index (AHI) and less recurrence in those who accept CPAP treatment. However important partner contributing factors could explain these findings. First, authors acknowledge the lack of data on coronary angiography, number of diseased vessels and MI classification, all relevant features for prognosis [3]. A possible selection bias could have occurred on this aspect between compliant and noncompliant patients. This is particularly relevant since data cannot be split between patients with mild and severe disease. Patients with severe OSA often have a longer history of disease and the lack of these data adds no more light on the “preconditioning” hypothesis [3] of OSA and on a possible different effectiveness of the CPAP treatment between the two groups in terms of severity and progression of coronary lesions. Second, pharmacological treatment adherence is relevant, (i.e.: use of post-MI drugs, particularly antiplatelet drugs) and the patients’ noncompliant to CPAP could be less compliant to drug treatment aswell, a key prognostic factor. Third, the authors focused on AMI alone, and do not analyze other major adverse cardiac events (MACE), such as cardiac death, reinfarction, anginaand target vessel revascularizationwhicharenotoriouslyhigher in patients with OSA [4]. Unstable angina could be of particular interest since in the absenceof adocumentationof coronaryartery lesions it could give an estimate of the progression of arterial coronary disease. Fourth, a stratification of OSA severity would have been really important: is CPAP treatment as effective in mild as in severe patients? What happens in patients with AHI index of N 30, myocardial infarction and recurrence after application of CPAP, compared to untreated OSA? Is a late diagnosis of OSA a relevant factor for the recurrence of MI or angina? Further studies are necessary to determine if the presence of OSA would affect the long-term occurrence of cardiovascular events after an MI [5].

Development and validation of the Maugeri Sleep Quality and Distress Inventory (MaSQuDI-17)

Objectives The aim of this study was to develop and validate a questionnaire designed to measure the impact of sleep impairment on emotional distress in patients with various sleep disorders. Methods Five experts created an item data-bank pertaining to sleep-related psychological symptoms and somatic perceptions. Fifty patients in two focus groups examined each item for: a) word clarity (indicating any ambiguity of interpretation) and b) appropriateness for the target population. This process permitted to identify 36 appropriate items. Classical Test Theory and Rasch Analysis were used to further refine the questionnaire, yielding the final 17-item set. Concurrent validation of the new scale was tested with the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and the Anxiety and Depression questionnaires. Results Starting from the initial item data-bank, a 17-item questionnaire, the Maugeri Sleep Quality and Distress Inventory (MaSQuDI–17), was produced. Parallel Analysis on the MaSQuDI–17 confirmed the presence of a single dimension; exploratory factor analysis showed salient loading for each item, explaining 58.7% of total variance. Item-remainder correlation ranged from 0.72 to 0.39 and Cronbach alpha was 0.896. Rasch analysis revealed satisfactory psychometric properties of the new scale: the rating structure performed according to expectations, model fit was good and no item dependencies emerged. The scale presented good convergent validity and scores significantly distinguished healthy subjects from OSAS or Insomnia or BSD (p < 0.001). Conclusions MaSQuDI –17 shows good psychometric qualities, and can be used to assess the impact of sleep disorders such as Insomnia, OSAS, Central Hypersomnia and BSD on emotional stress.

Anesthesiologists and Obstructive Sleep Apnea: Simple Things May Still Work

1. A recent meta-analysis 2 that included the STOP-Bang (snoring tiredness, observed apneas, elevated BP and BMI, age, neck circumference, and male gender), American Society of Anesthesiologists (ASA), and Berlin questionnaires concluded that only the ASA and STOP-Bang questionnaires had suffi cient power to identify patients with OSA in the perioperative setting. 2. The STOP-Bang questionnaire has good sensitivity for identifying patients with high or moderate OSA but not for fi nding mild OSA, and its use leads to a high number of false-positives (ie, men . 50 y with a history of hypertension). 3. The ASA article by Gross et al 3 published in 2006 states that when cardiopulmonary monitoring is lacking, a patient should always be considered as having moderate OSA. It also states that the patient should be considered as having severe OSA when he or she has a BMI . 35 kg/m 2 or a neck circumference . 43 cm in men ( . 41 cm in women), or when an observer witnesses the patient stop breathing during sleep. 4. The acronym PAP is used in the article for both positive airway pressure and pulmonary artery pressure. This is confusing (and wrong in the fl owchart legend); in the fl owchart, it is not clear which positive airway pressure should be applied. 5. Autocontinuous positive airway pressure has several limitations and should not be proposed to a patient without a well-established OSA diagnosis. 4 Moreover, it should be avoided when central apneas can occur (ie, opioids). Before considering auto-adjustable positive airway pressure, conventional noninvasive ventilation with a back-up rate ventilation should be recommended.

Response to Letter Regarding Article “Sleep and Exertional Periodic Breathing in Chronic Heart Failure: Prognostic Importance and Interdependence”

We thank Dr Guazzi for his interest in our article.1 In our study, a distinct hierarchical prognostic impact of breathing disorders in chronic heart failure patients is evident, and as a unique finding, apnea/hypopnea index (AHI) >30/h alone has a preeminent predictive role in the presence of exercise oscillatory ventilation …