J. Verbraecken

Non-CPAP therapies in obstructive sleep apnoea

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

Evaluation for sleep apnea in patients with Ehlers-Danlos syndrome and Marfan: a questionnaire study

Sleep complaints are frequently reported by patients with Marfan and Ehlers–Danlos syndrome (EDS). We examined the exact nature of sleep complaints in these patients. 
A representative sample of Marfan and EDS patients responded to a general sleep questionnaire, including the Epworth Sleepiness Scale (ESS) and the Medical Outcomes Study Short‐Form 36 (SF‐36) health‐related quality of life (QOL) questionnaire. Fifteen Marfan patients and 9 EDS patients were evaluated and compared to 24 healthy controls, matched for age, sex and body mass index. Maintaining sleep was frequently disturbed in Marfan (40%, p<0.04) as well as in EDS patients (56%, p<0.01). 
Sleep apnea was exclusively reported by Marfan patients (27%, p=0.03). Periodic limb movements were much more reported in EDS (67%, p=0.02) than in Marfan (27%, p=0.25) compared to controls (8%). Pain and back complaints were highly presented in both groups, but most pronounced in EDS patients (47% in Marfan versus 77% in EDS). No differences for the scores in the ESS were found. For all SF‐36 questionnaire items, scores were much lower in patient groups, except for emotional problems. We found that sleep complaints were not rare in Marfan and EDS patients and correlated well with different QOL items. Our study calls for greater attention to the presence of apnea, pain and periodic limb movements in these patients.

Management of obstructive sleep apnea in Europe

OBJECTIVES In Europe, the services provided for the investigation and management of obstructive sleep apnoea (OSA) varies from country to country. The aim of this questionnaire-based study was to investigate the current status of diagnostic pathways and therapeutic approaches applied in the treatment of OSA in Europe, qualification requirements of physicians involved in diagnosis and treatment of OSA, and reimbursement of these services. METHODS Two questionnaires were sent to 39 physicians in 22 countries in Europe. In order to standardize the responses, the questionnaire was accompanied by an example. RESULTS Sleep centers from 21 countries (38 physicians) participated. A broad consistency among countries with respect to the following was found: pathways included referral to sleep physicians/sleep laboratories, necessity for objective diagnosis (primarily by polysomnography), use of polygraphic methods, analysis of polysomnography (PSG), indications for positive airway pressure (PAP) therapy, application of standard continuous PAP (CPAP) therapy (100% with an CPAP/APAP ratio of 2.24:1), and the need (90.5%) and management of follow-up. Differences were apparent in reimbursement of the diagnostic procedures and follow-up, in the procedures for PAP titration from home APAP titration with portable sleep apnea monitoring (38.1%) up to hospital monitoring with PSG and APAP (85.7%), and in the qualification requirements of sleep physicians. CONCLUSIONS Management of OSA in different European countries is similar except for reimbursement rules, qualification of sleep specialists and procedures for titration of the CPAP treatment. A European network (such as the one accomplished by the European Cooperation in Science and Technology [COST] B26 Action) could be helpful for implementing these findings into health-service research in order to standardize management in a cost effective perspective.

Influence of longterm CPAP therapy on CO2 drive in patients with obstructive sleep apnea

According to recent publications, the values of the hypercapnic ventilatory responses (HCVR) in normocapnic obstructive sleep apnea (OSA) patients are highly variable, but they are usually within the normal range. In our study, CPAP therapy during 1 month did not seem to influence the HCVR [Verbraecken, J., De Backer, W., Willemen, M., De Cock, W., Wittesaele, W., Van de Heyning, P., 1995. Respir. Physiol. 101, 279-287]. It is, however, not well studied whether long term (1 year) CPAP therapy can influence HCVR in normocapnic patients. Therefore, we evaluated the effect of 1 year CPAP therapy on CO(2) drive in 20 OSA patients. The slope of HCVR (SHCVR) changed from 2.35+/-0.21 L min(-1) mmHg(-1) (control) to 1.66+/-0.16 L min(-1) mm Hg(-1) (P=0.04), but the mean within subject coefficient of variation in repeated measurements of SHCVR in treated and untreated OSA patients was not statistically different. Pa(O(2)) increased from 72+/-2 mm Hg to 80+/-2 (1 year) mm Hg. We conclude that CPAP therapy improves daytime gas exchange in normocapnic OSA and may possibly decrease CO(2) drive (slope) after a treatment period of 1 year.

Aortic root diameter and nasal intermittent positive airway pressure treatment in Marfan's syndrome

We report on a patient with Marfans syndrome, with coexistent obstructive sleep hypopnea (OSH) and restrictive lung disease, complicated by respiratory insufficiency, who was successfully treated with nasal intermittent positive airway pressure (NIPPV) and oxygen. NIPPV therapy turned out to be effective on arterial gas exchange and well tolerated. Moreover, progressive dilatation of the aortic root was attenuated during NIPPV, but could, however, not be reversed. We hypothetized that (at least partially) a decrease of nocturnal intrathoracic pressures could explain this.

Fatigue Associated with Obstructive Sleep Apnea in a Patient with Sarcoidosis

Many patients with sarcoidosis suffer from persistent constitutional symptoms such as fatigue and general weakness, even though physiological measures of disease activity returned within normal limits. The following case report demonstrates a sarcoidosis patient with recurring fatigue caused by an obstructive sleep apnea syndrome developed during the course of the disease.

Sleep HERMES: a European Core Syllabus in respiratory disorders during sleep

The clinical characterisation and description of the obstructive sleep apnoea–hypopnoea syndrome (OSAHS) and related syndromes were mainly revealed by several epidemiological studies conducted over the past fifty years. These highly prevalent syndromes affect about 9% of middle-aged men and 4% of women. These syndromes have serious medical and social consequences, such as cardiovascular or metabolic diseases, and even premature death. Consequently, respiratory sleep medicine (RSM) evolved and has progressed rapidly within the sleep medicine field over recent decades. New diagnostic and therapeutic techniques have appeared in response to an increasing number of patients and clinical interventions. The research progressed to focus not only on the clinical and pathophysiological but also the genetic and molecular aspects of these syndromes [1–6]. Nevertheless, the literature in the field does not provide any clear consensus on diagnostic classification and assessment. No harmonised standards of training exist across Europe for respiratory sleep medicine. The European Respiratory Society (ERS) provided external and postgraduate courses but the requirements and expectations in the field were not being fulfilled. There was a need for a project supporting both the teaching and certification. For this reason, ERS supported an application for a Sleep Harmonised Education in Respiratory Medicine for European Specialists (HERMES) Task Force project which aimed at establishing common standards in respiratory sleep training and education, in an adaptable framework which can be extended across Europe. HERMES was a project established in 2005 to provide documentation for the training and certification of adult respiratory specialists. Since 2005, the HERMES framework has been adapted for projects including paediatric respiratory medicine, critical care medicine and the development of the European Spirometry Driving Licence (spirometry). Within the HERMES model, a process of establishing consensus standards for training largely follows four key phases (fig. 1). In line with this …

Continuous Positive Airway Pressure and Lung Inflation in Sleep Apnea Patients

Background: It was shown in normals that an important decrease in upper airway resistance can be obtained with continuous positive airway pressure (CPAP). It was suggested that lung inflation in patients with sleep apnea syndrome (SAS) could also be a mechanism of action of CPAP. Objective: In the present study we wanted to evaluate the effects of nocturnal CPAP on the daytime lung function pattern in patients with SAS. Methods: We measured arterial blood gases and possible changes in static lung volumes in 57 SAS patients (37 with normal lung function, 10 with COPD and 10 with restrictive lung disease) after at least one month of CPAP therapy. Results: A significant increase in PaO2 (from 79 to 84 mm Hg, p = 0.01) and a decrease in AaDO2 (from 23 ± 1 to 16 ± 1, p < 0.01) was only observed in SAS patients with normal lung function. This improved gas exchange was parallelled by a small but non significant change in the FRC (from 96.5 ± 3.2 to 105.4 ± 3.7%pred, p = 0.07) and TLC (from 101.3 ± 1.7 to 104.1 ± 1.4%pred, p = 0.15). Similar changes in TLC and FRC were also observed in SAS patients with obstructive and restrictive lung disease. Conclusions: Chronic nocturnal CPAP therapy can improve daytime gas exchange and may influence lung inflation during the daytime. The small changes seem to be a functional effect but of no clinical relevance.

Intermittent Positive Airway Pressure by Nasal Mask as a Treatment for Respiratory Insufficiency in a Patient with Syringomyelia

We report a case of a 73-year-old woman with chronic respiratory failure in association with syringohydromyelia and sleep apnea. She was initially intubated and mechanically ventilated. Weaning from the ventilator was only successful after nasal intermittent positive airway pressure therapy was started. A normalization of arterial blood gas exchange could be achieved.

Intermittent positive airway pressure by nasal mask as a treatment for respiratory insufficiency in a patient with Charcot-Marie-Tooth disease

Abstract Charcot-Marie-Tooth disease (CMT) is a slowly progressive hereditary neuropathy characterised by degeneration of motor and sensory peripheral nerves resulting in distal muscle weakness with atrophy and sensory impairment. We report a 35-year-old woman with CMT presenting with respiratory failure due to a pneumonia, sputum impaction and insufficient cough reflex. After recovery, we diagnosed a very severe restrictive lung function disturbance caused by muscle weakness and a possible coexistent unilateral diaphragm paralysis. A very severe REM (Rapid Eye Movement Sleep) related sleep hypopnea syndrome was successfully treated with Nasal Intermittent Positive Pressure Ventilation (NIPPV).