Elevated Apnea-hypopnea Index Research Articles

1077 Epidural Abscess in a 9 Year Old Boy on Continuous Positive Airway Pressure Therapy

Intracranial extension of rhinosinusitis while on positive airway pressure (PAP) therapy is rare, particularly in children. We present the case of a 9 year old immunocompetent boy with central precocious puberty (bone age 13 years, 6 months), obesity, prior adenotonsillectomy, and obstructive sleep apnea-hypopnea syndrome. At age five years, polysomnography after adenotonsillectomy showed an elevated apnea-hypopnea index of 7. Over the ensuing four years, he adhered to PAP treatment with improvement in symptoms. At age 9 years, he developed frontal headache with photophobia, thickened nasal discharge, and fever to 104.7 ten days after being diagnosed with influenza. Four days later, he developed lethargy, vomiting, worsened headache, and puffiness over his forehead. Head CT showed pansinusitis and locules of gas adjacent to both the inner and outer calvarial tables over the right frontal sinus suggesting extension of a subperiosteal or epidural abscess. An MRI was consistent with epidural abscess. Surgical intervention was not indicated as he did not have mass effect nor did he further deteriorate clinically. Paranasal sinus cultures taken 2 days after starting antibiotics had no growth. He continued on broad spectrum antibiotic therapy and made a full recovery. He resumed intermittent use of CPAP within 2 months after infection. Nine months later, he was 32% compliant with PAP in the setting of mask discomfort. Apnea-hypopnea index was 1.3 when using the device. A literature search using Medline and Cochrane revealed no prior reports of epidural abscess developing in patients receiving PAP treatment. Epidural abscess secondary to direct extension of frontal rhinosinusitis is uncommon in a nine-year-old. The active growth of the frontal sinuses and their rich blood supply during his precocious puberty may have increased his vulnerability to a rostral, intracranial spread of infection. None

Residual Renal Function and Obstructive Sleep Apnea in Peritoneal Dialysis: A Pilot Study.

Obstructive sleep apnea is common in patients with end-stage renal disease, and there is increasing evidence that clinical factors specific to end-stage renal disease contribute pathophysiologically to obstructive sleep apnea. It is not known whether circumstances specific to dialysis modality, in this case peritoneal dialysis, affect obstructive sleep apnea. Our study aimed to investigate the prevalence of obstructive sleep apnea in the peritoneal dialysis population and the relevance of dialysis-specific measures and kidney function in assessing this bidirectional relationship. Participants with end-stage renal disease who were treated with nocturnal automated peritoneal dialysis for at least 3 months were recruited from a hospital-based dialysis center. Laboratory measures of dialysis adequacy, peritoneal membrane transporter status, and residual renal function were gathered by chart review. Patients participated in a home sleep apnea test using a level III sleep apnea monitor. Of fifteen participants recruited, 33% had obstructive sleep apnea diagnosed by apnea-hypopnea index ≥ 5 events per hour of sleep. Renal creatinine clearance based upon 24-h urine collection was negatively correlated with apnea-hypopnea index (ρ = - 0.63, p = 0.012). There were no significant associations between anthropometric measures, intra-abdominal dwell volume, or peritoneal membrane transporter status and obstructive sleep apnea measures. The prevalence of obstructive sleep apnea and sleep disturbances is high in participants receiving peritoneal dialysis. Elevated apnea-hypopnea index is associated with lower residual renal function, whereas dialysis-specific measures such as intra-abdominal dwell volume and peritoneal membrane transporter status do not correlate with severity of obstructive sleep apnea.

Heart Rate Variability and Sleep-Related Breathing Disorders in the General Population

Obstructive sleep apnea seems to have an important influence on the autonomic nervous system. In this study, we assessed the relations of sleep apnea-related parameters with 24-hour heart rate variability (HRV) in a large population of young and healthy adults. Participants aged 25 to 41years with a body mass index <35kg/m(2) and without known obstructive sleep apnea were included in a prospective population-based cohort study. HRV was assessed using 24-hour electrocardiographic monitoring. The SD of all normal RR intervals (SDNN) was used as the main HRV variable. Apnea-Hypopnea Index (AHI) and oxygen desaturation index (ODI) were obtained from nighttime pulse oximetry with nasal airflow measurements. We defined sleep-related breathing disorders as an AHI ≥5 or an ODI ≥5. Multivariable regression models were constructed to assess the relation of HRV with either AHI or ODI. Median age of the 1,255 participants was 37years, 47% were men, and 9.6% had an AHI ≥5. Linear inverse associations of SDNN across AHI and ODI groups were found (p for trend= 0.006 and 0.0004, respectively). The β coefficients (95% CI) for the relation between SDNN and elevated AHI were-0.20 (-0.40 to-0.11), p= 0.04 and-0.29 (-0.47 to-0.11), p= 0.002 for elevated ODI. After adjustment for 24-hour heart rate, the same β coefficients (95% CI) were-0.06 (-0.22 to 0.11), p= 0.51 and-0.14 (-0.30 to 0.01), p= 0.07, respectively. In conclusion, even early stages of sleep-related breathing disorders are inversely associated with HRV in young and healthy adults, suggesting that they are tightly linked with autonomic dysfunction. However, HRV and 24-hour heart rate seem to have common information.

Sleep-disordered Breathing and Incident Heart Failure in Older Men.

The directionality of the relationship between sleep-disordered breathing and heart failure is controversial. We assessed whether elevations in the obstructive or central sleep apnea index or the presence of Cheyne-Stokes breathing are associated with decompensated and/or incident heart failure. We conducted a prospective, longitudinal study of 2,865 participants derived from the Osteoporotic Fractures in Men Study, a prospective multicenter observational study of community-dwelling older men. Participants underwent baseline polysomnography and were followed for a mean 7.3 years for development of incident or decompensated heart failure. Our main exposures were the obstructive apnea-hypopnea index (AHI), central apnea index (CAI ≥ 5), and Cheyne-Stokes breathing. Covariates included age, race, clinic site, comorbidities, physical activity, and alcohol and tobacco use. CAI greater than or equal to five and presence of Cheyne-Stokes breathing but not obstructive AHI were significant predictors of incident heart failure (adjusted hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.16-2.77 for CAI ≥ 5) (HR, 2.23; 95% CI, 1.45-3.43 for Cheyne-Stokes breathing). After excluding those with baseline heart failure, the incident risk of heart failure was attenuated for those with CAI greater than or equal to five (HR, 1.57; 95% CI, 0.92-2.66) but remained significantly elevated for those with Cheyne-Stokes breathing (HR, 1.90; 95% CI, 1.10-3.30). An elevated CAI/Cheyne-Stokes breathing, but not an elevated obstructive AHI, is significantly associated with increased risk of decompensated heart failure and/or development of clinical heart failure in a community-based cohort of older men.

Transverse Retropalatal Collapsibility Is Associated with Obstructive Sleep Apnea Severity and Outcome of Relocation Pharyngoplasty.

The aim of this study was to investigate whether the retropalatal airway shape and collapsibility defined by awake nasopharyngoscopy with Müller's maneuver were associated with apnea-hypopnea index (AHI), positional dependency, and surgical outcome of relocation pharyngoplasty in patients with obstructive sleep apnea. Case series with planned data collection. Tertiary referral center. A total of 45 obstructive sleep apnea patients were included who underwent conservative treatment (n = 13) or relocation pharyngoplasty (n = 32), and their baseline and postoperative polysomnographies and awake nasopharyngoscopies with Müller's maneuver were reviewed. Shape ratio (transverse diameter [TD] / longitudinal diameter [LD]) in the stationary and Müller's phases and collapsibility (ColTD and ColLD) of the airway at the level of the uvular base were measured with a picture archiving and communication system. Intra- and interrater reliabilities were assessed. Associations among nasopharyngoscopic measurements, AHI, positional dependency, and surgical success (defined as a reduction of AHI ≥50% and a postoperative AHI ≤20/h) were statistically analyzed. Reliability tests indicated substantial agreements of all nasopharyngoscopic measurements between raters and within raters. A higher baseline ColTD was significantly associated with an elevated AHI (r = 0.49, P = .001), whereas a lower postoperative ColTD was significantly related to surgical success (r = -0.38, P = .034). Nasopharyngoscopic findings were not statistically significantly correlated with positional dependency. Transverse retropalatal collapsibility measured by awake nasopharyngoscopy with Müller's maneuver helps to predict individuals with moderate to severe sleep apnea and surgical outcome.

25-Hydroxyvitamin D Concentration and Sleep Duration and Continuity: Multi-Ethnic Study of Atherosclerosis

To determine the associations of 25-hydroxyvitamin D (25(OH)D) concentration with sleep continuity, quality, and symptoms, and to explore race/ethnic variation. Cross-sectional study. Multi-Ethnic Study of Atherosclerosis (MESA). There were 1,721 adults. Sleep outcomes were measured by polysomnography, actigraphy, and questionnaires. Serum 25(OH)D concentration was expressed by clinical thresholds (< 20, 20-29, ≥ 30 ng/mL) and continuously. Using linear regression, we determined the associations between 25(OH)D concentration and sleep duration, efficiency, and symptoms, and assessed race/ethnic variation. Mean age was 68.2 ± 9.1 y, and 37.2% were white, 27.7% African American, 11.9% Chinese Americans, and 23.2% Hispanic. Mean 25(OH)D concentration was 25.4 ± 10.5 ng/mL. 25(OH)D deficient participants had the shortest sleep duration, lowest sleep efficiency, and highest sleepiness scores. After adjusting for demographics, obesity, and health habits, deficient individuals slept an average of 13.0 min (95% confidence interval, -22.8, -3.2) shorter than sufficient individuals. Race/ethnic-stratified analyses indicated that the strongest associations were in African Americans, in whom adjusted sleep duration was 25.6 ± 11.7 min shorter in deficient versus sufficient individuals (P = 0.04), and in Chinese Americans, adjusted apnea-hypopnea index (AHI) was 7.5 ± 3.3 events/h higher in deficient versus sufficient individuals. Overall, there were modest associations between 25-hydroxyvitamin D (25(OH)D) concentration and sleep traits. However, race-stratified analyses suggested the association between 25(OH)D concentration and sleep traits varied by race/ethnicity. Vitamin D deficiency was most strongly associated with short sleep duration in African Americans and with elevated apnea-hypopnea index in Chinese Americans, suggesting that race/ethnicity may modify these associations.

Observation following tonsillectomy may be inadequate due to silent death.

The focus on the first 24 hours of care for respiratory events following tonsillectomy may be misplaced and a broader focus is warranted. Nocturnal hypoxemia, an elevated apnea-hypopnea index, or obstructive sleep apnea contributes to an increased sensitivity to narcotics and postoperative complications. Narcotic pain management depresses respiration through an increase in the frequency of central sleep apnea, decreased minute ventilation, increased hypercarbia pressure, and a decrease in the hypoxic ventilator response. Residual pain gives some margin of safety as it stimulates respiration. Children dying following tonsillectomy do so silently during sleep, often without arousing the attention of caregivers or nursing personnel in close proximity. Perioperative education of caregivers, use of the least morbid surgical technique, and the control of pain rather than its elimination are prudent steps in the management of tonsillectomy patients.

Role of FOXP3+ CD4+ and FOXP3+ CD8+ T Regulatory Cells in Obstructive Sleep Apnea

Objectives: 1) Examine the immune responses which may underlie adenotonsillar hypertrophy (ATH) associated with obstructive sleep apnea (OSA). 2) Discuss the role of effector and regulatory T-cells in the inflammatory process within the tonsil and its association with apnea-hypopnea index (AHI). Methods: Prospective tonsil specimens were collected from patients undergoing tonsillectomy for OSA at a tertiary-care pediatric hospital between October 2012 and January 2013. Single cell suspensions of the tonsil samples were stained with fluor-conjugated antibodies against CD3, CD4, CD8, FoxP3 (a regulatory T-cell marker), and CD45RO (an activated effector T-cell marker). The stained cells were then analyzed by flow cytometry. The levels of effector and regulatory T-cells were then correlated with severity of disease, as quantified by AHI determined from polysomnography. Results: CD4 effector T-cells (CD4 T-eff) were significantly upregulated in pediatric patients with an AHI 5 relative to those with AHI &lt; 5. This result, calculated by Mann-Whitney two-tailed test, indicates that the fraction of activated T-cells increased with elevated AHI (P &lt; 0.0095). FoxP3+ CD8 T-cells (CD8 TcReg) were present at lower levels in patients with an elevated AHI. When these data were plotted as the ratio of CD8 T-eff to CD8 TcReg versus AHI, a correlation coefficient of 0.67 was observed. Conclusions: The significant upregulation of CD4 T-eff and the increased ratio of CD8 T-eff to CD8 TcReg in relation to elevated AHI both suggest a immunologically-driven response that is contributing to ATH and the development of OSA.

Sleep Apnea: Why Should We Look for Cardiac Biomarkers?

Sleep Apnea: Why Should We Look for Cardiac Biomarkers?

Snoring and Obstructive Sleep Apnea Among Former World Trade Center Rescue Workers and Volunteers

Snoring is a common symptom among workers with adverse health effects from their World Trade Center (WTC) occupational exposures. Rhinitis and upper airway disease are highly prevalent among these workers. Rhinitis has been associated with snoring and, in some studies, with obstructive sleep apnea (OSA). We examined the association of WTC exposure and findings on nocturnal polysomnogram, as well as known predictors of OSA in this patient population. One hundred participants with snoring underwent a polysomnogram to exclude OSA. Comorbidities had been previously evaluated and treated. The apnea-hypopnea index (AHI) defined and categorized the severity of OSA. Age, sex, body mass index (BMI), and WTC exposure variables were examined in bivariate and multiple regression analyses. Our study sample had a similar prevalence of five major disease categories, as we previously reported. OSA was diagnosed in 62% of the patients and was not associated with any of those disease categories. A trend toward increasing AHI with increasing WTC exposure duration failed to reach the statistical significance (P = 0.14) in multiple regression analysis. An elevated AHI was associated with BMI (P = 0.003) and male sex (P < 0.001). OSA was associated with BMI and male sex but not with occupational WTC exposure indicators in this patient population.

Memory Before and After Sleep in Patients with Moderate Obstructive Sleep Apnea

The aim of this study was to investigate the effects of obstructive sleep apnea (OSA) on procedural and declarative memory encoding in the evening prior to sleep, on memory consolidation during subsequent sleep, and on retrieval in the morning after sleep. Memory performance (procedural mirror-tracing task, declarative visual and verbal memory task) and general neuropsychological performance were assessed before and after one night of polysomnographic monitoring in 15 patients with moderate OSA and 20 age-, sex-, and IQ-matched healthy subjects. Encoding levels prior to sleep were similar across groups for all tasks. Conventional analyses of averaged mirror tracing performance suggested a significantly reduced overnight improvement in OSA patients. Single trial analyses, however, revealed that this effect was due to significantly flattened learning curves in the evening and morning session in OSA patients. OSA patients showed a significantly lower verbal retention rate and a non-significantly reduced visual retention rate after sleep compared to healthy subjects. Polysomnography revealed a significantly reduced REM density, increased frequency of micro-arousals, elevated apnea-hypopnea index, and subjectively disturbed sleep quality in OSA patients compared to healthy subjects. The results suggest that moderate OSA is associated with a significant impairment of procedural and verbal declarative memory. Future work is needed to further determine the contribution of structural or functional alterations in brain circuits relevant for memory, and to test whether OSA treatment improves or normalizes the observed deficits in learning.

Effect of a Titration Polysomnogram on Treatment Success with a Mandibular Repositioning Appliance

Mandibular repositioning appliance (MRA) therapy is a treatment option for patients with mild to moderate sleep apnea and for patients who do not tolerate continuous positive airway pressure. Titration of MRAs consists of sequential mandibular advancement guided by symptom improvement. The goal of the study was to determine if patients with an elevated apnea hypopnea index (AHI), despite the use of a subjectively optimized MRA, could achieve better results with additional titration during polysomnography (PSG). Patients were enrolled if they had an AHI > or = 15/h and were referred for MRA therapy. The MRAwas advanced until symptoms improved. During the PSG, the technologist monitored the patient's sleep and increased mandibular protrusion until the AHI was improved. There was a significant improvement in AHI, minimum oxygen saturation, and total sleep time with the MRA before further advancement. At the final PSG, 65.2% of patients had an AHI < or = 10 associated with at least a 50% reduction in AHI. The incomplete responders had their appliance further titrated, and this improved the results of MRA therapy by 30.4% to a total success rate of 95.6%. This study shows that it is possible to improve the results of MRA therapy by further advancing the appliance during a titration PSG in patients with an incomplete response. The titration night improved the results of the usual clinical advancement of the MRA with substantially more patients achieving a successful outcome.

Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome

To report the findings of five years' experience using standardized coblation intracapsular tonsillectomy with adenoidectomy for treatment of pediatric sleep apnea. Case series. A five-year retrospective analysis of coblation tonsillectomy performed by a single department for sleep apnea was completed. A total of 159 tonsillectomy and adenoidectomy (T&A) cases performed with coblation technique were reviewed. The mean preoperative apnea-hypopnea index (AHI) was 17.8 and mean postoperative AHI was 3.3. Polysomnogram (PSG) normalization (AHI < 1), was achieved in 54.7% patients. Normalization of PSG data was achieved in only 42.2% of overweight patients (body mass index [BMI] >or= 85th percentile). Based on regression analysis, Friedman tongue position (III and IV) and elevated AHI were determined to be independent predictors of poor response to T&A. Contrary to popular belief, a review of 159 cases demonstrates that T&A does not always result in normalization of polysomnographic data. Although complete resolution is not achieved in most cases, T&A offers significant improvements in AHI. Predictive variables such as BMI, FTP, and AHI should be taken into account when designing a treatment plan. It is important to recognize the need for close follow-up and early detection of residual disease in the pediatric population.

Abstract 2360: Central Sleep Apnea with Nocturnal Hypoxia Promotes Increased Circulating Erythropoietin in Heart Failure

Central sleep apnea (CSA) with nocturnal hypoxia is frequent in heart failure (HF). Hypoxia causes increased circulating erythropoietin (EPO) in healthy normals. EPO promotes increased vasoconstriction and exogenous EPO administration is associated with adverse cardiovascular events. No prior studies have related EPO concentration to apnea or hypoxia due to CSA. EPO is elevated in HF patients with nocturnal hypoxia due to CSA. Ambulatory, non-anemic HF patients (n = 29) with LVEF &lt; 45% and healthy controls (n = 18) underwent polysomnography (PSG). Subjects with obstructive sleep apnea (OSA) were excluded. CSA was defined as apnea-hypopnea index (AHI) ≥ 15. Hypoxia was quantified as the proportion of sleep with arterial oxygen saturation &lt; 90% (T90%). Blood for EPO was drawn post-PSG. Other clinical characteristics were summarized from the medical record. HF subjects and controls were similar age (54 vs 60 y, p = 0.09). CSA was present in 14 HF subjects; 13 were men compared to 8 of 15 without CSA (p = 0.04). HF subjects had 42% higher mean EPO than controls (p &lt; 0.01) despite similar hemoglobin (13.9 vs 14.0 g/dL, p = 0.8). NYHA class III–IV HF subjects had 42% higher mean EPO than class I–II HF subjects (p = 0.05, figure ). EPO concentration was correlated with severity of nocturnal hypoxia by simple linear regression (r = 0.4; p = 0.02). By multivariate analysis, elevated EPO was associated with NYHA class III–IV HF and elevated AHI (p = 0.01 and 0.03, respectively; r = 0.6) after adjusting for age, gender, LVEF, renal function and hemoglobin. Nocturnal hypoxia due to CSA promotes increased endogenous EPO concentration in HF patients.

A Measure of Ventilatory Variability at Wake-Sleep Transition Predicts Sleep Apnea Severity*

Increased variability in ventilation may contribute to the pathogenesis of obstructive sleep apnea (OSA) by promoting ventilatory instability, fluctuations of neuromuscular output to the upper airway, and pharyngeal collapsibility. We assessed the association of a measure of ventilatory variability measured at the wake-sleep transition with OSA and associated covariates. Four hundred eighty-five participants in the Cleveland Family Study underwent overnight polysomnography with independent derivation of the ventilatory variability index (VVI) and the apnea-hypopnea index (AHI). The VVI was calculated from the variability in the power spectrum of the abdominal inductance signal over a 2-min period beginning at sleep onset. The VVI was strongly correlated with the AHI (r=0.43; p<0.001). After adjusting for age, body mass index, sex, and race, the VVI remained significantly associated with AHI (p<0.001). The adjusted odds ratio for OSA (AHI, >or=15) with each half SD increase in VVI was 1.41 (range, 1.25 to 1.59). In a subgroup analysis of obese snorers, to limit analyses to those with a presumed anatomic predisposition for apnea, VVI remained associated with an elevated AHI. Increased ventilatory variability may be a useful phenotype in characterizing OSA.

The Epworth Sleepiness Scale in the Identification of Obstructive Sleep Apnea

The Epworth sleepiness scale (ESS) is often used clinically to screen for the manifestations of the behavioral morbidity associated to obstructive sleep apnea (OSA). The purpose of this study was to assess the sensitivity of the ESS in the identification of OSA, as defined by an elevated apnea-hypopnea index. A retrospective chart review of 268 consecutive patients diagnosed with OSA at a multidisciplinary sleep medicine clinic was conducted. The ESS obtained a relatively low sensitivity (66%) in the identification of an apnea-hypopnea index of 5 and above at the suggested cutoff of 10 and increased to 76% at 8. The results of the study showed only fair discriminatory ability of the ESS as a screener for OSA. A score of 8 (instead of 10) is suggested as the cutoff among clinic populations being screened for a sleep disorder.

Sleep-Related Breathing Disorder in Children With Vagal Nerve Stimulators

The effects of vagal nerve stimulation on sleep-related breathing have not been well-described in children. Vagal nerve stimulation was reported to cause decreases in airflow during sleep, although most studies reported this condition to be clinically insignificant. We present a retrospective case series of nine children who underwent polysomnography after vagal nerve-stimulator placement. All children, except for one, had sleep-disordered breathing after stimulator implantation. We describe in further detail a child who manifested severe, obstructive sleep apnea postimplantation, with apneas occurring regularly and consistently with stimulator activity, resulting in an elevated apnea-hypopnea index of 37 per hour. Polysomnography was repeated with the stimulator turned off, and revealed complete resolution of the stimulator-related sleep apnea. With the vagal nerve stimulator back on, continuous positive airway pressure treatment was effective in normalizing the apnea-hypopnea index. This study demonstrates that severe and clinically significant disturbances in sleep-related breathing may occur with vagal nerve stimulators. Obstructive apneas of this severity, related to vagal nerve stimulators, were not previously described in pediatric patients. This effect on sleep-related breathing warrants further investigation and care in managing pediatric patients.

Natural course of complex sleep apnea—a retrospective study

Patients with complex sleep apnea syndrome (CompSAS) have obstructive sleep apnea but develop troublesome central sleep apnea activity or Cheyne-Stokes breathing when provided continuous positive airway pressure (CPAP) therapy. We examined whether CompSAS activity persists with long-term CPAP treatment. We retrospectively identified all patients with CompSAS who underwent two therapeutic polysomnograms (PSGs) separated by at least 1 month during 2003-2005. We compared PSG findings between the initial and follow-up study and noted clinical responses to therapy. We identified 13 CompSAS patients meeting criteria. Most follow-up PSGs were ordered after an abnormal overnight oximetry on CPAP or because of CPAP intolerance after 195 (49-562) days. The residual apnea-hypopnea index (AHI) on CPAP decreased from 26 (23-40) on the first PSG to 7 (3-21.5) on the follow-up PSG. Only seven patients reached AHI < 10 and 6 had AHI > or = 10 ("CPAP nonresponders") at follow-up. "CPAP nonresponders" were sleepier (Epworth Sleepiness Score 13 [12.5-14] vs 9 [6-9.5], p = 0.03) and trended toward lower body mass index (29.7 [28.6-31.6] vs 34.3 [32.5-35.1], p = 0.06). Both groups were equally compliant with CPAP therapy. Although the AHI tends to improve over time in CompSAS patients treated with CPAP, in this retrospective study nearly half-maintained a persistently elevated AHI. A prospective trial is merited to determine the optimal treatment for these patients.

OSAS in Down syndrome: T&A versus T&A plus lateral pharyngoplasty

Obstructive Sleep Apnea Syndrome (OSAS) is common in children with Down syndrome (DS). Adenotonsillectomy (T&A) has traditionally been the initial surgical treatment. More aggressive surgery has also been recommended. Previous studies have used parental reporting and not objective data to assess treatment outcomes. Polysomnography (PSG) is used to objectively evaluate the results of T&A versus T&A plus lateral pharyngoplasty in the initial treatment of OSAS in children with DS. This is a retrospective study of children with OSAS and DS. Group 1 consisted of 21 children with DS who underwent T&A. Group 2 consisted of 16 children of similar age who had T&A plus lateral pharyngoplasty as initial surgical treatment. Post-operative PSG's were available for all patients. Apnea/hypopnea index (AHI), presence of hypoxemia and hypercarbia, and arousal index were measured and compared. In group 1, after T&A, 48% continued to have an elevated AHI. If hypercarbia and hypoxemia are included in the result analysis, 67% continued to have abnormal PSG's after their surgery. In group 2, 63% had an elevated AHI post-operatively. When hypercarbia and hypoxemia are included in the analysis, 75% continued to have abnormal PSG's after surgery. There was no statistically significant difference in the outcome of the two groups. Pediatric patients with OSAS and DS may show improvement after T&A, however only about one third will have a normal post-operative sleep study. Adding a lateral pharyngoplasty does not improve these results. Further study with objective outcome data is needed to determine a better first line surgical treatment for these patients.

Obstructive sleep apnea, nocturia and polyuria in older adults.

The purpose of this study was to examine the relationship between nocturia and obstructive sleep apnea (OSA) in community dwelling older men and women. A repeated measures design was employed over a 24-hour period. The study was conducted in a clinical research center. Thirty community-dwelling elders (mean age=65.5, SD=8.4 years) with symptoms of nocturia and sleep disordered breathing, volunteered to participate. Both men (n = 13) and women (n = 17) and minority subjects (African-Americans, n = 19; Caucasian, n = 11) were included in the study. NA. Blood specimens were collected every 4 hours, except for an 8-hour collection period overnight. Urine specimens were collected ad libitum and at the end of each data collection interval. Urine and blood specimens were analyzed for ANP and AVP content. Polysomnography was conducted using a full 18-channel montage. Apnea was defined as a decrease in airflow of > or = 90% for a minimum of 10 seconds. Hypopnea was defined as > or = 30% decrease in airflow and desaturations required a > or = 3% decrease in oxygen saturation for a minimum of 10 seconds. The apnea hypopnea index (AHI) was calculated as the sum of apneas and hypopneas divided by hours of sleep. Twenty of the thirty subjects were found to have clinically diagnosable OSA (AHI > or = 5). AVP excretion was not correlated with changes in AHI levels. Conversely, total urine output, plasma ANP and urine ANP excretion were significantly higher among subjects with higher AHI levels (> 15). In subjects with elevated AHI (> 15), nighttime urine production and ANP excretion are elevated.