SLEEP

Langevin,, B.;Sukkar,, F.;Léger,, P.;Guez,, A.;Robert,, D.

doi: 10.1093/sleep/15.suppl_6.S25pmid: N/A

Summary: Sleep apnea syndrome (SAS) results from modification in the control of respiration and of upper airway caliber during sleep. Although there is some overlap between central (CSAS) and obstructive (OSAS) sleep apnea syndromes, each syndrome has specific pathological associations. The first part of this review concerns the pathophysiology of OSAS, including periodic breathing and upper airway collapse. In the second part, each specific etiology is examined, and the respective contribution of anatomic narrowing and neuromuscular dysfunction of the upper airway is mentioned. Our experience with about 375 patients with sleep-related breathing disorders is also reported, with regard to the specific etiologies of CSAS and OSAS. Sleep apnea syndrome, Upper airway collapse, Periodic breathing This content is only available as a PDF.

Sériès,, F.;Cormier,, Y.;La Forge,, J.;Desmeules,, M.

doi: 10.1093/sleep/15.suppl_6.S47pmid: N/A

Summary: Nasal continuous positive airway pressure (NCPAP) is considered the most effective treatment of obstructive sleep apnea. Its beneficial effects are related to the normalization of breathing during sleep and to the prevention of nocturnal desaturations. NCPAP interacts with the pathophysiologic mechanisms of sleep apnea onset and with the consequences of these apneas. Upper airway patency is maintained with NCPAP by a pneumatic splinting effect while changes in lung volume and pre-apnea Sa02 level may be implicated in the improvement of apnea-related desaturations. An improvement in central chemosensitivity could account for the improvement in diurnal oxygenation observed with long term NCPAP therapy. Continuous positive airway pressure, Airway resistance, Upper airway dilator muscles, Lung volumes, Apnea-related desaturation This content is only available as a PDF.

Crampette,, L.;Carlander,, B.;Mondain,, M.;Billiard,, M.;Guerrier,, B.;Dejean,, Y.

doi: 10.1093/sleep/15.suppl_6.S63pmid: 1470813

Summary: Uvulopalatopharyngoplasty (UPPP) is the surgery most often performed for sleep apnea syndrome (SAS). However, good results with UPPP, demonstrated by polysomnography, have been reported in only 50% of cases. Failure of UPPP may be caused by: 1) bad management of the SAS, which is better treated in some patients with nasal CPAP than with surgery; and 2) an airway obstruction located not only at the palatopharynx (PP) level. Other surgical procedures to enlarge other sites of obstruction are described. Retro-tongue-base-pharynx (RTBP) surgery is emphasized, including mandibular advancement, hyoid bone suspension, and tongue base reduction. Maxillomandibular advancement is the most efficient technique but also the most complicated. Uvulopalatopharyngoplasty, Retro-tongue-base-Pharynx surgery, Maxillomandibular advancement, Sleep apnea syndrome This content is only available as a PDF. © 1992 American Sleep Disorders Association and Sleep Research Society

Guilleminault,, Christian;Stoohs,, Riccardo;Clerk,, Alex;Simmons,, Jerald;Labanowski,, Michael

doi: 10.1093/sleep/15.suppl_6.S13pmid: N/A

Summary: Some patients with excessive daytime sleepiness who do not present the features of obstructive sleep apnea syndrome (OSAS) present a sleep fragmentation due to transient alpha EEG arousals lasting between three and 14 seconds. These transient EEG arousals are related to an abnormal amount of breathing effort, indicated by peak inspiratory esophageal pressure (Pes) nadir. In the studied population, these increased efforts were associated with snoring. Usage of nasal CPAP, titrated on Pes nadir values, for several weeks eliminated subjective daytime sleepiness and improved Multiple Sleep Latency Test scores from baseline evaluations. Patients suspected of CNS hypersomnia should be asked about continuous snoring, and their clinical evaluation should include a good review of maxillo-mandibular and upper airway anatomy. This content is only available as a PDF.

Guilleminault,, Christian;Suzuki,, Mayumi

doi: 10.1093/sleep/15.suppl_6.S20pmid: N/A

Summary: Many different hemodynamic changes can be observed during obstructive apneas in the nocturnal sleep period. The most significant changes are observed whenever apneas occur in rapid succession. Systemic, pulmonary, and wedge pressures are modified. Many of these changes are mediated through cholinergic mechanisms. The mechanical effort of breathing against a partially or completely obstructed airway may also have an impact on hemodynamics. This impact must be dissociated from the impact of hypoxemia and blood gas changes. It has been questioned whether obstructive sleep apnea syndrome (OSAS) has any significant role in the development of 24-hour hypertension. In support of this theory, we found that tracheostomy does eliminate hypertension in obstructive sleep apneic children. In adults the issue is more complicated. Hypertension was eliminated in a subgroup of our patients treated with tracheostomy or nasal continuous positive airway pressure (CPAP), although the total group had no statistically significant blood pressure differences. Many variables that might dissociate treatment responders from nonresponders are not available. Hypertensive patients whose blood pressure normalized with OSAS treatment were significantly less overweight than the nonresponders in our series. Patients who remained hypertensive after treatment did, however, develop a normal circadian blood pressure trough during nocturnal sleep. Hypertension, Obstructive sleep apnea, Nasal CPAP, Obesity This content is only available as a PDF.

Rodenstein, Daniel, O.

doi: 10.1093/sleep/15.suppl_6.S56pmid: 1470812

Summary: Uvulopalatopharyngoplasty (UPPP) consists in the surgical removal of the uvula, part of the muscular portion of the soft palate and redundant palatal and pillar mucosa, and the tonsils. Since 1981, UPPP has been proposed for the treatment of sleep apnea syndrome. Polysomnographic studies have shown that in about half of the patients submitted to UPPP there is a 50% or greater reduction in apnea index. Attempts to identify presurgically those patients more likely to benefit from UPPP have yielded inconsistent results. Limited retrospective follow-up data suggest that UPPP does not modify the increased mortality associated with moderate and severe sleep apnea syndrome. Patients submitted to UPPP report subjective improvement, irrespective of the objective polysomnographic postsurgical results. It is suggested that polysomnographic evaluation of UPPP results should be mandatory; that any patient with 20 or more apnea/hypopneas per hour of sleep or sleep fragmentation after UPPP should be considered a treatment failure and be offered alternative therapy; and that UPPP should be performed only as part of prospective clinical trials including long-term follow-up. Uvulopalatopharyngoplasty, Sleep apnea syndrome, Polysomnography, Sleep fragmentation This content is only available as a PDF. © 1992 American Sleep Disorders Association and Sleep Research Society

Weitzenblum,, E.;Krieger,, J.;Oswald,, M.;Chaouat,, A.;Bachez,, P.;Kessler,, R.

doi: 10.1093/sleep/15.suppl_6.S33pmid: N/A

Summary: The term “overlap syndrome” was introduced by Flenley to describe the association of sleep apnea syndrome (SAS) with chronic obstructive pulmonary disease (COPD). Epidemiologic data on the prevalence of the overlap syndrome are not available, but the frequency of an associated COPD in SAS patients has been emphasized in almost all the studies analyzing the development of respiratory insufficiency in SAS patients. In a large series (n = 264) of unselected SAS patients who had undergone detailed pulmonary function tests, we observed an obstructive ventilatory defect (FEV1/VC < 60%) in 30 of 264 patients (11%). These patients had lower daytime Pa02 and higher PaC02 than the other patients and they had higher resting and exercising pulmonary artery mean pressure (right heart catheterization was performed in 215 of 264 patients). We conclude that the risk of developing respiratory insufficiency and cor pulmonale is higher in overlap patients. Key Words: Sleep apnea syndrome—Chronic obstructive pulmonary disease—Respiratory insufficiency—Chronic hypoxemia—Chronic hypercapnia—Pulmonary hypertension. Sleep apnea syndrome, Chronic obstructive pulmonary disease, Respiratory insufficiency, Chronic hypoxemia, Chronic hypercapnia, Pulmonary hypertension This content is only available as a PDF.

Pépin, J., L.;Lévy,, P.;Veale,, D.;Ferretti,, G.

doi: 10.1093/sleep/15.suppl_6.S50pmid: N/A

Summary: The upper airway is the final common site for abnormalities in respiratory control and neuromuscular function leading to sleep apnea. This review summarizes the information that pharyngeal assessment provides for understanding upper airway pathophysiology and selecting treatment. The applications and limitations of both static and dynamic techniques are examined in awake and sleeping patients. The effects of posture on the upper airway and the usefulness for predicting treatment efficiency are examined. This content is only available as a PDF.

Aubert,, Geneviève

doi: 10.1093/sleep/15.suppl_6.S69pmid: 1470814

Summary: A number of therapeutic alternatives to continuous positive airway pressure (CPAP) and surgery have been proposed to treat sleep apnea syndrome. Nasopharyngeal intubation may provide an immediate, simple and cost-effective means of bypassing upper airway obstruction during sleep. Tolerance is good in small children but is lower, between 30 and 40%, in adults. Clinical improvement is reported by more than half of the patients treated with this device and is confirmed by polysomnography. However, in most of these subjects, breathing during sleep is only partially corrected and sleep remains fragmented. Nasopharyngeal intubation should be proposed in infants, in patients who do not tolerate CPAP or as a therapeutic substitute for CPAP during holidays or traveling. The tongue retaining device and variants of orthodontic appliances have been proposed in order to increase upper airway patency. Tolerance is low, efficacy is usually incomplete and limited to patients with moderate forms of SAS, and long-term follow-ups are scarce. Sleep position training has been advocated as a means of reducing time spent in the supine position. Long-term efficacy has not been proven. Weight loss by caloric restriction or surgical procedures produces a variable improvement of sleep architecture and breathing during sleep. It should be proposed to all patients with SAS, as cure has been achieved in a few patients with the adjunction of weight loss and another treatment modality. Nasopharyngeal tube, Tongue retaining device, Orthodontic appliance, Sleep position training, Weight loss, Sleep apnea syndrome, Snoring This content is only available as a PDF. © 1992 American Sleep Disorders Association and Sleep Research Society

Fleury,, B.

doi: 10.1093/sleep/15.suppl_6.S39pmid: 1470807

Summary: Sleep apnea syndrome (SAS) is a well established sleep disorder with high morbidity and mortality. Patients are most often middle-aged men. SAS occurs in at least 1% of the adult population. Several studies have suggested that SAS is extemely frequent in the elderly, its prevalence ranging from 18 to 73% in this group. However, the generalization of these results to elderly cohorts is questionable because of several limitations of these studies, including lack of standard selection criteria, variation in recording techniques, the night to night variability of sleep apnea and the use of a moderate level of sleep disordered breathing (SDB) to define SAS (5 apneas per hour). The study best designed for valid extrapolation to the whole aged population estimates the frequency of SAS at 18%. However, most of these patients reported satisfactory sleep, and epidemiologic criteria for a causal association between SAS in the elderly and cardiovascular disease have not been satisfied. The conclusions of numerous studies dealing with impairment in cognitive function and SAS in the elderly are controversial. In fact, if the diagnostic threshold is increased from 5 apneas to 10 apneas plus hypopneas per hour, elderly SAS patients have more sleep disturbances, are more depressed and have cognitive deficits as compared to normal old persons. When an appropriate diagnostic index is used, SAS in the elderly resembles SAS described in the middle-aged population. In addition, a high apnea plus hypopnea index is an ominous predictor of mortality in the elderly population, and a very high level of SDB is an extremely significant risk factor for mortality during sleep phase in these patients. This review of the epidemiologic evidence suggests that only symptomatic elderly patients need to be recorded in a sleep laboratory to diagnose and treat a sleep apnea syndrome. Epidemiologic studies including more numerous and more severely affected subjects are required to analyze the natural history of SDB in the elderly. This content is only available as a PDF. © 1992 American Sleep Disorders Association and Sleep Research Society