Severe obstructive sleep apnea in children with elevated blood pressure

The objective was to determine the prevalence of habitual snoring and obstructive sleep apnea (OSA) in a cohort of children referred for elevated blood pressure (BP), and to determine the association between OSA and BP elevation, learning difficulties, and behavioral problems. We performed a retrospective review of 446 consecutive new patients referred for elevated BP. One hundred four (23%) had habitual snoring. Patients with habitual snoring were more likely to be obese (86.5 vs. 55.6%, P < .001) and to have Medicaid insurance (52.4 vs. 36%, P = .004). Seventy-four patients had polysomnography, of which 57 (77%) had OSA; 21 (37%) had severe OSA. Severe OSA was associated with higher office systolic BP index after adjusting for body mass index, age, sex, and socioeconomic status (β = 0.07, P = .014). Fifty-two percent of patients with severe OSA had office systolic BP in the Stage 2 hypertension range. Children with habitual snoring or OSA were not at increased risk of receiving school services for a learning disability or receiving medications for inattention or mood problems. In summary, habitual snoring is common in children referred for elevated BP, and those with severe OSA are at higher risk of significantly increased BP.     

Factors associated with improvement in breathing capacity during exercise in patients with chronic obstructive pulmonary disease

OBJECTIVES: The aim of this study was to explore the relationship between resting pulmonary function indices and the ratio of minute ventilation at peak exercise to the maximal voluntary ventilation (VEmax/MVV) and to determine whether an improvement in breathing capacity during exercise (i.e. VEmax/MVV > 1) is associated with greater exercise capacity in patients with COPD. METHODOLOGY: The results of pulmonary function tests and incremental, symptom-limited cardiopulmonary exercise testing in 84 patients with predominantly moderate to severe COPD were reviewed. Multiple linear regression analysis was applied to determine the relationship of VEmax/MVV with selected independent variables at rest. Multiple logistic regression was used to determine significant predictors of VEmax/MVV 1. RESULTS: FEV1/FVC and inspiratory capacity (IC) were the only variables among resting pulmonary function indices that were significant independent determinants of VEmax/MVV and the stepwise analysis generated the following equation: VEmax/MVV = (-1.05E-02 x FEV1/FVC) + (0.15 x IC) + 1.28; r= 0.701, P < 0.001. Using multiple logistic regression with VEmax/MVV 1 as a dependent categorical variable, FEV1/FVC was the only significant predictor among resting pulmonary indices of a VEmax/MVV ratio of > 1 (Odds ratio 0.93, 95%CI 0.89, 0.97). There was a significant association between VEmax/MVV and peak oxygen uptake (VO2max) after adjusting for FEV1 (r = 0.66, P < 0.001). If the categorical variable of VEmax/MVV ( 1) was used instead of a continuous variable, a significant association with VO2max remained after adjusting for FEV1 (r = 0.60, P < 0.001). CONCLUSIONS: Among resting pulmonary function indices, the FEV1/FVC ratio is the best determinant of an improvement in breathing capacity during exercise in COPD patients. After adjusting for FEV1, an improvement in breathing capacity during exercise is associated with significantly higher exercise capacity.     

Natural history of snoring and obstructive sleep apnea in Thai school-age children

In 1999, a survey was carried out in 1,008 Thai children aged 7 years, which found that 85 (8.5%) children were habitual snorers, and 7 (0.69%) children had mild obstructive sleep apnea syndrome (OSAS). Since the natural history of snoring and untreated mild OSAS is still largely unknown, this study was undertaken in 2002 in the same group of children to determine the natural history of snoring and OSAS. Questionnaires, consisting of questions about snoring, were sent to the parents of the 1,008 children. Polysomnography was performed in 1) the 7 children who had OSAS in the previous survey, and 2) other habitual snorers who had sleep-related symptoms in this survey. Seventy-five percent of the questionnaires were returned. The prevalence of habitual snoring had decreased slightly, from 8.5% in 1999 to 6.9% in 2002. Sixty-five percent of the children who had snored habitually in the previous survey no longer did so, whereas 4.5% of the children who previously never snored or snored sometimes had become habitual snorers. Of the 7 children who had OSAS previously, 5 had persistent snoring, and polysomnographic studies revealed more severe OSAS, with an apnea-hypopnea index (AHI) of 1.5-9.2 per hour of sleep. Five children were newly diagnosed with OSAS in this survey, with an AHI of 1.5-7.5. The overall prevalence of OSAS in this survey was 10/755 (1.3%). In conclusion, 65% of children who snored habitually no longer did so when they got older, while 9% of children had developed OSAS. We suggest that regular follow-up in children with habitual snoring may be needed, and additional research is required to determine the indications for polysomnography and neurobehavioral and cardiovascular assessment. We also showed that children with mild OSAS could develop more severe disease if left untreated, suggesting that deferment of treatment may have negative consequences.     

Safety of ramelteon in individuals with mild to moderate obstructive sleep apnea

Ramelteon is a selective MT₁/MT₂-receptor agonist indicated for insomnia treatment. Because it has no depressant effects on the nervous system, it is not expected to affect the control of breathing. The potential effects of ramelteon on apneic and hypopneic events and arterial oxygen saturation (SaO₂) in individuals with obstructive sleep apnea were assessed. In this double-blind, randomized, crossover study, 26 adults with mild to moderate obstructive sleep apnea received ramelteon 16 mg and placebo for one night each, with a 5- to 12-day washout period between treatments. Treatments were administered 30 min before habitual bedtime. Respiratory effort was monitored using respiratory inductance plethysmography, SaO₂ was measured by pulse oximetry, and sleep onset and duration were measured by polysomnography and post-sleep questionnaire. Post-sleep questionnaire also measured next-day residual effects. The primary measure was apnea–hypopnea index. Apnea–hypopnea index was similar in ramelteon and placebo groups (11.4 vs 11.1, respectively; CI = −2.1, 2.6, P = 0.812). Ramelteon had no effect on the number of central, obstructive, or mixed apnea episodes. No significant differences were observed in SaO₂ for the entire night between ramelteon and placebo (95.1 vs 94.7%; P = 0.070). Ramelteon did not meaningfully affect sleep when evaluated by polysomnography and post-sleep questionnaire. Compared with placebo, ramelteon had no significant effect on next-day residual effects. Adverse events were reported by three subjects in the ramelteon group: headache (n = 2) and urinary tract infection (n = 1). No adverse events were reported with placebo. Ramelteon was well-tolerated and, as expected, did not worsen sleep apnea when administered to subjects with mild to moderate obstructive sleep apnea.     

Snoring and obstructive sleep apnea in Thai school-age children: prevalence and predisposing factors

We studied the prevalence of habitual snoring and its associations with tonsillar size, allergic rhinitis, obesity, and parental smoking, as well as prevalence of obstructive sleep apnea (OSAS) in a sample of 1,142 children aged 6-13 years (mean, 7.25 +/- 0.58) from seven randomly selected schools in Hat yai, Southern Thailand. Eighty-five (8.5%) of the children were habitual snorers; the prevalence was the same in boys and girls. Significant and independent association was present between snoring and allergic rhinitis with an odds ratio of 5.27 (95% CI, 1.57-17.77). The odds ratio was significantly increased to 2.65 (CI, 1.31-5.39), 5.72 (CI, 2.67-12.25), and 11.06 (CI, 1.91-63.84) in children with tonsillar size of 2+, 3+, and 4+, respectively. Of the 85 habitual snorers, 69 could be contacted by telephone call or by hospital visit. Eight of these were reported to have at least one of the following symptoms: difficulty breathing during sleep, stop breathing at night, restless sleeping and frequent awakening, sleeping with the head tipped back, and a tendency to breathe through the mouth rather than the nose. Polysomnographic studies in these 8 children demonstrated an apnea/hypopnea index of 0.6-4.7 per hr. Seven children met the criteria for OSAS. Thus, our estimate of the prevalence of OSAS among Thai schoolchildren was 7/1,008 (0.69%). We have shown that the prevalence of habitual snoring was 8.5%, and the prevalence of OSAS in a sample of Asian school-age children in Southern Thailand was 0.69%, which was similar to that observed in Western populations. An association of snoring with tonsillar size or allergic rhinitis was demonstrated. All but one of the snoring children with sleep-related symptoms had OSAS, but all were mild cases.     

老年男性阻塞性睡眠呼吸暂停综合征患者血清脂联素水平的变化

目的探讨老年男性阻塞性睡眠呼吸暂停综合征(OSAS)血清脂联素水平的变化。方法选择62例习惯性打鼾老年人行多导睡眠仪监测,根据呼吸暂停低通气指数(AHI)分为单纯打鼾组(对照组),OSAS组,以放射免疫法测定血清中脂联素水平。结果OSAS组的血清脂联素水平显著低于对照组(P<0.01)。而血清脂联素水平在轻度OSAS患者中即有显著降低(P<0.05),在中度和重度OSAS患者中进一步降低(P<0.01)。OSAS各亚组间的比较发现:中、重度组的血清脂联素水平均明显低于轻度OSAS组(P<0.05)。Pearson相关分析提示OSAS患者血清脂联素水平与AHI、体重指数(BMI)、腰围(WC)、颈围(NC)、反应性胰岛素抵抗的体内稳态模式(HOMA)指数呈负相关,与最低血氧饱和度(mini SpO2)呈正相关。偏相关分析提示血清脂联素水平与AHI呈负相关(r=-0.26,P<0.05),与SpO2呈正相关(r=0.24,P<0.05)。多元逻辑回归分析提示血清脂联素水平与OSAS独立相关。结论老年男性OSAS患者血清中脂联素水平较单纯打鼾者为低。     

Maintenance of wakefulness test in military personnel with upper airway resistance syndrome and mild to moderate obstructive sleep apnea

Background  Sleep-disordered breathing (SDB) and the associated symptom of excessive daytime sleepiness (EDS) in military personnel has influential consequences in both the garrison and the deployed environments. The maintenance of wakefulness test (MWT) is a daytime study used to evaluate the tendency to stay awake. We evaluated consecutive patients diagnosed with mild to moderate obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) to provide an objective measure of their EDS using the MWT. Materials and methods  All military personnel referred between February 2004 and March 2005 with a clinical evaluation suspicious for SDB were evaluated with an overnight polysomnography (PSG). After overnight PSG, military personnel with mild to moderate OSA and UARS were evaluated with a 40-min protocol MWT. Abnormal MWT was defined as sleep onset latency mean below 19.4 min (<2 SD below the mean). Results  Sixty-two military personnel met entry criteria. Fifty-nine were men. Nineteen patients (32%) were diagnosed with UARS with a mean respiratory disturbance index of 11/h (5–20/h). Forty-one (68%) of the military personnel had OSA with a mean apnea–hypopnea index of 12/h (5–29/h). As a collective group, the mean Epworth Sleepiness Scale was elevated at 13/24 (1–24). This subjective excessive sleepiness was assessed with the MWT test, which resulted in a group mean MWT sleep onset latency of 27 min (5–40 min). Eighteen soldiers (30% of the total patients) had abnormal MWTs [six patients (33.3%) with UARS and 12 (67%) with OSA]. Conclusion  Military personnel with mild to moderate OSA and UARS often have abnormal MWTs and therefore have a pathological tendency to fall asleep. This EDS could pose a safety hazard in those personnel, military or civilian, who operate dangerous vehicles, machinery, or carry a firearm. Military personnel with untreated SDB are also at risk for the consequences of decreased mental alertness and decreased cognitive functioning due to daytime sleepiness. All work was completed at the Brooke Army Medical Center, Fort Sam Houston, Texas. The opinions expressed herein are those of the authors and should not be construed as official or reflecting the policy of either the Department of the Army, Department of Defense, or the US Government.     

阻塞性睡眠呼吸暂停综合征合并高血压患者的睡眠分析

目的 分析阻塞性睡眠呼吸暂停综合征(OSAHS)合并高血压患者的睡眠.方法 将我院收治的OSAHS合并高血压患者作为研究1组,OSAHS血压正常患者作为研究2组,并以单纯鼾症患者作为对照组,应用多导睡眠监测仪对三组患者进行睡眠监测.结果①研究1组、研究2组觉醒时间较对照组明显增多,研究1组浅睡眠较研究2组、对照组明显增多;中度睡眠研究2组、对照组明显减少(P<0.05).② 研究1组呼吸暂停低通气指数、呼吸暂停指数明显高于研究2组(P<0.05).③研究1组呼吸暂停时间占睡眠时间百分比较研究2组升高(P<0.05).④ 研究1组最低血氧饱和度明显高于研究2组(P<0.05).结论 OSAHS合并高血压患者呼吸紊乱较血氧正常患者重,睡眠质量相对较差.     

性别差异对中重度慢性阻塞性肺疾病患者运动耐力的影响

目的 比较中重度慢性阻塞性肺疾病(COPD)患者运动耐力的性别差异.方法 本研究对151例中、重度COPD患者的肺功能(PFT)和功率递增心肺运动试验(CPET)结果进行了分析.将患者分为Ⅱ级COPD组和Ⅲ级COPD组.并选择43例年龄、性别、身高、体质量相匹配的正常人作为对照组.本研究测定第1秒用力呼气容积(FEV1)、用力肺活量(FVC)、峰值运动功率(Peak Load)、峰值摄氧量(Peak (V)O2)、峰值心率(Peak HR)、峰值氧脉搏(Peak(V)O2/HR)、最大分钟通气量(M(V)E)、气促指数(M(V)E/MVV)等指标.本研究分别在不同COPD分级和性别之间分析比较了上述指标的差异.结果 Ⅱ级COPD组和Ⅲ级COPD组的女性患者的Peak (V)O2实/预％和Peak (V)O2/HR实/预％较同组男性更高(P值均＜0.05).Ⅲ级COPD男性患者的运动耐力较Ⅱ级有明显降低(P＜0.0001),然而,Ⅲ级、Ⅱ级COPD女性患者之间运动耐力差异无统计学意义(P=0.246).结论 在中、重度COPD患者中,男性运动耐力下降较女性更为严重,吸烟可能是造成这一差异的重要因素.     

Detection of respiratory events using pulse rate in children with and without obstructive sleep apnea

Oximetry is a simple but insensitive diagnostic test modality for obstructive sleep apnea (OSA) in children. Sensitivity for OSA may be enhanced if pulse rate is analyzed in conjunction with oxygen saturation. We analyzed 25 ambulatory polysomnographic recordings obtained from children with (n = 5) and without (n = 20) OSA. To assess sensitivity and specificity, pulse rate increases were determined during respiratory (i.e., apneas and hypopneas; n = 965) and non‐respiratory sleep events (i.e., body movements; n = 1,197), and contrasted to baseline fluctuations (n = 209). The absolute pulse rate increase (APRI) was the parameter that differentiated best between baseline fluctuations and sleep events (area under the receiver operating characteristic curve [AUC]: 0.88). At a cutoff value of 12 beats per minute, APRI showed a sensitivity and specificity for detecting sleep events of 0.81 each. However, AUC was lower for the differentiation between respiratory and non‐respiratory sleep events (0.77) and between central and obstructive respiratory events (0.68). In OSA cases, influencing factors for APRI following respiratory events were age, occurrence of a body movement, and severity of concomitant oxygen desaturation. We conclude that pulse rate analysis may be used to detect respiratory events in oximetry recordings in children. Pediatr Pulmonol. 2010; 45:459–468. © 2010 Wiley‐Liss, Inc.     

Randomized controlled study of in-hospital exercise training programs in children with cystic fibrosis

The aim of this study was to compare aerobic and resistance training in children with cystic fibrosis (CF) admitted to hospital with an intercurrent pulmonary infection with a control group. The subjects were randomized into three groups on the first day of admission. The fat-free mass (FFM) was calculated, using the skin fold thickness from four sites (biceps, triceps, subscapular, and iliac crest). Pulmonary function tests were performed within 36 hr of admission and repeated on discharge from the hospital, and again at 1 month after discharge. All subjects performed an incremental treadmill exercise test, using a modified Bruce protocol. Lower limb strength was measured using a Cybex dynamometer. An assessment of quality of life was made using the Quality of Well Being Scale, as previously reported. Activity levels were measured using a 7-day activity diary, and subjects also wore an accelerometer on their hips. There were no significant differences between the three groups in terms of disease severity, and length of stay in hospital. Subjects in all three groups received intravenous antibiotics and nutritional supplementation as determined by the physician. Children randomized to the aerobic training group participated in aerobic activities for five sessions, each of 30-min duration, a week. The children randomized to the resistance training group exercised both upper and lower limbs against a graded resistance machine. Subjects in the control group received standard chest physiotherapy. Our study demonstrated that children who received aerobic training had significantly better peak aerobic capacity, activity levels, and quality of life than children who received the resistance training program. Children who received resistance training had better weight gain (total mass, as well as fat-free mass), lung function, and leg strength than children who received aerobic training. A combination of aerobic and resistance training may be the best training program, and future studies to assess optimal training programs for CF patients are indicated.     

稳定期COPD患者深吸气量与运动耐力的关系

目的 探讨深吸气量 (IC)及相关肺功能指标与稳定期中重度 COPD患者运动耐力的相关性.方法 对62例处于稳定期的中重度 COPD 患者进行常规肺功能检测及斜坡式功率递增症状限制性心肺运动试验,测定相关肺通气功能参数、气体交换参数.结果 COPD患者的 IC%pred与运动耐力 [峰值摄氧量占预计值的百分比 (peak ·V O2%pred)]有显著的相关性 (r =0.74,P <0.001),IC%pred对 peak ·V O2%pred 有显著预测意义.结论 IC%pred对稳定期 COPD患者运动耐力的预测较其他肺功能指标更有优势.     

Adenotonsillectomy for obstructive sleep apnea in children with Prader-Willi syndrome

The aim of our study was to evaluate the efficacy of adenotonsillectomy for the treatment of obstructive sleep apnea syndrome (OSA) in pediatric patients with Prader-Willi syndrome (PWS), and to describe the postoperative complications. Five patients (4 males; median age, 4.4 years; range, 1.6-14.2 years) were studied. All patients underwent an overnight cardiorespiratory sleep study. All patients had adenotonsillar hypertrophy (ATH), and two were also obese. The preoperative obstructive apnea/hypopnea index (AHI; median and range) was 12.2 (9.0-19.9) events/hr; the mean oxygen saturation was 95 (79-96)%; the nadir oxygen saturation was 71 (58-78)%; and the oxygen desaturation index (ODI) was 15.8 (11.4-35.9) events/hr. Preoperatively, patients were classified as having moderate to severe OSA. A second sleep study, performed 16 (3-43) months after adenotonsillectomy, showed a significant decrease in AHI (P = 0.009) and ODI (P = 0.009). Mean and nadir oxygen saturation did not differ significantly postsurgery (P = 0.188, P = 0.073, respectively). Four out of five children showed at least one postoperative complication. Difficult awakening from anesthesia, hemorrhages, and respiratory complications requiring reintubation and/or supplemental oxygen administration were observed. In conclusion, patients with PWS and OSA who underwent adenotonsillectomy showed a significant decrease in AHI and number of oxygen desaturations.     

Prediction of obstructive sleep apnea syndrome in a large Greek population

Purpose

We aimed to evaluate the predictive value of anthropometric measurements and self-reported symptoms of obstructive sleep apnea syndrome (OSAS) in a large number of not yet diagnosed or treated patients. Commonly used clinical indices were used to derive a prediction formula that could identify patients at low and high risk for OSAS.

Methods

Two thousand six hundred ninety patients with suspected OSAS were enrolled. We obtained weight; height; neck, waist, and hip circumference; and a measure of subjective sleepiness (Epworth sleepiness scale??ESS) prior to diagnostic polysomnography. Excessive daytime sleepiness severity (EDS) was coded as follows: 0 for ESS????3 (normal), 1 for ESS score 4?C9 (normal to mild sleepiness), 2 for score 10?C16 (moderate to severe sleepiness), and 3 for score >16 (severe sleepiness). Multivariate linear and logistic regression analysis was used to identify independent predictors of apnea?Chypopnea index (AHI) and derive a prediction formula.

Results

Neck circumference (NC) in centimeters, body mass index (BMI) in kilograms per square meter, sleepiness as a code indicating EDS severity, and gender as a constant were significant predictors for AHI. The derived formula was: $ {\hbox{AHIpred}} = {\hbox{NC}} \times 0.{84} + {\hbox{EDS}} \times {7}.{78} + {\hbox{BMI}} \times 0.{91} - [{8}.{2} \times {\hbox{gender constant }}\left( {\hbox{1 or 2}} \right) + {37}] $ . The probability that this equation predicts AHI greater than 15 correctly was 78%.

Conclusions

Gender, BMI, NC, and sleepiness were significant clinical predictors of OSAS in Greek subjects. Such a prediction formula can play a role in prioritizing patients for PSG evaluation, diagnosis, and initiation of treatment.     

茶碱缓释胶囊对轻中度阻塞型睡眠呼吸暂停低通气综合征的影响

目的观察轻中度阻塞型睡眠呼吸暂停低通气综合征(OSAHS)患者口服氨茶碱前后睡眠参数变化情况。方法随机选择60例经多导睡眠图(PSG)监测确诊的轻中度OSAHS患者,入选对象随机分成A、B两组,A组30例,给予口服茶碱缓释胶囊0.2/晚,B组30例,给予安慰剂口服。比较未给药、口服茶碱后、口服安慰剂后睡眠监测指标变化情况,包括:睡眠呼吸暂停低通气指数(apnea hypopnea index,AHI)、最低夜间血氧饱和度(LSaO_2)、平均夜间血氧饱和度(MSaO_2)、SaO_290%时间、睡眠呼吸障碍最长时间,同时监测茶碱血药浓度,观察药物不良反应发生情况。结果 (1)口服茶碱后LSaO_2:90.4%±2.1%,MSaO_2:92.2%±1.5%,SaO_290%时间(34.3±10.2)秒,睡眠呼吸障碍最长时间(25.0±2.3)秒,较未给药LSaO_2:86.2%±2.6%,MSaO_2:89.1%±1.8%,SaO_290%时间(45.1±18.6)秒,睡眠呼吸障碍最长时间(32.0±5.0)秒及给予安慰剂后LSaO_2:85.3%±3.8%,MSaO_2:90.8%±2.6%,SaO_290%时间(39.2±19.8)秒,睡眠呼吸障碍最长时间(31.0±3.4)秒,均有显著差异(P0.017)。但AHI改变无统计学差异。口服安慰剂与未给药时比较,睡眠监测指标差异无统计学意义。(2)口服茶碱缓释胶囊,观察药物不良反应发生1例,表现为恶心,监测茶碱血药浓度在安全范围,停药后症状缓解。结论轻中度OSAHS睡前口服茶碱缓释胶囊安全有效,可缩短睡眠呼吸障碍最长时间,改善夜间LSaO_2、MSaO_2、SaO_290%时间。     

Prevalence of obstructive sleep apnea syndrome and associated symptoms in 3--11-year-old Turkish children

Our objective was to investigate the prevalence of sleep-disordered breathing (SDB) and obstructive sleep apnea syndrome (OSAS) in 3-11-year-old Turkish children. A cross-sectional study was conducted in Zonguldak, northwestern Turkey. Symptomatic children were identified by using a self-administered questionnaire and were classified into three groups: nonsnorers, occasional snorers, and habitual snorers. All habitual snoring children were invited to undergo polysomnography (PSG). Nine hundred fifty-four children (79.5%) were nonsnorers, 205 (17.2%) were occasional snorers, and 39 (3.3%) were habitual snorers. There was no significant relationship between gender and habitual snoring (male, 3.4%; female, 3.1%; P > 0.05; odds ratio (OR), 1.13; 95% confidence interval (CI), 0.59-2.14). There was a statistically significant relationship between habitual snoring and allergic rhinitis (OR, 4.23; 95% CI, 2.14-8.35). Four children who snored every night, and who had apnea spells and/or troubled sleep, underwent adenoidectomy and/or tonsillectomy before polysomnographic evaluation because of clinical detoriation. Twenty-eight of 39 children with habitual snoring participated in PSG evaluation. PSG revealed that 11 children (0.9% of the total population) had OSAS. When 4 operated children were added to these 28 children, we found the minimum prevalence of OSAS to be 1.3% in our study group. There was a significant correlation between OSAS and troubled sleeping (P <0.001; OR, 4.37; 95% CI, 1.33-14.3). We found the prevalence of habitual snoring to be 3.3% in Turkish children by using self-administered questionnaires. Allergic rhinitis was significantly correlated with habitual snoring. Minimum estimated prevalence of OSAS was found to be 1.3%.