Michiel Eijsvogel

Sleep Position Trainer versus Tennis Ball Technique in Positional Obstructive Sleep Apnea Syndrome

STUDY OBJECTIVE Positional therapy (PT) is an effective therapy in positional obstructive sleep apnea syndrome (POSAS) when used, but the compliance of PT is low. The objective of this study was to investigate whether a new kind of PT is effective and can improve compliance. METHODS 29 patients were treated with the Sleep Position Trainer (SPT), 26 patients with the Tennis Ball Technique (TBT). At baseline and 1 month polysomnography, Epworth Sleepiness Scale (ESS) and the Quebec Sleep Questionnaire (QSQ) were taken. Daily compliance was objectively measured in both groups. RESULTS Both therapies prevent supine sleep position to a median of 0% (min-max: SPT 0.0% to 67%, TBT 0.0% to 38.9%), resulting in a treatment success (AHI <5) in 68.0% of the SPT and 42.9% of the TBT patients. The ESS at baseline was <10 in both groups. Sleep quality parameters as wake after sleep onset (WASO; p = 0.001) and awakenings (p = 0.006) improved more in the SPT group. Total QSQ scores (0.4±0.2, p = 0.03) and the QSQ domains nocturnal symptoms (0.7±0.2, p = 0.01) and social interactions (0.8±0.3, p = 0.02) changed in favor of the SPT group. Effective compliance (≥4 h/night + ≥5 days/week) was 75.9% for the SPT and 42.3% for the TBT users (p = 0.01). CONCLUSION In mild POSAS with normal EES the new SPT device and the standard TBT are equally effective in reducing respiratory indices. However, compared to the TBT, sleep quality, quality of life, and compliance improved significantly more in the SPT group.

Obstructive Sleep Apnea Syndrome in Company Workers: Development of a Two-Step Screening Strategy with a New Questionnaire.

STUDY OBJECTIVES To develop and evaluate a screening questionnaire and a two-step screening strategy for obstructive sleep apnea syndrome (OSAS) in healthy workers. METHODS This is a cross-sectional study of 1,861 employees comprising healthy blue- and white-collar workers in two representative plants in the Netherlands from a worldwide consumer electronic company who were approached to participate. Employees were invited to complete various sleep questionnaires, and undergo separate single nasal flow recording and home polysomnography on two separate nights. RESULTS Of the 1,861 employees, 249 provided informed consent and all nasal flow and polysomnography data were available from 176 (70.7%). OSAS was diagnosed in 65 (36.9%). A combination of age, absence of insomnia, witnessed breathing stops, and three-way scoring of the Berlin and STOPBANG questionnaires best predicted OSAS. Factor analysis identified a six-factor structure of the resulting new questionnaire: snoring, snoring severity, tiredness, witnessed apneas, sleep quality, and daytime well-being. Subsequently, some questions were removed, and the remaining questions were used to construct a new questionnaire. A scoring algorithm, computing individual probabilities of OSAS as high, intermediate, or low risk, was developed. Subsequently, the intermediate risk group was split into low and high probability for OSAS, based on nasal flow recording. This two-step approach showed a sensitivity of 63.1%, and a specificity of 90.1%. Specificity is important for low prevalence populations. CONCLUSION A two-step screening strategy with a new questionnaire and subsequent nasal flow recording is a promising way to screen for OSAS in a healthy worker population. CLINICAL TRIAL REGISTRATION Development and validation of a screening instrument for obstructive sleep apnea syndrome in healthy workers. Netherlands Trial Register (www.trailregister.nl), number: NTR2675.

Validation of the oxygen desaturation index in the diagnostic workup of obstructive sleep apnea

IntroductionObstructive sleep apnea (OSA) is common, and diagnosis requires expensive and laborious testing to assess the apnea hypopnea index (AHI). We performed an analysis to explore the relationship between the oxygen desaturation index (ODI) as measured with pulse oximetry and the AHI in our large portable monitoring (PM) database to find an optimal cutoff value for the ODI in order to be able to exclude AHI ≥ 5 on PM.MethodsThree thousand four hundred thirteen PM recordings were randomly divided into a training set (N = 2281) and a test set (N = 1132). The optimal cutoff for the ODI to exclude an AHI ≥ 5 on PM was determined in the training set and subsequently validated in the test set.ResultsArea under the curve of the ODI to exclude an AHI ≥ 5 on PM was 0.997 in the training set and 0.996 in the test set. In the training set, the optimal cutoff to predict an AHI < 5 was an ODI < 5. Using this cutoff in the test set provided a sensitivity of 97.7%, a specificity of 97.0%, a positive predictive value of 99.2%, and a negative predictive value of 91.4%.ConclusionAn ODI < 5 predicts an AHI < 5 with high sensitivity and specificity when measured simultaneously using the same oximeter during PM recording.

Reproducibility of hypercapnic ventilatory response measurements with steady-state and rebreathing methods

In this study, the hypercapnic ventilatory response (HCVR) was measured, defined as the ventilation response to carbon dioxide tension (PCO2). We investigated which method, rebreathing or steady-state, is most suitable for measurement of the HCVR in healthy subjects, primarily based on reproducibility. Secondary outcome parameters were subject experience and duration. 20 healthy adults performed a rebreathing and steady-state HCVR measurement on two separate days. Subject experience was assessed using numeric rating scales (NRS). The intraclass correlation coefficient (ICCs) of the sensitivity to carbon dioxide above the ventilatory recruitment threshold and the projected apnoea threshold were calculated to determine the reproducibility of both methods. The ICCs of sensitivity were 0.89 (rebreathing) and 0.56 (steady-state). The ICCs of the projected apnoea threshold were 0.84 (rebreathing) and 0.25 (steady-state). The steady-state measurement was preferred by 16 out of 20 subjects; the differences in NRS scores were small. The hypercapnic ventilatory response measured using the rebreathing setup provided reproducible results, while the steady-state method did not. This may be explained by high variability in end-tidal PCO2. Differences in subject experience between the methods are small. The hypercapnic ventilatory response measured by a rebreathing setup is reproducible, as opposed to a steady-state setup http://ow.ly/yGDg30hStIB

The TL,NO/TL,CO ratio cannot be used to exclude pulmonary embolism

The existing screening modalities for pulmonary embolism (PE), such as D‐dimer and clinical prediction rules, have low positive predictive values. With its capability to indicate pulmonary vascular abnormalities, the ratio of the transfer factor of the lungs for nitric oxide and the transfer factor of the lungs for carbon monoxide (TL,NO/TL,CO) might be an additional discriminating parameter.

Volumetric capnography in the exclusion of pulmonary embolism at the emergency department: a pilot study

The analysis of the [Formula: see text] in expired air as a function of the exhaled volume (volumetric capnography) might result in a more specific exclusion tool for pulmonary embolism (PE) in addition to the Wells-score and D-dimer. A novel combination of volumetric capnography parameters ([Formula: see text]) should be decreased in PE and could possibly be used to decrease the number of requested computed tomography pulmonary angiograms (CTPA). Volumetric capnography measurements were performed on consecutive patients seen in the emergency department for which, due to suspected PE (due to increased D-dimer level or Wells-score), a CTPA was ordered. A total of 30 subjects were included, of which in 13 PE was seen on CTPA. Median [Formula: see text] was 4.36 kPa (IQR 3.92-4.88) in the no PE group versus 4.07 kPa (IQR 3.37-4.39) in the PE group (p  =  0.086). Median of the novel parameter [Formula: see text] was 1.85 min.kPa dl-1 (IQR 1.21-3.00) in the no PE group versus 1.18 min.kPa dl-1 (IQR 0.61-1.38) in the PE group (p  =  0.006). Using a threshold for the new parameter of 1.90 min.kPa dl-1 or higher to exclude PE resulted in a negative predictive value of 100% (95% CI: 77%-100%) and would have potentially excluded PE in 47% (95% CI: 26%-69%) of the no PE group without the need for CTPA. This pilot study introduces a novel parameter [Formula: see text] which is significantly decreased in PE subjects. Future studies regarding validation and addressing aspects such as reproducibility and normalization after treatment are needed to confirm its usability in excluding PE in the emergency department.

Snurken en het obstructieve slaapapneusyndroom

SamenvattingSnurken is in de meeste gevallen een onschuldig verschijnsel, maar soms is het een symptoom van het obstructieve slaapapneusyndroom (OSAS). Kenmerkend voor OSAS zijn behalve snurken ook ademhalingsstilstanden en slaperigheid overdag. OSAS kan tot grote problemen leiden. Het is voor de huisarts dus essentieel om onderscheid te maken tussen onschuldig primair snurken en OSAS. De relatie van OSAS met cardiovasculaire aandoeningen is met epidemiologisch onderzoek duidelijk aangetoond. De huisarts moet verwijzen naar de tweede lijn als verdere diagnostiek en behandeling van OSAS nodig is. Primair snurken kan met conservatieve maatregelen behandeld worden. Bij een aantal patiënten zijn mandibulaire repositieapparatuur (MRA) of KNO-ingrepen noodzakelijk. Een effectieve oplossing bij OSAS is de toepassing van continuous positive airway pressure (CPAP). MRA is een bruikbaar alternatief.

Snurken en het slaapapneusyndroom

SamenvattingKnuistingh Neven A, Eijsvogel MMM. Snurken en het slaapapneusyndroom. Huisarts Wet 2013;56(5):238-41. Snurken is in de meeste gevallen een onschuldig verschijnsel, maar soms is het een symptoom van het obstructieve slaapapneusyndroom (OSAS). Kenmerkend voor OSAS zijn behalve snurken ook het voorkomen van ademhalingsstilstanden en slaperigheid overdag. OSAS kan tot grote problemen leiden. Het is voor de huisarts dus essentieel om onderscheid te maken tussen onschuldig, primair snurken en OSAS. Verwijzen naar de tweede lijn dient te geschieden indien verdere diagnostiek en behandeling van OSAS nodig is. Primair snurken is men met conservatieve maatregelen te behandelen. Bij een aantal patiënten zijn mandibulaire repositieapparatuur (MRA) of kno-ingrepen noodzakelijk. Een effectieve oplossing bij OSAS is de toepassing van continuous positive airway pressure (CPAP). MRA is een bruikbaar alternatief.