气道正压通气对睡眠呼吸暂停综合征的疗效

目的:了解阻塞型睡眠呼吸暂停综合征(OSAS)患者在经鼻持续气道正压通气(nCPAP)治疗前后的睡眠特征和心身状况变化。方法:nCPAP治疗35例OSAS患者,治疗前、后分别采用多导睡眠分析仪对患者进行检查,分析治疗前、后多导睡眠图(PSG)各项指标改变。结果:治疗后患者临床症状消除,睡眠结构、最低血氧饱和度及呼吸紊乱指数等各项指标均有明显改善(P<0·01)。结论:nCPAP治疗不仅使睡眠呼吸暂停综合征(SAS)患者嗜睡、疲乏等临床症状消失,明显改善睡眠结构,而且改善心身健康状况。     

Information processing speed in obstructive sleep apnea syndrome: a review

To provide a comprehensive review of studies on information processing speed in patients with obstructive sleep apnea syndrome (OSAS) as compared to healthy controls and normative data, and to determine whether continuous positive airway pressure (CPAP) treatment improves information processing speed. A systematic review was performed on studies drawn from Medline and PsycINFO (January 1990–December 2011) and identified from lists of references in these studies. After inclusion criteria, 159 articles were left for abstract review, and after exclusion criteria 44 articles were fully reviewed. The number of patients in the studies reviewed ranged from 10 to 157 and the study samples consisted mainly of men. Half of the studies reported that patients with OSAS showed reduced information processing speed when compared to healthy controls. Reduced information processing speed was seen more often (75%) when compared to norm‐referenced data. Psychomotor speed seemed to be particularly liable to change. CPAP treatment improved processing speed, but the improvement was marginal when compared to placebo or conservative treatment. Patients with OSAS are affected by reduced information processing speed, which may persist despite CPAP treatment. Information processing is usually assessed as part of other cognitive functioning, not as a cognitive domain per se. However, it is important to take account of information processing speed when assessing other aspects of cognitive functioning. This will make it possible to determine whether cognitive decline in patients with OSAS is based on lower‐level or higher‐level cognitive processes or both.     

Effect of continuous positive airway pressure on regional cerebral blood flow in patients with severe obstructive sleep apnea syndrome

ObjectivesObstructive sleep apnea (OSA) is commonly associated with neural and cognitive deficits induced by recurrent hypoxemia and sleep fragment. The aims of this study were to use statistical parametric mapping (SPM) to analyze changes in regional cerebral blood flow (rCBF) in untreated patients with severe OSA before and after nasal continuous positive airway pressure (CPAP) treatment, examine the impact of OSA-related variables on rCBF, and assess the therapeutic effect of nasal CPAP treatment.MethodsThirty male patients with severe OSA underwent brain single photon emission computed tomography (SPECT) scans twice before and after nasal CPAP treatment for ≥6 months, whereas 26 healthy controls underwent a single SPECT scan. The rCBF differences were compared between two OSA sub-groups (untreated and treated) and the control group, and correlations between rCBF differences and clinical parameters were analyzed.ResultsCompared with the controls, the untreated OSA patients showed a significantly lower rCBF in multiple brain areas. After the treatment, partial reversal of the rCBF decreases was observed in the limbic and prefrontal areas. Moreover, complete reversal of the rCBF decreases was observed in the medial orbitofrontal, angular and cerebellar areas. Significant improvements in some clinical and polysomnographic variables (Epworth Sleepiness Scale, apnea–hypopnea index, CPAP duration, and arousal index) paralleled the rCBF changes after the treatment.ConclusionsDecreased rCBF in severe OSA was significantly reversible by CPAP treatment and correlated with the improvements in the apnea–hypopnea index, arousal index, CPAP duration and Epworth Sleepiness Scale. These results suggest that long-term CPAP treatment improves rCBF in areas responsible for executive, affective, and memory function.     

Altered regional cerebral blood flow in obstructive sleep apnea is associated with sleep fragmentation and oxygen desaturation

Altered cerebral perfusion has been reported in obstructive sleep apnea (OSA). Using dynamic susceptibility contrast MRI, we compared cerebral perfusion between male OSA patients and male healthy reference subjects and assessed correlations of perfusion abnormalities of OSA patients with sleep parameters and neuropsychological deficits at 3 T MRI, polysomnography and neuropsychological tests in 68 patients with OSA and 21 reference subjects. We found lower global and regional cerebral blood flow and cerebral blood volume, localized mainly in bilateral parietal and prefrontal cortices, as well as multiple focal cortical and deep structures related to the default mode network and attention network. In the correlation analysis between regional hypoperfusion and parameters of polysomnography, different patterns of regional hypoperfusion were distinctively associated with parameters of intermittent hypoxia and sleep fragmentation, which involved mainly parietal and orbitofrontal cortices, respectively. There was no association between brain perfusion and cognition in OSA patients in areas where significant association was observed in reference subjects, largely overlapping with nodes of the default mode network and attention network. Our results suggest that impaired cerebral perfusion in important areas of functional networks could be an important pathomechanism of neurocognitive deficits in OSA.     

Depression and anxiety in obstructive sleep apnea syndrome: a review

OBJECTIVE - To provide an update on recent research on depression and anxiety in obstructive sleep apnea syndrome (OSAS). METHODS - A review was carried out on reports drawn from MEDLINE and PSYCHLIT (January 1995-June 2006) and identified from their list of references. The selection criteria were met by 55 articles. RESULTS - Sample sizes in the reviewed studies varied widely and consisted mainly of working age men. Depression and anxiety were mostly evaluated with commonly used mood scales; only a few studies provided a psychiatric diagnosis. Prevalence figures fluctuated considerably for both depression (7-63%) and anxiety (11-70%). The effect of the continuous positive airway pressure (CPAP) on mood was inconsistent. CONCLUSIONS - Variations in the prevalence of depression and anxiety are affected by patient characteristics, mood assessment methods, and overlap between mood alterations and OSAS-related symptoms. CPAP might improve mood alterations but more long-term follow-up studies are needed to verify the effectiveness.     

Improvement of subjective work performance among obstructive sleep apnea patients after treatment with continuous positive airway pressure

Obstructive sleep apnea syndrome (OSAS) is a significant problem for some patients presenting with snoring and excessive daytime sleepiness. The 'golden standard' therapy in OSAS is considered to be nasal continuous positive airway pressure (CPAP). The effects of CPAP on work performance in sleep apnoics has not been studied previously. One hundred and fifty-two patients with OSAS participated in an open label study. The patients were diagnosed as suffering from severe OSAS after they underwent overnight polysomnography showing that their apnea indexes were at least 20. The participants answered four questions concerning self-perceived work performance prior to and after using CPAP during 6 months. There were highly statistically significant decreases (P < 0.000001) in work performance difficulties as graded by the patient. The results of this study indicate that CPAP treatment improves subjective work performance in patients suffering from OSAS.     

Effect of nasal continuous positive airway pressure on edema in patients with obstructive sleep apnea

BACKGROUND AND PURPOSE: Previous research has identified an association between idiopathic edema and obstructive sleep apnea (OSA) in women, but a causal relationship between OSA and edema has not been established. This study was undertaken to determine whether nasal continuous positive airway pressure (CPAP) lessens edema in patients with idiopathic edema and OSA. PATIENTS AND METHODS: This was a case-series study that enrolled eight ambulatory, obese, adults with bilateral, pitting pre-tibial edema and OSA from an inner city family practice and a suburban family practice from July 1995 until March 2003. Enrollees underwent subjective and physical examination assessment of changes in edema after initiation of nasal CPAP. RESULTS: All but one of the subjects had severe OSA. The edema was typically 1+ to 2+, and the duration of the edema ranged from 6 months to more than 20 years. Seven of the eight subjects experienced a reduction in the amount of edema following nasal CPAP (P=0.04). CONCLUSIONS: In subjects with OSA and idiopathic edema, nasal CPAP reduces the amount of edema. If valid, these results indicate that OSA can cause edema.     

Hypercoagulability in patients with obstructive sleep apnea

BACKGROUND: Obstructive sleep apnea (OSA) has been linked to cardiovascular complications such as stroke and myocardial infarction. Previous studies demonstrate that OSA patients show elevated fibrinogen levels and increased platelet aggregation that are reversed with 1 night of nasal continuous positive airway pressure treatment (NCPAP). Questioning overall coagulability in OSA, we examined whole blood coagulability in 11 chronically NCPAP treated OSA subjects, 22 previously untreated OSA subjects, and in 16 of these after 1 night of NCPAP treatment. PATIENTS AND METHODS: During full polysomnography, subjects from each group had blood drawn prior to bedtime (21:00 h) and upon waking in the morning (07:00 h). RESULTS: Untreated OSA patients had faster P.M. clotting times than chronically treated OSA patients (3.33+/-0.31 versus 6.12+/- 0.66 min, P<0.05 by ANOVA). A.M. values showed similar results (4.31+/- 0.34 min versus 7.08+/-0.52 min, P<0.05 by ANOVA) for the respective groups. One overnight treatment with nasal CPAP did not produce a significant change in A.M. whole blood coagulability (4.35 +/-0.43 to 5.31+/-0.53 min; n=16; P=0.1) in 16 treated subjects. CONCLUSIONS: These data indicate a relationship between obstructive sleep apnea and blood hypercoagulability status that appears to be reversed by chronic NCPAP treatment. These data suggest that NCPAP might protect against the development of cardiovascular complications in OSA patients.     

Effects of long‐term treatment on brain volume in patients with obstructive sleep apnea syndrome

We assessed structural brain damage in obstructive sleep apnea syndrome (OSA) patients (21 males) and the effects of long‐term continuous positive airway pressure (CPAP) treatment (18.2 ± 12.4 months; 8–44 months) on brain structures and investigated the relationship between severity of OSA and effects of treatment. Using deformation‐based morphometry to measure local volume changes, we identified widespread neocortical and cerebellar atrophy in untreated patients compared to controls (59 males; Cohen's D = 0.6; FDR < 0.05). Analysis of longitudinally scanned magnetic resonance imaging (MRI) scans both before and after treatment showed increased brain volume following treatment (FDR < 0.05). Volume increase was correlated with longer treatment in the cortical areas that largely overlapped with the initial atrophy. The areas overlying the hippocampal dentate gyrus and the cerebellar dentate nucleus displayed a volume increase after treatment. Patients with very severe OSA (AHI > 64) presented with prefrontal atrophy and displayed an additional volume increase in this area following treatment. Higher impairment of working memory in patients prior to treatment correlated with prefrontal volume increase after treatment. The large overlap between the initial brain damage and the extent of recovery after treatment suggests partial recovery of nonpermanent structural damage. Volume increases in the dentate gyrus and the dentate nucleus possibly likely indicate compensatory neurogenesis in response to diminishing oxidative stress. Such changes in other brain structures may explain gliosis, dendritic volume increase, or inflammation. This study provides neuroimaging evidence that revealed the positive effects of long‐term CPAP treatment in patients with OSA. Hum Brain Mapp 37:395–409, 2016. © 2015 Wiley Periodicals, Inc.     

Differences in arousal response between aged and middle-aged patients with obstructive sleep apnea syndrome

Abstract The aim of this study is to show the clinical significance of the differences in arousal response at a termination of apnea/hypopnea between aged and middle-aged patients with obstructive sleep apnea syndrome (OSAS). We polygraphically assessed electrocardiographic (ECG) and electroencephalographic (EEG) arousal. Electrocardiographic arousal was defined as an abrupt increase in heart rate at a termination of apnea/hypopnea. Our findings showed that EEG and ECG arousal at a termination of apnea/hypopnea were significantly suppressed in aged patients with OSAS, which might provide useful information on the pathophysiology of OSAS.     

Prognosis of the middle-aged and aged patients with obstructive sleep apnea syndrome

Abstract The long-term natural course of obstructive sleep apnea syndrome (OSAS) is studied in order to determine whether severity of nocturnal oxygen desaturation associated with apnea/hypopnea, body mass index (BMI), and hypertension influence survival in young (<40 years), middle-aged (40–64 years), and aged (65 years) using a questionnaire survey. One hundred and forty-eight patients with OSAS aged 17–78 years (136 men, 12 women, mean 52.0±12.3 yean), who were diagnosed by standard polysomnography (PSG) between 1983 and 1993, participated in the study. The survey revealed 15 deaths and 101 survivors; 32 subjects could not be located. The survival rate was 71.4% (95% confidence interval:55.6–87.2%). The survival rate in patients with OSAS was significantly lower than that in the age and sex-adjusted control Japanese population (87.6%). In the young group, only one death (a 19–year-old woman) occurred unexpectedly during sleep. The patient showed an apnea/hypopnea index (AHI) of 33 per h and the length of time that the nocturnal oxygen saturation (SaO₂) fell below 90% (time of SaO₂ < 90%) of 205 min. The survival rate in middle-aged patients with OSAS was significantly lower than that in the age and sex-adjusted control Japanese population (79.2 vs 91.0%), but this pattern was not seen among the aged. Time of SaO₂ <90% was significantly longer in the middle-aged patients than in the aged patients, but AHI did not differ between the two groups. Moreover, it was significantly correlated with AHI in middle-aged patients, but not in the aged patients. The survival rate was significantly lower in patients with hypertension than in the patients without such complications in the middle-aged group (57.9 vs 90.4%). Cox proportional-hazard regression model including age, hypertension, BMI, AHI, lowest SaO₂, and time of SaO₂ <90% showed that hypertension was only significantly associated with lower survival rate in total group and middle-aged patients, but not in the young or aged patients. The prognosis in patients with OSAS may differ among the generations. The prognosis in the middle-aged population may depend on the role of OSAS on the complications of hypertension or severity of oxygen desaturation, but not on AHI only.     

Identification and treatment of obstructive sleep apnea in adults and children with epilepsy: a prospective pilot study

OBJECTIVE: To determine the effect of treating obstructive sleep apnea (OSA) on seizure frequency in adults and children with epilepsy in a prospective study. Several case series documented an improvement in seizure control with treatment of coexisting OSA, but published series did not sample a clinic population, were not prospective in design, and did not account for concurrent changes in antiepileptic drug (AED) doses or levels. PATIENTS AND METHODS: Adult patients and the parents of pediatric patients seen in the University of Michigan Epilepsy and Pediatric Neurology Clinics were given validated questionnaires. Thirteen adults (aged 20-56) and 5 children (aged 14-17) were selected for polysomnography (PSG) based on frequency of seizures and risk for OSA. Seizure frequency was compared during 8-week baseline and treatment phases and AED levels were done to document stability in medication levels. RESULTS: Six of 13 adults and 3 of 5 children met PSG criteria for OSA. Three adults and 1 child were treated with continuous positive airway pressure (CPAP), were tolerant of the device, and had no change in AED doses; all four had at least a 45% reduction in seizure frequency during CPAP treatment. One adult was treated with an oral appliance with a reduction in nocturnal seizures only, and 2 adults and 2 children were intolerant of CPAP. CONCLUSIONS: Treatment of OSA in patients with epilepsy may improve seizure control and a large randomized placebo-controlled trial appear warranted.     

Diagnostic approach to obstructive sleep apnea in children

Obstructive sleep apnea syndrome (OSAS) in childhood is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns. A spectrum of severity related to the degree of upper airway resistance, to the duration of the disease, to the presence or absence of hypoxemia episodes, and to certain clinical features can be described. Symptomatic children may not fit the criteria for diagnosis established for OSAS in adults; age-specific standards are needed. Both anatomical factors that increase upper airway resistance, e.g. adenotonsillar hypertrophy, and functional processes that decrease upper airway tone, e.g. REM sleep, contribute to the pathogenesis of pediatric OSAS. Sequelae of OSAS in children include neurobehavioural abnormalities, stunting of growth, and cor pulmonale. Both the history and physical examination should target the sleeping child; parents often report loud snoring, difficulty breathing, and obstructive apneas. The gold standard investigation to establish the diagnosis and to quantitate disease severity is overnight polysomnography. Home cardiopulmonary sleep studies have been shown to be an accurate and practical alternative to overnight laboratory polysomnography for routine evaluation of non-complex children with adenotonsillar hypertrophy. Children with documented severe OSAS are at increased post-operative risk for airway compromise and should be observed and monitored carefully. Adenotonsiliectomy is the most common therapy for OSAS in children; as a second-line treatment, the use of nasal CPAP in children with OSAS has been very successful in experienced hands.     

Regional cerebral blood flow changes in patients with idiopathic REM sleep behavior disorder

Background: Recent studies have shown an association between rapid eye movement sleep behavior disorder (RBD) and neurodegenerative disorders, especially alpha‐synucleinopathies. Objective: We investigated regional cerebral blood flow (rCBF) changes using single photon emission computed tomography (SPECT) in patients with idiopathic RBD (iRBD), to determine functional brain alterations associated with the disorder. Methods: The SPECT data of 24 patients with iRBD were compared with those of 18 age‐matched normal controls using statistical parametric mapping 2. Results: We found decreased rCBF in the parietooccipital lobe (precuneus), limbic lobe, and cerebellar hemispheres in patients with iRBD, which is commonly seen in patients with Lewy body disease (Parkinson’s disease and dementia with Lewy bodies) or multiple system atrophy. Conclusion: Our SPECT study suggests that iRBD can be a presymptomatic stage of alpha‐synucleinopathies.     

Parallel changes in resting muscle sympathetic nerve activity and blood pressure in a hypertensive OSAS patient demonstrate treatment efficacy

Studies comparing the efficacy of continuous positive airway pressure (CPAP) versus surgery in correcting cardiovascular abnormalities in OSAS are lacking. We describe an OSAS patient with hypertension who responded favorably to CPAP treatment, whereas subsequent uvulopalatopharyngoplasty (UPPP) was less successful. While CPAP markedly lowered daytime muscle sympathetic nerve activity (MSNA) and blood pressure (BP), findings after UPPP were comparable to pre-treatment baseline. Thus, parallel changes in MSNA and BP demonstrated treatment efficacy.     

Polysomnographic and urodynamic changes in a case of obstructive sleep apnea syndrome with enuresis

A 53-year-old female patient with obstructive sleep apnea syndrome was reported. She had complained of enuresis as well as a 15-year history of snoring, but she had no complaint of sleep and awake disturbance. Polysomnographic study showed repeated obstructive apnea and hypopnea with an apnea/hypopnea index of 52.6, and severe oxygen desaturation during sleep. On cystometography during sleep, the changing amplitude of the spike wave corresponds to the changes of respiratory efforts against a closed upper airway. The patient was treated successfully with imipramine and acetazolamide for the obstructive sleep apnea and enuresis. Apnea/hypopnea index, nocturnal oxygen desaturation, and sleep architecture were improved, and enuresis completely disappeared. Cystometrography during sleep showed that the average amplitude of the spike wave tended to be low. Percentage urinary volume during sleep compared with 24 h volume was significantly reduced. We considered that the enuresis was mainly related to increased intra-abdominal pressure produced by respiratory efforts and enhanced nocturnal urine production.     

Seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea

ObjectiveThis study examined seasonal differences in continuous positive airway pressure (CPAP) therapy adherence among patients with obstructive sleep apnea (OSA).MethodsPatients aged ≥20 years with OSA who had used CPAP devices on the automatic setting for >12 consecutive months (n = 141) were included in this retrospective study from December 2015–2016. The information of CPAP use (pressure, hours of actual use) was extracted from database downloaded from patients’ CPAP devices. Patients were divided into adherent and non-adherent groups using the cutoff point of 70% CPAP use for ≥4 h daily over the 1-year study period. CPAP use data were averaged for each season.ResultsPatients in the adherent group were significantly older than those in the non-adherent group (p < 0.001). In the adherent group, the rate of ≥4 h daily CPAP use was significantly lower, the daily duration of CPAP use was significantly shorter, and the residual apnea–hypopnea index (AHI; events/hour) was significantly higher in summer than in other seasons (all p < 0.001). In the non-adherent group, the duration of daily CPAP use and the AHI differed significantly between winter and summer (p = 0.008 and p < 0.001, respectively).ConclusionsSeasonal changes were associated with the CPAP adherence of patients with OSA. The study findings suggest that there is possibility of increasing the duration of CPAP use by adjusting the bedroom environment in hot and humid seasons.     

Nasal CPAP treatment for obstructive sleep apnea: developing a new perspective on dosing strategies and compliance

Nasal continuous positive airway pressure (CPAP) is presently considered as the “treatment of choice” for obstructive sleep apnea (OSA). Though some OSA patients adhere to treatment recommendations and ultimately respond quite well to CPAP therapy, there is a substantial subgroup for which compliance is a particularly difficult issue. Despite receiving recommendations to the contrary and for reasons that are incompletely understood, the majority of OSA patients settle for a partial compliance pattern. Whether a partial compliance schedule is beneficial or harmful is virtually unexamined: Unlike other medical treatments, there are few data concerning the “dose–response relationship” of CPAP to its desired effects. We argue that CPAP “dose” is a function not only of CPAP pressure but of time-on-CPAP as well. Critical questions that remain unanswered are what “dose” of CPAP is needed to effect an appropriate treatment outcome and which treatment outcomes should form the basis of our recommendations. Recent placebo-controlled studies comparing CPAP to suboptimal CPAP pressures may be informative in this regard. Directions for future research are suggested.