Nocturnal Breathing Research Articles

0839 Complex Sleep Apnea Improved with Decompression of a Chiari I Malformation in a Pediatric Patient

Abstract Introduction Chiari malformation (CM) occurs when a portion of the cerebellum herniates through the foramen magnum. CM is categorized as two types. Type 1 involves the cerebellar tonsils and type 2 involves the cerebellum and brain stem. Those with CM can be asymptomatic to having debilitating neurologic symptoms such as dysphagia, tinnitus, emesis, balance difficulty, muscle weakness, and/or headache. Central sleep apnea (CSA) and obstructive sleep apnea (OSA) have been associated with CM. It is postulated that the sleep disordered breathing (SDB) is due to compression of the medulla which houses the breathing center and cranial nerves that play a role in nocturnal breathing. OSA has been thought to be related to muscle weakness of the lower airway in those with CM. After resolving CM with surgical decompression, residual OSA is common requiring treatment with positive airway pressure therapy. Report of Cases: A 3-year-old male with a history of OSA and tonsillar hypertrophy. Polysomnography (PSG) was performed after tonsillectomy and adenoidectomy indicating severe OSA (oAHI 17.7/hr) and CSA (CSAI 29.9/hr). A titration study was conducted and bilevel positive airway pressure spontaneous/timed (BPAP ST) 10/6 cmH2O with a backup rate of 12 breaths per minute was utilized further resolving his SDB and daytime sleepiness. After months of BPAP ST therapy, he presented to an urgent care with symptoms of somnolence, emesis, and nystagmus of the left eye. Magnetic resonance imaging of the brain revealed a 2 cm herniation of the cerebellar tonsils indicating CM type 1. Neurosurgery performed surgical decompression without complication. Post-operative PSG indicated significant improvement of OSA (oAHI of 3.45/hr) and resolution of CSA (0.9/hr). BPAP ST therapy was discontinued with the resolution of his daytime sleepiness and SDB. Conclusion This case demonstrates a patient with severe OSA and CSA due to an undiagnosed CM type 1. OSA and CSA are associated with CM; however, residual OSA typically exists status post decompression and can require positive airway pressure therapy for treatment. Our case demonstrates the need for consideration of CM in patients with complex sleep apnea and that surgical decompression can improve both OSA and CSA in these patients. Support (If Any)

Sex-Specific Difference in the Effect of Altitude on Sleep and Nocturnal Breathing in Young Healthy Volunteers.

Importance: To date, there is no established evidence of sex-specific differences in altitude-induced sleep-disordered breathing (SDB) during polysomnography-confirmed sleep. Objective: The aim of this study was to investigate whether differences in sex play a pivotal role in incidences of SDB and acute mountain sickness (AMS) when staying overnight at high altitude. Design: This was a prospective cohort study. Setting: Participants underwent overnight polysomnography (PSG) and clinical assessment in a sleep laboratory at 500 m and two consecutive days at 3270 m. Participants: The participants comprised 28 (18 women) healthy, young, low-altitude residents with a median (interquartile range) age of 26.0 (25.0, 28.0) years. Exposures: Altitude exposure. Main outcomes and Measures: The primary outcome was altitude-induced change in the PSG-confirmed apnea–hypopnea index (AHI) at 3270 m compared to 500 m between men and women. Secondary outcomes included sex differences in other parameters related to SDB, sleep structure, AMS, psychomotor vigilance test reaction time and parameters from arterial and venous blood analyses. Results: The median (interquartile range) AHIs at 500 m and 3270 m on night 1 and on night 2 were 6.5/h (3.6, 9.1), 23.7/h (16.2, 42.5) and 15.2/h (11.8, 20.9) in men, respectively, and 2.2/h (1.0, 5.5), 8.0/h (5.3, 17.0) and 7.1/h (4.9, 11.5) in women, respectively (p < 0.05 nights 1 and 2 at 3270 m vs. 500 m in men and women). The median difference (95% CI) of altitude-induced change in AHI (3270 m night 1 compared to 500 m) between men and women was 11.2/h (1.9 to 19.6) (p < 0.05). Over the time course of 2 days at 3270 m, 9 out of 18 (50%) women and 1 out of 10 (10%) men developed AMS (p < 0.05 women versus men). Conclusions and Relevance: This prospective cohort study showed that men were more susceptible to altitude-induced SDB but that they had a lower AMS incidence when staying for 2 days at 3270 m than women. These findings indicate that sex-related prevention and intervention strategies against SDB and AMS are highly warranted. Trial Registration: This trial was registered at the Chinese Clinical Trial Registry; No. ChiCTR1800020155.

Primary cheilorhinoseptoplasty using the Talmant protocol in unilateral complete cleft lip: functional and aesthetic results on nasal correction and comparison with the Tennison–Malek protocol

Many surgical procedures used to treat patients with unilateral complete cleft lip do not include a complete primary rhinoseptoplasty, which is delayed until the end of growth as part of secondary surgery. Primary cheilorhinoseptoplasty using the Talmant technique has been performed at Lapeyronie University Hospital, Montpellier for 15 years. This retrospective study evaluated and compared the functional and aesthetic results obtained in such patients at 4–6 years after surgery with those obtained without primary rhinoseptoplasty in patients undergoing the Tennison–Malek technique. This study included a cohort of 60 children who presented a unilateral complete cleft lip: 29 were operated on with the Tennison–Malek technique and 31 with the Talmant technique. Three functional and 14 aesthetic criteria were evaluated. All functional criteria showed better results in the Talmant group: nocturnal nasal breathing (P < 0.001), incidence of closed rhinolalia (P = 0.0019), and presence of asymmetric nasal breathing (P < 0.001). Concerning the aesthetic results, all criteria evaluated on the frontal and basal photographs of each patient showed significantly better results in the Talmant technique group. The rate of satisfactory results was> 75% for 12 of the 14 criteria in the Talmant group, compared with none of the 14 criteria in the Tennison–Malek group.

Influence of nocturnal hypoxemia on follow-up course after type B acute aortic syndrome

IntroductionAssociation between sleep nocturnal breathing disorders and acute aortic syndrome (AAS) has been described but mid-term data are scarce.ObjectivesWe assessed the prognostic value of sleep apnea parameters and their relationship with aortic morphology after the onset of a type B AAS.MethodsBetween January 2010 and January 2018, sleep apnea screening in post type B AAS was prospectively performed. The association of sleep apnea parameters with aortic morphology and aortic expansion during follow-up was studied.ResultsOver the 8-year-study period, 103 patients were included, with a mean age of 57.8 ± 12.1 years old. Median follow-up was 25.0 months (11.0–51.0). Thirty-two patients (31%) required aortic stenting during the acute phase. In patients treated by aortic stenting, the descending thoracic aortic diameter was positively associated with a higher percentage of nocturnal time of saturation ≤ 90% after adjustment (p = 0.016). During follow-up, the nocturnal time of saturation ≤ 90% in patients treated by medical therapy was the only parameter associated with significant aortic expansion rate (r = 0.26, p = 0.04). Thirty-eight patients started and sustained nocturnal ventilation during follow-up. The association between aortic expansion rate and nocturnal time of saturation ≤ 90% did not persist during follow-up after adjustment on nocturnal ventilation initiation (r = 0.25, p = 0.056).ConclusionsNocturnal hypoxemia parameters are positively associated with the max onset aortic diameter and significant aortic growth after type B AAS. Nocturnal ventilation seems to mitigate aortic expansion during follow-up.

Reconstitution of Monocyte Subsets and PD-L1 Expression but Not T Cell PD-1 Expression in Obstructive Sleep Apnea Patients upon PAP Therapy.

Obstructive sleep apnea (OSA) is characterized by nocturnal breathing intermissions resulting in oxidative stress and eventually, a low-grade systemic inflammation. The study aimed to investigate the impact of positive airway pressure (PAP) therapy on the inflammatory milieu as measured by monocyte and T cell phenotypic alterations. Participants were assessed for their OSA severity before PAP therapy and about six months later, including patient-reported outcome and therapy usage by telemetry readout. The distributions of the CD14/CD16-characterized monocyte subsets as well as the CD4/CD8-characterized effector T cell subsets with regard to their PD-1 and PD-L1 expression were analyzed by flow cytometry from blood samples. Data of 25 patients revealed a significant reconstitution of the monocyte subset distribution and a decrease in PD-L1 expression on pan-monocytes and CD8+ T cells without an association to initial AHI and overweight. The PD-1 expression was still increased on T cell subsets, especially on CD4+ TH17/22 cells. We conclude that PAP therapy might have a rapid effect on the monocyte phenotype and overall PD-L1 expression levels. However, T cell immune alterations especially on TH17/22 cells persist longer, indicating an ongoing disturbance of the adaptive immune system.

Reduced tongue mobility: an unrecognized risk factor of childhood obstructive sleep apnea.

Childhood obstructive sleep apnea (OSA) is an important and prevalent disease. A short lingual frenulum is a risk factor for OSA, but whether tongue mobility also plays a role in OSA etiology remains unknown. This study aimed to examine tongue mobility in children with and without OSA. We hypothesized that reduced tongue mobility was associated with OSA. We also evaluated the relationship between tongue mobility and craniofacial profile. This was a cross-sectional case-control study. Prepubertal Chinese children aged 5-12 years, suspected to have OSA were recruited from our sleep disorder clinic. All subjects underwent overnight polysomnography. The lingual frenulum was evaluated based on tongue mobility and free tongue length. Craniofacial measurements were assessed by lateral cephalometry. Eighty-two subjects (mean age: 8.32 ± 1.70 years, 57 males) were recruited. The mean tongue mobility was 58.2 (±19)% and 67.4 (±15)% (p = 0.019) in subjects with and without OSA, respectively. Tongue mobility was inversely correlated with OAHI (r = -0.218, p = 0.049). In multivariate logistic regression, low tongue mobility was independently associated with a higher risk of OSA after adjustment for age, sex, body mass index z-score, presence of large tonsils and turbinates, and nocturnal oral breathing (odds ratio = 3.65, 95% CI = 1.22 to 11.8). Tongue mobility was found to correlate with the cranial base angle (Ba-S-N) (r = 0.262, p = 0.018), which determines the relative position of the mandible. In prepubertal children, reduced tongue mobility is associated with the occurrence and severity of OSA. Assessing tongue mobility is recommended in childhood OSA management.

Effects of opioids on respiration assessed by a contact-free unconstraint respiratory monitor with load cells under the bed in patients with advanced cancer.

Nocturnal periodic breathing of chronic opioid users has been predominantly documented by the use of polysomnography. No previous studies have assessed the opioid effects of respiratory rhythms throughout the day without the use of physical restraint. We recently developed a contact-free unconstraint vital sign monitoring system with four load cells placed under the bed legs, which allows continuous measurements of respiratory change at the center of gravity on the bed. We aimed to reveal details of the patient's 24-h respiratory status under a monitoring system and to test the hypothesis that respiratory rhythm abnormalities are opioid dose-dependent and worsen during the night time. Continuous 48-h respiratory measurements were successfully performed in 51 patients with advanced cancer (12 opioid-free patients and 39 opioid-receiving patients). Medians of respiratory variables with minimal body movement artifacts were calculated for each 8-h split time period. Compared with opioid-free patients, opioid-receiving patients had slower respiratory rate with higher respiratory rate irregularity without changing tidal centroid shift regardless of the time period. Irregular ataxic breathing was only identified in opioid-receiving patients (33%, P = 0.023) whereas incidence rate of periodic breathing did not differ between the groups. Multivariate regression analyses revealed that opioid dose was an independent risk factor for occurrence of irregular breathing [odds ratio 1.81 (95% CI: 1.39-2.36), P < 0.001], and ataxic breathing [odds ratio 2.08 (95% CI: 1.60-2.71), P < 0.001]. Females developed the ataxic breathing at lower opioid dose compared with males. We conclude that respiratory rhythm irregularity is a predominant specific feature of opioid dose-dependent respiratory depression particularly in female patients with advanced cancer.NEW & NOTEWORTHY Through usage of a novel contact-free unconstraint vital sign monitoring system with four load cells placed under the bed legs allowing continuous measurements of respiratory changes of center of gravity on the bed, this study is the first to assess detailed respiratory characteristics throughout day and night periods without interference of daily activities in patients with advanced cancer receiving opioids. Respiratory rhythm irregularity is a predominant specific feature of opioid dose-dependent respiratory depression particularly in female patients with advanced cancer.

Interrelationships Between the Posterior Pharyngeal Space and the Dento-Maxillary Anomalies

Introduction: Nocturnal breathing problems have become more common and cause problems during the day for both those affected by this condition and those around them. These problems are caused in most cases by a decrease in the size of the pharyngeal posterior space, which is associated with various abnormalities of the facial skeleton, and the positioning of the tongue. Purpose: The present study has the purpose to determine the existence of a correlation between different facial skeletal abnormalities and the size of the pharyngeal posterior space. Materials and methods: In the present study we performed the analysis of 131 teleradiographs from the database of the department of orthodontics and dentofacial orthopedics within UMFST “Târgu Mureș” performed on patients in order to perform an orthodontic treatment. Patients range in age from 10 to 21 years. Results: To observe the existence of a link between the median differences in values in the lower pharyngeal space between class I and class II, we used the Mann-Whitney U test to compare median values. Thus, the median value in class I is 0, while the median value in class II is 0.3. It was concluded that this difference is statistically significant (p = 0.02). Conclusion: Patients with skeletal class II have smaller dimensions of the lower pharyngeal space than patients with class I and class III. Patients with skeletal class II have an increased risk compared to those with class I or class III of developing obstructive sleep apnea-hypopnea syndrome during their lifetime.

Brugada syndrome: current concepts and genetic background

Brugada syndrome (BrS) is a hereditary clinical-electrocardiographic arrhythmic entity with low worldwide prevalence. The syndrome is caused by changes in the structure and function of certain cardiac ion channels and reduced expression of Connexin 43 (Cx43) in the Right Ventricle (RV), predominantly in the Right Ventricular Outflow Tract (VSVD), causing electromechanical abnormalities. The diagnosis is based on the presence of spontaneous or medicated ST elevation, characterized by boost of the J point and the ST segment ≥2 mm, of superior convexity "hollow type" (subtype 1A) or descending rectilinear model (subtype 1B). BrS is associated with an increased risk of syncope, palpitations, chest pain, convulsions, difficulty in breathing (nocturnal agonal breathing) and/or Sudden Cardiac Death (SCD) secondary to PVT/VF, unexplained cardiac arrest or documented PVT/VF or Paroxysmal atrial fibrillation (AF) in the absence of apparent macroscopic or structural heart disease, electrolyte disturbance, use of certain medications or coronary heart disease and fever. In less than three decades since the discovery of Brugada syndrome, the concept of Mendelian heredity has come undone. The enormous variants and mutations found mean that we are still far from being able to concretely clarify a genotype-phenotype relationship. There is no doubt that the entity is oligogenetic, associated with environmental factors, and that there are variants of uncertain significance, especially the rare variants of the SCN5A mutation, with European or Japanese ancestors, as well as a spontaneous type 1 or induced pattern, thanks to gnomAD (coalition) researchers who seek to aggregate and harmonize exome and genome sequencing data from a variety of large scale sequencing projects and make summary data available to the scientific community at large). Thus, we believe that this in depth analytical study of the countless mutations attributed to BrS may constitute a real cornerstone that will help to better understand this intriguing syndrome.

Obstructive sleep apnea in Norwegian adults with achondroplasia: a population-based study

BackgroundPrevious studies have found a high prevalence of obstructive sleep apnea (OSA) in children with achondroplasia, but clinical studies on this complication in adults with achondroplasia are lacking.ObjectivesThis population-based, cross-sectional study investigated the prevalence, severity, and predictive factors of OSA in Norwegian adults with achondroplasia.MethodsWe collected clinical data on 49 participants. Participants without a preexisting diagnosis of OSA had an overnight sleep registration. OSA was defined as an apnea–hypopnea index (AHI) ≥ 5 plus characteristic clinical symptoms, or AHI ≥ 15. We used the Berlin Questionnaire to assess clinical symptoms of OSA.ResultsOSA was found in 59% (29/49) of the participants (95% confidence interval 44 to 73%), of whom 59% (17/29) had moderate to severe OSA (AHI ≥ 15), and 48% (14/29) were previously undiagnosed. Variables predictive of OSA were: excessive daytime sleepiness; unrested sleep; loud snoring; observed nocturnal breathing stops; hypertension; age > 40 years; and BMI > 30 kg/m2.ConclusionOSA was highly prevalent in Norwegian adults with achondroplasia, which we believe is representative of this population worldwide. Follow-up of adults with achondroplasia should include assessment of symptoms and signs of OSA, with a low threshold for conducting an overnight sleep registration if findings suggestive of OSA are present.

ÉJSZAKAI LÉGZÉSZAVAR EPIZÓDOK ÉS A SZÍVFREKVENCIA VARIABILITÁS KAPCSOLATA

Bevezetés: Vizsgálatunk célja volt összehasonlítani, a szívfrekvencia variabilitás éjszakai és nappali értékeit alvási apnoe szindrómában szenvedők és kontroll csoport között. Célunk volt továbbá vizsgálni, az apnoe súlyosságának hatását a HRV index mutatókra. &#x0D; Célkitűzés: Célunk volt vizsgálni, hogy az éjszakai légzészavar epizódok befolyásolják -e a HRV indexeket. &#x0D; Módszer: A vizsgálatban 40 fő adatait elemeztük, akik közül 20 személy alvási apnoes. A kontroll csoportba 20 olyan személy adatai kerültek, akiknek nincs alvási apnoéjuk. A szívfrekvencia variabilitás idő és frekvencia paramétereit vizsgáltuk, melyhez 24 órás Schiller Medilog Holter monitor által rögzített adatok nappali és éjszakai értékeit használtunk. A két csoport átlagának eltérését kétmintás t-próbával vizsgáltuk, ahol a p&lt;0,05.&#x0D; Eredmények: A vegetatív egyensúlyi arányszámot és az R-R intervallumok standard deviációját vizsgálva, egyaránt szignifikáns különbséget kaptunk az apnoes betegek és egészséges csoport között az éjszakai időszakban. Az apnoe súlyosságát vizsgálva az idő és frekvencia mutatók átlagában nem találtunk szignifikáns különbséget a két csoport között, azonban az apnoes csoport értékeinek szűkülése a kontroll csoporthoz képest megfigyelhető. &#x0D; Következtetés: Az apnoes betegek és a kontroll csoport vegetatív egyensúlyi arányszámának és idő paramétereinek éjszakai különbségei, illetve a kórkép súlyosságának változásával regisztrálható HRV mutató eltérések felhívják a figyelmet, a HOLTER monitorral mért HRV mutatók jelentőségére az éjszakai légzészavar epizódok szűrésének lehetőségére.

Effect of the novel dual orexin receptor antagonist daridorexant on night-time respiratory function and sleep in patients with moderate chronic obstructive pulmonary disease.

In patients with chronic obstructive pulmonary disease (COPD), sleep is often fragmented while, conversely, the use of sleep medications is of concern in these patients due to potential impairment of nocturnal breathing. This randomised, double-blind, placebo-controlled, two-period crossover study was conducted to evaluate the effect of the new dual orexin receptor antagonist daridorexant on night-time respiratory function and sleep in patients with moderate COPD. In each period, the highest Phase-III dose of 50mg daridorexant or placebo was administered once daily in the evening for 5 consecutive days. The primary endpoint was peripheral oxygen saturation (SpO2 ) during total sleep time (TST) after last dosing. Night-time respiratory function and sleep were further evaluated based on the apnea-hypopnea index (AHI), sleep duration, and objective sleep parameters. Pharmacokinetics, safety, and tolerability were also assessed. Primary endpoint analysis revealed no significant mean treatment difference (i.e. daridorexant-placebo) for SpO2 during TST as it was 0.18% (90% confidence interval: -0.21 to 0.57). There was also no difference from placebo for SpO2 during non-rapid eye movement (REM) and REM sleep at Night 5 and after first dosing. The AHI was slightly increased compared to placebo, but not to a clinically meaningful extent. In addition, daridorexant improved objective sleep parameters (i.e. prolonged TST, increased sleep efficiency, and decreased wake after sleep onset), reached expected plasma concentrations, and was safe and well tolerated. In conclusion, single and multiple doses of 50mg daridorexant do not impair night-time respiratory function and improves sleep in patients with moderate COPD.

Effects of endobronchial coils for endoscopic lung volume reduction on sleep in COPD patients with advanced pulmonary emphysema.

Treatment of advanced pulmonary emphysema with endobronchial coils can improve clinical outcomes like quality of life (QOL). Yet, patients with chronic obstructive pulmonary disease (COPD) are also known to suffer from reduced sleep quality. The effect of coil therapy on sleep has not yet been investigated. The primary aim of this study was to investigate sleep efficiency before and after coil treatment. Secondly, we investigated the effects on nocturnal breathing pattern, QOL, and physical activity. Polysomnography (PSG) testing was performed before (T0), 6 month after (T3), and 12 months after (T4) treatment with endobronchial coils. Further examinations included QOL by St George's Respiratory Questionnaire (SGRQ) and COPD assessment test (CAT), and physical activity using an accelerometer for 1 week after each visit. Of 21 patients, 14 completed the study: 6 women; meanage 58.0 ± 4.9years; BMI 22.6 ± 4.6 kg/m2; FEV1 28.6 ± 7.1% predicted; residual volume (RV) 278.2 ± 49.4% predicted. Sleep efficiency did not vary between baseline and follow-up examinations (T0 69.0 ± 15.8%; T3 70.9 ± 16.0%; T4 66.8 ± 18.9%). Non-REM respiratory rate decreased compared to baseline (T0 19.4 ± 3.9/min; T3 17.8 ± 3.5/min; T4 17.1 ± 3.1/min (p = 0.041; p = 0.030) and QOL improved meeting the minimal clinically important difference (MCID) (SGRQ, T3 -12.8 units; T4 -7.1 units; CAT: T3 -5.6 units; T4 -3.4 units). No increase in physical activity was recorded (light activity T0 31.9 ± 9.9; T3 30.8 ± 16.9; T4 26.3 ± 10.6 h/week). Treatment with endobronchial coils did not influence objectively measured sleep quality or physical activity, but reduced nocturnal breathing frequency and improved QOL in severe emphysema patients. ClinicalTrials.gov Identifier: NCT02399514, First Posted: March 26, 2015.

Effect of Nocturnal Oxygen Therapy on Nocturnal Hypoxemia and Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease Traveling to 2048 Meters

There are no established measures to prevent nocturnal breathing disturbances and other altitude-related adverse health effects (ARAHEs) among lowlanders with chronic obstructive pulmonary disease (COPD) traveling to high altitude. To evaluate whether nocturnal oxygen therapy (NOT) prevents nocturnal hypoxemia and breathing disturbances during the first night of a stay at 2048 m and reduces the incidence of ARAHEs. This randomized, placebo-controlled crossover trial was performed from January to October 2014 with 32 patients with COPD living below 800 m with forced expiratory volume in the first second of expiration (FEV1) between 30% and 80% predicted, pulse oximetry of at least 92%, not requiring oxygen therapy, and without history of sleep apnea. Evaluations were performed at the University Hospital Zurich (490 m, baseline) and during 2 stays of 2 days and nights each in a Swiss Alpine hotel at 2048 m while NOT or placebo treatment was administered in a randomized order. Between altitude sojourns, patients spent at least 2 weeks below 800 m. Data analysis was performed from January 1, 2015, to December 31, 2018. During nights at 2048 m, NOT or placebo (room air) was administered at 3 L/min by nasal cannula. Coprimary outcomes were differences between NOT and placebo intervention in altitude-induced change in mean nocturnal oxygen saturation (SpO2) as measured by pulse oximetry and apnea-hypopnea index (AHI) measured by polysomnography during night 1 at 2048 m and analyzed according to the intention-to-treat principle. Further outcomes were the incidence of predefined ARAHE, other variables from polysomnography results and respiratory sleep studies in the 2 nights at 2048 m, clinical findings, and symptoms. Of the 32 patients included, 17 (53%) were women, with a mean (SD) age of 65.6 (5.6) years and a mean (SD) FEV1 of 53.1% (13.2%) predicted. At 490 m, mean (SD) SpO2 was 92% (2%) and mean (SD) AHI was 21.6/h (22.2/h). At 2048 m with placebo, mean (SD) SpO2 was 86% (3%) and mean (SD) AHI was 34.9/h (20.7/h) (P < .001 for both comparisons). Compared with placebo, NOT increased SpO2 by a mean of 9 percentage points (95% CI, 8-11 percentage points; P < .001), decreased AHI by 19.7/h (95% CI, 11.4/h-27.9/h; P < .001), and improved subjective sleep quality measured on a visual analog scale by 9 percentage points (95% CI, 0-17 percentage points; P = .04). During visits to 2048 m or within 24 hours after descent, 8 patients (26%) using placebo and 1 (4%) using NOT experienced ARAHEs (P < .001). Lowlanders with COPD experienced hypoxemia, sleep apnea, and impaired well-being when staying at 2048 m. Because NOT significantly mitigated these undesirable effects, patients with moderate to severe COPD may benefit from preventive NOT during high altitude travel. ClinicalTrials.gov Identifier: NCT02150590.

Palliative Care in Pediatrics: Perception of the Multi-Professional Team

Introduction: Palliative care with the Cicely Saunders, in the 20th century and consists of the care and assistance to the patient and their families, ensuring better quality of life, aiming at controlling pain and suffering, with attention to physical aspects, spiritual, social and psychic. Objectives: To approach the respiratory and motor care of a pediatric patient in palliative care by nursing and physiotherapy, restricted to the bed, with non-progressive Hypoxic-Ischemic Encephalopathy, with metabolic syndrome under investigation, chronic pulmonary disease dependent on oxygen, alternating macronebulization and ventilatory prosthesis (PSV) for nocturnal breathing comfort. Methodology: This is an experience report lived by residents in a public university hospital in Rio de Janeiro, during the month of June 2018 in the pediatric ward. Through multidisciplinary action, interventions were carried out to improve the patient’s condition and minimize pain aspects through the care of the patient’s respiratory and motor functions and maternal guidance. Results and Discussion: Bearing in mind that palliative care focuses on minimizing pain and suffering, the actions presented above are in line with most of the published studies relating palliative care and improving quality of life with reducing the suffering of child and family members, guided by the bioethical principles of beneficence and non-maleficence. Conclusion: Through the applied procedures, greater independence of the ventilatory prosthesis was found, enabling the strengthening of the family bond, concomitant to the learning of the professionals involved related to palliative care in pediatric patients.

Palliative Care in Pediatrics: Perception of the Multiprofessional Team

Introduction: Palliative care with the Cicely Saunders, in the 20th century and consists of the care and assistance to the patient and their families, ensuring better quality of life, aiming at controlling pain and suffering, with attention to physical aspects, spiritual, social and psychic.Objectives: To approach the respiratory and motor care of a pediatric patient in palliative care by nursing and physiotherapy, restricted to the bed, with non-progressive Hypoxic-Ischemic Encephalopathy, with metabolic syndrome under investigation, chronic pulmonary disease dependent on oxygen, alternating macronebulization and ventilatory prosthesis (PSV) for nocturnal breathing comfort. Methodology: This is an experience report lived by residents in a public university hospital in Rio de Janeiro, during the month of June 2018 in the pediatric ward. Through multidisciplinary action, interventions were carried out to improve the patient’s condition and minimize pain aspects through the care of the patient’s respiratory and motor functions and maternal guidance.Results and Discussion: Bearing in mind that palliative care focuses on minimizing pain and suffering, the actions presented above are in line with most of the published studies relating palliative care and improving quality of life with reducing the suffering of child and family members, guided by the bioethical principles of beneficence and non-maleficence.Conclusion: Through the applied procedures, greater independence of the ventilatory prosthesis was found, enabling the strengthening of the family bond, concomitant to the learning of the professionals involved related to palliative care in pediatric patients.

Subjective nocturnal symptoms have different associations with depressive symptoms and anxiety than with daytime sleepiness in patients with obstructive sleep apnea

BackgroundWe determined the relationships among the subjective symptoms of sleep apnea and daytime sleepiness, depressive symptoms, and anxiety in adults with obstructive sleep apnea (OSA). MethodsWe developed the Subjective Apnea Severity Questionnaire (SASQ) to measure subjective OSA symptoms during the night and on waking in the morning. Construct validity and reliability were assessed. The Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), and State Scale of State Trait Anxiety Inventory (STAI-S) were applied. Multiple linear regression analyses were performed, and the results were adjusted for several confounders. ResultsA total of 337 OSA patients were included. The SASQ consists of eight items with three domains. Cronbach's α for the SASQ was 0.657. The mean SASQ score was 1.35 ± 0.59. Symptoms related to nocturnal breathing difficulties were associated with polysomnographic (PSG) respiratory parameters. In the adjusted models, total SASQ scores were associated with ESS scores but not with BDI or STAI-S scores. Unlike other symptom groups, nocturnal breathing difficulties tended toward a positive relationship with ESS scores (p = 0.076), but were negatively related to BDI scores (p = 0.003) and STAI-S scores (p = 0.012). Symptoms related to nocturnal awakening or morning waking were either positively related or unrelated to ESS, BDI, and STAI-S scores. ConclusionsThe subjective OSA symptoms measured via the SASQ were associated with daytime sleepiness in adults with OSA, but not with depressive symptoms or anxiety. Nocturnal breathing difficulties were positively related to daytime sleepiness, but negatively related to depressive symptoms and anxiety.

Asymmetry of lagged Poincare plot in heart rate signals during meditation

Background and aimHeart rate variability (HRV) quantifies the variability in the heart’s beat-to-beat intervals. This signal is a potential marker of cardiac function in normal, pathological, and psychological states. Signal asymmetry refers to an unequal distribution in the signal, which can be found by a two-dimensional Poincare plot. Earlier, heart rate asymmetry (HRA) was assessed using a conventional Poincare plot (lag of 1). In this study, we have investigated the effect of delay on the phase space asymmetry using lagged Poincare’s plot. Experimental procedureThis study compared the presence/lack of asymmetries in the HRV data of 12 meditators (four Kundalini yoga (Yoga) at an advanced level of meditation, eight Chinese Chi meditators (Chi) ∼1–3 months) to 25 non-meditators (11 spontaneous nocturnal breathing (Normal) and 14 metronomic breathing (Metron)). Poincare’s plots were constructed with six different lags, and HRA was calculated. The analysis was conducted using HRV data provided in the Physionet database. ResultsThe results showed that using conventional Poincare’s plot (lag of 1), the lowest HRA was observed in the Metron group. In addition, the HRA index was different between meditators and non-meditator groups. Moreover, as the most significant difference between groups was observed in a delay of 6, the role of the delay selection on the signal asymmetry was revealed. ConclusionThe difference between lagged HRA responses on Yoga in comparison with other groups can be an emphasis on the importance of choosing the type of meditation technique and its effects on the cardiovascular system.

Brugada Syndrome: Clinical Features, Risk Stratification, and Management.

In 1992, the Brugada brothers published a patient series of aborted sudden death, who were successfully resuscitated from ventricular fibrillation (VF). These patients had a characteristic coved ST-segment elevation in the right precordial leads on their 12-lead electrocardiogram with no apparent structural heart abnormality. This disease was referred to as “right bundle branch block, persistent ST-segment elevation, and sudden death syndrome.” The term Brugada syndrome (BrS) was first coined for this new arrhythmogenic entity in 1996. BrS is more prevalent in Southeast Asian ethnic groups and was considered a familial disease due to the presence of syncope and/or sudden deaths in several members of the same family, however, the genetic alteration was only noted in 1998. The genetic characterization of BrS has proven to be challenging. The most common and well-established BrS genotype involves loss-of-function mutations in the SCN5A gene, but only represents between 15% and 30% of the diagnosed patients. Patients with BrS can present with a range of symptoms which can include syncope, seizures, and nocturnal agonal breathing due to polymorphic ventricular tachycardia or VF. If these arrhythmias are sustained, sudden cardiac death may result. Despite the significant progress on the understanding of BrS over the last two decades, there remain a number of uncertainties and challenges; we present an update review on the subject.

Association of Epworth Sleepiness Score with Anthropometric Measurements in Malaysian University Students

Malaysia has high prevalence of obesity in young adults. Obesity leads to health problems such as obstructive sleep apnea (OSA). It is a condition where nocturnal breathing cessation occurs during sleep. Thus, the quantity and quality of sleep is affected. Epworth Sleepiness Score (ESS) is a standardized tool to determine the quality of sleep. The aim of this study was to find the relationship between students’ sleep quality using this questionnaire and their anthropometric measurements. This study adopted a cross-sectional study design, with the convenience sampling technique applied on students of a private university in Malaysia. The participants answered the ESS questionnaire. Their height, weight, neck circumference, and abdominal circumference were obtained and the body mass index (BMI) was calculated. This study was conducted on 200 students with a mean age of 21.55 years. Their average BMI was 23.24 ± 6.1. The mean duration of sleep in the study population was 6.3 ± 1.4 SD hours. In the study population, the mean score for ESS was 10.32. A negative correlation between ESS scores and the BMI was noted. Pearson correlation showed —0.026 with a significance of 0.712. ESS scores showed that 17.9% of the study population had high risk of developing OSA. This study shows that as the BMI increases, the quality of sleep decreases, although it is not statistically significant.