J. Moutinho dos Santos

Escala de sonolência de Epworth na síndroma de apneia obstrutiva do sono: uma subjetividade subestimada

Excessive daytime sleepiness is a major symptom in obstructive sleep apnea syndrome (OSAS) and can be evaluated using both subjective and objective methods. The Epworth Sleepiness Scale (ESS) is a simple and validated questionnaire for assessing subjective daytime sleepiness in the context of sleep disorders. Although its subjective character may limit the accurate expression of daytime sleepiness, the clinical benefit of sequential ESS is clear and demonstrates how ESS scores evolve in individual patients and how these scores may relate to various parameters. In this context we compared the severity of daytime sleepiness reported at baseline visit with severity of baseline sleepiness assessed, retrospectively, after treatment with automatic positive airway pressure (APAP). We conducted a prospective study that included 66 patients evaluated in a sleep clinic diagnosed with OSAS. The diagnosis was confirmed by in-laboratory or portable sleep studies. Their mean age was 53.3 years and the majority were men (88%, n=58). The ESS was answered during the first interview (baseline daytime sleepiness). During follow-up visits, after APAP treatment, the patient was asked to assess baseline sleepiness, retrospectively, as well as post-treatment sleepiness. The mean baseline ESS score was 11.8, mean retrospective baseline ESS 15.4, with a mean difference of 3.55 (p<0.001 t-Test) and post-treatment ESS 7.3. There was no significant correlation between the difference in ESS score (baseline - retrospective baseline) with the average daily (hours) use of APAP, the apnea-hypopnea index (AHI), the minimal recorded SatO(2), disease duration, body mass index (BMI) and age. Our findings confirm that the severity of subjective sleepiness reported before treatment with positive airway pressure is often underestimated by patients with OSAS.

Insomnia as an expression of obstructive sleep apnea syndrome --- the effect of treatment with nocturnal ventilatory support

INTRODUCTION Obstructive sleep apnea syndrome (OSAS) and insomnia often coexist, and it is estimated that nearly half of those who suffer from the former report symptoms of the latter. The fact that these patients have no other causes of insomnia indicates that it is a sign of OSAS. OBJECTIVE The aim of the study is to evaluate the effectiveness of nocturnal ventilatory support (NVS) in the treatment of insomnia secondary to OSAS. MATERIALS AND METHODS In order to conduct the retrospective study, the authors reviewed the medical records of patients with insomnia and OSAS that had received NVS. Patients with psychiatric disorders, sleep movement disorders, psycho-physiological insomnia, circadian rhythm sleep disorders, inadequate sleep hygiene, use and abuse of hypnotic agents, stimulants, antidepressants, anxiolytics and alcohol, were excluded. For the selected patients, the effects of NVS in terms of clinical signs and symptoms of insomnia, apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS) score, and number of sleep hours were analyzed, before and after treatment with NVS. RESULTS After reviewing 1241 medical records, 56 patients were selected, with a mean age of 60.9±10.0 years. Twenty-two (39.3%) suffered from intermediate insomnia, 19 (33.9%) had initial insomnia, eight (14.3%) had the mixed type, and seven patients (12.5%) had terminal insomnia. The majority of patients (n=48; 85.7%) were treated with auto-titrating continuous positive airway pressure (APAP). Forty-four patients (78.6%) overcame insomnia; insomnia symptoms persisted in nine (16.1%), and three (5.4%) patients abandoned during the medical follow-up. There was an association between the type of insomnia and its resolution and, in percentage terms patients with the mixed type did not manage to overcome insomnia symptoms (75%). There was a statistically significant difference between patients that overcame insomnia and those who did not in terms of the average time which elapsed between the initiation of treatment with NVS and compliance with the adherence criteria: 161±61 days for the former, and 225±141 days for the latter (p=0.003). Before and after the NVS treatment, patients slept an average of 5.29±1.37 and 6.37±1.55h per night, respectively (p<0.001). Among the patients who overcame insomnia, six did not meet the treatment adherence criteria: five adhered more than 4h/night in less than 70% of all nights (60.6±3.2%), and one patient adhered less than 4h in all nights (3.5h/night). CONCLUSION NVS has proved effective in treating insomnia secondary to OSAS, and favorable results could be observed even in patients that did not meet the criteria of NVS adherence. Results suggest that all insomnia subtypes, except the mixed subtype, may derive from OSAS.

From heart to bad sleep—Lessons for sleep apnoea in times of crisis

Obstructive sleep apnoea syndrome (OSAS) is a largely prevalent disorder characterized by repeated episodes of pharyngeal obstruction that causes oxygen desaturation and sleep fragmentation. Besides the consequences of excessive daytime sleepiness including increased risk of traffic and labour accidents, OSAS has been implicated, with great or less evidence, as an independent risk factor for different cardiovascular diseases as hypertension, stroke, heart failure, arrhythmias, coronary heart disease and myocardial infarction.1 The recognition of OSAS as a treatable putative cause of hypertension and the need for screening is present in international recommendations since 2003.2 Several studies have found an association between OSAS and coronary artery heart disease (CAD). In a large prospective longitudinal study in men and women who were free of CAD at baseline and followed for 8.7 years, after adjustment for multiple risk factors, OSAS was positively associated to myocardial infarction, revascularization procedure or death only in men aged <70 years old (adjusted ratio 1.10 [95% CI 1.00, 1.21] per 10-unit increase in apnoea--hypopnea index), but not in older men or in women of any age.3 Other studies showed that patients suffering from CAD with an AHI greater than 10 events/hour were more prone to die in 5-year follow-up than patients without OSAS (37.5% vs. 9.3%, respectively) after controlling for age, weight, and smoking.4,5 On the other hand in patients with CAD that had percutaneous intervention the probability of restenosis, vessel remodelling and cardiac mortality was greater in the presence of OSAS.6,7 Moreover patients with CAD treated with CPAP had better prognosis than those who were not treated.8--11 So, it appears rational to establish strategies to search for OSAS in patients with a diagnosis of CAD. In this issue of RPP, Areias et al.12 contribute to this purpose: using a level IV equipment (ApneaLinkTM, a two-channel device that monitores respiratory flow and O2 saturation) they were able to detect the presence of OSAS, confirmed by polysomnography, in 43% of patients admitted to ICU for acute coronary syndrome. These results are not much different from other t p t

Prevalence of bronchial obstruction in a tobacco smoke exposed population - the PNEUMOBIL project.

The use of spirometry is not yet widespread enough in chronic respiratory or at -risk patients whose diagnosis is incomplete. There is scarce knowledge and inadequate management of the burden of these diseases, particularly chronic obstructive pulmonary disease (COPD). Pneumobil, an initiative aimed at raising awareness among smokers and ex -smokers, was reactivated 10 years after its launch in Portugal. It found a large prevalence of bronchial obstruction as measured by spirometry (30% and 25% in men and women respectively) in a sample of 5324 smoke -exposed individuals, 50% current smokers, screened at state or business (private company group) health institutions. This risk is neither mainly attributable to occupational exposure nor mainly related to respiratory symptoms, which were very common in our population. Only dyspnoea (OR=1.28; p=0.02) and frequent episodes of sputum production (OR=1.21; p=0.008) or acute bronchitis (OR=1.31; p=0.05) were somewhat related to bronchial obstruction. Prior knowledge of COPD is rare and bronchial obstruction is not correlated (p=0.204) to a possible diagnosis of COPD.

Titration with automatic continuous positive airway pressure in obstructive sleep apnea

BACKGROUND AND OBJECTIVE Autotitrating positive airway pressure (APAP) is an accepted titration method to determine the optimal positive airway pressure (PAP), for the treatment of obstructive sleep apnea (OSA). The required duration of APAP monitoring to determine a fixed continuous positive airway pressure level still remains to be established. We aimed to evaluate the variation in PAP level, delivered by APAP devices, at different periods of treatment, to determine the APAP treatment duration required to reach an effective and stable PAP level. METHODS A cross-sectional study of 62 patients newly diagnosed with OSA were evaluated after 3 months of APAP therapy. APAP data corresponding to the first day (D1), first week (W1), seventh week (W7) and twelfth week (W12) under APAP therapy was collected. For the analysis of the pressure behaviour, the difference of P95th pressure level between W12 and W7 (P W12-W7), W12 and W1 (P W12-W1) and W12 and D1 (P W12-D1) was calculated. RESULTS There was a high correlation in P95th pressure level between D1 and W12 (r=0.771; p>0.0001), W1 and W12 (r=0.817; p>0.0001), and W7 and W12 (r=0.926; p>0.0001). This correlation progressively increased with APAP use. A significance difference was found in concordance between P W12-W7 and P W12-D1 (p=0.046) within the pressure range ±2cmH2O. However there was no significant difference in concordance between P W12-W7 and P W12-W1. CONCLUSIONS One week of APAP therapy seems sufficient to determine an effective and stable PAP level, within the pressure range ±2cmH2O.