[Effectiveness of a mandibular advancement prosthesis in the treatment of obstructive sleep apnea syndrome]. / Eficacia de una prótesis de avance mandibular en el tratamiento del síndrome de apneas obstructivas del sueño.

OBJECTIVE: To assess the efficacy of a mandibular advancement prosthesis for treating obstructive sleep apnea syndrome (OSAS). METHOD: Mandibular advancement appliances were prescribed for 21 patients (20 men) with OSAS diagnosed by polysomnography. Mean age was 51 (8) years, BMI was 30 (4) kg/m2, and the apnea-hypopnea index (AHI) per hour was 48 (17). If the device was well tolerated, regardless of clinical response, polysomnography was repeated between 1 to 3 months after start of treatment. The device was considered effective if the AHI decreased to < 15/h and symptoms related to OSAS disappeared. RESULTS: Seven patients withdrew from treatment after only a few days. The remaining 14 (66%) tolerated treatment well and the second polysomnogram was performed. In six of the 14 (43%), the device proved effective for correcting OSAS. In six more patients, the AHI decreased but failed to become normal. In the remaining two patients, no improvement was observed. Improvement in the AHI was unrelated to severity of OSAS. CONCLUSION: The mandibular advancement prosthesis is effective for some patients with OSAS, including those in whom the AHI is high. Larger studies are needed to allow us to define the type of patients that might benefit.

Eficacia de una prótesis de avance mandibular en el tratamiento del síndrome de apneas obstructivas del sueño / Efficacy of a mandibular advancement prosthesis for treating obstructive sleep apnea syndrome

Objetivo: Evaluar la eficacia de un modelo de prótesis de avance mandibular en el tratamiento del síndrome de apneas obstructivas del sueño. Método: Se realizó tratamiento con prótesis de avance mandibular en 21 pacientes (20 varones) diagnosticados de síndrome de apneas obstructivas del sueño mediante polisomnografía. La edad media (DE) era de 51 (8) años, el índice de masa corporal de 30 (4) kg/m2, y el índice de apnea-hipopnea/hora de 48 (17). Si el tratamiento era bien tolerado, independientemente de la respuesta clínica, se repetía el control polisomnográfico con prótesis entre 1 y 3 meses de iniciado el tratamiento. La prótesis de avance mandibular se consideró eficaz si el índice de apnea-hipopnea se reducía a < 15/h y desaparecerían los síntomas relacionados con el síndrome de apneas obstructivas del sueño. Resultados: Siete pacientes abandonaron el tratamiento en los primeros días de uso. Los 14 restantes (66 por ciento) toleraron bien el tratamiento, y se realizó el control polisomnográfico. En 6 de los 14 casos (43 por ciento) la prótesis de avance mandibular demostró ser eficaz en la corrección del síndrome de apneas obstructivas del sueño. En 6 pacientes más se conseguía una reducción del índice de apnea-hipopnea, sin llegar a su normalización. En los 2 casos restantes no hubo ninguna mejoría. La mejoría del índice de apnea-hipopnea no se relacionaba con el grado de gravedad del síndrome de apneas obstructivas del sueño. Conclusión: La prótesis de avance mandibular es un tratamiento eficaz para un subgrupo de pacientes con síndrome de apneas obstructivas del sueño, incluyendo algunos con índice de apnea-hipopnea elevado. Son necesarios estudios más amplios que nos permitan definir el tipo de pacientes que pueden beneficiarse. (AU)

Transtracheal catheter acceptance and adverse events in long-term home oxygen therapy.

The acceptance of transtracheal catheters (TTC) in chronic obstructive pulmonary disease (COPD) patients with severe hypoxaemia was analysed and the adverse events associated with this system of oxygenation described. Once the TTC (Oxycat) was inserted, each patient was monitored on an outpatient basis and information about the associated adverse events was collected. In a group of 70 patients that met the inclusion criteria, only 14 (20%) accepted TTC insertion. The observed adverse events were: haemorrhage through the stoma (3); ejection of the TTC in a cough reflex (2); subcutaneous emphysema (2); mucous plugging (1); and haemoptysis (1). Removal of the TTC was necessary in 29% of the cases, and was associated with the onset of an adverse event in all cases except one. Despite the proven benefits of oxygen therapy performance and the improvement in effort tolerance, transtracheal catheter has a low level of acceptance among patients with extremely disabling diseases. The adverse events observed were frequent, but could have been corrected and in no case worsened our patients' prognosis.

Long-term mechanical ventilation in amyotrophic lateral sclerosis.

BACKGROUND: Acute respiratory insufficiency (ARI) with alveolar hypoventilation or incapacitating dyspnoea but without peripheral muscle involvement can be an early manifestation of respiratory involvement in amyotrophic lateral sclerosis (ALS). Some of these patients benefit from assisted ventilation. The object of this study was to analyse the results of long-term mechanical ventilation (LTMV) in ten patients with ALS. METHODS: A retrospective analysis of intensive care unit (ICU) or ambulant patients with ALS who underwent LTMV in a conventional hospital ward was performed. Erect and supine spirometry, blood gas analysis and pulse oximetry were performed before the start and during the course of ventilation. RESULTS: Ten patients on LTMV were included. Four from the ICU were ventilated via tracheostomy, and six ambulant patients had non-invasive (nasal) ventilation. In all cases, ventilation was performed in a conventional hospital ward. The ambulant patients improved symptomatically during ventilation, confirmed by measurement of gas exchange and of SaO2 by continuous pulse oximetry. Three of the ten patients survive in long-term care--two with nasal and one with tracheostomy ventilation. CONCLUSIONS: LTMV outside ICU was possible in ten patients, seven of whom returned home. Returning home is very difficult for patients dependent on a ventilator who lack family support.

Randomised trial of corticosteroids in the treatment of tuberculous pleurisy.

BACKGROUND: Tuberculous pleurisy can result in pleural fibrosis, calcification and thickening. To prevent these complications, corticosteroids are frequently used in addition to antituberculous drugs; however, new therapeutic regimens can control the disease and minimise the sequelae, and there is no convincing evidence of the benefit of the use of corticosteroids as adjuvant therapy. METHODS: Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Additionally, they were randomly assigned to a double blind treatment with either prednisone (1 mg/kg/day for 15 days and then tapering off) or placebo during the first month of treatment. Different clinical, radiological, and functional parameters were evaluated to assess the effect of corticosteroids. RESULTS: Fifty seven patients received prednisone and 60 placebo. At the end of the treatment the clinical outcome, the rate of reabsorption of the pleural fluid, the pleural sequelae, as well as lung capacity were similar in both groups. CONCLUSIONS: Corticosteroids do not influence the clinical outcome or the development of long term pleural sequelae in tuberculous pleurisy.

Tuberculous pleural effusion: experience with six months of treatment with isoniazid and rifampicin.

BACKGROUND: Tuberculous pleurisy is associated with small numbers of bacteria. Due to the low rate of primary resistance to antituberculous drugs a two-drug regimen was used to treat the condition. METHODS: Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Clinical, radiological, and haematological assessments were performed during treatment and patients were followed up for a median period of 41 (range 6-96) months. RESULTS: One hundred and thirty patients were studied with a mean age of 27 (range 11-53) years. Seven were withdrawn due to parenchymal disease and eight were lost to follow up during the treatment period. Side effects during treatment were frequent (20.7%), but only three patients required a change in medication. No treatment failures were observed. One hundred and fifteen patients completed therapy and were followed up for 41 (range 6-96) months with no evidence of a relapse. CONCLUSIONS: Tuberculous pleurisy responds well to a two-drug regimen of antituberculous therapy given for six months.

[Effectiveness of the concentrator as a supply source in home oxygen therapy]. / Efectividad del concentrador como fuente de suministro en la oxigenoterapia domiciliaria (OD).

The oxygen concentrator is an effective supply source in home oxygen-therapy (HO). In order to study the effectivity of the concentrator in HO, we visited at home 31 patients using the concentrator as the only oxygen supply source in the exit gas and counted the hours of concentrator usage. Only 13 concentrators (41.9%) supplied a percentage of oxygen higher than 87% at a flow of two liters per minute. In three cases (9.7%), sporadic control measures of the percentage of oxygen in the exit gas were being taken and only four patients (12.9%) said that these controls were made monthly. The concentrator did not supply the adequate percentage of oxygen in 12 out of the 29 patients correctly taking the HO, so the effectivity of the treatment can only be expected in 28.6% of studied cases. The concentrator operates well under ideal conditions, but potential breakdowns in standard conditions of use must be considered. The efficiency of the HO with concentrator in our environment is very low, but it can be improved with regular controls of the concentrators or the introduction of devices warning the patient when they detect a reduction of the percentage of oxygen in the exit gas.

[The evaluation of the oxygen-conserving valve during exertion]. / Evaluación de la válvula ahorradora de oxígeno durante el esfuerzo.

BACKGROUND: The oxygen-conserving valve (OCV) permits reduction in oxygen consumption upon the release of oxygen only during inhalation thereby increasing the autonomy of portable sources. METHODS: In order to confirm its efficacy during exercise, 15 patients with chronic limitation of air flow and gasometric criteria of domiciliary oxygen therapy were selected. The patients underwent three walking tests (WT) of 6 minutes during which the continuous form of transcutaneous hemoglobin saturation (SaO2) and the distance covered were registered. The first was carried out breathing synthetic air at a flow of 2 liters per minute; the second with continuous oxygen released by a portable source at 2 liters per minute and the third with the OCV coupled to a portable source at the same flow. RESULTS: SaO2 reached with the continuous oxygen is significantly higher to that of synthetic air while there was no difference between the SaO2 with continuous oxygen and with valve. Improvement in SaO2 upon use the valve was not obtained in only 2 of the 15 patients. A significant increase was observed in the distance covered upon oxygen administration not only in the continuous form but also with OCV with respect to synthetic air. CONCLUSIONS: OCV is as effective as continuous oxygen in the correction of desaturation during exercise, however its indications must be individualized by exercise tests (WT) in each patients in order to ensure its correct functioning.

[Long-term effects of home mechanical ventilation with positive pressure using a nasal mask]. / Efectos a largo plazo de la ventilación mecánica a domicilio con presión positiva mediante máscara nasal.

Home mechanical ventilation (HMV) is an efficient alternative in the treatment of patients with chronic respiratory failure secondary to restrictive mechanical disorders (neuromuscular disease, such as Duchenne's disease, thorax deformities due to kyphoscoliosis or tuberculosis sequelae). The case of a patient with severe kyphoscoliosis in the phase of chronic respiratory failure (PaO2 34 mmHg and PaCO2 61 mmHg, breathing ambient air) is presented in which, following the failure of negative pressure mechanical ventilation ("poncho"), positive pressure ventilation was tested with a silicon made-to-measure nasal mask as the access via. Adaptation to HMV was good with the patient using the ventilation nightly. Following 12 months of treatment the patient is able to carry out everyday activities and arterial gasometry breathing ambient air is PaO2 77 mmHg and PaCO2 43 mmHg.

[A multicenter study of the breaking of the smoking habit with nicotine chewing gum in health personnel]. / Estudio multicéntrico de la deshabituación tabáquica con chicle de nicotina en personal sanitario.

BACKGROUND: The health professionals have a leading role in the reduction of the smoking prevalence. Spain has one of the big rate of "per capita" tobacco consumption in the world, and the Spanish doctors have the biggest prevalence of smokers among their colleagues from the EEC countries. METHODS: The effectiveness of a stop smoking programme in health care professionals was evaluated. This programme combined group therapy, nicotine chewing gum and behavioural assistance through the evaluation of CO contained in expired breath; and it is being applied with good results between the smokers of general population in Spain. A total of 211 voluntary smokers working in Spanish six general hospitals were treated, from those 149 (71%) were physicians and nurses (PS) and 62 (29%) others professionals without sanitary responsibilities (PNA). RESULTS: At one year follow-up, 64 (30%) were not smoking, and the P.S. had a higher rate of give up than the PNA (p less than 0.05). Specifically the women of P.S. obtained a greater issue than the women of PNA (p less than 0.05). Both, nicotine chewing gum and behavioural assistance were as effective as usual in smoking cessation programme like this, in our country. CONCLUSIONS: Although the outcome is lower than the obtained with the same approaches in smokers from general population, the better results of the PS than the PNA imply a good change of attitude of them. Specially the women PS obtained a big success, and this is outstanding in this group with a great prevalence of smokers, increasing in the recent years. The subjects who give up smoking increased their corporal weight less than the observed in smokers of the general population, who also give up with this treatment.

[The introduction of liquid oxygen as a portable source in continuous home oxygen therapy]. / Introducción del oxígeno líquido como fuente portátil en la oxigenoterapia continua domiciliaria.

The most widespread types of oxygen delivery at home in our area are bottles where the gas is stored under pressure and concentrators. Both devices can only be used at rest. We have assessed a new system for the delivery of liquid oxygen to be used at home, provided with a portable unit which permits that the patients receive oxygen also outside their homes. Seven such devices have been implemented in the Barcelona area, with an excellent acceptance and without technical problems. To verify the clinical indication, exercise tests were carried out both in baseline conditions and receiving oxygen from the portable source. Oxyhemoglobin saturation and the walked distance were continuously measured. In all patients important drops in the saturation of oxyhemoglobin were recorded during walking, which was corrected with oxygen administration. Liquid oxygen with a portable source is a good delivery system for oxygen therapy at home, permitting to receive oxygen throughout the day, particularly during exercise. Although the availability of liquid oxygen is limited, it should be recommended to the patients in whom exercise hypoxemia is shown to be corrected and who desire an active social life.

[The tobacco habit in patients using home oxygen therapy]. / Hábito tabáquico en pacientes con oxigenoterapia domiciliaria.

The persistence of smoking habits results in a worse prognosis of patients with chronic airflow limitation. Some authors consider that oxygen therapy at home (OTH) is meaningless if the patient does not give up smoking. To assess the number of smokers in a group of 65 patients on OTH, a questionnaire on smoking habits was administered and the CO concentration in the expired air was measured. 27.7% of the study patients smoked; 12.3% admitted that they smoked on being questioned and the remaining 15.4% were identified by CO concentrations in the expired air equal to or higher than 10 ppm. There were no significant differences between the groups of smokers and nonsmokers regarding age and pulmonary function, but the rate of those declaring a poor compliance with OTH was higher among smokers.