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Apnea, sleep, obstructive [keywords]
- Supraglottoplasty Outcomes in Neurologically Affected and Syndromic Children. [JOURNAL ARTICLE]
- JAMA Otolaryngol Head Neck Surg 2014 Jun 19.
Supraglottoplasty (SGP) failure is frequently attributed to coexistent medical comorbidities, but studies specifically evaluating outcomes in these populations are lacking.To assess SGP outcomes in patients with neurologic and syndromic comorbidities and severe laryngomalacia (LM).Case series with retrospective review of medical records of 54 patients with neurologic and/or syndromic comorbidity and severe LM who underwent SGP between 2004 and 2012 at a tertiary care pediatric institution.Patients presented with severe LM that required SGP. Supraglottoplasty failure necessitated revision SGP, tracheostomy, or gastrostomy tube insertion, or LM and obstructive sleep apnea that required assisted ventilation (continuous positive airway pressure and bilevel positive airway pressure).Medical records were reviewed with a focus on patient factors, surgical timing, complications, and surgical and dysphagia outcomes. Patients were grouped based on their age at the time of SGP as infants (aged ≤12 months) and children (aged >12 months). Statistical comparisons were performed with SGP outcomes of infants with LM and no comorbidities.Fifty-four patients met the inclusion criteria. Thirty-one (13 infants, 18 children) had a neurologic condition and 23 (15 infants, 8 children) had syndromes. The overall success rate of SGP was 67% (36 of 54) in these populations. Neurologic (P = .003) and syndromic (P < .001) comorbidities were associated with significant reduction in SGP success rates vs no comorbidities. Among SGP failures (18 of 54 [33%]), 13% (7 of 54) required tracheostomy, 9% (5 of 54) needed assisted ventilation, 7% (4 of 54) required a postoperative gastrostomy tube, and 4% (2 of 54) required revision SGP. In the neurologic comorbidities group, patients with cerebral palsy had significantly higher tracheostomy rates compared with those who had other neurologic pathologies constituting comorbidities (2 of 11 [18%] vs 0 of 20; P = .049). In infants, acute airway obstruction was the most common indication for SGP in the neurologically comorbidity and syndrome populations (success rates, 69% and 67%, respectively). In children, obstructive sleep apnea was the most common indication for SGP in the neurologic comorbidity and syndrome populations (success rates, 78% and 50%, respectively).Supraglottoplasty remains useful and outcomes were better in patients with neurologic comorbidity than in patients with syndromic comorbidity.
- Sleep-disordered breathing and inappropriate defibrillator shocks in chronic heart failure. [JOURNAL ARTICLE]
- Herzschrittmacherther Elektrophysiol 2014 Jul 29.
Supraventricular tachyarrhythmias are a major cause of inappropriate defibrillator shocks. Sleep-disordered breathing (SDB) is a known risk factor for atrial fibrillation (AF). We hypothesized that Cheyne-Stokes respiration (CSA) and obstructive sleep apnea (OSA) have an impact on inappropriate defibrillator discharges in patients witch chronic heart failure (CHF) and cardiac resynchronization therapy with defibrillator (CRT-D).In this study, 172 patients with CHF (LVEF ≤ 45 %, NYHA-class ≥ 2) and CRT-D underwent overnight polygraphy; 54 had no SDB (apnea-hypopnea index < 5/h), 59 had OSA, and 59 had CSA. During follow-up (36 months), inappropriate defibrillator shocks were documented.In all, 17 patients had inappropriate defibrillator shocks (9.9 %; eight oversensing due to lead fractures, five caused by atrial fibrillation, four because of sinus tachycardia). Mean event-free survival time was 33.5 ± 1.2 months in the CSA group, 35.2 ± 0.7 months in the OSA group, and 32.1 ± 1.5 months in the no SDB group, respectively (CSA vs. no SDB p = 0.63; OSA vs. no SDB p = 0.31; CSA vs. OSA p = 0.45). Stepwise Cox proportional hazard regression analysis revealed an independent association for age (per year: hazard ratio 0.90, 95 % confidence interval 0.85-0.96, p < 0.001), but not for any kind of SDB.SDB was not associated with inappropriate defibrillator shocks. We assume this is due to the low incidenceand low proportion of inappropriate therapies in response to AF.
- Cognitive impairment in obstructive sleep apnea. [REVIEW]
- Pathol Biol (Paris) 2014 Jul 25.
Obstructive sleep apnea (OSA) is characterised by repetitive cessation or reduction of airflow due to upper airway obstructions. These respiratory events lead to chronic sleep fragmentation and intermittent hypoxemia. Several studies have shown that OSA is associated with daytime sleepiness and cognitive dysfunctions, characterized by impairments of attention, episodic memory, working memory, and executive functions. This paper reviews the cognitive profile of adults with OSA and discusses the relative role of altered sleep and hypoxemia in the aetiology of these cognitive deficits. Markers of cognitive dysfunctions such as those measured with waking electroencephalography and neuroimaging are also presented. The effects of continuous positive airway pressure (CPAP) on cognitive functioning and the possibility of permanent brain damage associated with OSA are also discussed. Finally, this paper reviews the evidence suggesting that OSA is a risk factor for developing mild cognitive impairment and dementia in the aging population and stresses the importance of its early diagnosis and treatment.
- Growth After Adenotonsillectomy for Obstructive Sleep Apnea: An RCT. [JOURNAL ARTICLE]
- Pediatrics 2014 Jul 28.
Adenotonsillectomy for obstructive sleep apnea syndrome (OSAS) may lead to weight gain, which can have deleterious health effects when leading to obesity. However, previous data have been from nonrandomized uncontrolled studies, limiting inferences. This study examined the anthropometric changes over a 7-month interval in a randomized controlled trial of adenotonsillectomy for OSAS, the Childhood Adenotonsillectomy Trial.A total of 464 children who had OSAS (average apnea/hypopnea index [AHI] 5.1/hour), aged 5 to 9.9 years, were randomized to Early Adenotonsillectomy (eAT) or Watchful Waiting and Supportive Care (WWSC). Polysomnography and anthropometry were performed at baseline and 7-month follow-up. Multivariable regression modeling was used to predict the change in weight and growth indices.Interval increases in the BMI z score (0.13 vs 0.31) was observed in both the WWSC and eAT intervention arms, respectively, but were greater with eAT (P < .0001). Statistical modeling showed that BMI z score increased significantly more in association with eAT after considering the influences of baseline weight and AHI. A greater proportion of overweight children randomized to eAT compared with WWSC developed obesity over the 7-month interval (52% vs 21%; P < .05). Race, gender, and follow-up AHI were not significantly associated with BMI z score change.eAT for OSAS in children results in clinically significant greater than expected weight gain, even in children overweight at baseline. The increase in adiposity in overweight children places them at further risk for OSAS and the adverse consequences of obesity. Monitoring weight, nutritional counseling, and encouragement of physical activity should be considered after eAT for OSAS.
- Cost Minimization Using An Artificial Neural Network Sleep Apnea Prediction Tool for Sleep Studies. [JOURNAL ARTICLE]
- Ann Am Thorac Soc 2014 Jul 28.
Rationale: Over a million polysomnograms (PSGs) are performed annually in the United States to diagnose obstructive sleep apnea (OSA). Third party payers now advocate a home sleep test (HST), rather than an in-laboratory PSG, as the diagnostic study for OSA regardless of clinical probability but the economic benefit of this approach is not known. Objectives: We determined the diagnostic performance of OSA prediction tools including the newly developed OSUNet, based on artificial neural network, and performed a cost-minimization analysis when the prediction tools are used to identify patients who should undergo HST. Methods: The OSUNet was trained to predict the presence of OSA in a derivation group of patients who underwent an in-laboratory PSG (n=383). Validation group 1 consisted of in-laboratory PSG patients (n=149). The network was trained further in 33 patients who underwent HST and then validated in a separate group of 100 HST patients (validation group 2). Likelihood ratios (LRs) were compared to two previously published prediction tools. The total costs from the use of the three prediction tools and the third party approach within a clinical algorithm were compared. Measurements and Main Results: The OSUNet had higher +LR in all groups compared to the STOP-BANG and the Modified Neck Circumference (MNC) prediction tools. The +LRs for STOP-BANG, MNC, and OSUNet in validation group 1 were: 1.1 [1.0-1.2], 1.3 [1.1-1.5], and 2.1 [1.4-3.1]; and in validation group 2 they were: 1.4 [1.1; 1.7], 1.7 ([1.3-; 2.2], and 3.4 [1.8-6.1], respectively. With an OSA prevalence of <52%, the use of all three clinical prediction tools resulted in cost savings compared to the third party approach. Conclusions: The routine requirement of a HST to diagnose OSA regardless of clinical probability is more costly compared to the use of OSA clinical prediction tools that identify patients who should undergo this procedure when OSA is expected to be present in less than half of the population. With OSA prevalence less than 40%, the OSUNet offers the greatest savings which are substantial when the number of sleep studies done annually is considered.
- Safety and Efficacy of Drug-Induced Sleep Endoscopy Using a Probability Ramp Propofol Infusion System in Patients with Severe Obstructive Sleep Apnea. [JOURNAL ARTICLE]
- Anesth Analg 2014 Jul 25.
Drug-induced sleep endoscopy (DISE) uses sedative-hypnotics to induce moderate obstruction in sleep apnea patients, thereby facilitating anatomic assessment of obstructive physiology. Implementation of DISE with propofol requires a dosing strategy that reliably and efficiently produces obstruction while minimizing oxygen desaturation.The surgeon in a prospective study of transoral robotic resection of the tongue base enrolled 97 patients with obstructive sleep apnea confirmed by polysomnography who failed continuous positive airway pressure. All patients were screened by DISE. Propofol dose was determined using custom software written in MATLAB, which has been previously described. Studies were performed in an operating room with standard monitors and resuscitation equipment. No topical anesthesia was used, and no IV drugs other than propofol were used. All patients received 2 L/min supplemental oxygen via a nasal cannula placed in the mouth. After initiation of propofol sedation, a pediatric bronchoscope was positioned via the naris to observe the velopharynx. The sedation sequence was continued until the clinical end point of obstruction onset was noted. Observation of the pharynx was performed for a sufficient period to obtain images of the anatomic site(s) of obstruction. The infusion was then terminated. Statistical analysis was performed with MATLAB (MathWorks, version 2012b). Comparison of saturation nadirs between DISE and subject sleep studies was performed with both the paired and unpaired Student's t test.The subject population was characterized by a median body mass index of 32.1 (interquartile range [IQR] 6.8) kg/m and apnea-hypopnea index of 48 (IQR 32). All patients demonstrated obstruction within the design variables. Obstruction was observed after 236 (±57.9) seconds at an estimated effect-site concentration of 4.2 ± 1.3 mcg/mL. The median saturation nadir during DISE was significantly higher (91.4% (IQR 5.1)) than that during standard sleep studies (81.0% [IQR 11.2], P < 0.0001). Ninety-five percent confidence intervals for correlations between DISE saturation nadir and body mass index, age, apnea-hypopnea index, or administered propofol dose included zero in all cases.A propofol infusion strategy that requires limited experience with propofol dose selection and only 1 pump dosing change reliably produced airway obstruction in patients with severe sleep apnea. Clinical obstruction was achieved faster than target-controlled infusion-based systems for similar procedures reported in the literature. The observed degree of oxygen desaturation in the model system was within a clinically acceptable range.
- Ventricular-arterial coupling in obstructive sleep apnea. [JOURNAL ARTICLE]
- J Am Soc Hypertens 2014 Jun 4.
Arterial elastance (Ea) and systolic elastance are important parameters determining effective functional interaction of heart and vessels. The aims of this study were to (1) compare arterial (arterial elastance index [EaI]) and ventricular (end-systolic elastance [Ees] and end-diastolic elastance [Eed]) elastance in subjects with obstructive sleep apnea (OSA) and patients with treated 'high-risk' hypertension (HHT) and (2) test whether these parameters in OSA patients can be improved by continuous positive airway pressure (CPAP) therapy. Echocardiographic parameters of cardiac and vascular stiffness (EaI, Ees, and Eed) were quantified in 28 patients with OSA (mean [standard deviation], age 51  years; 79% male) and 28 treated subjects with HHT (mean [standard deviation], age 48  years; 61% male). Twenty-three OSA patients were treated with CPAP for median of 26 weeks. Ea was calculated from stroke volume and systolic BP and adjusted by body area (EaI). Both study groups had preserved and comparable left ventricle contractility. There was no significant differences in EaI (P = .94), Ees (P = .5), Eed (P = .63), and arterial-ventricular interaction (P = .62) between OSA and HHT groups. After CPAP therapy, there was a significant reduction in EaI (paired t test, P = .013) and arterial-ventricular interaction (paired t test, P = .004). Ees (P = .17) and Eed (P = .66) parameters did not change significantly. OSA and HHT patients have similar parameters of elastance and ventricular-arterial coupling. CPAP treatment in OSA patients significantly improved ventricular-arterial coupling.
- Comparison of treatment modalities in syndromic children with Obstructive Sleep Apnea-A randomized cohort study. [JOURNAL ARTICLE]
- Int J Pediatr Otorhinolaryngol 2014 Jul 7.
Obstructive Sleep Apnea (OSA) is a common medical problem in adults that is becoming increasingly recognized in children. It occurs in the pediatric age group, from newborns to teens. More recently, many specialists have estimated OSA prevalence to be between 5 and 6%. However, in syndromic children, the prevalence of OSA can be from 50 to 100%, having a significant effect on their Quality-of-Life. As they are a challenging population for management, it is essential to evaluate them thoroughly before planning appropriate intervention.To compare the efficacy of Adenotonsillectomy (T&A) and Continuous Positive Airway Pressure (CPAP) in syndromic children [Down syndrome (DS) and Mucopolysaccharidoses (MPS)] with Obstructive Sleep Apnea (OSA).In a prospective, randomized, cohort comparative study, 124 syndromic children (DS and MPS) aged between 6 and 12 years were recruited from a private MPS support group and the Down Syndrome Society, Chennai. A standard assessment was performed on all children who entered the study including a full overnight Polysomnogram (PSG), Epworth Sleepiness Scale-Children (ESS-C) and Quality-of-Life (QOL) tool OSA-18. The children with positive PSG who consented for the study (n=80) were randomly distributed to two groups, T&A group & CPAP group. The children were followed up with repeat PSG, clinical evaluation, ESS-C and Quality-of-Life (QOL) tool OSA-18 for a period of 1 year.Follow-up was available for 73 syndromic children. Both the groups, T&A group and CPAP group, showed statistically significant (p<0.05) improvement in Apnea-Hypoapnea Index (AHI), ESS-C, QOL from the intervention. In our study, T&A showed equal outcome compared to CPAP. The contrasting feature between the two groups was that CPAP use gave immediate sustained improvement while T&A gave gradual progressive improvement of symptoms over a period of 1 year.On average, T&A gives equal outcomes as CPAP and it can be suggested as a first-line treatment in this group of syndromic children.
- Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up. [JOURNAL ARTICLE]
- J Otolaryngol Head Neck Surg 2014 Jul 27; 43(1):26.
ObjectivesTo study the long-term effect of tonsillotomy and tonsillectomy in young children after two years in comparison to the results after six months.MethodChildren, age 4-5 with Sleep Disordered Breathing (SDB) and tonsil hyperplasia, were randomized to TE (32) or TT (35). TT was performed ad modum Hultcrantz with radiofrequency technique (Ellman). An adenoidectomy with cold steel was performed in the same session for 80% of cases. The patients were assessed prior to surgery, at six and 24 months postoperatively. Effects of surgery were evaluated clinically, through questionnaire (general health/snoring/ENT-infections), Quality of Life (QoL), survey of pediatric obstructive sleep apnea with OSA-18, and children¿s behavior with the Child Behavior Checklist.ResultsAfter two years there was still no difference between the groups with respect to snoring and frequency or severity of upper airway infections. Both TT and TE had resulted in large improvement in short and long term QoL and behavior. Three TT-children and one TE child had been re-operated due to recurrence of obstructive problems, the TE-child and one of the TT-children with adenoidectomy and two of the TT-children with tonsillectomy. Three of the TT-children had tonsil tissue protruding slightly out of the tonsil pouch and twelve TE-children had small tonsil remnants within the tonsil pouches, but with no need for surgery.ConclusionYounger children have a small risk of symptom-recurrence requiring re-surgery within two years after TT. For the majority, the positive effect on snoring, infections, behavior and quality of life remain and is similar to TE.
- POOR RESPONDERS TO BEVACIZUMAB PHARMACOTHERAPY IN AGE-RELATED MACULAR DEGENERATION AND IN DIABETIC MACULAR EDEMA DEMONSTRATE INCREASED RISK FOR OBSTRUCTIVE SLEEP APNEA. [JOURNAL ARTICLE]
- Retina 2014 Jul 24.
To investigate the risk for obstructive sleep apnea (OSA) in patients with exudative age-related macular degeneration (AMD) or diabetic macular edema with poor response to anti-vascular endothelial growth factor therapy with bevacizumab (Avastin).Age-related macular degeneration group was categorized into nonexudative, exudative, or poor response exudative. Diabetic macular edema group included patients with nonproliferative diabetic retinopathy and cystoid macular edema. Patients were categorized based on the number of intravitreal injections of bevacizumab received. Both groups were compared with age-matched controls. Patients completed a screening questionnaire to assess the risk for OSA, the main outcome measure.Of 103 patients with AMD, 56 (54.37%) had nonexudative AMD and 47 (45.63%) had exudative AMD, of which 14 (29.79%) had poor response exudative AMD and were at a significantly higher risk of OSA (P < 0.05). Of 30 diabetic macular edema patients with cystoid macular edema, 4 (19%) received 1 injection, 18 (81.82%) received 2 or more consecutive injections, and 16 (72.73%) received 3 or more consecutive injections. Risk for OSA increased significantly with increasing number of injections (P < 0.05).Patients with exudative AMD and diabetic macular edema with poor response to anti-vascular endothelial growth factor therapy have a significantly higher risk of OSA compared with age-matched controls and should be screened to assess the risk of OSA.