Odile Romero

Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial.

Objectives This controlled trial assessed the effect of continuous positive airway pressure (CPAP) on blood pressure (BP) in patients with obstructive sleep apnea (OSA) and resistant hypertension (RH). Methods We evaluated 96 patients with resistant hypertension, defined as clinic BP at least 140/90 mmHg despite treatment with at least three drugs at adequate doses, including a diuretic. Patients underwent a polysomnography and a 24-h ambulatory BP monitoring (ABPM). They were classified as consulting room or ABPM-confirmed resistant hypertension, according to 24-h BP lower or higher than 125/80 mmHg. Patients with an apnea-hypopnea index at least 15 events/h (n = 75) were randomized to receive either CPAP added to conventional treatment (n = 38) or conventional medical treatment alone (n = 37). ABPM was repeated at 3 months. The main outcome was the change in systolic and diastolic BP. Results Sixty-four patients completed the follow-up. Patients with ABPM-confirmed resistant hypertension treated with CPAP (n = 20), unlike those treated with conventional treatment (n = 21), showed a decrease in 24-h diastolic BP (−4.9 ± 6.4 vs. 0.1 ± 7.3 mmHg, P = 0.027). Patients who used CPAP > 5.8 h showed a greater reduction in daytime diastolic BP {−6.12 mmHg [confidence interval (CI) −1.45; −10.82], P = 0.004}, 24-h diastolic BP (−6.98 mmHg [CI −1.86; −12.1], P = 0.009) and 24-h systolic BP (−9.71 mmHg [CI −0.20; −19.22], P = 0.046). The number of patients with a dipping pattern significantly increased in the CPAP group (51.7% vs. 24.1%, P = 0.008). Conclusion In patients with resistant hypertension and OSA, CPAP treatment for 3 months achieves reductions in 24-h BP. This effect is seen in patients with ABPM-confirmed resistant hypertension who use CPAP more than 5.8 h.

A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial

Background Compliance with continuous positive airway pressure (CPAP) therapy is essential in patients with obstructive sleep apnoea (OSA), but adequate control is not always possible. This is clinically important because CPAP can reverse the morbidity and mortality associated with OSA. Telemedicine, with support provided via a web platform and video conferences, could represent a cost-effective alternative to standard care management. Aim To assess the telemedicine impact on treatment compliance, cost-effectiveness and improvement in quality of life (QoL) when compared with traditional face-to-face follow-up. Methods A randomised controlled trial was performed to compare a telemedicine-based CPAP follow-up strategy with standard face-to-face management. Consecutive OSA patients requiring CPAP treatment, with sufficient internet skills and who agreed to participate, were enrolled. They were followed-up at 1, 3 and 6 months and answered surveys about sleep, CPAP side effects and lifestyle. We compared CPAP compliance, cost-effectiveness and QoL between the beginning and the end of the study. A Bayesian cost-effectiveness analysis with non-informative priors was performed. Results We randomised 139 patients. At 6 months, we found similar levels of CPAP compliance, and improved daytime sleepiness, QoL, side effects and degree of satisfaction in both groups. Despite requiring more visits, the telemedicine group was more cost-effective: costs were lower and differences in effectiveness were not relevant. Conclusions A telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as standard hospital-based care in terms of CPAP compliance and symptom improvement, with comparable side effects and satisfaction rates. The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity (indirect costs). Trial register number NCT01716676.

A randomized controlled study of CPAP effect on plasma aldosterone concentration in patients with resistant hypertension and obstructive sleep apnea.

Objective: The high prevalence of obstructive sleep apnea in patients with resistant hypertension could be mediated by an activation of the renin-angiotensin-aldosterone system. This study assessed the impact of continuous positive airway pressure (CPAP) treatment on plasma aldosterone concentration (PAC). Methods: One hundred and twenty-four patients with resistant hypertension were assessed, and those who fulfilled inclusion criteria (n = 116) underwent full night polysomnography, 24-h ambulatory blood pressure monitoring, and PAC measurement. Patients with an apnea–hypopnea index above 15 (n = 102) were randomized to CPAP (n = 50) or to conventional treatment (n = 52) for 3 months. Results: Seventy-eight patients completed the follow-up (36 CPAP, 42 conventional treatment); 58 had true resistant hypertension (74.3%), whereas 20 had white-coat resistant hypertension (25.6%). Most patients were men (70.7%), age 58.3 ± 9.4 years, and the mean apnea–hypopnea index was 50.1 ± 21.6. In patients with true resistant hypertension, CPAP achieved a significant decrease in most 24-h BP measurements and a nonsignificant decrease in PAC (25 ± 8.7 vs. 22.7 ± 9 ng/dl; P < 0.182). In patients with white-coat resistant hypertension, CPAP achieved a significant decrease in PAC (26.1 ± 11.2 vs. 18.9 ± 10.1 ng/dl; P < 0.041) and in night-time DBP. After adjustment, a weak but significant association was found between cumulative time spent with SaO2 below 90% (CT90%) and baseline PAC (P < 0.047, R2 0.019), and between changes in PAC and changes in office DBP (P < 0.020, R2 0.083) Conclusions: Night-time hypoxemia and changes in DBP showed an association with baseline and changes in PAC, respectively. CPAP achieved a significant reduction in PAC only in patients with white-coat resistant hypertension, although the CPAP effect on BP was highest in patients with true resistant hypertension.

Diabetes Is an Independent Risk Factor for Severe Nocturnal Hypoxemia in Obese Patients. A Case-Control Study

Background Type 2 diabetes mellitus (T2DM) and obesity have become two of the main threats to public health in the Western world. In addition, obesity is the most important determinant of the sleep apnea-hypopnea syndrome (SAHS), a condition that adversely affects glucose metabolism. However, it is unknown whether patients with diabetes have more severe SAHS than non-diabetic subjects. The aim of this cross-sectional case-control study was to evaluate whether obese patients with T2DM are more prone to severe SAHS than obese non-diabetic subjects. Methodology/Principal Findings Thirty obese T2DM and 60 non-diabetic women closely matched by age, body mass index, waist circumference, and smoking status were recruited from the outpatient Obesity Unit of a university hospital. The exclusion criteria included chronic respiratory disease, smoking habit, neuromuscular and cerebrovascular disease, alcohol abuse, use of sedatives, and pregnancy. Examinations included a non-attended respiratory polygraphy, pulmonary function testing, and an awake arterial gasometry. Oxygen saturation measures included the percentage of time spent at saturations below 90% (CT90). A high prevalence of SAHS was found in both groups (T2DM:80%, nondiabetic:78.3%). No differences in the number of sleep apnea-hypopnea events between diabetic and non-diabetic patients were observed. However, in diabetic patients, a significantly increase in the CT90 was detected (20.2±30.2% vs. 6.8±13,5%; p = 0.027). In addition, residual volume (RV) was significantly higher in T2DM (percentage of predicted: 79.7±18.1 vs. 100.1±22.8; p<0.001). Multiple linear regression analyses showed that T2DM but not RV was independently associated with CT90. Conclusions/Significance T2DM adversely affects breathing during sleep, becoming an independent risk factor for severe nocturnal hypoxemia in obese patients. Given that SAHS is a risk factor of cardiovascular disease, the screening for SAHS in T2DM patients seems mandatory.

Acute Hypercapnic Respiratory Failure in Patients with Sleep Apneas

Abstract Introduction Acute hypercapnic respiratory failure (AHRF) is a serious condition observed in some patients with sleep apnea-hypopnea syndrome (SAHS). The objective of the present study was to study the clinical characteristics of SAHS patients who develop AHRF and their prognosis. Patients and method A total of 70 consecutive SAHS patients who survived an AHRF episode and 70 SAHS patients paired by age with no previous history of AHRF were prospectively studied and followed up for 3 years. Results The deterioration of lung function due to obesity or concomitant chronic obstructive pulmonary diseases (COPD) was common in SAHS patients with AHRF. In the multivariate analysis, the risk factors associated with AHRF were baseline PaO 2 , the theoretical percentage value of the forced vital capacity, alcohol consumption, and benzodiazepines. The mortality during follow up was higher among patients who had AHRF than in the control group. The main cause of death was respiratory, and the coexistence of COPD was identified as a mortality risk factor. Conclusions The development of AHRF in SAHS patients is associated with a deterioration in lung function and with alcohol and benzodiazepine consumption. The patients had a higher mortality after the AHRF episode, mainly a respiratory cause. New studies are required that evaluate the different available therapeutic options in these patients.

Insuficiencia respiratoria hipercápnica aguda en pacientes con apneas del sueño

INTRODUCTION Acute hypercapnic respiratory failure (AHRF) is a serious condition observed in some patients with sleep apnea-hypopnea syndrome (SAHS). The objective of the present study was to study the clinical characteristics of SAHS patients who develop AHRF and their prognosis. PATIENTS AND METHOD A total of 70 consecutive SAHS patients who survived an AHRF episode and 70 SAHS patients paired by age with no previous history of AHRF were prospectively studied and followed up for 3 years. RESULTS The deterioration of lung function due to obesity or concomitant chronic obstructive pulmonary diseases (COPD) was common in SAHS patients with AHRF. In the multivariate analysis, the risk factors associated with AHRF were baseline PaO(2,) the theoretical percentage value of the forced vital capacity, alcohol consumption, and benzodiazepines. The mortality during follow up was higher among patients who had AHRF than in the control group. The main cause of death was respiratory, and the coexistence of COPD was identified as a mortality risk factor. CONCLUSIONS The development of AHRF in SAHS patients is associated with a deterioration in lung function and with alcohol and benzodiazepine consumption. The patients had a higher mortality after the AHRF episode, mainly a respiratory cause. New studies are required that evaluate the different available therapeutic options in these patients.

Análisis de coste-eficacia de la graduación automática de la presión positiva continua de la vía aérea en el domicilio: ¿una o 2 noches?

OBJETIVO: Evaluar el coste-eficacia de la graduacion automatica de la presion positiva continua de la via aerea (CPAP) en el domicilio, en una y 2 noches consecutivas, en pacientes con sindrome de apneas-hiponeas durante el sueno. PACIENTES Y METODOS: Se practico un estudio de graduacion domiciliaria con un equipo de CPAP automatica (APAP) durante 2 noches consecutivas a 100 pacientes con sindrome de apneas-hipopneas durante el sueno e indicacion de tratamiento con CPAP. Se evaluaron el numero de estudios satisfactorios y el coste resultante de la primera noche y de las 2 noches. Se compararon las necesidades de presion durante cada noche y la concordancia entre la presion seleccionada visualmente por 2 observadores. RESULTADOS: La graduacion de CPAP fue satisfactoria en el 85 y el 80% de los pacientes en la primera y la segunda noches, respectivamente, y en el 88% despues de las 2 noches. No hubo diferencias significativas entre las 2 noches en la presion percentil 95% (media ± desviacion estandar: 10,2 ± 1,8 y 10,2 ± 1,6 cmH2O), la presion media (7,8 ± 1,7 y 7,7 ± 1,7 cmH2O) y la presion visual (9,4 ± 1,5 y 9,4 ± 1,4 cmH2O). Se obtuvo un buen grado de concordancia entre 2 observadores en la seleccion de presion (kappa = 0,956 para la noche 1; kappa = 0,91 para la noche 2). El coste de los estudios fue 232,63 ? para la primera noche y 227,93 ? para las 2 noches consecutivas. CONCLUSIONES: Con un coste similar, la adopcion de un protocolo de graduacion automatica de la CPAP una noche en el domicilio permite incrementar sustancialmente el numero de pacientes estudiados, respecto a 2 noches consecutivas.

Neurophysiological two-channel polysomnographic device in the diagnosis of sleep apnea.

STUDY OBJECTIVE Our objective was to evaluate a portable device (Somté, Compumedics, Australia), which incorporates 2 neurophysiological channels (electroencephalography and electrooculography) with cardiorespiratory monitoring for the diagnosis of obstructive sleep apnea (OSA). METHOD Full polysomnography (PSG) and Somté recordings were simultaneously performed in 68 patients with suspected OSA. Data were analyzed blindly by 2 scorers. RESULTS A good agreement between methods in sleep efficiency was observed (68.8% [18.4] with PSG vs 68% [19.1] with Somté [p: n.s.] for scorer 1, and 67.5% [19.1] vs 68.4% [18.5; p: n.s.] for scorer 2). The apnea-hypopnea index (AHI) obtained with Somté was lower than with PSG: 19 (17.8) vs 21.7 (19) (p < 0.001) for scorer 1, and 16.6 (16.7) vs 20 (18.8) (p < 0.001) for scorer 2. The sensitivity of Somté for a PSG-AHI > 5 was 91% for scorer 1 and 90% for scorer 2, while specificity was 77% and 90%, respectively. The areas under the receiver operating curve for different PSG-AHI cutoff points (≥ 5, ≥ 15, and ≥ 30) were 0.81, 0.90, and 0.86, respectively, for scorer 1, and 0.90, 0.88, and 0.83 for scorer 2. CONCLUSIONS These data suggest that Somté is an effective device to identify sleep and respiratory variables in patients with suspected OSA.

Sleep-Related Breathing Disorders in Chiari Malformation Type 1: A Prospective Study of 90 Patients

Study objective The aim of the present study is to describe the prevalence of sleep disorders in a large group of patients with Chiari malformation type 1 (CM-1) and determine the presence of risk factors associated with these abnormalities. Methods Prospective study with consecutive patient selection. We included 90 adult patients with CM-1, defined by the presence of a cerebellar tonsillar descent (TD) ≥3 mm. Clinical, neuroradiological studies, and nocturnal polysomnography (PSG) was carried out. In addition, patients were also subclassified into 2 CM subtypes: CM-1, with the obex above the foramen magnum (FM) and CM-1.5, in which along with a TD ≥3 mm, the obex was located below the FM. Results We observed a high prevalence (50%) of sleep-related breathing disorders (SRBDs) with predominant hypopnea. Only six patients showed a central apnea index of ≥5. Hypoventilation was observed in only three patients. SRBD severity was associated with male sex, older age, excess weight, and the presence of hydrocephalus. No differences in clinical or PSG parameters were found when comparing CM subtypes (CM-1 and CM-1.5). Sleep architecture study showed decreased sleep efficiency with an increase in arousal and waking after sleep onset. The presence of SRBDs was found to be associated with poorer sleep architecture parameters. Conclusions This study confirms a high prevalence of SRBDs in patients with CM-1 and CM-1.5, with a predominant obstructive component. Nocturnal PSG recordings should be systematically conducted in these patients, especially those who are male, older, or overweight or those who present hydrocephalus.

Cost-Effectiveness Analysis of Automatic Titration of Continuous Positive Airway Pressure at Home in 1 Night Versus 2 Nights

OBJECTIVE To assess the cost-effectiveness of automatic continuous positive airway pressure (CPAP) titration at home on 1 night or 2 consecutive nights in patients with the sleep apnea-hypopnea syndrome (SAHS). PATIENTS AND METHODS A home titration study was performed using automatic CPAP for 2 consecutive nights on 100 patients with SAHS and an indication for CPAP. The number of successful studies and the costs of the first night and both nights were analyzed. The pressure requirements on each night and the agreement between the pressures selected visually by 2 different observers were compared. RESULTS CPAP titration was successful in 85% and 80% of patients on the first night and second night, respectively, and in 88% of patients after both nights. No significant differences between the 2 nights were found for the following parameters: 95th percentile pressure (mean [SD], 10.2 [1.8] cm H(2)O and 10.2 [1.6] cm H(2)O on the first and second nights, respectively), mean pressure (7.8 [1.7] cm H(2)O and 7.7 [1.7] cm H(2)O), or the pressure selected visually (9.4 [1.5] cm H(2)O and 9.4 [1.4] cm H(2)O). Interobserver agreement on the pressure selected was good: the k statistics were 0.956 for the first night and 0.91 for the second night. The 1-night study cost euro232.63 and the 2-night study cost euro227.93. CONCLUSIONS Automatic CPAP titration at home for 1 night enables a substantially greater number of patients to be studied at a similar cost than is possible when titration is accomplished in 2 consecutive nights.