Marcelo Gervilla Gregório

Critical closing pressure during midazolam-induced sleep

The critical closing pressure (Pcrit) is the airway pressure at which the airway collapses and reflects the anatomical contribution to the genesis of obstructive sleep apnea. Pcrit is usually determined during non-rapid eye movement sleep at night, but has been determined under midazolam sedation during the day in the absence of sleep stage monitoring. Indeed, little is known about the effects of midazolam on sleep architecture. Moreover, deeper sedation with midazolam can decrease upper airway muscle activity and increase collapsibility compared with natural sleep. Pcrit under sedation has not been systematically compared with the usual method performed during natural sleep. Therefore, this study aimed to test the hypothesis that Pcrit following low doses of midazolam during the day would be comparable to Pcrit measured during natural sleep in the same patient. Fifteen men (age 54 ± 10 yr, body mass index 30 ± 4 kg/m(2)) with obstructive sleep apnea underwent a baseline standard overnight polysomnogram (apnea-hypopnea index 38 ± 22 events/h, range: 8-66 events/h), and Pcrit was determined during natural sleep and following midazolam. Sleep induction was obtained with low doses of midazolam (2.4 mg, range 2.0-4.4 mg), and sleep architecture was comparable to natural sleep. Natural sleep and induced sleep Pcrit were similar (-0.82 ± -3.44 and -0.97 ± 3.21 cmH(2)O, P = 0.663) and closely associated (intraclass correlation coefficient = 0.92; 95% confidence interval, 0.78-0.97, P < 0.001). Natural and midazolam-induced Pcrit correlated with obstructive sleep apnea severity, indicating that both Pcrit measures provided meaningful physiological information. Pcrit determined during the day with sleep induction is similar to natural overnight sleep and is a valid alternative approach in which to determine Pcrit.

Bronchoscopic techniques for removal of foreign bodies in children's airways.

The management of airway foreign bodies (AFB) can be a dramatic situation in the emergency treatment of children and different techniques have been used to improve the therapeutic success and minimize risks.

Continuous positive airway pressure delivered by oronasal mask may not be effective for obstructive sleep apnoea

To the Editors: Continuous positive airway pressure (CPAP) is considered the gold standard treatment for patients with moderate to severe obstructive sleep apnoea (OSA). The treatment of OSA with CPAP was first conceptualised using a nasal-only interface because the pressure delivered through the nose would be transmitted to the back of the upper airway and would push the palate anteriorly [1]. Since the first description, the CPAP industry has developed a large number of different interfaces in order to improve patient comfort and adherence to treatment. Patients with OSA frequently present nasal obstruction and oronasal interfaces may be used to deliver CPAP. Nasal and oronasal masks are often used interchangeably and the choice of CPAP delivery interface for OSA therapy remains largely based on clinical experience. However, patients with OSA on oronasal mask are less adherent to CPAP for reasons that are not completely understood [2]. One recent randomised trial [3] and a preliminary report [4] suggest that the effectiveness of CPAP for treating OSA is variable when delivered by an oronasal interface. We describe a well-documented patient in whom CPAP was not effective when an oronasal mask was used due to the posterior displacement of the tongue. A 69-yr-old Japanese–Brazilian, body mass index 26.1 kg·m−2, presented to the outpatient sleep clinic complaining of typical symptoms suggestive of OSA, including loud snoring, witnessed apnoeas and excessive daytime sleepiness. The patient had a positive medical history of systemic hypertension and diabetes mellitus. A standard overnight polysomnography (Alice 5; Philips Respironics, Murrysville, PA, USA) confirmed severe OSA, with apnoea-hypopnoea index (AHI) 76 events per h and lowest oxygen saturation 58%. An in-laboratory manual CPAP titration study was performed with an oronasal mask because of reported oral breathing during sleep. CPAP was …

Broncoscopia flexível como primeira opção para a remoção de corpo estranho das vias aéreas em adultos

OBJECTIVE To determine the success rate of flexible bronchoscopy as the first-choice method of removing foreign bodies from the airways of adults. METHODS This was a retrospective study of all adult patients (over 18 years of age) with foreign body aspiration submitted to bronchoscopy between January of 2009 and January of 2011 at the University of São Paulo School of Medicine Hospital das Clínicas, located in São Paulo, Brazil. RESULTS The study sample comprised 40 adult patients, with a mean age of 52 years (range, 18-88 years). The median time of permanence of the foreign body in the airway was 15 days (range, 12 h to 10 years). All of the patients first underwent diagnostic flexible bronchoscopy. Foreign bodies were successfully removed with flexible bronchoscopy in 33 (82.5%) of the patients. In 1 patient, a metal object lodged in the distal bronchial tree required the use of fluoroscopy. Six patients (15%) required rigid bronchoscopy due to tracheal foreign body-induced dyspnea, in 2, and because the foreign body was too large for the flexible forceps, in 4. Bronchoscopy failed in 1 patient, who therefore required surgical bronchotomy. CONCLUSIONS Although rigid bronchoscopy is considered the gold standard for the removal of foreign bodies from the airways, our experience showed that flexible bronchoscopy can be safely and effectively used in the diagnosis and treatment of stable adult patients.

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.

Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial

BACKGROUND Snoring is extremely common in the general population and may indicate OSA. However, snoring is not objectively measured during polysomnography, and no standard treatment is available for primary snoring or when snoring is associated with mild forms of OSA. This study determined the effects of oropharyngeal exercises on snoring in minimally symptomatic patients with a primary complaint of snoring and diagnosis of primary snoring or mild to moderate OSA. METHODS Patients were randomized for 3 months of treatment with nasal dilator strips plus respiratory exercises (control) or daily oropharyngeal exercises (therapy). Patients were evaluated at study entry and end by sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index) and full polysomnography with objective measurements of snoring. RESULTS We studied 39 patients (age, 46 ± 13 years; BMI, 28.2 ± 3.1 kg/m2; apnea-hypopnea index (AHI), 15.3 ± 9.3 events/h; Epworth Sleepiness Scale, 9.2 ± 4.9; Pittsburgh Sleep Quality Index, 6.4 ± 3.3). Control (n = 20) and therapy (n = 19) groups were similar at study entry. One patient from each group dropped out. Intention-to-treat analysis was used. No significant changes occurred in the control group. In contrast, patients randomized to therapy experienced a significant decrease in the snore index (snores > 36 dB/h), 99.5 (49.6-221.3) vs 48.2 (25.5-219.2); P = .017 and total snore index (total power of snore/h), 60.4 (21.8-220.6) vs 31.0 (10.1-146.5); P = .033. CONCLUSIONS Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01636856; URL: www.clinicaltrials.gov.

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.

Comparison of full versus short induced‐sleep polysomnography for the diagnosis of sleep apnea

Polysomnography (PSG) is the gold‐standard method for diagnosing obstructive sleep apnea (OSA). However, the gap between demand and capacity in performing PSG is a major health‐care problem. We sought to validate a short day‐time induced sleep for the diagnosis of OSA.

High-dose-rate brachytherapy in symptom palliation due to malignant endobronchial obstruction: A quantitative assessment

PURPOSE This study was performed to objectively evaluate the effect of high-dose-rate endobronchial brachytherapy (HDREB) in symptom palliation of patients with malignant airway obstruction and treatment-related toxicity. METHODS AND MATERIALS Seventy-eight patients were treated with palliative intent according to a prospective observational protocol. HDREB was delivered in three fractions of 7.5 Gy at weekly or fortnightly intervals, associated or not with external beam irradiation. Most patients presented with lung cancer primaries and were treated because of lesions located in the trachea and/or main bronchi. Performance status, degree of obstruction, and symptom palliation were graded according to an objective score index, defined before and after HDREB at the last followup visit. Survival was considered from the end of HDREB for at least 3 years or until death. RESULTS Overall, there was a 70% improvement, with migration of patients from lower to higher performance status. Bronchial obstruction was improved in 73.4% of the patients. The symptom that presented the better response was hemoptysis (100% complete relief) followed by postobstructive pneumonia (80%), dyspnea (57.4%), and cough (33.9%). Median survival was 6 months and improved in patients with complete response at bronchoscopy (9 months). There were two (2.6%) cases of bronchial fistulae and eight cases (10.2%) of fatal hemoptysis. CONCLUSIONS HDREB is an excellent modality for palliating malignant airway obstruction resulting in quality of life improvement, with a good tolerance, patient compliance, and low rate of complications.

Original ResearchSleep DisordersEffects of Oropharyngeal Exercises on Snoring: A Randomized Trial

BACKGROUND Snoring is extremely common in the general population and may indicate OSA. However, snoring is not objectively measured during polysomnography, and no standard treatment is available for primary snoring or when snoring is associated with mild forms of OSA. This study determined the effects of oropharyngeal exercises on snoring in minimally symptomatic patients with a primary complaint of snoring and diagnosis of primary snoring or mild to moderate OSA. METHODS Patients were randomized for 3 months of treatment with nasal dilator strips plus respiratory exercises (control) or daily oropharyngeal exercises (therapy). Patients were evaluated at study entry and end by sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index) and full polysomnography with objective measurements of snoring. RESULTS We studied 39 patients (age, 46 ± 13 years; BMI, 28.2 ± 3.1 kg/m2; apnea-hypopnea index (AHI), 15.3 ± 9.3 events/h; Epworth Sleepiness Scale, 9.2 ± 4.9; Pittsburgh Sleep Quality Index, 6.4 ± 3.3). Control (n = 20) and therapy (n = 19) groups were similar at study entry. One patient from each group dropped out. Intention-to-treat analysis was used. No significant changes occurred in the control group. In contrast, patients randomized to therapy experienced a significant decrease in the snore index (snores > 36 dB/h), 99.5 (49.6-221.3) vs 48.2 (25.5-219.2); P = .017 and total snore index (total power of snore/h), 60.4 (21.8-220.6) vs 31.0 (10.1-146.5); P = .033. CONCLUSIONS Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01636856; URL: www.clinicaltrials.gov.