João Carlos Winck

Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema – a systematic review and meta-analysis

IntroductionContinuous positive airway pressure ventilation (CPAP) and non-invasive positive pressure ventilation (NPPV) are accepted treatments in acute cardiogenic pulmonary edema (ACPE). However, it remains unclear whether NPPV is better than CPAP in reducing the need for endotracheal intubation (NETI) rates, mortality and other adverse events. Our aim was to review the evidence about the efficacy and safety of these two methods in ACPE management.MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials on the effect of CPAP and/or NIPV in the treatment of ACPE, considering the outcomes NETI, mortality and incidence of acute myocardial infarction (AMI). We searched six electronic databases up to May 2005 without language restrictions, reviewed references of relevant articles, hand searched conference proceedings and contacted experts.ResultsOf 790 articles identified, 17 were included. In a pooled analysis, 10 studies of CPAP compared to standard medical therapy (SMT) showed a significant 22% absolute risk reduction (ARR) in NETI (95% confidence interval (CI), -34% to -10%) and 13% in mortality (95%CI, -22% to -5%). Six studies of NPPV compared to SMT showed an 18% ARR in NETI (95%CI, -32% to -4%) and 7% in mortality (95%CI, -14% to 0%). Seven studies of NPPV compared to CPAP showed a non-significant 3% ARR in NETI (95%CI, -4% to 9%) and 2% in mortality (95%CI, -6% to 10%). None of these methods increased AMI risk. In a subgroup analysis, NPPV did not lead to better outcomes than CPAP in studies including more hypercapnic patients.ConclusionRobust evidence now supports the use of CPAP and NPPV in ACPE. Both techniques decrease NETI and mortality compared to SMT and none shows increased AMI risk. CPAP should be considered a first line intervention as NPPV did not show a better efficacy, even in patients with more severe conditions, and CPAP is cheaper and easier to implement in clinical practice.

Translation of Berlin Questionnaire to Portuguese language and its application in OSA identification in a sleep disordered breathing clinic

BACKGROUND Berlin Questionnaire (BQ), an English language screening tool for obstructive sleep apnea (OSA) in primary care, has been applied in tertiary settings, with variable results. AIMS Development of BQ Portuguese version and evaluation of its utility in a sleep disordered breathing clinic (SDBC). MATERIAL AND METHODS BQ was translated using back translation methodology and prospectively applied, previously to cardiorespiratory sleep study, to 95 consecutive subjects, referred to a SDBC, with OSA suspicion. OSA risk assessment was based on responses in 10 items, organized in 3 categories: snoring and witnessed apneas (category 1), daytime sleepiness (category 2), high blood pressure (HBP)/obesity (category 3). RESULTS In the studied sample, 67.4 % were males, with a mean age of 51 ± 13 years. Categories 1, 2 and 3 were positive in 91.6, 24.2 and 66.3 %, respectively. BQ identified 68.4 % of the patients as being in the high risk group for OSA and the remaining 31.6 % in the low risk. BQ sensitivity and specificity were 72.1 and 50 %, respectively, for an apnea-hipopnea index (AHI) > 5, 82.6 and 44.8 % for AHI > 15, 88.4 and 39.1 % for AHI > 30. Being in the high risk group for OSA did not influence significantly the probability of having the disease (positive likelihood ratio [LR] between 1.44-1.49). Only the items related to snoring loudness, witnessed apneas and HBP/obesity presented a statistically positive association with AHI, with the model constituted by their association presenting a greater discrimination capability, especially for an AHI > 5 (sensitivity 65.2 %, specificity 80 %, positive LR 3.26). CONCLUSIONS The BQ is not an appropriate screening tool for OSA in a SDBC, although snoring loudness, witnessed apneas, HBP/obesity have demonstrated being significant questionnaire elements in this population.

Expiratory flow maneuvers in patients with neuromuscular diseases

Bach JR, Gonçalves MR, Páez S, Winck JC, Leitão S, Abreu P: Expiratory flow maneuvers in patients with neuromuscular diseases. Am J Phys Med Rehabil 2006;85:105–111. Objectives:To compare cough peak flows (CPF), peak expiratory flows (PEF), and potentially confounding flows obtained by lip and tongue propulsion (dart flows, DF) for normal subjects and for patients with neuromuscular disease/restrictive pulmonary syndrome and to correlate them with vital capacity and maximum insufflation capacity. Design:A cross-sectional analytic study of 125 stable patients and 52 normal subjects in which CPF, PEF, and DF were measured by peak flow meter and vital capacity and maximum insufflation capacity by spirometer. Results:In normal subjects and in patients, the DF significantly exceeded PEF and CPF (P ≤ 0.001). For normal subjects, PEF and CPF were not significantly different. For patients with neuromuscular disease/restrictive pulmonary syndrome, the CPF significantly exceeded PEF (P < 0.05). No normal subjects but 14 patients had DF lower than CPF. Thirteen of these 14 had the ability to air stack (maximum insufflation capacity greater than vital capacity), indicating greater compromise of mouth and lip than of glottic muscles. For 14 of 88 patients, maximum insufflation capacity values did not exceed vital capacity, mostly because of inability to close the glottis (inability to air stack). Nonetheless, for 11 of these 14 patients, the DF were within a standard deviation of the whole patient group; thus, bulbar-innervated muscle dysfunction was not uniform. CPF and PEF correlated with vital capacity (r = 0.85 and 0.86, respectively), and with maximum insufflation capacity (r = 0.76 and 0.72, respectively). Conclusions:Measurements of CPF, PEF, and DF are useful for assessing bulbar-innervated, inspiratory, and expiratory muscle function. Care must be taken to not confuse them.

Effects of mechanical insufflation-exsufflation in preventing respiratory failure after extubation: a randomized controlled trial

IntroductionWeaning protocols that include noninvasive ventilation (NIV) decrease re-intubation rates and ICU length of stay. However, impaired airway clearance is associated with NIV failure. Mechanical insufflation-exsufflation (MI-E) has been proven to be very effective in patients receiving NIV. We aimed to assess the efficacy of MI-E as part of an extubation protocol.MethodPatients with mechanical ventilation (MV) for more than 48 hours with specific inclusion criteria, who successfully tolerated a spontaneous breathing trial (SBT), were randomly allocated before extubation, either for (A) a conventional extubation protocol (control group), or (B) the MI-E extubation protocol (study group). During the postextubation period (48 hours), group A patients received standard medical treatment (SMT), including NIV in case of specific indications, whereas group B received the same postextubation approach plus three daily sessions of mechanical in-exsufflation (MI-E). Reintubation rates, ICU length of stay, and NIV failure rates were analyzed.ResultsSeventy-five patients (26 women) with a mean age of 61.8 ± 17.3 years were randomized to a control group (n = 40; mean SAPS II, 47.8 ± 17.7) and to a study group (n = 35; mean SAPS II, 45.0 ± 15.0). MV time before enrollment was 9.4 ± 4.8 and 10.5 ± 4.1 days for the control and the study group, respectively. In the 48 hours after extubation, 20 control patients (50%) and 14 study patients (40%) used NIV. Study group patients had a significant lower reintubation rate than did controls; six patients (17%) versus 19 patients (48%), P < 0.05; respectively, and a significantly lower time under MV; 17.8 ± 6.4 versus 11.7 ± 3.5 days; P < 0.05; respectively. Considering only the subgroup of patients that used NIV, the reintubation rates related to NIV failure were significantly lower in the study group when compared with controls; two patients (6%) versus 13 (33%); P < 0.05, respectively. Mean ICU length of stay after extubation was significantly lower in the study group when compared with controls (3.1 ± 2.5 versus 9.8 ± 6.7 days; P < 0.05). No differences were found in the total ICU length of stay.ConclusionInclusion of MI-E may reduce reintubation rates with consequent reduction in postextubation ICU length of stay. This technique seems to be efficient in improving the efficacy of NIV in this patient population.

Clinical assessment of pediatric obstructive sleep apnea: A systematic review and meta‐analysis

Clinical symptoms and signs are routinely used to investigate pediatric obstructive sleep apnea (OSA). This study aimed to systematically assess the evidence for the diagnostic accuracy of individual or combined clinical symptoms and signs in predicting pediatric OSA.

Prevalence and characteristics of sleep apnoea in patients with stable heart failure: Results from a heart failure clinic

BackgroundHeart failure (HF) and sleep apnoea (SA) association has been recognized but whether it results from confounding factors (hypertension, ischaemia, obesity) remains unclear.We aimed to determine the prevalence of SA in HF and to identify potential risk factors for SA in HF population.MethodsWe prospectively evaluated 103 patients with stable HF on optimized therapy. In-laboratory polysomnography was performed. Type and severity of SA were defined according international criteria. Demographic, anthropometric and clinical characteristics were collected. Continuous data are expressed as median and interquartile range.ResultsSA was found in 72.8%, moderate to severe in a significant proportion (apnoea-hypopnoea index ≥ 15- 44.7% of all patients) and predominantly obstructive (60.0% of patients with SA). Most patients were non-sleepy (Epworth < 10- 66%). SA patients were predominantly men (85.3 vs 60.7%, p-0.015), had larger neck (38.0 (35.0-42.0) vs 35.0 (33.2-38.0) cm, p-0.003), severe systolic dysfunction, (63.9 vs 33.3%, p-0.018), left ventricle (LV) hypertrophy (16.2 vs 0.0%, p-0.03), LV and left atria (LA) dilatation (49.0 (44.0-52.0) vs 42.0 (38.0-48.0) mm, p < 0.001; 60.0 (54.0-65.0) vs 56.0 (52.0-59.0) mm, p-0.01). However, only LA diameter was an independent predictor of SA. Higher body-mass index (BMI) was associated with moderate to severe SA. Patients with obstructive SA had larger neck and a trend for higher BMI, snoring and sleepiness. Hypocapnia was not associated with central SA.ConclusionsIn our HF population, SA was prevalent, frequently asymptomatic and without characteristic risk factors. Unlike previously reported, obstructive SA was the predominant type. These results suggest that SA is underdiagnosed in HF and there is a possible correlation between them, independent of confounding factors. Recent advances in HF therapy might influence prevalence and type of SA in this population.

Indications and Compliance of Home Mechanical Insufflation-Exsufflation in Patients with Neuromuscular Diseases

Introduction: Neuromuscular disease (NMD) patients frequently have impaired cough. Mechanical insufflation-exsufflation (MI-E) has proven efficacy in improving airway clearance, however data related to its long-term home use is lacking. The purpose of this study was to describe indications, safety and compliance of home MI-E in NMD patients. Methods: Four years observational analysis of 21 NMD patients on home MI-E. Diagnosis included bulbar and non-bulbar Amyotrophic Lateral Sclerosis (ALS) and other NMD. Median age was 58 years. Only cooperative patients with unassisted baseline Peak Cough Flow (PCF) < 270 L/min were included. All patients were under continuous mechanical ventilation (6 by tracheostomy). Pulmonary function before initiation of MI-E (median): FVC = 0.81 L, MIP = 28 cmH2O, MEP = 22 cmH2O and PCF = 60 L/min. MI-E was performed by previously trained non-professional caregivers, with an on-call support of a trained health care professional. Patients had pulse oximetry monitorization and applied MI-E whenever SpO2 < 95 %. Median follow-up was 12 months (3-41 months). Results: Ten patients (9 ALS) used MI-E daily. Eleven patients used MI-E intermittently, during exacerbations, and in 8 patients early application of MI-E (guided by oximetry feed-back) avoided hospitalization. All tracheostomized patients used MI-E daily and more times a day than patients under NIV. Four patients (3 bulbar ALS), were hospitalized due to secretion encumbrance. MI-E was well-tolerated and there were no complications. In general, caregivers considered MI-E effective. During this period, 4 patients died, related to disease progression. Conclusions: Home MI-E is well tolerated, effective and safe if used by well trained caregivers. MI-E should be considered as a complement to mechanical ventilation.

Psychological morbidity, illness representations, and quality of life in female and male patients with obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder that affects both women and men. The aim of this study was to characterize and investigate the differences in terms of anxiety, depression, illness perception, and quality of life between female and male OSAS patients from a total of 111 patients (33 women and 78 men) who were recently diagnosed with OSAS in an outpatient clinic of a University Hospital in Portugal. They underwent a standardized protocol that included evaluation to assess of psychological morbidity (anxiety and depression – Hospital Anxiety and Depression Scale), illness representations (Brief Illness Perception Questionnaire), and quality of life (Sleep Apnea Quality of Life Index). The most significant differences between female and male OSAS patients result of apnea/hypopnea index (AHI), after controlling for body mass index (p < 0.05); anxiety (p = 0.000) and depression (p < 0.005); consequences (p < 0.005), identity (p = 0.000), coherence (p < 0.01), and emotional representation (p < 0.005) of OSAS; and for daily functioning (p = 0.000), emotional (p = 0.001), and symptoms (p < 0.05) domains of quality of life. Data suggest that women revealed more psychological morbidity associated with OSAS. Therefore, it seems extremely important to look at women as potential patients for sleep apnea and avoid looking up for a pattern of symptoms that rely on men as a norm to which women are compared.

Antigen characterization of major cork moulds in Suberosis (cork worker's pneumonitis) by immunoblotting

Background:  We characterized by immunoblotting the antigenicity of the most frequent fungi colonizing cork during its industrial processing, Penicillium glabrum and Chrysonilia sitophila. Penicillium glabrum is the main causative agent of Suberosis, a hypersensitivity pneumonitis of cork workers. Chrysonilia sitophila induces both IgE sensitization and occupational asthma in the wood processing industry.

Autoadjusting-CPAP effect on serum Leptin concentrations in Obstructive Sleep Apnoea patients

BackgroundLeptin is an hormone that regulates body weight. Studies have shown increasing leptin concentrations according to body mass index (BMI) and intermittent hypoxia.Our aim is to evaluate the basal leptin levels in OSA patients and its possible relation to OSA severity, independently of confounders and investigate the Autoadjusting-CPAP effect on leptin values.MethodsIn ninety eight male patients with moderate to severe OSA leptin serum levels were evaluated before therapy, 9 days and 6 months after therapy.ResultsIn this group mean age was 55.3 years, mean BMI was 33.2 Kg/m2 and mean Apnoea- Hypopnea Index (AHI) was 51.7/h. Mean basal serum leptin value was 12.1 ug/L. Univariate analysis showed a significant correlation between serum leptin values and BMI (R = 0.68; p < 0.001), waist-hip ratio (R = 0.283; p = 0.004) and AHI (R = 0.198; p = 0.048); in stepwise multiple regression analysis only BMI (p < 0.001) was a predictor of serum leptin values.One week after therapy, mean leptin serum level decreased to 11.0 ug/L and 6 months after it was 11.4 ug/L. (p = 0.56 and p = 0.387, respectively)ConclusionBaseline leptin serum levels positively correlate with BMI, fat distributioand OSA severity.BMI is the only predictor of basal leptin levels.Treatment with Autoadjusting-CPAP has a small effect on leptin levels.