Geraldo Lorenzi Filho

Evaluation of airway obstruction by nasopharyngoscopy: comparison of the Müller maneuver versus induced sleep

UNLABELLED The use of nasopharyngoscopy during the application of intrathoracic pressure (Müller maneuver) is frequently employed to establish the site of upper airway obstruction. The Müller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. AIM To compare the degree of pharyngeal obstruction in the retropalatal and retroglossal regions during the Müller maneuver versus induced sleep using nasopharyngoscopy. STUDY DESIGN A prospective, case series study. MATERIAL AND METHODS Eight patients (three males, five females), with a mean age of 48.6 +/- 9.2 year, underwent nasopharyngoscopy to assess airway anatomy and function during the Müller maneuver while awake and during sleep induced by drip infusion of Midazolam. RESULTS Retropalatal obstruction was similar during the Müller maneuver and sleep (mean + standard deviation = 3.13 +/- 0.99 and 2.75 +/- 0.46, p= 0.234). Retroglossal obstruction was significantly lower during Müller maneuver compared to sleep (mean + standard deviation 0.63 +/- 1.06 and 2.63 +/- 1.30, respectively, p= 0.005). CONCLUSIONS The sleep inducing method was safe under the monitored conditions of this study, and detected more retroglossal obstruction than the Müller maneuver.

Effect of Morning School Schedule on Sleep and Anthropometric Variables in Adolescents: A Follow-Up Study

The aim of this study was to assess whether the shift from afternoon to morning classes reduces the duration of sleep and whether this reduction has any relation to body fat measurements. This is a follow-up study in which students (n = 379), 12.4 (SD ± 0.7) yrs old, were evaluated before and after the school schedule shift, with a 1-yr interval between the first and second data collections. Adolescents were divided into two groups: an afternoon-morning group (students who shifted from afternoon to morning classes) and an afternoon-afternoon group (students who remained in afternoon classes). The morning schedule of classes lasted from 07:30 and 12:00 h, and the afternoon schedule of classes lasted from 13:00 and 17:30 h. Self-reported bedtime, wake-up time, and time-in-bed were obtained. Body mass index, waist circumference, and body fat percentage were obtained by direct measures. The results showed a reduction of time-in-bed during weekdays for those students who changed to the morning session (p < .001). Analysis of covariance (ANCOVA) for repeated measures of anthropometric differences between afternoon-afternoon and afternoon-morning groups showed no effect of the school schedule change on weight gain. In conclusion, the time-in-bed reduction in the period analyzed cannot be considered to be a mediating factor to modifications in overweight anthropometric indicators. (Author correspondence: michelleb_fisio@yahoo.com.br)

Avaliação da obstrução da via aérea superior através da videonasofaringoscopia: comparação da manobra de Müller com o sono induzido

The use of nasopharyngoscopy during the application of intrathoracic pressure (Muller maneuver) is frequently employed to establish the site of upper airway obstruction. The Muller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. AIM: to compare the degree of pharyngeal obstruction in the retropalatal and retroglossal regions during the Muller maneuver versus induced sleep using nasopharyngoscopy. STUDY DESIGN: A prospective, case series study. MATERIAL AND METHODS: Eight patients (three males, five females), with a mean age of 48.6 +/- 9,2 year, underwent nasopharyngoscopy to assess airway anatomy and funciton during the Muller maneuver while awake and during sleep induced by drip infusion of Midazolam. RESULTS: Retropalatal obstruction was similar during the Muller maneuver and sleep (mean + standard deviation = 3.13 +/- 0.99 and 2.75 +/- 0.46, p= 0.234). Retroglossal obstruction was significantly lower during Muller maneuver compared to sleep (mean + standard deviation 0.63 +/- 1.06 and 2.63 +/- 1.30, respectively, p= 0.005). CONCLUSIONS: The sleep inducing method was safe under the monitored conditions of this study, and detected more retroglossal obstruction than the Muller maneuver.

ANALYSIS OF THE SPUTUM AND INFLAMMATORY ALTERATIONS OF THE AIRWAYS IN PATIENTS WITH COMMON VARIABLE IMMUNODEFICIENCY AND BRONCHIECTASIS

INTRODUCTION: Common variable immunodeficiency is characterized by defective antibody production and recurrent pulmonary infections. Intravenous immunoglobulin is the treatment of choice, but the effects of Intravenous immunoglobulin on pulmonary defense mechanisms are poorly understood. OBJECTIVE: The aim of this study was to verify the impact of intravenous immunoglobulin on the physical properties of the sputum and on inflammatory alterations in the airways of patients with Common variable immunodeficiency associated with bronchiectasis. METHOD: The present study analyzed sputum physical properties, exhaled NO, inflammatory cells in the sputum, and IG titers in 7 patients with Common variable immunodeficiency and bronchiectasis with secretion, immediately before and 15 days after Intravenous immunoglobulin. A group of 6 patients with Common variable immunodeficiency and bronchiectasis but no sputum was also studied for comparison of the basal IgG level and blood count. The 13 patients were young (age=36±17 years) and comprised predominantly of females (n=11). RESULTS: Patients with secretion presented significantly decreased IgG and IgM levels. Intravenous immunoglobulin was associated with a significant decrease in exhaled NO (54.7 vs. 40.1 ppb, p<0.05), sputum inflammatory cell counts (28.7 vs. 14.6 cells/mm3, p<0.05), and a significant increase in respiratory mucus transportability by cough (42.5 vs. 65.0 mm, p < 0.05). CONCLUSION: We concluded that immunoglobulin administration in Common variable immunodeficiency patients results in significant improvement in indexes of inflammation of the airways with improvement in the transportability of the respiratory mucus by cough.

Behçet's Disease: A Rare Case of Simultaneous Pulmonary and Cerebral Involvement

B ehcets disease is a clinical syndrome of unknown etiology, originally described in 1937, in which the classic triad was iritis and oral and genital ulceration [1]. Since then, the advances of immunology and anatomopathology as well as numerous reports of other manifestations indicate that Behcets disease is a systemic vasculitis affecting the skin, joints, eyes, gastrointestinal tract, neural tissue, and blood vessels [2,3]. Thoracic involvement, which includes pulmonary artery aneurysms, superior and inferior venocaval obstruction, pulmonary infiltrates, pulmonary infarction, recurrent pneumonias, pleural effusion, and irreversible airways obstruction, is uncommon [4]. Central nervous system disorders include a brain stem syndrome, an organic confusional state, and a meningomyelitic illness. The cerebral vein thrombosis manifesting as intracranial hypertension can be seen in Behcets disease and may be the initial manifestation [5-8]. We report a rare case of Behcets syndrome in which pulmonary artery aneurysms and intracranial venous thromboses occurred simultaneously.

Consequências cardiovasculares na SAOS

Obstructive sleep apnea syndrome (OSAS) is a common condition associated with various cardiovascular diseases, including systemic arterial hypertension, atrial fibrillation, and atherosclerosis. The association between OSAS and cardiovascular disease has been related to the overlapping of risk factors, including obesity, having a sedentary lifestyle, being male, and being older. However, there is mounting evidence that OSAS can also independently contribute to the development and progression of various cardiovascular diseases. The mechanisms by which OSAS can affect the cardiovascular system are multiple, including the activation of the sympathetic nervous system, systemic inflammation, insulin resistance, and oxidative stress. There is also evidence that the treatment of OSAS with CPAP can reduce arterial blood pressure, early signs of atherosclerosis, the risk of atrial fibrillation recurrence, and mortality (principally mortality due to stroke or acute myocardial infarction) in patients with severe OSAS.Obstructive sleep apnea syndrome (OSAS) is a common condition associated with various cardiovascular diseases, including systemic arterial hypertension, atrial fibrillation, and atherosclerosis. The association between OSAS and cardiovascular disease has been related to the overlapping of risk factors, including obesity, having a sedentary lifestyle, being male, and being older. However, there is mounting evidence that OSAS can also independently contribute to the development and progression of various cardiovascular diseases. The mechanisms by which OSAS can affect the cardiovascular system are multiple, including the activation of the sympathetic nervous system, systemic inflammation, insulin resistance, and oxidative stress. There is also evidence that the treatment of OSAS with CPAP can reduce arterial blood pressure, early signs of atherosclerosis, the risk of atrial fibrillation recurrence, and mortality (principally mortality due to stroke or acute myocardial infarction) in patients with severe OSAS.

Screening for Obstructive Sleep Apnea in Patients with Atrial Fibrillation

Obstructive sleep apnea (OSA) and atrial fibrillation (AF) are common conditions in the adult population and independently associated with increased morbidity and mortality. There is evidence, although not definitive, that OSA independently contributes to AF incidence and recurrence. Full polysomnography is expensive and may not be readily available to diagnose all patients with OSA and AF. Several patients with OSA do not present the classical signs and symptoms of OSA, impairing the accuracy of screening questionnaires for OSA. In this context, home sleep test is a promising alternative to screen and diagnose OSA in AF patients. However, the cost-effectiveness of such approach need to be studied.

Sleep Disordered Breathing challenges: From diagnosis totreatment

This issue of Sleep Science brings three Latin American articles that deal with contemporary challenges in the diagnosis and management of sleep disordered breathing (SDB). In one of the studies, a simple approach to facilitate OSA diagnosis and shortcut the initiation of CPAP treatment is tested1. In another study, overall adherence to CPAP is explored, focusing on the prevalence and motivations of failure to initiate CPAP after prescription2. The third study describes sleep disordered breathing among patients with decompensated heart failure in Bogota, a city located at the Andes at 2640m above sea level3. It is now evident that obstructive sleep apnea (OSA) is much more common in the general population than previously imagined, ranging from 17% (apnea-hypopnea index[AHI]>15 events/h) to around 40% (AHI>5 events/h)4. More than just a common disease, treatment with CPAP abolishes OSA, improves symptoms and may also impact positively on long term cardiovascular consequences. However, the vast majority of patients remains undiagnosed. Reasons for underdiagnosis include insufficient clinical suspicion and impaired access to OSA diagnosis. OSA diagnostic methods ranges from full polysomnography, portable respiratory monitoring and overnight oximetry. In this issue of Sleep Science, Borsini and collaborators propose that simple questionnaires (STOP-BANG) and Epworth Sleep Scale (ESS) made it possible to indicate CPAP reliably (low rate of false-positive results) in 20-40% of patients referred for suspected OSA without a diagnostic test1. This information is of relevance in clinical practice because the queues for in-lab polysomnography are long. A simpler and more affordable approach for OSA management is highly wanted and may eventually improve the gap between CPAP prescription and CPAP use initiation. In another study of the current issue of Sleep Science, Nogueira and collaborators show that most compliance studies often only include patients under CPAP treatment, neglecting the importance of access to treatment2. The authors show that after in-lab polysomnography (PSG) and CPAP titration in a private sleep center in Buenos Aires, 28% did not start using CPAP. Possible explanations were extracted from the differences between those who started and those who did not start CPAP and included less severe sleepiness, lack of insurance coverage and higher therapeutic pressures. Among those starting CPAP, 78% were using it after one year2. The reported adherence to CPAP (including only those who started therapy) is higher than many previous reports5. Improving access to CPAP device is fundamental. It is our duty to convince insurance providers and the government that CPAP is costeffective and reduces health-associated costs among OSA patients. While OSA is by far the most common sleep disordered breathing condition, patients with congestive heart failure (CHF) frequently present central sleep apnea6. Low PaCO2 plays a critical role in the genesis of central sleep apnea among patients with CHF7. Interestingly enough, high altitude decreases PaO2, induces hyperventilation and lower PaCO2. Cities sitting at high altitudes such as Bogota, are the ideal place to ask a simple question: What happens to breathing during sleep when the 2 conditions (CHF and high altitude) are present? In this issue of Sleep Science, Vargas-Ramirez and collaborators studied 16 patients hospitalized for decompensated heart failure in Bogota3. The main finding of this study is that all patients Geraldo Lorenzi Filho1 Pedro Rodrigues Genta1