Charalampos Mermigkis

How common is sleep-disordered breathing in patients with idiopathic pulmonary fibrosis?

Background and aimThe frequency of obstructive sleep apnea–hypopnea syndrome (OSAHS) in patients with idiopathic pulmonary fibrosis (IPF) remains controversial. The aim of this study was to assess the frequency of OSAHS in newly diagnosed IPF patients and to identify possible correlations with body mass index and pulmonary function testing parameters.Materials and methodsThirty-four newly diagnosed IPF patients were included. All subjects underwent attended overnight PSG. None of the included subjects was under any of the currently available IPF treatments or nocturnal supplemental oxygen therapy.ResultsTotal apnea–hypopnea index (AHI) was <5, 5–15, and ≥15/h of sleep in 14 (41%), 15 (44%), and five patients (15%), respectively. REM AHI was statistically significant correlated with TLC [Total lung capacity] (p = 0.03, r = −0.38). Diffusing capacity of the lung for carbon monoxide was correlated with mean oxygen saturation during sleep (p = 0.02, r = 0.39).ConclusionsSleep-disordered breathing seems frequent, although remains usually under diagnosed in IPF patients. A decrease in TLC, reflecting the severity of pulmonary restriction, might predispose IPF patients in SDB, especially during the vulnerable REM sleep period.

Sleep patterns in patients with acute coronary syndromes

BACKGROUND Little is known about sleep quality in patients with acute coronary syndromes (ACS) admitted to the coronary care unit (CCU). The aim of this study was to assess nocturnal sleep in these patients, away from the CCU environment, and to evaluate potential connections with the disease process. METHODS Twenty-two patients with first ever ACS, who were not on sedation or inotropes, underwent a full-night polysomnography (PSG) in our sleep disorders unit within 3 days of the ACS and follow-up PSGs 1 and 6 months later. RESULTS PSG parameters showed a progressive improvement over the study period. There was a statistically significant increase in total sleep time (TST), sleep efficiency, slow wave sleep (SWS), and rapid eye movement (REM) sleep, while arousal index, wake after sleep onset (WASO) and sleep latency decreased. Six months after the acute event, sleep architecture was within the normal range. CONCLUSIONS Patients with ACS have marked alterations in sleep macro- and micro-architecture, which have a negative influence on sleep quality. The changes tend to disappear over time, suggesting a relationship with the acute phase of the underlying disease.

Sleep Disordered Breathing in Patients with Acute Coronary Syndromes

STUDY OBJECTIVES Although the prevalence of obstructive sleep apnea/hypopnea syndrome (OSAHS) is high in patients with acute coronary syndromes (ACS), there is little knowledge about the persistence of OSAHS in ACS patients after the acute event. We aimed to assess the prevalence and time course of OSAHS in patients with ACS during and after the acute cardiac event. METHODS Fifty-two patients with first-ever ACS, underwent attended overnight polysomnography (PSG) in our sleep center on the third day after the acute event. In patients with an apnea hypopnea index (AHI) > 10/h, we performed a follow up PSG 1 and 6 months later. RESULTS Twenty-eight patients (54%) had an AHI > 10/h. There was a significant decrease in AHI 1 month after the acute event (13.9 vs. 19.7, p = 0.001), confirming the diagnosis of OSAHS in 22 of 28 patients (79%). At 6-month follow-up, the AHI had decreased further (7.5 vs. 19.7, p < 0.05), and at that time only 6 of the 28 patients (21%) were diagnosed as having OSAHS. Twelve of the 16 current smokers stopped smoking after the acute event. CONCLUSIONS We have demonstrated a high prevalence of OSAHS in ACS patients, which did not persist 6 months later, indicating that, to some degree, OSAHS may be transient and related with the acute phase of the underlying disease or the reduction in the deleterious smoking habit.

C-reactive protein evolution in obstructive sleep apnoea patients under CPAP therapy

Eur J Clin Invest 2010; 40 (11): 968–975

Intensive versus standard follow-up to improve continuous positive airway pressure compliance

We aimed to compare the effect of intensive versus standard interventions on continuous positive airway pressure (CPAP) adherence 2 years after CPAP initiation, as well as on sleepiness, quality of life, depression, hospitalisation and death rate due to cardiovascular disease (CVD). 3100 patients with newly diagnosed sleep apnoea were randomised into the standard group, with usual follow-up care, or the intensive group, with additional visits, telephone calls and education. Subjective daytime sleepiness (Epworth Sleepiness Scale; ESS), quality of life (36-item Short Form Health Survey; SF-36) and the patient’s level of depression (Beck Depression Inventory; BDI) were recorded before and 2 years after CPAP initiation, together with CVD hospitalisations and death rate. 2 years after CPAP initiation, the intensive group used CPAP significantly more than the standard group (6.9 versus 5.2 h per night; p<0.001). ESS, SF-36 and BDI scores were also significantly better in the intensive group. Furthermore, the standard group had significantly more deaths and hospitalisations due to CVD. CPAP usage can be improved by both intensive and standard patient support. However, the patients who received intensive CPAP support had significantly better ESS, BDI and SF-36 scores, and lower cardiovascular morbidity and mortality, suggesting that an intensive programme could be worthwhile. Intensive CPAP support improves sleepiness, quality of life, depression, hospitalisation and death rate http://ow.ly/xHejr

Epworth Sleepiness Scale scores and adverse pregnancy outcomes

Sleep disturbances generally increase with the onset of pregnancy and continue to increase in frequency as pregnancy progresses [1–4]. Although these disturbances may arise as a consequence of numerous physiologic and hormonal changes accompanying pregnancy, it is important for clinicians to consider the possible presence of primary sleep-related breathing disorders (SRBD), such as snoring and sleep apnea [5]. Sleep apnea, snoring, and excessive sleepiness are identified as the most frequently sleep disturbances among pregnant women. There is conflictive evidence in regard to whether sleep-disordered breathing increases in prevalence during pregnancy, but existing research indicates that such disorders may enhance the risk of potentially adverse maternal–fetal outcomes by increasing the likelihood of preterm birth, preeclampsia, and gestational diabetes [6]. In this issue of Sleep and Breathing, Ghada Bourjeily and colleagues of The Warren Alpert Medical School of Brown University in their paper “Epworth Sleepiness Scale scores and adverse pregnancy outcomes” tried to investigate whether excessive daytime sleepiness (EDS) in snorers and non-snorers contributed to adverse pregnancy outcomes such as gestational hypertensive disorders, gestational diabetes, or mode of delivery. The authors found that there is an increased association between pregnant women with higher Epworth Sleepiness Scale (ESS) score and planned caesarean delivery. Although retrospective, this study extends previous observations that EDS and snoring are risk factors for gestational diabetes by showing that when higher cut off values of ESS were used, the risk of gestational diabetes was significantly elevated and sevenfold higher than women below the cutoff point, even after adjusting for confounders. However, in this study, neither gestational diabetes nor hypertensive disorder was associated with EDS, when EDS was defined as an ESS >10. In the literature, studies that address SRBD in pregnant women are scarce with the only available data come from case studies, case series, small cohort studies, and a few small longitudinal studies. As no large population-based epidemiological studies have been performed, the prevalence of obstructive sleep apnea in pregnant women is not known. Previously, the same authors found that snoring, gasping, and apneas, all three symptoms of SRBD, were associated with higher mean ESS scores [7]. Furthermore, they found that these symptoms are common in pregnancy and associated with a higher likelihood of gestational hypertensive disorders, gestational diabetes, and unplanned caesarean deliveries [8]. The question, therefore, that arises is whether EDS assessed by ESS increases the risk of adverse pregnancy outcomes. In this new study, Bourjeily et al. attempted to answer this question. However, the fact that their major findings were that EDS was not associated with adverse pregnancy outcomes both in snorers and in non-snorers but severe EDS (ESS >16) increases the risk of gestational diabetes is still not clear. Although the authors mentioned the small sample size of the subgroups (ESS >16) as a limitation, it seems not enough to reach their conclusion that severe EDS is risky with this small sample size. The main limitation of this study was the retrospective nature of the study leading to the possibility of recall bias. Furthermore, as the authors explain, another major limitation of this study is its questionnaire-based character and the lack of objective assessment of snoring and daytime sleepiness using more objective techniques such as polysomnography and MSLT. In addition, although the ESS questionnaire the authors used to estimate EDS has been validated outside of S. E. Schiza : I. Bouloukaki :C. Mermigkis Sleep Disorders Unit, Department of Thoracic Medicine, University General Hospital, Medical School of the University of Crete, Heraklion, Crete, Greece

Prediction of obstructive sleep apnea syndrome in a large Greek population

PurposeWe aimed to evaluate the predictive value of anthropometric measurements and self-reported symptoms of obstructive sleep apnea syndrome (OSAS) in a large number of not yet diagnosed or treated patients. Commonly used clinical indices were used to derive a prediction formula that could identify patients at low and high risk for OSAS.MethodsTwo thousand six hundred ninety patients with suspected OSAS were enrolled. We obtained weight; height; neck, waist, and hip circumference; and a measure of subjective sleepiness (Epworth sleepiness scale—ESS) prior to diagnostic polysomnography. Excessive daytime sleepiness severity (EDS) was coded as follows: 0 for ESS ≤ 3 (normal), 1 for ESS score 4–9 (normal to mild sleepiness), 2 for score 10–16 (moderate to severe sleepiness), and 3 for score >16 (severe sleepiness). Multivariate linear and logistic regression analysis was used to identify independent predictors of apnea–hypopnea index (AHI) and derive a prediction formula.ResultsNeck circumference (NC) in centimeters, body mass index (BMI) in kilograms per square meter, sleepiness as a code indicating EDS severity, and gender as a constant were significant predictors for AHI. The derived formula was:

Idiopathic pulmonary fibrosis and sleep disorders: No longer strangers in the night

{\hbox{AHIpred}} = {\hbox{NC}} \times 0.{84} + {\hbox{EDS}} \times {7}.{78} + {\hbox{BMI}} \times 0.{91} - [{8}.{2} \times {\hbox{gender constant }}\left( {\hbox{1 or 2}} \right) + {37}]