Alejandro Salvado

“Diagnosis of sleep apnea in network” respiratory polygraphy as a decentralization strategy

Introduction Obstructive sleep apnea syndrome (OSA) is diagnosed through polysomnography (PSG) or respiratory polygraphy (RP). Self-administered home-based RP using devices with data transmission could facilitate diagnosis in distant populations. The purpose of this work was to describe a telemedicine initiative using RP in four satellite outpatient care clinics (OCC) of Buenos Aires Hospital Británico Central (HBC). Materials and methods OCC technicians were trained both in the use of RP. Raw signals were sent to HBC via intranet software for scoring and final report. Results During a 24-month 499 RP were performed in 499 patients: 303 men (60.7%) with the following characteristics (mean and standard deviation): valid time for manual analysis: 392.8 min (±100.1), AHI: 17.05 (±16.49 and percentile 25–75 [Pt]: 5–23) ev/hour, ODI (criterion 3%): 18.05 (±16.48 and Pt 25–75: 6–25) ev/hour, and time below 90% (T<90): 17.9% (±23.4 and Pt 25–75: 1–23). The distribution of diagnoses (absolute value and percentage) was: normal (66/13%), snoring (70/14%), mild (167/33.5%), moderate (110/22%), and severe (86/17.2%). Continuous positive airway pressure (CPAP) was indicated for 191 patients (38.6%). Twenty recordings (4%) were considered invalid and the RP had to be repeated. PSG at HBC was indicated in 60 (12.1%) cases (mild OSA or normal AHI with high ESS or cardiovascular disease). Conclusions Physicians were able to diagnosis OSA by doing portable respiratory polygraphy at distance. The remote diagnosis strategy presented short delays, safe data transmission, and low rate of missing data.

Simulated intention-to-treat analysis based on clinical parameters ofpatients at high risk for sleep apnea derivated to respiratorypolygraphy

Purpose Obstructive Sleep Apnea-Hypopnea Syndrome (OSAS) is a public health problem. We designed a pilot study to validate empiric indication of CPAP therapy in a population with moderate-to-high pre-test probabilities who underwent self-administered home-based respiratory polygraphy (RP). Methods A cross-sectional simulation study was performed. CPAP therapy could be indicated by two independent blind observers. Observer 1´s decision was based on the results of STOP-BANG (SBQ) and Epworth Sleepiness Scale (ESS) and Observer 2 used all objective data provided by RP + SBQ + ESS. Results We evaluated 1763 patients; 1060 men and 703 women (39.2%) with a mean age of 53.6±13.8 and a body mass index (BMI) of 32.8±7.5 kg/m2. We found evidence of mild (34.1%), moderate (26.6%), and severe (18.3%) There were Apnea-Hypopnea Index (AHI) relationship between > 5 or < 5 SBQ and RP AHI (p<0.05). BMI > 25 kg/m2 + snoring (S) + observed apnea (O) + 1 of the following: ESS > 11, hypertension (HT) or > 5 SBQ components showed sensitivity of 40% (CI95%: 37.3-43) and specificity of 95.1% (CI93.4-96.4). The performance of 5 SBQ components with regard to gender and empirical CPAP therapy was; (women vs. men): AUC-ROC 0.625 (CI95%: 0.599-0.651) vs. 0.70 (CI95%: 0.68-0.72), p<0.01, respectively. Conclusions STOP-BANG and ESS made it possible to indicate CPAP reliably (low rate of false-positive results) in 20-40% of patients who needed such therapy according to clinical history and RP results. These clinical criteria performed better in male.

Ambulatory positional obstructive sleep apnea syndrome

Objective To establish the prevalence of positional (PP) OSA patients using self-administered home-based respiratory polygraphy (RP). Materials and Methods 52 month retrospective study based on RP records. Results 200 PR records: 70.5% men 29.5% women. 76% were diagnosed with OSA and 54.6% with PP OSA. There were no significant differences in Epworth Sleepiness Scale, apnea hypopnea index and oxygen desaturation index. PP OSA patients were younger, had a lower BMI (30.3±0.9 vs. 35.3±1.2) (p<0.0001), and the time they spent with oxygen saturation <90% (T<90) was lower (8.8 vs. 28.7±6.7, p=0.0038). The PP OSA group spent 43% of total recording time in the supine position. Conclusions The prevalence of PP OSA patients studied with RP is similar to the one described by sleep laboratories. They have lower BMI, present mostly mild OSA with less desaturation, and are less likely to receive CPAP therapy.

Prevalence of sleep apnea and cardiovascular risk factors in patients with hypertension in a day hospital model

ABSTRACT Introduction: To identify patients at risk for obstructive sleep apnea (OSA) syndrome at a specialized hypertension center, we administered questionnaires and used respiratory polygraphy (RP). Results: We studied 168 patients (64.8% men and 35.2% women). Patients’ body mass index (BMI) was 34.7 ± 6.79 and Epworth Sleepiness Scale (ESS) scores were 8.01 for male and 8.92 for women (p = 0.69). RP recordings revealed AHI (Apnea-Hypopnea Index) of 18.03 ± 15.7, an ODI (Oxygen Desaturation Index) of 18.6 ± 15.2, and a time oxygen saturation <90% (%) of 20.8 ± 24.3. Around 44% of patients had an AHI of >15 events/h, and continuous positive airway pressure (CPAP) was recommended to 69 patients (41.07%). Pulse wave velocity (PWV) showed high values in AHI > 15/h (p = 0.050), and carotid intima-media thickness (IMT) did not correlate with AHI > 15; right IMT: 0.83 ± 1.3 versus 0.78 ± 0.13 mm (p = 0.41) and 0.82 ± 0.16 versus 0.78 ± 0.19 mm (p = 0.40). However, we find correlation with carotid plaque (p = 0.046). The ACC/AHA calculator revealed a gradual increase in the risk of cardiovascular events: 8.7% with AHI < 5/h, and 30.3% in severe OSA. Conclusions: In hypertension (HT) patients, RP revealed a high prevalence of OSA associated with carotid artery disease, high PWV, and increased cardiovascular risk.

Utilización de la ventilación no invasiva en pacientes con parálisis diafragmática. Reporte de casos.

IntroduccionLa paralisis diafragmatica (PD) es una enfermedad infrecuente, generalmente secundaria a procesos sistemicos, aunque han sido descriptas formas idiopaticas.ObjetivoDescribir la utilizacion de la ventilacion no invasiva (VNI) como una modalidad de tratamiento en PD.Material y MetodosEstudio descriptivo de una serie de casos consecutivos en un hospital general.ResultadosDescribimos 4 pacientes portadores de PD unilateral con disminucion de las presiones bucales maximas y de la capacidad vital en posicion supina. Tres pacientes presentaron hipercapnia, uno de los cuales requirio intubacion con asistencia respiratoria.Los 4 casos fueron tratados con VNI modo S/T bilevel, permitiendo disminuir la PCO2, mejorar los sintomas y los parametros en la poligrafia respiratoria nocturna.ConclusionesLa aplicacion de la VNI en los pacientes portadores de PD ofrece beneficios clinicos y en la funcion respiratoria que hacen recomendable su indicacion en casos seleccionados.

Neumonía intersticial inducida por bloqueo androgénico máximo como tratamiento de cáncer de próstata avanzado: Report of one case

Maximum androgen blockade is the standard endocrine treatment for advanced prostate cancer. Interstitial lung disease in different degrees of severity, with low mortality and excellent response to treatment may appear with its use. We report a 77 years old patient with advanced prostate cancer who developed severe and progressive respiratory failure associated to bilateral pulmonary infiltrates, attributed to the direct effect of maximum androgen blockade. Despite the therapeutic efforts, the patient died. Lung pathology revealed Usual Interstitial Pneumonia.

Papel del sexo y de la edad como predictores de un índice de apneas e hipopneas superior a 5/hora en pacientes con índice de masa corporal normal usando poligrafía respiratoria domiciliaria

INTRODUCTION To establish whether predictors of sleep apnea (OSAHS) from patients with normal body mass index (BMI) could facilitate the prioritization of candidates for sleep tests. Aim To describe the role of sex and age as predictors of apnea and hypopnea index (AHI)>5 events per hour in patients with normal BMI (<25kg/m(2)). METHODS Retrospective study of patients referred for home respiratory polygraphy level iii. RESULTS One hundred and forty-three patients with BMI<25kg/m(2), of which 70 had OSA defined by an AHI>5/h were analyzed. The clinical variables to predict AHI>5/h in a multiple logistic regression model, found statistical significance for age>60 years (OR=5.67; 95% CI 2.38-13.53; P<.0001) and male (OR=3.15; 95% CI 1.47-6.73; P<.003). CONCLUSION Forty-eight point ninety-five percent of normal weight patients in a population at risk had OSAHS defined by an AHI>5/h. The sex and age would be risk predictors in this population and most likely in men.

Comparative Study between Sequential Automatic and Manual Home Respiratory Polygraphy Scoring Using a Three-Channel Device: Impact of the Manual Editing of Events to Identify Severe Obstructive Sleep Apnea

Objective. According to current guidelines, autoscoring of respiratory events in respiratory polygraphy requires manual scoring. The aim of this study was to evaluate the agreement between automatic analysis and manual scoring to identify patients with suspected OSA. Methods. This retrospective study analyzed 791 records from respiratory polygraphy (RP) performed at home. The association grade between automatic scoring and manual scoring was evaluated using Kappa coefficient and the agreement using Bland and Altman test and intraclass correlation coefficient (CCI). To determine the accuracy in the identification of AHI ≥ 30 eV/h, the ROC curve analysis was used. Results. The population analyzed consisted of 493 male (62.3%) and 298 female patients, with an average age of 54.7 ± 14.20 years and BMI of 32.7 ± 8.21 kg/m2. There was no significant difference between automatic and manual apnea/hypopnea indexes (aAHI, mAHI): aAHI 17.25 (SD: 17.42) versus mAHI 21.20 ± 7.96 (p; NS). The agreement between mAHI and aAHI to AHI ≥ 30 was 94%, with a Kappa coefficient of 0.83 (p < 0.001) and a CCI of 0.83. The AUC-ROC, sensitivity, and specificity were 0.99 (CI 95%: 0.98-0.99, p < 0.001), 86% (CI 95%: 78.7–91.4), and 97% (CI 95%: 96–98.3), respectively. Conclusions. We observed good agreement between automatic scoring and sequential manual scoring to identify subjects with AHI ≥ 30 eV/h.

Histidine-rich glycoprotein and idiopathic pulmonary fibrosis

Histidine-rich glycoprotein (HRG) is an enigmatic glycoprotein able to interact with a variety of ligands such as IgG, complement components, heparan sulfate, thrombospondin, fibrinogen and plasminogen. HRG is present at high concentrations in plasma and there is evidence indicating that it is able to modulate the course of biological processes such as angiogenesis, fibroblast proliferation, complement activation, coagulation and fibrinolysis. Because these processes are involved in the pathogeneses of lung fibrosis we here analyzed a possible link between HRG and idiopathic pulmonary fibrosis (IPF). We found that plasma concentrations of HRG are significantly diminished in IPF patients compared to healthy subjects. Moreover, we found a positive correlation between HRG plasma levels and forced vital capacity (FVC) values, suggesting that plasma concentration of HRG would be a useful indicator of disease activity in IPF. HRG has been described as a negative acute phase reactant able to accumulate at sites of tissue injury. Hence, we also measured the concentrations of HRG in BAL samples from IPF patients. We found that the concentrations of HRG in samples from IPF patients were significantly higher compared to controls, suggesting that the reduced concentration of HRG in plasma from IPF patients could be due, at least in part, to an enhanced uptake of this protein in the lung.

Tracheobronchial Tuberculosis Without Lung Involvement

Endotracheal tuberculosis (ETTB) is an infrequent form of tuberculosis whose major feature is the infection of the tracheobronchial tree by Mycobacterium tuberculosis. This case presents a 73-year-old man admitted to our hospital with fatigue, weakness, dry cough and weight loss. His chest X-ray was normal but the high resolution computed tomography (HRCT) showed normal parenchyma images with mediastinal and hilar lymphadenopathy. There was inflammation of the tracheal wall and infiltrates in pavement epithelium; however, the tracheal biopsy for acid-fast bacilli was negative. He was finally diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the lymph nodes. Four drugs were prescribed and symptoms improved. EBUS-TBNA contributed to prompt diagnosis. The patient was treated and evolved without complications, such as tracheal stenosis.