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Obstructive Sleep Dyspnea: Diagnosis and treatment
Abstract
Polysomnography was performed on obstructive sleep dyspnea patients before and after treatment. Based on the value of intraesophageal pressure, the grade of respiratory disturbance was classified in 4 groups; normal, slightly obstructed, moderately obstructed and highly obstructed. In general, as the grade advanced, more parameters showed abnormality, Transnasal continuous positive pressure (CPAP) was a useful diagnostic method to evaluate the severity of obstruction. During the past 7 years, polysomnography has been performed on 50 children and 62 adults who complained of sleep dyspnea. Only highly obstructed cases underwent surgery; intranasal corrective surgeries, adenotonsillectomy, sinusectomy, UPPP and any combination of these. Most of them had more than one cause. After surgery, all of them were satisfied, except for a few whose snores were not so loud even when we tested before surgery. Postoperative survey by inquiry sheets demonstrated that recovery of sound sleep and enough rest resulted in refreshing and active lives during daytime.
In order to reduce pre- and postoperative risk and morbidity, sleep surgeons try to do as much as necessary and contemporaneously as few as possible. Therefore, the identification of the site(s) of obstruction in SDB is very important. Pressure measurements with one or more sensors, flexible endoscopy in the awake and during sedation, analysis of sounds during sleep, and various imaging techniques are used to identify the site of obstruction and/or the origin of breathing sounds.
In recent years, the spectrum of therapy for sleep-related breathing disorders has been immensely enriched by numerous innovative surgical procedures and techniques. Deciding which therapy is most appropriate for which patient is often a difficult matter, especially in light of the non-surgical alternatives. This book analyses the efficiency of the recognised surgical procedures; it is rooted in evidence-based medicine. Indications, techniques, complications, and specific follow-up treatments in the realm of sleep medicine have been compiled in the form of a primer. The authors are directors of one of the largest otolaryngological sleep laboratories in the world and perform approximately 1,500 surgical sleep medicine procedures per year. The complete surgical and sleep medicine know-how of the authors, as well as the experience of numerous international courses on sleep surgery, have been incorporated into this volume. It is therefore the fundamental textbook for sleep medicine surgeons. © Springer-Verlag Berlin Heidelberg 2005. All rights are reserved.
The treatment of sleep disordered breathing has been enriched by the development of various new and largely surgical techniques. The question of which treatment best suits each individual patient has become a highly sophisticated decision. Among others, the most important factors for selecting the most appropriate treatment modality are the cruelty of the disease, the pathology found within the upper airway, and the sites of obstruction. Therefore, the second edition of this book focuses on both the surgical treatment modalities and the current concepts for treatment decisions. For each procedure, current data (including data for the entirety of 2007) were reanalyzed according to the principles of evidence-based medicine, and are presented in well-arranged tables. Indications, techniques, complications, and specific follow-up treatments in the realm of sleep medicine have been compiled in the form of a primer. New chapters concerning radiofrequency- uvulopalatoplasty and combined soft palate procedures were added. Both authors run prominent otolaryngological sleep laboratories, and perform approximately 1,500 surgical sleep medicine procedures per year. The complete surgical and sleep medicine expertise of the authors, as well as the experience of numerous international courses on sleep surgery, have been incorporated into this volume, making it an indispensable textbook for sleep medicine surgeons. © Springer-Verlag Berlin Heidelberg 2010. All rights are reserved.
Patients with upper airway resistance syndrome (UARS) have clinical signs and symptoms of excessive daytime somnolence (EDS) in the absence of obstructive sleep apnea. These patients have increased upper airway resistance, reflected by an elevated intrathoracic pressure measurement, despite a normal respiratory disturbance index (RDI). Physical findings often include excessive palatal tissue and narrowing of the oropharynx and hypopharynx.
Nine patients with UARS who received surgical treatment were prospectively evaluated. The four men and five women had signs of EDS, with or without snoring. The mean (±standard deviation) RDI was 2.1 (±1.2), and the mean esophageal pressure recording during polysomnography was ‐36.7 (±16.2) cm H 2 O. The Epworth sleepiness scale was used to quantify EDS. The preoperative score of 12.0 (±6.6) decreased to 3.4 (±1.9) ( P =.001) after surgical treatment. A variety of procedures, all including some type of palatal surgery, were performed. No treatment complications occurred.
The recognition of UARS and an understanding of the mechanisms responsible for the progressive development of obstructive sleep apnea syndrome may facilitate the prompt identification and treatment of such patients. The pathophysiology of UARS and a preliminary report of its surgical treatment are discussed.
A case of Creutzfeldt-Jakob disease (CJD) with presenting Wernicke encephalopathy (WE)-like symptoms and severe insomnia is presented. An 80-year-old alcoholic man with a 6 month history of tremors, ataxia, memory loss and confabulation, developed profound insomnia, confusion, and delirium with vivid hallucinations. Polysomnography revealed a marked reduction of sleep time, with central-type sleep apnea. Neither myoclonus nor periodic synchronous discharge (PSD) was observed. An autopsy revealed diffuse spongiform changes and astrocytosis throughout the cerebral gray matter, with severe involvement of the mammillary bodies and thalamus. Prion protein (PrP) immunostaining was positive in kuru plaques in the cerebellum, PrP polymorphism at codon 129 was heterozygous Met/Val, and proteinase K resistant PrP (PrP(res)) was demonstrated by Western blotting. The lack of necrotizing lesions in the mammillary bodies, thalamus, and periaqueductal gray matter could rule out WE. The data suggest that the present case of CJD is consistent with PrP(res) type 2 (CJD M/V 2), but was unique in the lack of some typical CJD signs and the presence of signs of WE and sleep abnormalities.
To evaluate the effect of nasal obstruction in infants and young children upon ventilation during sleep, change of ventilation was followed by polygraphic recordings of esophageal pressure, tidal volume and percutaneous oxygen tension when the nostrils were mechanically obstructed in 10 subjects; 3 types of ventilatory changes were noted. In 4 subjects periodic breathing appeared in which hypoventilation was alternated with occasional hyperventilation. Esophageal pressure, tidal volume and PO2 showed concomittant fluctuation. PO2 lowered during hypoventilatory phase was compensated by periodic hyperventilation. In 5 subjects upper airway obstruction was compensated for by increased respiratory endeavor and tidal volume and PO2 remained normal in spite of markedly increased esophageal pressure. In 1 subject tidal volume and PO2 remained decreased with marked increase of esophageal pressure. Largest airway obstruction was noted between the upper and the lower lips.
The influence of hypertrophied tonsils and adenoids upon ventilation during sleep was evaluated by polygraphic recording before and after adenotonsillectomy. In all 19 cases, esophageal pressure during sleep was elevated as high as 4-6 times normal. This was caused by nasal obstruction due to adenoid hypertrophy and obstruction of the “oral airway” by hypertrophied tonsil and collapse of the tongue due to muscular relaxation during sleep. When minimal amount of contrast media was instilled slowly into the nasopharynx aspiration of the contrast media into the lung was found significantly more frequently in subjects with upper airway obstruction. Active aspiration of the secretion by marked inspiratory negative pressure during sleep may play a major role in causing recurrent infection of the lower airway frequently seen in these children.
Laryngotracheomalacia usually is a self-limited disease causing only noisy respiration. This report describes an infant born with a severe form of this anomaly who manifested cor pulmonale and congestive heart failure by 29 months of age. Suprasystemic pulmonary artery pressures were noted at the time of the initial cardiac catheterization. The child improved clinically after tracheostomy, and a repeat cardiac catheterization at 4 years of age showed a marked decrease in pulmonary artery pressure. Though a frequent cause of stridor in infancy, to our knowledge laryngotracheomalacia has not been reported as associated with cor pulmonale.
The importance of breathing through the normal nose can never be overstressed. Disturbance in nasal breathing caused by an anomalous configuration of the septum and the turbinates results in the change of respiratory function in varying degrees. The purpose of this study os to re-evaluate the relationship between structure and function from the viewpoint of aerodynamics.
Twin brothers suffering from severe alveolar hypoventilation secondary to tonsillar hypertrophy are presented. The ventilatory abnormalities were more severe in the child with greater degree of upper airway obstruction. Pulmonary hypertension and right ventricular failure developed only in the latter twin thus confirming a cause-effect relationship between upper airway obstruction and the cardiac complications. The cardiac abnormalities were completely relieved after tonsillectomy, but not after adenoidectomy in the child who had both procedures. The procedure of cardiac catheterization was complicated by considerable respiratory difficulty and cardiac arrest in the twin with larger tonsils. When the right heart catheter was left open to air for a short time, large quantities of air were sucked into the heart causing near fatal air embolism. This danger should be kept in mind when patients with upper airway obstructions are catheterized. There seems to be a definite place for tonsillectomy when the tonsils are sufficiently large to interfere with ventilation.
OBSTRUCTION in the nasal passages has been shown to affect the mechanics of breathing.1 It follows that pulmonary function may be related to the nose, and that the function of the nose is not that of a mere conduit for the lower respiratory tract. In a small series of patients with nasal obstruction, we found a decreased lung compliance and increased pulmonary resistance when measured during mouth respiration as well as through the nose. The basis of this relationship has not been established. This report deals with a critical study of this relationship, carried out on patients before and after surgical correction of nasal obstruction.
Review of Literature
Interrelationships between the nose and the bronchopulmonary system have been investigated by many physiologists and clinicians from the standpoint of air conditioning, aerodynamics, gas exchange, and reflex regulation of breathing. Through animal experiments and clinical observations a definite respiratory influence of
Partial airway obstruction and respiratory abnormality due to enlargement of tonsils and adenoids is a well-recognized clinical entity, but the cardiorespiratory changes which severe chronic obstruction may cause have not been widely documented. Four patients with severe nasopharyngeal obstruction have been observed to have cardiorespiratory complications ranging from moderate cardiac enlargement and right ventricular hypertrophy to cor pulmonale and pulmonary edema. Hemodynamic studies showed swings in pulmonary artery and aortic pressures; pCO2 was varyingly elevated in arterialized capillary blood.
It is believed that hypoxia leads to increased pulmonary resistance and elevated pulmonary artery pressure which, over a period of months, results in right heart hypertrophy and failure. Furthermore, hypoxia may contribute to the development of pulmonary edema in a manner similar to that which occurs at high altitudes. Wide swings in intrathoracic pressure also probably played an important role in the etiology of pulmonary edema. Individual susceptibility to hypoxia and pressure changes is suspected to be an important etiologic factor.
The problem of chronic upper airway obstruction caused by tremendously enlarged tonsils and adenoids in children warrants further investigation and more widespread recognition as being potentially dangerous from cardiorespiratory standpoints.
Excessive daytime sleepiness and loud snoring are the major symptoms of obstructive sleep apnea, often leading to serious medical complications if unrecognized and untreated. Tracheostomy has been the only effective treatment in most adult cases. This paper reports on a new surgical approach to treat obstructive sleep apnea by uvulopalatopharyngoplasty designed to enlarge the potential airspace in the oropharynx. Twelve patients underwent this operation. In nine there was relief of symptoms and in eight there was objective improvement in nocturnal respiration and sleep pattern, demonstrated by polysomnography.
Three hundred six infants were referred for evaluation of "near-miss" sudden infant death syndrome (SIDS) from 1973 to 1980. Following the hospitalization and medical evaluation, there were 156 infants (115 term and 41 preterm) for whom there was no explanation for the presenting event and who were considered near-miss infants; 88% of these infants were seen during the first 3 months of life. A repeat near-miss event was reported in 63% (term) and 83% (preterm) infants. Twelve percent of term infants and 17% of the preterm infants had ten or more repeat events. A home apnea/cardiac monitor was prescribed for 88% of the infants for an average duration of 5.6 months in term infants and 3.5 months in preterm infants. Monitoring had been discontinued in 69% of the infants by 7 months of age. One full-term infant was later a SIDS victim. The risk of a repeat near-miss event is concluded to be sufficiently great to demand immediate hospitalization, medical evaluation, home monitoring when there is no specific treatment, and close clinical follow-up. Follow-up studies are needed to determine whether there is any long-term morbidity for infants who have had near miss events.
The association of alveolar hypoventilation with obesity is described. The literature relating to the clinical manifestations of this association is reviewed.
Contribution of the nose in respiratory physiology
- K Togawa
Polysomnographic study of snore
- Togawa K
- Miyazaki S
- E N Myers
- Togawa K
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Influence of nasal obstruction on sleep
- Togawa K
- Togawa K
Nasal obstruction and mechanics of breathing
- J H Ogura
Clinical overview of the sleep apnea syndrome
- C Guilleminault
- W C Guilleminault
- Dement
Polysomnographic study of snore. New dimension in otorhinolaryngology—Head and Neck Surgery
- K Togawa
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- Togawa K