Management Of Apnea Research Articles

Obstructive Sleep Apnea Management: An Overview of the Literature.

Different approaches have been proposed to treat obstructive sleep apnea (OSA). This article reviews a synopsis of the available literature regarding the management of OSA. A comprehensive review of the literature on the management of OSA began with a search of English-language peer-reviewed manuscripts using PubMed and MEDLINE. The focus was on clinical research articles published between 1996 and 2016. A search of relevant dental journals was also completed. OSA can be managed through behavior management, continuous positive airway pressure (CPAP), oral appliances, and other therapies. Clinicians may select treatment modalities based on the severity of clinical presentation and the patient's symptoms. Studies showed an enhancement in the quality of life in many patients who have been treated with oral appliances, and patients in general prefer oral appliances over CPAP therapy or any other treatments for OSA because of its convenience.

Current integrated management of obstructive sleep apnea in patients with type 2 diabetes mellitus

Obstructive sleep apnea (OSA) is a common disorder in upper respiratory tract, and high prevalent in patients with Type 2 Diabetes Mellitus (DM-2). OSA can lead to the development of glucose metabolism disorder and accelerate diabetic complications especially the microvascular. Screening for OSAS and selecting appropriate treatment is very important to optimize the efficacy and improve prognosis in patients with DM-2 and ordinary people. More effective strategy should target both controlling blood sugar and improving ventilation in OSA patients with DM-2. Current therapeutic regimens include: therapy of continuous positive airway pressure, controlling blood sugar with insulin, building good sleep habits, weight loss, and orthognathic surgery. Key words: Sleep apnea, obstructive; Diabetes mellitus, type 2; Review

The ABCs of Sleep Apnea Management

The ABCs of Sleep Apnea Management

The ABCs of Sleep Apnea Management

The ABCs of Sleep Apnea Management

The ABCs of Sleep Apnea Management

The ABCs of Sleep Apnea Management

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Objective: Recurrent apnea and hypoxia, which is associated with obstructive sleep apnea syndrome (OSAS), leads to an increase in the degradation of adenosine triphosphatase (ATP) into xanthine, which in turn increases uric acid (UA) concentrations. The study aimed to determine whether an association exists between UA levels and OSAS in patients with hypertension from Xinjiang, China. Design and method: A total of 1893 hospitalized patients with hypertension who firstly attended Hypertension Center of Xinjiang from 2006 to 2012 were consecutively recruited, all subjects underwent polysomnography recordings for OSAS diagnosis, blood pressure assessment, and biochemical blood analysis. Results: The mean age of patients with hyperuricemia was younger than that in controls [(45.5 ± 10.2)yr vs.(47.8 ± 10.1)yr, P < 0.001 in whole population; (44.9 ± 9.9)yr vs.(46.1 ± 9.7)yr, P = 0.035 in males] respectively. Adjusted for age, body mass index, blood pressure, the patients with hyperuricemia presented shorter deep sleep time but greater AHI, mean oxyhemoglobin saturation (SpO2), frequency of SpO2 decreased >=4% and >=5%, and light sleep time. The UA levels significantly increased with the severity of OSAS in whole population and in males, but in females, the lowest level of UA was detected in patients with mild OSAS. Further analysis indicated that waist circumference (WC) displayed lower level in female patients with mild OSAS than those without OSAS. Importantly, AHI and age were significant contributing factors of UA levels in males by stepwise linear regression. While in females, the WC, besides of AHI and age, played as significantly predictor of UA level [β=1.32(0.76–1.88), P < 0.001) regardless of OSAS status.Conclusions: A strong association was found between UA levels and OSAS in a large number of hospitalized patients of Xinjiang. Although it does not qualify for a biomarker alone, besides of obesity, UA levels may be involved in OSAS severity and should be considered in sleep apnea management in the future.

A four-year retrospective review of very low birth weight babies seen at the University of Abuja Teaching Hospital, Abuja, Nigeria

To review the outcome of very low birthweight infants admitted into the Special Care Baby Unit (SCBU) of University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja, Nigeria. A retrospective review of medical records of very low birthweight (VLBW) babies seen at the SCBU of UATH over a 4-year period from April 2006 to March 2010, was undertaken. Data were obtained from patients' folders and analyzed. Overall survival was 60.8%. Survival of infants with birth weight below 1000 grams was 26.8% compared to 66.4% for those between 1000 and 1499 grams. The main determinants of survival were birth weight (p< 0.0001) and gestational age (p = 0.0106). Other predictors of outcome were development of features of respiratory distress syndrome within hours of delivery, recurrent apnoea, drainage of liquor of more than 18 hours before delivery, hyperkalaemia, lack of antenatal care and being born-before-arrival (outborn). Survival rate is low compared to values from other communities in developing countries but better than values from many centres in Nigeria. Timely and effective management of apnoea, respiratory distress syndrome and prevention of extremely low birthweight (ELBW) deliveries through adequate antenatal care are required to improve on the current survival rate.

Management of post-hyperventilation apnea during dental treatment under monitored anesthesia care with propofol.

Although hyperventilation syndrome generally carries a good prognosis, it is associated with the risk of developing severe symptoms, such as post-hyperventilation apnea with hypoxemia and loss of consciousness. We experienced a patient who suffered from post-hyperventilation apnea. A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure. We subsequently successfully provided her with monitored anesthesia care with propofol. Monitored anesthesia care with propofol may be effective for the general management of patients who have severe hyperventilation attacks and post-hyperventilation apnea. This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

Current management of apnea in premature infants: Is caffeine the magic bullet?

Apnea of prematurity is one of the most common problems observed in premature infants and it is associated with other morbidities including worse neurodevelopmental outcome. The incidence is higher in the more immature infants and it occurs in up to 90% of infants born under 28 weeks of gestation. The pathogenesis of apnea is due to immaturity of the respiratory control systems characterized by an abnormal ventilatory response to carbon dioxide and hypoxia combined with immature reflex responses. Upper airway obstruction due to airway instability is also a frequent component in apnea of prematurity. These abnormalities frequently persist until the infants reach 32–36 weeks corrected age or longer in the more immature infants. Severe apneic episodes are frequently associated with hypoxia and bradycardia and because of this they can lead to increased risk of CNS damage and neurological sequelae [1]. Infants who are mechanically ventilated also present frequently with episodes of hypoxemia but the mechanisms for these episodes differ from those of apnea of prematurity. The management of the infant with apnea episodes should start by identifying and correcting known conditions that can increase their incidence. These include metabolic abnormalities such as hypoglycemia, hypocalcemia and metabolic alkalosis, anemia and arterial hypotension, and any condition that increases the work of breathing. Medications that depress CNS activity also favor apnea and should be avoided. The level of arterial oxygenation plays a critical role in control of breathing in premature infants and low arterial oxygen tension increases the incidence of periodic breathing and apnea episodes [2].

Apnea in preterm newborns: determinants, pathophysiology, effects on cardiovascular parameters and treatment

Abstract Apnea, especially in preterm newborns (AoP) is one of the common problems encountered at neonatal units. Numerous factors are likely to play a role in the etiology of apnea. Recent data sugest a role for genetic predisposition of AoP. It seems, that physiological rather than pathological immaturity of the respiratory, or cardiorespiratory control, play a major part in the pathophysiology of AoP. Immaturity of the brainstem, cerebral cortex, receptors of the lungs and the airways as well as of the chemoreceptors contribute to the development of apnea in preterm newborns. Several neurotransmitters (GABA, adenosin, endorphins) and their maturational changes are including in pathogenesis of apnea, too. The instability of the upper airway in preterm infants, asynchrony of musculature of the upper airway and diaphragm, pathological changes in the upper airway and malformations of the central nervous system might also contribute to the occurrence and severity of AoP. In newborns, apnea occurs more frequently in active sleep than in quiet sleep and the frequency of apnea in active sleep is higher in the warm conditions. Durations of apnea correlate with the body heat loss. Cardiovascular changes during apnea - bradycardia, peripheral vasoconstriction and various changes in peripheral blood flow and pressure occur together with changes in ECG. The standard clinical management of apnea includes non-pharmacological treatment (eliciting arousal reactions and reflex breathing by mechanical skin, or mucosa stimulations), pharmacological treatment (methylxanthines are preferred) and application of continuous positive airway pressure (CPAP) or in severe apnea - mechanical ventilation.

Telemedicine-Based Approach for Obstructive Sleep Apnea Management: Building Evidence

BackgroundTelemedicine seems to offer reliable solutions to health care challenges, but significant contradictory results were recently found. Therefore, it is crucial to carefully select outcomes and target patients who may take advantage of this technology. Continuous positive airway pressure (CPAP) therapy compliance is essential to treat patients with obstructive sleep apnea (OSA). We believe that OSA patients could benefit greatly from a telemedicine approach for CPAP therapy management.ObjectiveThe objective of our study was to evaluate the application of a telemedicine-based approach in the CPAP therapy management, focusing on patients’ CPAP follow-up and training.MethodsWe performed two studies. First, (study 1) we enrolled 50 consecutive OSA patients who came to our sleep center for the CPAP follow-up visit. Patients performed a teleconsultation with a physician, and once finalized, they were asked to answer anonymously to a questionnaire regarding their opinion about the teleconsultation. In a second randomized controlled trial (RCT) (study 2), we included 40 OSA patients scheduled for CPAP training. There were 20 that received the usual face-to-face training and 20 that received the training via videoconference. After the session, they were blindly evaluated on what they learned about OSA and mask placement.ResultsMore than 95% (49/50) of the interviewed patients were satisfied with the teleconsultation, and 66% (33/50) of them answered that the teleconsultation could replace 50%-100% of their CPAP follow-up visits. Regarding the RCT, patients who received the CPAP training via videoconference demonstrated the same knowledge about OSA and CPAP therapy as the face-to-face group (mean 93.6% of correct answers vs mean 92.1%; P=.935). Performance on practical skills (mask and headgear placement, leaks avoidance) was also similar between the two groups.ConclusionsOSA patients gave a positive feedback about the use of teleconsultation for CPAP follow-up, and the CPAP training based on a telemedicine approach proved to be as effective as face-to-face training. These results support the use of this telemedicine-based approach as a valuable strategy for patients’ CPAP training and clinical follow-up.

Management of post-hyperventilation apnea during dental treatment under monitored anesthesia care with propofol

Although hyperventilation syndrome generally carries a good prognosis, it is associated with the risk of developing severe symptoms, such as post-hyperventilation apnea with hypoxemia and loss of consciousness. We experienced a patient who suffered from post-hyperventilation apnea. A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure. We subsequently successfully provided her with monitored anesthesia care with propofol. Monitored anesthesia care with propofol may be effective for the general management of patients who have severe hyperventilation attacks and post-hyperventilation apnea. This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

Does Positive Airway Pressure Therapy Result in Improved Sleep Quality?

Introduction:Positive airway pressure (PAP) therapy is the gold-standard for obstructive sleep apnea (OSA) management. While it is known that PAP is efficacious for controlling breathing events during sleep when it is worn at the right pressure for the amount of time prescribed, there is less clear data on how well it improves sleep quality. There are few studies that have examined the effectiveness of PAP therapy on sleep quality.Methods:OSA participants (n = 241) from a larger trial examining a PAP adherence were included. Participants were provided with PAP instruction and followed at 2 months and 4 months. PAP adherence was measured as the number of hours per night at prescribed pressure, an objective measure of treatment adherence. The Pittsburgh Sleep Quality Index (PSQI) was used as the primary measure of sleep quality.Results:The PSQI was significantly correlated with PAP adherence at both the 2-month and 4-month time points, such that lower sleep quality was associated with lower PAP use. This finding held for the sleep disturbance subscale of the PSQI. Over 55% of those using PAP therapy at the 4-month time point continued to report significantly disturbed sleep.Discussion:This study shows that PAP therapy does not appear to improve sleep quality to a degree that would be expected. Over half of those patients using PAP therapy still experienced disturbed sleep. Whether the disturbed sleep is directly attributable to the PAP device itself or to disturbed sleep secondary to uncontrolled OSA when PAP is not worn is worthy of further investigation.

Sleep Apnea Management in “Possible IPF” and “Idiopathic NSIP”: A Case- Series

Purpose: The clinical course of patients with possible idiopathic pulmonary fibrosis (IPF) and idiopathic nonspecific interstitial pneumonia (NSIP) is not well understood. While these patients are clinically followed for disease progression before rendering therapy, the import of sleep-disordered breathing on the disease course is unknown. Methods: Retrospective analysis of possible IPF and idiopathic NSIP patients seen at a single center with review of clinical data pertinent to therapy for co-morbid sleep-disordered breathing was done. Results: 7 patients with possible IPF based upon radiologic possible UIP patterns (5 male and 2 female) and 6 patients with idiopathic NSIP (5 female and 1 male) were followed for an average duration of 40 and 30 months respectively. 6/7 patients with possible IPF required continuous positive airway pressure (CPAP) therapy for sleepdisordered breathing and out of this 5/6 were compliant with therapy. Of idiopathic NSIP patients, 2/6 presented with acute exacerbations. All 6 patients required therapy for OSA out of which 5/6 were treated with CPAP and 1 treated with supplemental oxygen. Patients with possible IPF appeared to stabilize their disease following treatment of OSA and none of the study patients experienced any recurrence of acute exacerbations on CPAP therapy. Conclusions: OSA can be an important problem in patients with possible IPF and idiopathic NSIP. Treatment with nocturnal CPAP therapy in these patients with concomitant OSA may result in stability of underlying interstitial lung disease.

Effectiveness of Three Sleep Apnea Management Alternatives

Home respiratory polygraphy (HRP) may be a cost-effective alternative to polysomnography (PSG) for diagnosis and treatment election in patients with high clinical probability of obstructive sleep apnea (OSA), but there is conflicting evidence on its use for a wider spectrum of patients. To determine the efficacy and cost of OSA management (diagnosis and therapeutic decision making) using (1) PSG for all patients (PSG arm); (2) HRP for all patients (HRP arm); and (3) HRP for a subsample of patients with high clinical probability of being treated with continuous positive airway pressure (CPAP) and PSG for the remainder (elective HRP arm). Multicentric study of 366 patients with intermediate-high clinical probability of OSA, randomly subjected to HRP and PSG. We explored the diagnostic and therapeutic decision agreements between the PSG and both HRP arms for several HRP cutoff points and calculated costs for equal diagnostic and/or therapeutic decision efficacy. For equal diagnostic and therapeutic decision efficacy, PSG arm costs were 18% higher than HRP arm costs and 20% higher than elective HRP arm costs. HRP arm costs tended to be lower than elective HRP arm costs, and both tended to be lower than PSG arm costs if patient costs were omitted. Home respiratory polygraphy is a less costly alternative than polysomnography for the diagnosis and therapeutic decision making for patients with suspected obstructive sleep apnea. We found no advantage in cost terms, however, in using home respiratory polygraphy for all patients or home respiratory polygraphy for the most symptomatic patients and polysomnography for the rest.

Changing the Direction of Sleep Medicine: Business can Boom, but it is Not as Usual

Changing the Direction of Sleep Medicine: Business can Boom, but it is Not as Usual

Association between uric acid levels and obstructive sleep apnea syndrome in a large epidemiological sample.

IntroductionRecurrent hypoxia, which is associated with obstructive sleep apnea syndrome (OSAS), leads to an increase in the degradation of adenosine triphosphatase into xanthine, which in turn increases uric acid concentrations.ObjectiveThe current study aimed to determine whether an association exists between OSAS and uric acid levels in the peripheral blood from a representative population of Sao Paulo (Brazil).MethodsA population-based survey adopting a probabilistic 3-stage cluster sample of Sao Paulo was used to represent the population according to gender, age, and socioeconomic class. A total of 1,042 volunteers underwent polysomnography recordings for OSAS diagnosis, blood pressure assessment, and biochemical blood analysis, and answered questionnaires.ResultsUric acid levels were correlated with most important risk factors for OSAS, such as AHI, desaturation time and index, minimum oxyhemoglobin saturation (SpO2), blood pressure, cholesterol, BMI, triglycerides and arousal, and with OSAS itself. Also, uric acid was increased in OSAS volunteers even after controlling for all confounders. Hyperuricemic volunteers presented lower mean and minimum SpO2 and increased desaturation index. Importantly, minimum SpO2 was a significant predictor of uric acid levels, which in turn was considered an independent predictor for OSAS in the binary logistic model. However, a ROC curve analysis for establishing cut-off points for uric acid levels as a biomarker of OSAS revealed moderate sensitivity and specificity.ConclusionA strong association was found between uric acid levels and OSAS in a representative sample of the population of Sao Paulo. Although they do not qualify for a biomarker alone, uric acid levels may be involved in OSAS severity and should be considered in sleep apnea management in the future.

Methylxanthine use for apnea of prematurity among an international cohort of neonatologists

A recent multinational clinical trial in preterm infants has demonstrated pulmonary and neurodevelopmental benefits from caffeine therapy. Indications for caffeine use in that study were predominantly for treatment of apnea and facilitation of extubation rather than prophylaxis. There are no recent studies that describe current practice of neonatologists and regional differences in regards to indications for starting, monitoring and discontinuing methylxanthine therapy in premature infants. To characterize the spectrum of current practice and demonstrate the extent to which methylxanthine therapy varies by location. A cross-sectional survey of all neonatologists in Thailand, Lebanon, Australia, and a representative sample in the USA regarding management of apnea of prematurity. The response rate was 50% (342/681). The methylxanthine of choice varied greatly across study locations. Prophylactic methylxanthine use is common (62%) among neonatologists in all four study locations. Significant variation exists in almost all aspects of apnea pharmacotherapy practice among neonatologists in different international locations. Prophylactic use of methylxanthine therapy for apnea of prematurity is widespread. We speculate that this expanded use is possibly attributed to the beneficial effects of caffeine therapy in the Caffeine for Apnea of Prematurity (CAP) Trial.

Analysis of cardiopulmonary coupling to assess adaptive servo-ventilation success in complex sleep apnea management

Adaptive servo-ventilation (ASV) is used to treat complex sleep apnea syndrome (CompSAS), but with variable success. Factors influencing success are poorly understood. ASV devices determine their output based upon characteristics of a given breath and on proprietary algorithms that assume a periodic breathing pattern. Periodic breathing patterns produce elevated narrow band low-frequency cardiopulmonary coupling (eNB-LFC). Therefore, we hypothesized that ASV success would correlate with elevated proportions of periodic breathing as marked by eNB-LFC on cardiopulmonary coupling (CPC) analysis. This was a retrospective study of 106 consecutive patients presenting to an academic tertiary care sleep center with CompSAS between July 2008 and July 2009 who underwent ASV titration with polysomnographic signals amenable to CPC analysis. The study included 89 males (84 %) and 17 females (16 %), with mean age of 63.3 years. Median diagnostic apnea-hypopnea index (AHI) was 38 (21, 56)/h, and on continuous positive airway pressure (CPAP), the median residual AHI (CompSAS) was 36.5 (23, 58)/h, with central apneas occurring on average 22.5 (13, 39)/h. ASV brought AHI to 11.0 ± 13.0, with success in 81.1 % of patients, as defined by an AHI of <10/h. NB-LFC was elevated (>0) in 45.3 %; however, the percentage of eNB-LFC did not correlate with ASV treatment success (p = 0.518). No clinical factors were found to be associated with ASV success. ASV was successful in 81 % of patients with CompSAS. However, eNB-LFC calculated from CPC, a marker for periodic breathing, did not correlate with ASV success and therefore may not be a useful tool to predict ASV success.

Perioperative management of obstructive sleep apnea in transsphenoidal neurosurgery

Perioperative management of obstructive sleep apnea in transsphenoidal neurosurgery