Valérie Attali

Assessment of the voluntary activation of the diaphragm using cervical and cortical magnetic stimulation.

The twitch occlusion technique is a promising tool for use in accessing central drive to the diaphragm and determining maximal transdiaphragmatic pressure (Pdi) from submaximal efforts. It clinical use is limited by difficulties inherent to bilateral electrical stimulation (BES) of the phrenic nerves. This study was designed to revisit the technique using cervical magnetic stimulation (CMS). In addition, the effects of a voluntary contraction on diaphragm response to magnetic stimulation of the cortex (CxMS) were studied. Seven volunteers aged 23-33 yrs were studied. Pdi was determined at relaxed functional residual capacity (FRC) in response to BES (Pdi,P-ES) and CMS (Pdi,p-CMS), and the effects of an increasing voluntary contraction (Pdi, vol) were assessed, The same procedure was applied to CxMS. Pdi,p-CMS at relaxed FRC was 27.5 +/- 2.2 cmH2O (mean+/-SEM), about 20% higher than Pdi,p-ES, and reported previously. Pd,p-CMS linearly decreased with Pdi, vol, and six out of seven subjects were capable of producing voluntary contractions sufficient to extinguish the twitch. More complex patterns were observed with CxMS. Cervical magnetic stimulation provides diaphragmatic twitch occlusion data very similar to bilateral electrical phrenic stimulation. Magnetic stimulation, be it cervical or cortical, could probably be helpful for the assessment of central and peripheral mechanisms of diaphragmatic dysfunction in the clinical setting.

Salmeterol/fluticasone propionate vs. double dose fluticasone propionate on lung function and asthma control in children

There is a large body of data to support the use of an inhaled corticosteroid (ICS) plus a long‐acting β2‐agonist vs. increasing the dose of ICS in adults, but less data in children. This double‐blind, parallel group, non‐inferiority study compared lung function and asthma control, based on Global Initiative for Asthma guidelines, in children receiving either salmeterol/fluticasone propionate (SFC) 50/100 μg bd (n = 160) or fluticasone propionate (FP) 200 μg bd (n = 161) for 12 wks. Change from baseline in mean morning peak expiratory flow increased following both treatments, but was significantly greater in the SFC group compared with FP [Adjusted mean change (s.e.) (l/min): SFC: 26.9 (2.13), FP: 19.3 (2.12); treatment difference: 7.6 (3.01); 95% CI: 1.7, 13.5; p = 0.012)]. Asthma control improved over time in both groups. Mean pre‐bronchodilator maximal‐expiratory flow at 50% vital capacity and percentage rescue‐free days showed significantly greater improvements in the SFC group compared with FP. All other efficacy indices showed comparable improvements in each group. Treatment with SFC 50/100 μg bd compared with twice the steroid dose of FP (200 μg bd), was at least as effective in improving individual clinical outcomes and overall asthma control, in asthmatic children previously uncontrolled on low doses of ICS.

Residual sleepiness in obstructive sleep apnoea: phenotype and related symptoms.

The characteristics of residual excessive sleepiness (RES), defined by an Epworth score >10 in adequately treated apnoeic patients, are unknown. 40 apnoeic patients, with (n = 20) and without (n = 20) RES, and 20 healthy controls underwent clinical interviews, cognitive and biological tests, polysomnography, a multiple sleep latency test, and 24-h sleep monitoring. The marked subjective sleepiness in the RES group (mean±sd score 16.4±3) contrasted with moderately abnormal objective measures of sleepiness (90% of patients with RES had daytime sleep latencies >8 min). Compared with patients without RES, the patients with RES had more fatigue, lower stage N3 percentages, more periodic leg movements (without arousals), lower mean sleep latencies and longer daytime sleep periods. Most neuropsychological dimensions (morning headaches, memory complaints, spatial memory, inattention, apathy, depression, anxiety and lack of self-confidence) were not different between patients with and without RES, but gradually altered from controls to apnoeic patients without and then with RES. RES in apnoeic patients differs markedly from sleepiness in central hypersomnia. The association between RES, periodic leg movements, apathy and depressive mood parallels the post-hypoxic lesions in noradrenaline, dopamine and serotonin systems in animals exposed to intermittent hypoxia.

Long‐term study of fluticasone propionate aqueous nasal spray in acute and maintenance therapy of nasal polyposis

Background:  Topical steroids are first‐line medication to control nasal polyposis (NP), a disease with long‐term clinical course.

Responses of the diaphragm to transcranial magnetic stimulation during wake and sleep in humans

UNLABELLED The human ventilation depends on bulbospinal and corticospinal commands. This study assessed their interactions in five healthy volunteers (two men, age 25-35) through the description of diaphragm and abductor pollicis brevis (APB) motor potentials (DiMEPs, abpMEPs) evoked by transcranial magnetic stimulation (TMS) during relaxed expiration and tidal inspiration and during wake and sleep. NREM decreased corticospinal excitability and REM further did so, for both the diaphragm and the APB. During wake, inspiration shortened supine DiMEPs latencies (expiration 18.56+/-1.90ms; inspiration 17.37+/-1.48ms, P<0.001). This persisted during sleep in an augmented manner (expiration: 21.05+/-1.39ms; inspiration 18.69+/-1.17ms, P=0.002). Inspiration had no effect on apbMEPs during wake and sleep. IN CONCLUSION (1) the tidal bulbospinal input to phrenic motoneurones is sufficient to modulate the throughput of the corticospinal pathway to these neurones; (2) this modulation is best seen after the sleep related removal of corticospinal and/or afferent inputs.

Reduced survival in patients with ALS with upper airway obstructive events on non-invasive ventilation

Introduction Non-invasive ventilation (NIV) is part of standard care in amyotrophic lateral sclerosis (ALS). Intolerance or unavailability of NIV, as well as the quality of correction of nocturnal hypoventilation, has a direct impact on prognosis. Objectives We describe the importance of NIV failure due to upper airway obstructive events, the clinical characteristics, as well as their impact on the prognosis of ALS. Methods Retrospective analysis of the data of 190 patients with ALS and NIV in a single centre for the period 2011–2014. 179 patients tolerating NIV for more than 4 h per night without leaks were analysed. Results Among the 179 patients, after correction of leaks, 73 remained inadequately ventilated at night (defined as more than 5% of the night spent at <90% of SpO2), as a result of obstructive events in 67% of cases (n=48). Patients who remained inadequately ventilated after optimal adjustment of ventilator settings presented with shorter survival than adequately ventilated patients. Unexpectedly, patients with upper airway obstructive events without nocturnal desaturation and in whom no adjustment of treatment was therefore performed also presented with shorter survival. On initiation of NIV, no difference was demonstrated between patients with and without upper airway obstructive events. In all patients, upper airway obstruction was concomitant with reduction of ventilatory drive. Conclusions This study shows that upper airway obstruction during NIV occurs in patients with ALS and is associated with poorer prognosis. Such events should be identified as they can be corrected by adjusting ventilator settings.

A custom-made mandibular repositioning device for obstructive sleep apnoea–hypopnoea syndrome: the ORCADES study

BACKGROUND Mandibular repositioning devices (MRDs) are usually recommended as the first therapy option in patients with mild-to-moderate obstructive sleep apnoea (OSA). However, data on the long-term efficacy of MRDs are limited, not only in OSA patients who are noncompliant with continuous positive airway pressure (CPAP) but also in those with more severe OSA. The ORCADES study aimed to prospectively determine the long-term efficacy and tolerability of two custom-made Narval(™) MRDs for obstructive sleep apnoea-hypopnoea syndrome (OSAHS) patients. The interim 3- to 6-month data are reported. METHODS Eligible patients had OSAHS and had refused or were noncompliant with prescribed CPAP. Outcome measurements after gradual mandibular advancement titration included: apnoea-hypopnoea index (AHI), oxygen saturation, sleepiness, symptoms, quality of life, side effects and compliance. RESULTS A total of 369 patients were included. Overall, MRD treatment was successful (≥50% decrease in AHI) in 76.2% of the participants; complete response (AHI <10/h) was achieved in 63.5%. Severe OSAHS was effectively treated (AHI <15/h) in about 60% of the participants; 38% had complete symptom resolution. Mandibular repositioning devices significantly decreased subjective sleepiness, eliminated symptoms and improved quality of life. They were well tolerated and compliance was excellent. Only 8% of the participants stopped MRD treatment due to side effects. CONCLUSION Custom-made Narval(™) MRDs are effective for mild to severe OSA in patients who refuse or are noncompliant with CPAP. They are well tolerated and have excellent compliance.

Multidetector row computed tomography to assess changes in airways linked to asthma control.

Background: In asthma, multidetector row computed tomography (MDCT) detects abnormalities that are related to disease severity, including increased bronchial wall thickness. However, whether these abnormalities could be related to asthma control has not been investigated yet. Objective: Our goal was to determine which changes in airways could be linked to disease control. Methods: Twelve patients with poor asthma control were included and received a salmeterol/fluticasone propionate combination daily for 12 weeks. Patients underwent clinical, functional, and MDCT examinations before and after the treatment period. MDCT examinations were performed using a low-dose protocol at a controlled lung volume (65% TLC). Bronchial lumen (LA) and wall areas (WA) were evaluated at a segmental and subsegmental level using BronCare software. Lung density was measured at the base of the lung. Baseline and end-of-treatment data were compared using the Wilcoxon signed-rank test. Results: After the 12-week treatment period, asthma control was achieved. Airflow obstruction and air trapping decreased as assessed by the changes in FEV1 (p < 0.01) and expiratory reserve volume (p < 0.01). Conversely, LA and WA did not vary significantly. However, a median decrease in LA of >10% was observed in half of the patients with a wide intra- and intersubject response heterogeneity. This was concomitant with a decrease in lung density (p < 0.02 in the anteroinferior areas). Conclusions: MDCT is insensitive for demonstrating any decrease in bronchial wall thickness. This is mainly due to changes in bronchial caliber which may be linked to modifications of the elastic properties of the bronchopulmonary system under treatment.

Sexsomnia: A Specialized Non-REM Parasomnia?

Introduction: To describe patients with sexsomnia and to contrast their clinical and sleep measures with those of healthy controls and sleepwalkers. Aims and Methods: Subjects referred for sexsomnia and for sleepwalking/night terror were interviewed, completed the Paris Arousal Disorder Severity Scale (PADSS), and were monitored 1‐2 nights with video‐polysomnography. Results: Seventeen patients (70.6% male, aged 17‐76 years) had sexsomnia, with amnestic fondling of the bed partner (n = 11), complete sexual intercourse (n = 8), masturbation (n = 8), and spontaneous orgasm (n = 1). The sexual behaviors were more direct during sleep than during wakefulness (n = 12), leading to 6 sexual assaults, including intra‐conjugal rape (n = 3), assault of a family member (n = 2), rape of a friend (n = 1), and forensic consequences (n = 2). In 47% of sexsomnia patients, there was a history or current occurrences of sleepwalking/night terrors. Patients with sexsomnia had more N3 awakenings than healthy matched controls and the same amount as regular sleepwalkers. Half of them presented evidence of cortico‐cortical dissociation, including concomitant slow (mostly frontal) and rapid (mostly temporal and occipital) electroencephalography (EEG) rhythms, with concomitant N3 penile erection in 1 case. Of 89 sleepwalkers, 10% had previous episodes of amnestic sexual behaviors, with a higher PADSS‐A score and a trend of a higher total PADSS score than the 80 sleepwalkers without sexsomnia. Conclusion: In this single‐center series, we confirmed the male predominance of sexsomnias and its potential for severe clinical and forensic consequences. The results suggest a continuum of regular sleepwalking, sleepwalking with occasional sexsomnia, and quasi‐exclusive sexsomnia.

Choking during sleep: can it be expression of arousal disorder?

BACKGROUND Choking during sleep may be caused by various respiratory and non-respiratory problems. OBJECTIVE We aimed at documenting a new, rare cause of hallucinatory choking. METHODS We documented the clinical and video-polysomnographic features of 11 adult patients referred for swallowing and choking during sleep. We conducted a systematic search for similar sensations in 68 consecutive adult patients with sleepwalking/sleep terrors and in 37 patients with obstructive sleep apnea. RESULTS The 11 patients with sleep-related swallowing and choking were all current or former sleepwalkers. The symptoms occurred during the first third of the night. The patients consistently reported a frequent hallucinatory feeling of swallowing an unusual object (ring, nails, pebble, chewing gum, spoon, fork, electrical cables, lizard tail, needles, brush, computer, or gas container) that blocked the upper airways during sleep, followed by attempts to unblock them by spitting or swallowing water. When monitored, the choking sensations were not stereotypic, and occurred exclusively during arousals from N3 sleep, despite normal airway patency and absence of epileptic activity. The patients demonstrated simultaneous intense adrenergic stimulation and emotional distress. Of the 68 sleepwalkers, 13% had occasional choking sensations and 4% once inhaled a fictitious object. In the sleep apnea group, choking was never the motive of referral, but 38% of patients had occasional choking sensations, and 5% once inhaled something fictitious. CONCLUSION Although insular seizure could also be discussed, these results suggest that sleep-related swallowing and choking syndrome may be a rare, specialized variant of the arousal disorders in some cases.