Schlafbezogene Atmungsstörungen beim Hochbetagten

Although the prevalence of sleep-disordered breathing increases with age, it still remains unclear whether this represents a phenomenon that depends on age or is naturally associated with age. Assuming that it represents a phenomenon that depends on age, consequent diagnosis and therapy of the disease in elderly persons must also be demanded. The main indications for starting CPAP therapy in these patients are deficits in daily cognitive daytime performance. Independent of age, CPAP should be tried in these cases.     

Schlafbezogene Atmungsstörungen und zerebrovaskuläre Erkrankungen

Sleep-related breathing disorders comprise obstructive sleep apnea (OSA), central sleep apnea (CSA), Cheyne–Stokes respiration (CSR), and central alveolar hypoventilation. OSA is significantly associated with known cardiovascular risk factors, e.g., arterial hypertension, atrial fibrillation, and carotid atheromatosis. In addition, OSA has been shown to independently increase stroke risk. Thus, OSA is a direct and indirect risk factor of ischemic stroke, and early diagnosis and treatment of OSA may be crucial for stroke prevention. Acute ischemic stroke may cause any type of sleep-related breathing disorder in an affected patient. Nocturnal breathing abnormalities may be present transiently or persist for a longer period of time, affecting both neurological outcome and the risk of recurrent stroke. Sleep-disordered breathing is highly prevalent in patients with large supratentorial or bihemispheric infarctions, brainstem and cerebellar infarctions. It is associated with worse prognosis, increased disability, and higher mortality. Recently, several interventional studies showed that early implementation of continuous positive airway pressure (CPAP) treatment overnight is feasible and significantly improves neurological outcome in patients with ischemic stroke even if overall mortality may not be significantly reduced.     

Schlafbezogene Atmungsst?rungen und Vorhofflimmern

Sleep-disordered breathing is one of the most common sleep disorders. Especially obstructive sleep apnea (OSA) is an independent cardiovascular risk factor. Clinical studies have proven a significant association between OSA and atrial fibrillation, the most common cardiac arrhythmia. Currently, there is no proven evidence for causality. Untreated OSA seems to be a risk factor for failure of rhythm control strategy in atrial fibrillation. The recurrence rate after cardioversion is higher in case of additional untreated OSA. Continuous positive airway pressure (CPAP) therapy in OSA patients could reduce relapse rate. However, there is a lack of randomized controlled clinical trials with defined end points on this topic. A specific sleep medicine interview as well as sleep studies with portable monitoring and cardiorespiratory polysomnography are recommended when sleep-disordered breathing is suspected. Procedures for the management of patients with atrial fibrillation are given.     

Koronare Herzkrankheit und schlafbezogene Atmungsstörungen

Sleep-related breathing disorders (SRBD) and coronary artery disease (CAD) are common disorders in the industrial countries. There is no doubt that SRBD contribute to cardiovascular risk and clinical course of CAD. Epidemiologic and clinical studies suggest that nocturnal breathing disorders promote the progression of CAD. In this regard it has been shown that obstructive sleep apnea syndrome is associated with an increase in coronary plaque-burden, endothelial dysfunction, and a worse course outcome after percutaneous coronary intervention. Consequently, SRBD should be included in the diagnostic work up of patients with CAD and myocardial infarction.     

Schlafbezogene Atmungsstörungen bei Parkinsonsyndromen: Häufigkeit, Art und Behandlungsansätze

Objective

In recent literature the contribution of sleep related breathing disorders [SRBD] to the complex sleep disorder of Parkinson's disease [PD] patients is controversely discussed. In our study we discovered the frequency and kind of SRBD in a group of PD patients with sleep complaints.

Patients and methods

83 patients with different types of parkinsonism were studied polysomnographically. Respiration was measured by means of inductance plethysmography, capnography, and pulse oximetry. Different analysing techniques were used. Besides the evaluation of apneas and hypopneas a visual classification of the respiratory pattern and a breath-to-breath calculation of the laboured breathing index [LBI] was carried out.

Results

More than 50% of the patients showed sleep disordered breathing. Most of them had upper airway obstructions. Central apnea was observed in 5 cases, three of those suffered from a heart disease. In 25% the SRBD should be treated. The LBI calculation revealed hints for short pharyngeal obstructions in each patient. This parameter turned out to be highly sensitive to detect changes in upper airway mechanics and was therefore considered to be useful in testing dopaminergic influences on respiratory movements.

Conclusion

Disturbances of the extrapyramidal motor system may lead to long lasting obstructive hypoventilation of different clinical importance. Specific measurement techniques should be used to identify these disturbances. The laboured breathing index may be useful to detect dopaminergic deficits in respiratory motion. As more than 50% of severe SRBD patients are not able to handle nCPAP it is necessary to develop pharmacological options. Dopaminergic medication as a possible therapeutical alternative to nCPAP should be tested in further studies.     

Unterkieferprotrusionsschienen bei schlafbezogenen Atmungsstörungen

Continuous positive airway pressure (CPAP, automatic CPAP, APAP) is the standard therapy of obstructive sleep-related breathing disorders (oSDB). Mandibular advancement devices (MADs) can be used as alternatives to CPAP/APAP in mild to moderate obstructive sleep apnoea (OSA) (AHI?≤?30/h). This implies in particular the use of MADs in patients with a body mass index below 30?kg/m² and position-dependent OSA (pOSA). MADs can be considered in individual patients with severe OSA (AHI?>?30/h) if CPAP/APAP has been shown to be ineffective despite the full utilisation of all efforts of support. CPAP therapy can be provided by a qualified sleep physician immediately after confirmation of the diagnosis of oSDB. For the delivery of custom-made titratable oral appliances, the patient should be referred to a specialized dentist or orthodontist. Although there is a broad agreement on the indications for oral appliances, the rules of collaboration between sleep medicine and dentistry/orthodontics are not agreed upon. Therefore, the aim of this consensus paper is to describe the rules for the interdisciplinary collaboration that provides patients with MADs in North-Rhine Westphalia, Germany.     

Zur Lokalisation Zentraler Atmungsstörungen

Ohne ZusammenfassungErscheint ausführlich in der Zeitschr. f. d. ges. exp. Med.     

Autonome Regulation und nächtliche Arrhythmien bei Patienten mit schlafbezogener Atmungsstörung

Nocturnal cardiac arrhythmias occur in patients with obstructive sleep apnea as a consequence of autonomic effects of recurrent apneas with subsequent desaturation, arousal, and intrathoracic pressure changes. Bradyarrhythmias (BA) in obstructive sleep apnea (OSA) are induced by a cardioinhibitory vagal reflex due to the obstructed airway. Tachyarrhythmias in OSA and CSA-CSR (central sleep apnea and Cheyne–Stokes respiration) patients are mainly found in combination with cardiovascular comorbidity (coronary heart disease, chronic heart insufficiency), hypoxia and increased sympathetic activity. CPAP (continuous positive airway pressure) therapy has been demonstrated to reduce BA and TA significantly. Increases in apnea-associated sympathetic activity contribute to cardiovascular and cerebrovascular morbidity and mortality.     

Positionspapier zur Diagnostik und Therapie schlafbezogener Atmungsstörungen bei Erwachsenen

Sleep related breathing disorders (SRBD) impair quality of live, morbidity and mortality of affected patients seriously. Moreover, due to their high prevalence, they have a huge impact on health care systems and national economics. The members of the German Respiratory Society, the German Society of Sleep Research and Sleep Medicine, the Association of Pneumological Clinics and the Association of Pneumologists focus strongly on the diagnosis and treatment of SRBD in their daily work. Prevailing developments in the provision of patients with SRBD, have strong impact on the quality of diagnosis and treatment, on the supply of devices, on the follow-up care and on the role and duties of the physician. Therefore, the societies estimate it essential, to publish this common position paper based on the evaluation and discussion of the scientific literature, the clinical practice and a consensus process of an expert group which is published in more detail (Randerath, Somnologie, DOI 10.1007/s11818-013-0649-2; Pneumologie 2/2014).     

Konsensuspapier zur Diagnostik und Therapie schlafbezogener Atmungsstörungen bei Erwachsenen

Diagnosis and treatment of sleep disordered breathing (SDB) undergo substantial changes, both in terms of increasing scientific knowledge and also in terms of patient provision and socio-economic aspects. Increasing evidence shows the relevance of SDB on morbidity and mortality of affected patients. The precise differentiation of different phenotypes of SDBs has improved substantially in recent years. These proceedings influence the approach to the patients suspected of suffering from SDB. The scientific advances on the one hand are facing intentions to simplify diagnostical processes and treatment initiation and intentions to translate duties of physicians to non-medical personnel on the other hand. This consensus paper presents the principals of diagnosis, treatment initiation and provision, including the role of different participants of the healthcare system, and compares different treatment options. Major aspects include the differentiation of the diagnostical process in screening, affirmation of diagnosis and differential diagnosis. In addition, it focusses on the relevance of the pretest probability and describes a therapeutical algorithm.     

Effekte einer adaptiven Servoventilation auf Herzrhythmusstörungen bei Patienten mit chronischer Herzinsuffizienz und schlafbezogenen Atmungsstörungen

Background

In patients with chronic heart failure with reduced left ventricular ejection fraction (HFrEF) sleep-disordered breathing (SDB) is linked with an increased risk for nocturnal cardiac arrhythmias. SDB can be effectively treated with adaptive servo-ventilation (ASV). Therefore, we tested the hypothesis that ASV therapy reduces nocturnal arrhythmias and heart rate in patients with HFrEF and SDB.

Methods

In a non-prespecified subanalysis of a multicenter randomized-controlled trial (ISRCTN04353156) twenty consecutive patients with stable HFrEF (age 67 ± 9 y; left ventricular ejection fraction 32 ± 7?%) and SDB (apnea-hypopnea index, AHI 48 ± 20/h) were randomized to either ASV (n = 10; Philips Respironics, Murrysville, PA, USA) or optimal medical treatment alone (control, n = 10). Polysomnography (PSG) with centralized scoring and blinded analysis where obtained at baseline and 12 weeks. The electrocardiograms (ECG) of the PSGs were analyzed with 24 h-Holter electrocardiography software (Pulse Biomedical Inc., QRS-Card^TM Cardiology Suite, USA).

Results

There was a decrease in ventricular ectopic beats (VEBs) per hour recording time in the ASV-group compared to the control group (?8.1 ± 42.4 versus +9.8 ± 63.7/h, p = 0.356). ASV reduced the number of ventricular couplets as well as non-sustained ventricular tachycardias (nsVT) compared to the control-group (?2.3 ± 6.9 versus +2.1 ± 12.7/h, p = 0.272, and ?0.1 ± 0.5 versus +0.1 ± 1.1/h, p = 0.407, respectively). Mean nocturnal heart rate decreased in the ASV group compared to the control-group (?2.0 ± 2.7 versus +3.9 ± 11.5/minute, p = 0,169). Described changes were not significantly different between groups.

Conclusions

In HFrEF patients with SDB ASV treatment may reduce nocturnal ventricular ectopic beats, couplets, nsVT and mean nocturnal heart rate. Findings underscore the need for further analyses in larger studies.

     

Fatigue, exzessive Tagesschläfrigkeit und schlafbezogene Atmungsstörungen bei myotonen Dystrophien

The myotonic dystrophies are dominantly inherited multisystem disorders characterized by progressive muscle weakness, endocrine symptoms, and mild-to-moderate cognitive impairment. Many patients report chronic fatigue. Excessive daytime sleepiness (EDS) is an early and highly relevant complaint of patients with myotonic dystrophy type 1 (DM 1). Sleep-related breathing disorders are a common cause of EDS in these patients, including both obstructive sleep apnea and nocturnal alveolar hypoventilation. In DM 1, EDS can also reflect secondary CNS hypersomnia. This article outlines our current knowledge on the etiology, diagnosis, and therapy of both fatigue and EDS in patients with myotonic dystrophy.     

Zur Lokalisation zentraler Atmungsst?rungen

Zusammenfassung 1. Durch Abkühlung einzelner Rindenareale (motorische Region, Stirnhirn) wie auch der ganzen konvexen Oberfl?che beider Hemisph?ren gelang es ebensowenig wie durch Mittelhirndurchtrennung, eine Periodenbildung der Atmung auszul?sen. 2. Andererseits konnte an Tieren, bei welchen nur das Rhombencephalon und h?chstens in einigen Versuchen die caudalsten Teile des Mittelhirns erhalten waren, durch verschiedene (thermische, toxische, mechanische) Eingriffe Gruppenbildung erzeugt werden, die teils demCheyne-Stokesschen Typus, teils demBiotschen ?hnelte. 3. Da kein Anhaltspunkt für die Annahme vorliegt, da? die Funktion des rhombencephalen Atmungsapparates bei Mensch und Tier wesentlich verschieden sei, mu? geschlossen werden, da? auch beim Menschen die Losl?sung dieses Mechanismus von corticalen Regulationen und das Hervortreten seiner Eigenfunktion nicht zumCheyne-Stokesschen Atemtypus führen k?nne, diese Atmungsform vielmehr durch eine Sch?digung der rhombencephalen Zentren selbst zustande komme. 4. Durch umschriebene L?sion der im Bereiche des Mesencephalon gelegenen Ganglien (Tectum der Vierhügel, H?hlengrau um den Aqu?dukt, mesencephale Trigeminuswurzel auch im Bereiche der Brücke, Tegmentum, Nucl. ruber) gelang es nicht, konstante und dauernde Atemst?rungen zu erzeugen. Es kam h?chstens zu vorübergehendem Atemstillstand, resp. Verl?ngerung des In- oder Exspiriums, St?rungen, die wegen ihrer Flüchtigkeit und leichten Reversibilit?t, besonders durch reflektorische Reize, als Chokwirkung auf das Rhombencephalon gedeutet werden mu?ten. Es konnte somit kein Anhaltspunkt für die Existenz eines atmungsregulierenden mesencephalen Zentrums gewonnen werden, auf welches pathologische Atmungsformen bezogen werden k?nnten. Das Ku?maulsche Atmen kommt wahrscheinlich ebenfalls durch eine Sch?digung des rhombencephalen Atemapparates zustande. Vorl?ufig mitgeteilt durchH. Enghoff bei den Verhandl. d. Nord. Kongr. für Physiol. u. exp. Med. in Lund 14. u. 15. IV. 1925; vgl. Skandinav. Arch. f. Physiol.46, H. 5/6. 1925.     

Zur Pathogenese und Behandlung Funk-Tioneller Hör- und Sprachstörungen

Ohne Zusammenfassung     

Entstehung und Behandlung von Sprachstörungen

Ohne Zusammenfassung     

Zur Differenzierung obstruktiver und restriktiver Ventilationsstörungen

Ohne Zusammenfassung