Joaquín Terán

Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea.

RATIONALE Continuous positive airway pressure (CPAP) is the current treatment for patients with symptomatic obstructive sleep apnea (OSA). Its use for all subjects with sleep-disordered breathing, regardless of daytime symptoms, is unclear. OBJECTIVES This multicenter controlled trial assesses the effects of 1 year of CPAP treatment on blood pressure (BP) in nonsymptomatic, hypertensive patients with OSA. METHODS We evaluated 359 patients with OSA. Inclusion criteria consisted of an apnea-hypopnea index (AHI) greater than 19 hour(-1), an Epworth Sleepiness Scale score less than 11, and one of the following: under antihypertensive treatment or systolic blood pressure greater than 140 or diastolic blood pressure greater than 90 mm Hg. Patients were randomized to CPAP (n = 178) or to conservative treatment (n = 181). BP was evaluated at baseline and at 3, 6, and 12 months of follow-up. MEASUREMENTS AND MAIN RESULTS Mean (SD) values were as follows: age, 56 +/- 10 years; body mass index (BMI), 32 +/- 5 kg x m(-2); AHI, 45 +/- 20 hour(-1); and Epworth Sleepiness Scale score, 7 +/- 3. After adjusting for follow-up time, baseline blood pressure values, AHI, time with arterial oxygen saturation less than 90%, and BMI, together with the change in BMI at follow-up, CPAP treatment decreased systolic blood pressure by 1.89 mm Hg (95% confidence interval: -3.90, 0.11 mm Hg; P = 0.0654), and diastolic blood pressure by 2.19 mm Hg (95% confidence interval: -3.46, -0.93 mm Hg; P = 0.0008). The most significant reduction in BP was in patients who used CPAP for more than 5.6 hours per night. CPAP compliance was related to AHI and the decrease in Epworth Sleepiness Scale score. CONCLUSIONS In nonsleepy hypertensive patients with OSA, CPAP treatment for 1 year is associated with a small decrease in BP. This effect is evident only in patients who use CPAP for more than 5.6 hours per night. Clinical trial registered with www.clinicaltrials.gov (NCT00127348).

Daytime sleepiness and polysomnography in obstructive sleep apnea patients

BACKGROUND Excessive daytime sleepiness (EDS) is the major complaint in subjects with obstructive sleep apnea syndrome (OSAS). However, EDS is not universally present in all patients with OSAS. The mechanisms explaining why some patients with OSAS complain of EDS whereas others do not are unknown. OBJECTIVE To investigate polysomnographic determinants of excessive daytime sleepiness (EDS) in a large multicenter cohort of patients with obstructive sleep apnea (OSAS). METHODS All consecutive patients with an apnea-hypopnea index greater than 5h(-1) who were evaluated between 2003 and 2005. EDS was assessed using the Epworth Sleepiness Scale (ESS), and patients were considered to have EDS if the ESS was >10. RESULTS A total of 1649 patients with EDS ((mean [+/-SD] Epworth 15+/-3) and 1233 without EDS (Epworth 7+/-3) were studied. Patients with EDS were slightly younger than patients without EDS (51+/-12 vs 54+/-13 years, p<0.0001), had longer total sleep time (p<0.007), shorter sleep latency (p<0001), greater sleep efficiency (p<0.0001) and less NREM sleep in stages 1 and 2 (p<0.007) than those without EDS. Furthermore, patients with EDS had slightly higher AHI (p<0.005) and arousal index (p<0.001) and lower nadir oxygen saturation (p<0.01). CONCLUSIONS Patients with OSAS and EDS are characterized by longer sleep duration and increased slow wave sleep compared to those without EDS. Although patients with EDS showed a mild worsening of respiratory disturbance and sleep fragmentation, these results suggest that sleep apnea and sleep disruption are not the primary determinants of EDS in all of these patients.

A controlled trial of noninvasive ventilation for chronic obstructive pulmonary disease exacerbations

PURPOSE This prospective, multicenter, double-blind, placebo-controlled study tested the hypothesis that noninvasive positive pressure ventilation reduces the need for endotracheal intubation in patients hospitalized in a pulmonary ward because of acute exacerbation of chronic obstructive pulmonary disease. MATERIALS AND METHODS Seventy-five consecutive patients with exacerbation (pH, 7.31 +/- 0.02; Pao(2), 45 +/- 9 mm Hg; Paco(2), 69 +/- 13 mm Hg) were randomly assigned to receive noninvasive ventilation or sham noninvasive ventilation during the first 3 days of hospitalization on top of standard medical treatment. RESULTS The need for intubation (according to predefined criteria) was lower in the noninvasive ventilation group (13.5% vs 34%, P < .01); in 31 patients with pH not exceeding 7.30, these percentages were 22% and 77%, respectively (P < .001). Arterial pH and Paco(2) improved in both groups, but changes were enhanced by noninvasive ventilation. Length of stay was lower in the noninvasive ventilation group (10 +/- 5 vs 12 +/- 6 days, P = .06). In-hospital mortality was similar in both groups. CONCLUSIONS These results demonstrate that noninvasive positive pressure ventilation, in a pulmonary ward, reduces the need for endotracheal intubation, particularly in the more severe patients, and leads to a faster recovery in patients with acute exacerbation of chronic obstructive pulmonary disease.

Validity of spirometry performed online

Spirometry is essential for the diagnosis and management of common respiratory diseases. However, its use and quality are low in primary care. An important reason for this is the technical difficulty in performing conventional spirometry. If high-quality spirometry could be performed online, from the pulmonary function laboratory in hospitals, most of the technical problems could be solved. The aim of the present study was to compare spirometries performed online by remote technicians with conventional spirometry. This was a controlled, randomised crossover study of 261 patients referred from primary care centres for pulmonary consultation. They were randomised to undergo either conventional or online spirometry. The technician, located remotely, controlled the spirometer computer. Using a teleconference link, the technician guided the patient through the spirometry. The comparison between conventional and online spirometries was performed on intention to treat and per protocol bases for spirometric values and quality criteria. Agreement between the two spirometric methods was assessed with a Bland–Altman plot. A subpopulation of off-range patients was also characterised. Finally, intra- and interobserver agreement was evaluated using the intraclass correlation coefficient. No clinically significant differences were seen between the online and conventional spirometric values in both the intention to treat and per protocol analyses. The agreement in Bland–Altman analysis was poorer for intention to treat than for the per protocol analysis. The latter had a lower percentage of off-range patients and high agreement to determine abnormal spirometry in the off-range group. Conventional spirometry had a higher percentage of patients with spirometric quality criteria although the quality criteria difference was only 5.9%, when both procedures were the first to start. Very good agreement was found between intra- and interobserver reliability. Spirometry performed online from a hospital can be an adequate alternative to conventional spirometry for primary care centres.

Conventional Polysomnography Is Not Necessary for the Management of Most Patients with Suspected Obstructive Sleep Apnea. Noninferiority, Randomized Controlled Trial

Rationale: Home respiratory polygraphy may be a simpler alternative to in‐laboratory polysomnography for the management of more symptomatic patients with obstructive sleep apnea, but its effectiveness has not been evaluated across a broad clinical spectrum. Objectives: To compare the long‐term effectiveness (6 mo) of home respiratory polygraphy and polysomnography management protocols in patients with intermediate‐to‐high sleep apnea suspicion (most patients requiring a sleep study). Methods: A multicentric, noninferiority, randomized controlled trial with two open parallel arms and a cost‐effectiveness analysis was performed in 12 tertiary hospitals in Spain. Sequentially screened patients with sleep apnea suspicion were randomized to respiratory polygraphy or polysomnography protocols. Moreover, both arms received standardized therapeutic decision‐making, continuous positive airway pressure (CPAP) treatment or a healthy habit assessment, auto‐CPAP titration (for CPAP indication), health‐related quality‐of‐life questionnaires, 24‐hour blood pressure monitoring, and polysomnography at the end of follow‐up. The main outcome was the Epworth Sleepiness Scale measurement. The noninferiority criterion was −2 points on the Epworth scale. Measurements and Main Results: In total, 430 patients were randomized. The respiratory polygraphy protocol was noninferior to the polysomnography protocol based on the Epworth scale. Quality of life, blood pressure, and polysomnography were similar between protocols. Respiratory polygraphy was the most cost‐effective protocol, with a lower per‐patient cost of 416.7&U20AC;. Conclusions: Home respiratory polygraphy management is similarly effective to polysomnography, with a substantially lower cost. Therefore, polysomnography is not necessary for most patients with suspected sleep apnea. This finding could change established clinical practice, with a clear economic benefit. Clinical trial registered with www.clinicaltrials.gov (NCT 01752556).

Influencia del sexo en las variables clínicas y polisomnográficas del síndrome de apneas del sueño

Objetivo Comparar, en una cohorte amplia de pacientes con sindrome de apneas-hipopneas durante el sueno, las caracteristicas clinicas, antropometricas y polisomnograficas en funcion del sexo. Pacientes y metodos En el estudio, realizado en 6 hospitales universitarios espanoles, se incluyo a pacientes consecutivos con un indice de apneas-hipopneas del sueno mayor de 5 h−1, que fueron evaluados entre 2003 y 2005. Se dividieron en funcion del sexo y, posteriormente, en funcion de la edad: pacientes jovenes (45 anos) y adultos (> 45 anos). Resultados Se ha estudiado a 2.464 varones y 424 mujeres. Las mujeres eran mayores (edad media ± desviacion estandar: 56 ± 12 frente a 51 ± 12 anos; p < 0,0001), pesaban mas (indice de masa corporal: 31 ± 6 frente a 30 ± 5 kg/m2; p < 0,0001) y presentaban una mayor circunferencia de cadera (119 ± 15 frente a 111 ± 12 cm; p < 0,0001) y una menor circunferencia de cuello (38 ± 3 frente a 42 ± 9 cm; p < 0,0001) que los varones. El grado de somnolencia diurna (escala de Epworth) y el indice de apneas-hipopneas eran similares en ambos grupos, aunque el de mujeres presentaba una latencia de sueno mas larga (23 ± 28 frente a 27 ± 32 min; p < 0,004) y una saturacion de oxigeno media (un 92 ± 4 frente a un 91 ± 5%) y minima menor (un 78 ± 11 frente a un 75 ± 12%; p < 0,0001) que los varones. Al diferenciar los grupos por edad, en el grupo de jovenes solo se mantenian las diferencias ponderales, mientras que entre los adultos reaparecian las diferencias en los valores de saturacion nocturna. Conclusiones Las mujeres con sindrome de apneas-hipopneas durante el sueno son mas obesas que los varones y consultan a una edad mas avanzada. Desde el punto de vista clinico y polisomnografico, no hay grandes diferencias en funcion del sexo. Unicamente la latencia de sueno es superior y la hipoxemia nocturna mas acentuada.

Apnoeic and obstructive nonapnoeic sleep respiratory events

Obstructive nonapnoeic event (ONE) scoring is shrouded in confusion. This is important in patients with mild disease, in whom precision is crucial. The aims of the present study were: 1) to identify ONEs using oesophageal pressure (OP) (OP-ONEs) and a noninvasive (NI) method (NI-ONEs); 2) to compare both methods of scoring; and 3) to determine the contribution of ONE definitions to clinical findings. Patients with suspected sleep apnoeas (respiratory disturbance index ≤10) during a first polysomnography were subjected to a second with an OP measurement. OP-ONEs and NI-ONEs were defined as an increase in OP or discernible reduction in the amplitude of thoracoabdominal bands with both desaturation and/or arousal. Bland–Altman analysis established agreement. Comparisons were made between OP-ONEs, NI-ONEs and clinical findings. In our sample (n = 90), the addition of an arousal to the NI-ONEs or OP-ONEs with only desaturation increased the number of NI-ONEs by 329 and 362%, respectively. NI-ONEs with arousal and/or desaturation detected 91% of OP-ONEs. The association with sleepiness depended on the incorporation of arousal into the definition of ONEs. In patients with mild disease, the addition of an arousal to ONEs, with only desaturation, markedly increased respiratory disturbance index, with probable therapeutic implications. Scoring respiratory events as apnoea and ONEs is easier and sufficiently accurate.

Differences in Clinical and Polysomnographic Variables Between Male and Female Patients With Sleep Apnea-Hypopnea Syndrome

OBJECTIVE The aim of this study was to compare the clinical, anthropometric, and polysomnographic characteristics of a broad group of patients with sleep apnea-hypopnea syndrome according to sex. PATIENTS AND METHODS The study, conducted in 6 Spanish university hospitals, included consecutive patients attended from 2003 through 2005 with an apnea-hypopnea index greater than 5. Groups were formed according to sex and then stratified into age subgroups of younger (< or = 45 years) and older patients (> 45 years) for further comparison. RESULTS The study included 2464 men and 424 women. Women were older (mean [SD] age, 56 [12] years vs 51 [12] years), weighed more (body mass index, 31 [6] kg/m(2) vs 30 [5] kg/m2), and had a larger hip circumference (119 [15] cm vs 111 [12] cm) and smaller neck circumference (38 [3] cm vs 42 [9] cm) than men (P< .001 in all cases). The degree of daytime sleepiness (Epworth scale) and the apnea-hypopnea index were similar in both groups, although women had a longer sleep latency (23 [28] minutes vs 27 [32] minutes; P< .004) and a higher mean oxygen saturation (92% [4%] vs 91% [5%]) and minimum oxygen saturation (78% [11%] vs 75% [12%]; P< .0001) than men. On stratification by age, only weight differences between men and women were observed in the younger group whereas the older group also showed differences in oxygen saturation during sleep. CONCLUSIONS Women with sleep apnea-hypopnea are more overweight than men and tend to seek medical attention at an older age. The clinical and polysomnographic variables were generally similar for men and womenthe only differences were that sleep latency was longer and hypoxemia during sleep was more accentuated in women.

Predictors of obstructive sleep apnoea in patients admitted for acute coronary syndrome

Identifying undiagnosed obstructive sleep apnoea (OSA) patients in cardiovascular clinics could improve their management. Aiming to build an OSA predictive model, a broad analysis of clinical variables was performed in a cohort of acute coronary syndrome (ACS) patients. Sociodemographic, anthropometric, life-style and pharmacological variables were recorded. Clinical measures included blood pressure, electrocardiography, echocardiography, blood count, troponin levels and a metabolic panel. OSA was diagnosed using respiratory polygraphy. Logistic regression models and classification and regression trees were used to create predictive models. A total of 978 patients were included (298 subjects with apnoea–hypopnoea index (AHI) <15 events·h−1 and 680 with AHI ≥15 events·h−1). Age, BMI, Epworth sleepiness scale, peak troponin levels and use of calcium antagonists were the main determinants of AHI ≥15 events·h−1 (C statistic 0.71; sensitivity 94%; specificity 24%). Age, BMI, blood triglycerides, peak troponin levels and Killip class ≥II were determinants of AHI ≥30 events·h−1 (C statistic of 0.67; sensitivity 31%; specificity 86%). Although a set of variables associated with OSA was identified, no model could successfully predict OSA in patients admitted for ACS. Given the high prevalence of OSA, the authors propose respiratory polygraphy as a to-be-explored strategy to identify OSA in ACS patients. Given the high prevalence of OSA in patients suffering ACS, respiratory polygraphy should be routinely performed http://ow.ly/tmKE306wyDc

Cardiac Troponin Values in Patients With Acute Coronary Syndrome and Sleep Apnea: A Pilot Study

Background An analysis of cardiac injury markers in patients with OSA who sustain an episode of acute coronary syndrome (ACS) may contribute to a better understanding of the interactions and impact of OSA in subjects with ACS. We compared peak cardiac troponin I (cTnI) levels in patients with OSA and patients without OSA who were admitted for ACS. Methods Blood samples were collected every 6 hours from the time of admission until two consecutive assays showed a downward trend in the cTnI assay. The highest value obtained defined the peak cTnI value, which provides an estimate of infarct size. Results We included 89 patients with OSA and 38 patients without OSA with an apnea‐hypopnea index of a median of 32 (interquartile range [IQR], 20.8‐46.6/h and 4.8 [IQR, 1.6‐9.6]/h, respectively. The peak cTnI value was significantly higher in patients without OSA than in patients with OSA (median, 10.7 ng/mL [IQR, 1.78‐40.1 ng/mL] vs 3.79 ng/mL [IQR, 0.37‐24.3 ng/mL]; P = .04). The multivariable linear regression analysis of the relationship between peak cTnI value and patient group, age, sex, and type of ACS showed that the presence or absence of OSA significantly contributed to the peak cTnI level, which was 54% lower in patients with OSA than in those without OSA. Conclusions The results of this study suggest that OSA has a protective effect in the context of myocardial infarction and that patients with OSA may experience less severe myocardial injury. The possible role of OSA in cardioprotection should be explored in future studies.