Negative-pressure pulmonary Hemorrhaging Due to Severe Obstructive Sleep Apnea

A 24-year-old man with a history of bloody sputum for 6 months was referred to our hospital with suspected alveolar hemorrhaging due to vasculitis. Chest computed tomography showed ground-glass opacities in both lungs, and an examination of his bronchoalveolar lavage fluid showed alveolar hemorrhaging. However, no evidence of vasculitis was found, and subsequent polysomnographic testing confirmed that he had severe obstructive sleep apnea (OSA). Since the alveolar hemorrhaging improved after the initiation of continuous positive airway pressure treatment, the diagnosis was negative-pressure alveolar hemorrhaging due to severe OSA.     

Obstructive Sleep Apnea in a Referral Population in India

There are few published studies of obstructive sleep apnea in the Asian subcontinent. The objectives were to describe the syndrome and evaluate the utility of computed tomography (CT) cephalometry in patients found to have obstructive sleep apnea (OSA) by polysomnography. This article reports on a retrospective case series in a referral population. A total of 880 patients (560 males and 320 females) were seen in a referral center in Hyderabad, South India, during the last 7 years. All patients with suspected obstructive sleep apnea were evaluated with 16-channel polysomnogram by overnight sleep study; 600 subjects (68%; 480 males and 120 females) underwent evaluation with CT cephalometry. Mean age was 51.4 ± 9.5 years (standard deviation). The mean apnea-hypopnea index (AHI) was 27.93 ± 3.8. The majority of patients had more than 10 AHI; mean percentage of sleep efficiency was 80.62 ± 15.38; mean percentage of rapid eye movement (REM) sleep was 13.79 ± 7.89; mean awake arterial oxygen saturation (SaO₂) was 90%; mean sleep SaO₂ was 84% ± 4.4%; mean Epworth Sleepiness Scale (ESS) score was 12.3 ± 2.8. The tongue base area (TBA) was found to be significantly associated with obstructive sleep apnea (OSA), with mean TBA 1032.8 ± 427 mm² compared with normal controls at 561.1 ± 197.6 mm² (p < 0.001). Mean gonion-gnathion-hyoid angle (Go-Gn-H) was 28.5 ± 10.5 in OSA and 16 ± 16.7 in controls; uvula area was 452.5 ± 145.8 mm² in OSA and 221.4 ± 49.85 mm² in controls; uvula diameter was 13.8 ± 2.74 mm in OSA and 10.1 ± 1.72 mm in controls. A total of 704 patients with OSA (80%) were found to be hypertensive, with daytime mean blood pressure of 160/100 ± 8.5/4.8 mm Hg. Mean duration of reported hypertension was 2 years. The present study showed moderate to severe OSA in a majority of suspected cases referred for polysomnogram. Mild disease was seen in 20.45% of patients (n = 180). On CT cephalometry, the TBA correlated significantly with OSA; hypertension is common in patients with OSA.     

慢性心力衰竭合并阻塞性睡眠呼吸暂停患者的临床表现和超声心动图特点

目的了解心力衰竭(HF)合并阻塞性睡眠呼吸暂停(OSA)患者的临床表现和超声心动图特点。方法连续入选2003年11月-2005年8月住院慢性心力衰竭患者,进行睡眠呼吸监测和超声心动图检查。睡眠呼吸暂停指发生在睡眠过程中与睡眠相关的呼吸调节和上呼吸道开放调节失常的病理生理改变,一次呼吸暂停定义为气流停止≥10s,睡眠呼吸暂停定义为睡眠呼吸暂停低通气指数(AHI)≥10次/h。阻塞性睡眠呼吸暂停和低通气分别是源于完全或部分狭窄咽腔的塌陷,鼻气流消失而胸腹运动存在,超过总呼吸暂停事件的50%。低通气定义为气流与基础水平比较减低50%以上,同时伴有脉搏血氧饱和度降低≥3%。结果 223例符合标准的慢性心力衰竭患者入选,160例心力衰竭[160/223(71.7%)]合并有睡眠呼吸暂停,其中心力衰竭合并OSA为HF+OSA组[n=77;77/223(34.5%)],不合并睡眠呼吸暂停的心力衰竭患者为HF组[n=63;63/223(28.3%)]。HF+OSA组的升主动脉内径大于HF组[(31.7±4.2)比(29.7±3.7)mm,(P0.05)],HF+OSA组的左室后壁厚度大于HF组[(9.32±1.39)比(8.72±1.44)mm,(P0.05)]。Logistic回归分析显示,心力衰竭合并OSA者的独立危险因素是年龄(OR=1.068)和高血压病史(OR=3.76),其显著临床特点是习惯性打鼾(OR=8.29)。结论高龄和有原发性高血压病史的心力衰竭患者易合并OSA。心力衰竭合并OSA患者显著临床特点是习惯性打鼾,超声心动图特点是升主动脉内径增宽,左室后壁厚度增厚。     

Continuous Positive Airway Pressure and Obstructive Sleep Apnea in an Hispanic Population

Objectives: We sought to explore the relationship between the diagnosis of hypertension and obstructive sleep apnea (OSA) in a Hispanic population, describe the effect of continuous positive airway pressure (CPAP) on blood pressure regulation, and assess the effect of CPAP on quality of life. Design: A retrospective, recall interview study. Participants: Patients enrolled at the Home Oxygen Program of the San Juan V.A. Medical Center with the diagnosis of OSA and treatment with CPAP. Measurements: The Calgary Sleep Apnea Quality of Life Index was administered to all patients after informed consent. Information regarding co-morbid conditions and fluctuations in blood pressure and anthropometric variables were obtained on a follow-up evaluation. Results: After excluding for the use of antihypertensive medications, weight, and age, a 10% decrease in mean arterial pressure (MAP) from 100 mm Hg to 92 mm Hg was observed in an average of 40 months of therapy (p < 0.05). With the Calgary Quality of Life Index, 67% of the patients reported an extreme improvement in their quality of life. Compliance with CPAP therapy correlated with improved quality of life (r = 0.33, p < 0.015). Conclusions: In this pilot study, there appears to be a correlation between our intervention and decline of blood pressure, independent of body weight, age, or medication usage. CPAP treatment is an effective modality in improving symptoms and quality of life.     

Mortality in Obstructive Sleep Apnea: Association with Impaired Wakefulness

Sleep fragmentation from obstructive sleep apnea (OSA) is correlated with a shortened sleep latency on the Maintenance of Wakefulness Test (MWT) and the Multiple Sleep Latency Test. Whether impairment of wakefulness is associated with increased mortality in OSA patients is unknown. We evaluated survival over an average timespan of 7.5 years from the date of diagnosis in a consecutive series of 322 OSA patients who had undergone nocturnal polysomnograpy and the MWT. Evaluable survival data were obtained in 142 patients. Twenty two had died. Deaths were predominantly due to cardiovascular disease. A comparison of the demographic and sleep study data between the alive and dead groups was significant for differences in MWT sleep latency and in age at time of diagnosis. The MWT mean sleep latency, when adjusted for age, was significantly shortened in the dead patients (28 ± 11 min vs. 21 ± 10 min, p < 0.005). Also, there was a significant decrease in survival in the patients whose MWT mean sleep latency was less than 20 min. These findings demonstrate an association between impairment of wakefulness and long-term mortality in OSA patients. This association was not evident for the other measures used to assess OSA severity.Supported by NIH grants NS30019, MH47680 to Dr. Mitler and Clinical Research Center grant AA08235 to the Scripps Research Institute.     

儿童阻塞性睡眠呼吸暂停综合征与高血压的关系

目的探讨儿童阻塞性睡眠呼吸暂停综合征(OSAS)患者中高血压的患病情况。方法选取90例有睡眠打鼾的儿童,实施多导睡眠监测并同步进行24 h 动态血压监测。按呼吸暂停低通气指数(AHI)分为(OSAS 组(AHI≥5次/h)和对照组(AHI<5次/h),比较两组的临床血压指数值、高血压的发病率和非杓型血压的情况。结果 1)OSAS 组的体质量指数(BMI)、氧减指数(ODI)和睡眠期间血氧饱和度<92%的时间(TST92%)均比对照组高(P<0.05);2)OSAS 组夜间睡眠时的收缩压(SBP)和舒张压(DBP)指数,以及白昼的收缩压指数较对照组高(P<0.05);3)OSAS 组的高血压发病率及非杓型血压情况比对照组多(P<0.01)。结论儿童 OSAS 与高血压密切相关,且是高血压发病的危险因素,血压多呈非杓型改变。     

高血压合并阻塞性睡眠呼吸暂停综合征患者治疗前后的血压昼夜节律变化

目的探讨高血压合并阻塞性睡眠呼吸障碍患者持续气道内正压通气(CPAP)或手术治疗前后的血压昼夜节律变化。方法入选高血压患者105例,根据多导睡眠仪监测结果分为单纯高血压组47例、高血压合并轻度阻塞性睡眠呼吸暂停综合征(OSAS)组36例和高血压合并中、重度 OSAS 组22例。CPAP 或手术治疗前后行24 h 动态血压监测,比较治疗前后睡眠呼吸参数与血压昼夜节律的关系。结果治疗前单纯高血压组昼夜血压呈非杓型占23.4%,高血压合并轻度和中、重度阻塞性睡眠呼吸暂停综合征组昼夜血压呈非杓型的分别占47.2%和59.1%。与单纯高血压组比较,差异有统计学意义(P<0.05)。治疗后各组昼夜血压呈非杓型的比例均有所下降,分别为19.1%,38.9%和45.5%,与治疗前各组间比较,差异有统计学意义(P<0.05)。中、重度阻塞性睡眠呼吸暂停综合征组非杓型血压下降最为明显。结论高血压患者昼夜血压呈非杓型时应考虑合并睡眠呼吸暂停综合征,且昼夜血压变化与 OSAS 严重性相关,CPAP 或手术治疗后非杓型明显减少。     

男性高血压病患者长期饮酒与阻塞性睡眠呼吸暂停综合征

目的 探讨男性高血压病患者长期饮酒与阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的相关关系.方法 以男性高血压患者304例为研究对象,经标准多导睡眠呼吸监测后分为OSAHS组220例和非OSAHS对照组84例.采用回顾性问卷调查所有研究对象的饮酒史,包括饮酒种类、平均饮酒频率、平均每次饮酒量、饮酒年限等,计算平均每月饮酒量及累积饮酒量,分析长期酒精摄入与OSAHS的相关关系.结果 1)OSAHS组和非OSAHS对照组的平均每次饮酒量(白酒)、平均每月饮酒量及累积饮酒量的差异无统计学意义(P＞0.05).2)以平均每月饮酒量≥50 g定义为饮酒者,将研究对象分为饮酒组244例和非饮酒组60例,饮酒组和非饮酒组的睡眠呼吸监测参数及OSAHS患病状况的差异无统计学意义(P＞0.05).3)将所有研究对象按睡眠呼吸暂停低通气指数(AHI)水平分层,在AHI＜20次/h的样本中,均衡了年龄、体质量指数及血压等危险因素后,与非饮酒组比较,饮酒组的AHI增大、平均及最长呼吸暂停时间延长,差异有统计学意义(P＜0.05).4)进一步以累积饮酒量的中位数(108 kg)将饮酒组划分为少量饮酒组和大量饮酒组,与非饮酒组进行睡眠呼吸监测参数的比较;在AHI＜20次/h的样本中,大量饮酒组(累积饮酒量＞108 kg)的最低血氧饱和度(SaO2)、平均、最长呼吸暂停持续时间比非饮酒组明显加重,差异有统计学意义(P＜0.05);但在AHI≥20次/h的样本中比较未见上述结果.结论 在AHI＜20次/h的男性高血压患者中,长期大量饮酒与阻塞性睡眠呼吸暂停的频率、时程及缺氧程度有关.     

Mortised Genioplasty in the Treatment of Obstructive Sleep Apnea: An Historical Perspective and Modification of Design

We describe a modified technique for mortised genioglossus advancement for treating obstructive sleep apnea and review the history of osteotomies in this region. This new osteotomy technique allows for greater soft tissue advancement of the hypopharyngeal region. Anatomical data from a previous study were used to evaluate the dimensions of the anterior mandible and design an osteotomy that overcomes shortcomings of previous designs. These anatomic measurements enabled us to estimate the size and formulate a design utilized in the anterior mandible for the treatment of obstructive sleep apnea. We believe this design offers the greatest amount of muscular advancement by including genioglossus, geniohyoid, digastric, and mylohyoid. This advancement results in increasing the posterior airway space by volumetric expansion. Custom-designed fixation was utilized to increase stability laterally and decrease the risk of mandibular fracture. The design should be a significant aid in reconstruction of the hypopharyngeal airway in patients with obstructive sleep apnea.     

Association of Sleep Apnea Severity and Obesity with Insulin Resistance,C-Reactive Protein,and Leptin Levels in Male Patients with Obstructive Sleep Apnea

Obesity is the major confounding factor in the relationship between obstructive sleep apnea and increased risk for cardiovascular disease. The aim of the study was to investigate the association of sleep apnea severity with insulin resistance, leptin, and CRP levels in a cohort of male patients. Sixty-seven men referred to our sleep laboratory for evaluation of suspected obstructive sleep apnea syndrome (OSAS) were divided into three groups according to apnea severity: non-OSAS group (n=15), mild to moderate OSAS group (n=26), and severe OSAS (n=26). Insulin resistance was estimated by the homeostasis model assessment method. HOMA values were similar in the three groups: (3.2+/-2.2 vs. 3.3+/-1.8 vs. 3.6+/-1.5, respectively, p=0.71). Leptin levels were higher in the mild to moderate OSAS group (23.1+/-21.8 ng/ml, p<0.05) and in the severe OSAS group (20.2+/-17.5 ng/ml, p<0.05) than in the non-OSAS group (9.4+/-6.4 ng/ml). CRP levels were significantly higher in severe sleep apnea (0.35+/-0.3 vs. 0.19+/-0.1 mg/dl, p<0.05). In multiple regression analyses, waist-to-hip ratio (WHR) was the most significant determinant of HOMA estimation for insulin resistance. WHR and the percentage of total sleep time spent with hypoxemia (%TST with SaO2 <90%) were significant predictors for leptin levels, while body mass index (BMI) and the %TST with SaO2 <90% were the best predicting parameters for CRP levels. Insulin resistance estimated by the HOMA method in male patients with OSAS was not associated with sleep apnea severity independent of obesity. The severity of nocturnal hypoxemia was associated with leptin and CRP levels independent of obesity.     

无创正压通气在治疗脑卒中合并重度OSAHS患者二级康复中的疗效分析

摘要 目的:分析无创正压通气在治疗脑卒中合并重度OSAHS患者二级康复中的临床疗效。方法：选取2011年8月至2013年5月武汉市汉口医院康复中心收治的脑卒中合并OSAHS的104名患者，对所有患者均给予常规治疗及康复训练。同意无创正压通气治疗并坚持12周的46名患者为无创通气组，未采取无创正压通气治疗的36名患者为对照组。22名患者因为各种原因不能坚持12周无创正压通气治疗，退出该研究。2组患者分别按脑卒中性质分为脑梗塞亚组和脑出血亚组。对患者治疗前后治疗12周后进行NISS评分、barthel评分及MMSE评分，并记录患者入组后12周因出现不良临床事件再入院次数及病死率。结果：（1）无创通气组的各亚组的NISS评分治疗前后差值、Barthel指数评分治疗前后差值、简易智能量表评分治疗前后差值（MMSE）与对照组相同亚组比较，P＜0.05，有统计学差异。无创通气组各亚组患者神经功能、日常生活能力、认知的恢复较对照组相应的各亚组明显。（2)2组患者的临床结局比较：无创通气组因不良临床事件（再发脑卒中、急性冠脉综合症、心律失常、心力衰竭、肺部感染）再入院次数及病死率均较观察组低，两组差异有统计学意义。结论：无创正压通气治疗可以有效改善二级康复的脑卒中合并重度OSAHS患者的神经功能、日常活动能力、认知功能及临床结局。康复科医师应充分认识卒中与OSAHS的相关性，加强与睡眠呼吸医师的合作，并积极采取有效的干预措施促进患者的康复。     

Effect on Quality of Life of Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea Syndrome: A Meta-analysis

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS). However, the impact of CPAP on quality of life (QOL) is controversial. The aim of this study was to systematically review and determine whether CPAP improves QOL in patients with OSAS. We performed a comprehensive literature search to identify studies published between 1966 and 2007 comparing values of CPAP with control. Weighted mean difference (WMD) was used to analyze the data. The pooled WMD was calculated by using a fixed or random-effect model. The outcomes for 1,256 patients from 16 studies, of whom 656 patients underwent CPAP and 600 were controls, were included. CPAP led to significant improvements in the Nottingham health profile part 2 (WMD=1.657; 95% CI=3.005, -0.308; p=0.016), but there was no difference in other general QOL scores. Patients undergoing CPAP scored better in physical function (WMD=3.457; 95% CI=0.144, 6.771; p=0.041), body pain (WMD=4.017; 95% CI= -0.008, 8.042; p=0.05), energy vitality (WMD=6.984; 95% CI = 0.557, 13.411; p=0.033) and physical component summary (PCS) (WMD=2.040; 95% CI=0.045, 4.035; p=0.045) using the SF-36 tool. This meta-analysis shows that CPAP does not improve general QOL scores but does improve physical domains and vitality. Study design and QOL questionnaire tools are important to capture and evaluate information efficiently. However, generic QOL instruments may not be adequate in detecting important changes in quality of life in patients with OSAS.     

Clinical manifestations of sleep apnea

Obstructive sleep apnea (OSA) may manifest in a number of ways from subtle intrusion into daily life to profound sleepiness, snoring, witnessed apneas and other classic symptoms. Although there is increasing evidence suggesting OSA can adversely affect health in a variety of ways, this disorder remains underdiagnosed. The most well-escribed health consequences of OSA relate to the cardiovascular system. Hypertension and arrhythmias have a strong association with OSA, and evidence suggests that treatment of OSA in patients with refractory hypertension and in patients planning cardioversion for atrial fibrillation may be of particularly importance. Significant associations between heart failure and OSA as well as complex sleep apnea have also been well-described. Cerebrovascular insult, impaired neurocognition, and poorly controlled mood disorder are also associated with in OSA. Therapy for OSA may ameliorate atherosclerotic progression and improve outcomes post-cerebrovascular accident (CVA). OSA should be considered in patients complaining of poor concentration at work, actual or near-miss motor vehicle accidents, and patients with severe sleepiness as a component of their co-morbid mood disorders. The metabolic impact of OSA has also been studied, particularly in relation to glucose homeostasis. Also of interest is the potential impact OSA has on lipid metabolism. The adverse effect untreated OSA has on glucose tolerance and lipid levels has led to the suggestion that OSA is yet another constituent of the metabolic syndrome. Some of these metabolic derangements may be related to the adverse effects untreated OSA has on hepatic health. The cardiovascular, neurocognitive, and metabolic manifestations of OSA can have a significant impact on patient health and quality of life. In many instances, evidence exists that therapy not only improves outcomes in general, but also modifies the severity of co-morbid disease. To mitigate the long-term sequela of this disease, providers should be aware of the subtle manifestations of OSA and order appropriate testing as necessary.     

阻塞性睡眠呼吸暂停合并肺癌的研究进展

阻塞性睡眠呼吸暂停(OSA)是患者在夜间睡眠时形成周期性缺氧-复氧循环,即间歇性缺氧。肺癌是最常见的恶性肿瘤,预后差。近年来,越来越多的研究探讨了OSA对肺癌的影响,提示OSA可增强肺癌细胞的增殖、侵袭及迁移能力。这可能与OSA造成的间歇性缺氧诱导缺氧诱导因子-1α(HIF-1α)增加及肺癌细胞中程序性死亡配体1(PD-L1)表达增强有关。该文综述了OSA与肺癌的关系及影响肺癌的可能机制,总结了模拟OSA样间歇性缺氧合并肺癌的细胞及动物模型。