The Mediator Role of Illness Representations in Patients with Obstructive Sleep Apnea: A Preliminary Study / [El papel mediador de las representaciones de la enfermedad en pacientes de apnea obstructiva del sueño: un estudio preliminar]

Background: This preliminary study examined the mediating role of illness representations on health-related quality of life (HRQoL) between adherent and poorly adherent obstructive sleep apnea patients (OSA) to the automatic positive airway pressure (APAP) therapy. Method: A total of 185 patients were assessed on determinants of APAP treatment, illness representations, family coping, and self-efficacy, at T1 (prior to APAP treatment) and T2 (1 to 2 months with APAP treatment). Results: Regarding the determinants of APAP, adherent patients showed higher self-efficacy, outcome expectations, and decisional balance index, compared to poorly adherent patients. Adherent patients also showed higher family coping and HRQoL, but less threatening cognitive representations compared to poorly adherent patients. Illness cognitive and emotional representations mediated the relationship between self-efficacy/family coping and HRQoL, in adherent patients. Only illness cognitive representations mediated the relationship between self-efficacy and HRQoL in poorly adherent patients. Conclusions: The results highlight the importance of illness representations during OSA treatment in the promotion of adherence to APAP.(AU)

Antecedentes: Este estudio preliminar examina el papel mediador de la representación de la enfermedad en la calidad de vida relacionada con la salud (CVRS) entre pacientes con apnea obstructiva del sueño (AOS) observantes y poco observantes de la terapia de presión positiva automática en las vías respiratorias (APAP). Método: Se evaluó a un total de 185 pacientes sobre los determinantes del tratamiento APAP, las representaciones de la enfermedad, el afrontamiento familiar y la autoeficacia en T1 (antes del tratamiento APAP) y T2 (1 a 2 meses con tratamiento APAP). Resultados: En cuanto a los determinantes de la APAP, los observantes mostraron mayor autoeficacia, expectativas de resultados e índice de equilibrio decisional en comparación con los poco observantes. Los observantes también mostraron un mayor afrontamiento familiar y CVRS pero menos representaciones cognitivas amenazantes en comparación con los observantes deficientes. Las representaciones cognitivas y emocionales de la enfermedad mediaron la relación entre la autoeficacia/afrontamiento familiar y la CVRS en pacientes observantes. Solo las representaciones cognitivas de enfermedad mediaron la relación entre la autoeficacia y la CVRS en pacientes de baja observancia. Conclusiones: Los resultados destacan la importancia de las representaciones de la enfermedad durante el tratamiento de la AOS en la promoción de la adherencia a la APAP.(AU)

Validation of the Multi-INdependence Dimensions (MIND) questionnaire for prolonged mechanically ventilated subjects.

BACKGROUND: Evaluating severity of illness of patients with prolonged mechanical ventilation (PMV) is important to adopt the best appropriate care management for each individual. Yet, no severity-of-illness scoring system has been specifically designed for this type of patients. The aim of this study was to develop and validate a new instrument, the Multi-INdependence Dimensions (MIND) questionnaire designed to comprehensively measure the severity of illness of patients under PMV. METHODS: The validation of the MIND questionnaire was performed during a longitudinal observational study conducted with PMV subjects in weaning facilities in three countries (Argentina, Colombia and Germany). The questionnaire validity was tested in 3 stages: 1) Specification of components, with description of item responses, inter-item and Cronbach alpha correlations; 2) Creation of the composite scores; 3) Measurement properties determination including test-retest reliability after 30 days, clinical validity (Medical Research Council (MRC) muscle strength score, Sepsis-related Organ Failure Assessment (SOFA), Glasgow Coma Scale (GCS), Dependence Nursing Scale and EuroQol-5 Dimension evaluated at inclusion), and ability to detect change. RESULTS: A total of 128 subjects participated in the validation study. Eleven component scores and four composite scores were created. MIND scores significantly correlated with MRC muscle strength, SOFA, DNS, GCS and EQ-5D, supporting the validity of the new scores. Intraclass Correlation Coefficient greater than 0.82 were observed for all composite scores, indicating good test-retest reliability. MIND scores were able to detect improvement in subject severity of illness. CONCLUSION: The MIND questionnaire is a valid and reliable instrument for measuring comprehensively the multiple dimensions characterizing the severity of illness of PMV patients. TRIAL REGISTRATION: NCT02255058 .

Translation and cross-cultural adaptation of the Pediatric Sleep Questionnaire into Portuguese language.

OBJECTIVE: The need for culturally appropriate and linguistically accessible instruments for assessing sleep quality among children has expanded. The Pediatric Sleep Questionnaire (PSQ) is a validated tool for sleep disordered breathing among children. Our aim was to cross-culturally translate and adapt the PSQ into Portuguese language for use in clinical and research settings. METHODS: The PSQ was translated into Portuguese language in accordance with the stages recommended by International Guidelines and reviewed by a panel of experts. The caregivers of 180 children (aged from 4 to 12 years) answered the Portuguese version of PSQ. The reliability of the translated questionnaire was measured by Cronbach α, Pearson correlation and Kappa statistics. RESULTS: Reliability analysis yielded an overall Cronbach α of 0.781, confirming the survey's consistency. The Cronbach α of the Portuguese PSQ domains ranged between 0.61 and 0.7. Test-retest reliability for all items was robust with correctness of >90.0% in all items, and the Kappa statistic ranged between 0.5 and 0.8. CONCLUSION: The Portuguese version of PSQ has sufficient reliability and validity to measure sleep disordered breathing outcomes, and showed to be linguistically accurate and acceptable for use by children in Portugal.

Unattended sleep studies in pediatric OSA: a systematic review and meta-analysis.

The objective of this study was to systematically assess the evidence for the diagnostic accuracy of unattended type 2 or type 3 multichannel studies for predicting and monitoring pediatric obstructive sleep apnea (OSA). Four medical databases were searched for eligible studies. Only studies that evaluated the ability of unattended multichannel devices to accurately diagnose or monitor OSA in children were included. Those with appropriate data were selected for meta-analysis. Study quality was assessed by using the Quality Assessment Tool for Diagnostic Accuracy Studies tool. Summary estimates of diagnostic accuracy were determined by using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, summary receiver operating characteristics, and the area under the curve (AUC). Ten diagnostic studies with 724 patients were included in the systematic review, which was followed by a meta-analysis using studies that provided sufficient information for the calculation of diagnostic parameters. The overall analysis revealed a moderate sensitivity of 76% (95% confidence interval [CI]: 64%-85%), a moderate specificity of 76% (95% CI: 60%-88%), and a pooled diagnostic odds ratio of 15.18 (95% CI: 3.52-65.43). The AUC (0.88) indicated that unattended multichannel devices showed good diagnostic performance for predicting pediatric OSA. Using a cutoff of AHI > 1 for the diagnosis of OSA, the results appeared to be more useful, with a higher sensitivity (88%) while maintaining a moderate specificity (71%). These findings suggest that unattended sleep studies are a good tool for predicting both the presence and severity of OSA in children, especially in those with mild-to-moderate disease.

Obstructive sleep apnea representations, self-efficacy and family coping regarding APAP adherence: a longitudinal study.

Adherence is still an important issue considering new advances in Obstructive Sleep Apnea (OSA) treatment, as automatic positive airway pressure (APAP). The aim of the present study was to identify and explore relationships between identified predictors of adherence, over time. After overnight sleep study and OSA diagnosis and during a six-month APAP treatment period, a total of 153 patients underwent a three time psychological protocol evaluation. Generalized estimating equations were applied to analyzed repeated measurements in the same individuals. Results show that 40% of patients were poorly adherent and 60% were adherent after six months of treatment. The results confirmed a predictive value of age, self-efficacy, decisional balance index and health-related quality of life (HRQoL) in APAP adherence. Furthermore, the results revealed an interaction between time and illness cognitive representations, and self-efficacy and family coping, in explaining adherence patterns over time. Therefore, understanding the causality of theoretically derived constructs is crucial to predict the continuity of APAP adherence.

A new characterization of adherence patterns to auto-adjusting positive airway pressure in severe obstructive sleep apnea syndrome: clinical and psychological determinants.

PURPOSE: The aim of this study was to examine the joint role of demographic, clinical, psychological and family coping variables as predictors of adherence patterns to auto-adjusting positive airway pressure (APAP). METHODS: A total of 153 patients diagnosed with obstructive sleep apnea syndrome (OSAS) were assessed during a 6-months APAP treatment period. All patients underwent psychological evaluation prior to treatment (T1) and 1 to 3 months (T2) and 4 to 6 months (T3) post-APAP treatment. Of these, 107 patients maintained a stable adherence pattern to APAP during the treatment period. RESULTS: Forty-seven percent were poorly adherent, 27 % were moderately adherent and 26 % were optimally adherent OSAS patients. Several factors distinguished the three adherence patterns and some of these emerged as the main predictors. In T1, the first model included age, apnea-hypopnea index, outcome expectations and coping spiritual support, as main predictors to distinguish adherence patterns. In T2 and T3, two models emerged adjusted to the variables of model 1 that included leakage, self-efficacy, mobilizing family acquire/accept support and reframing in model 2 and self-efficacy in model 3. Generally, the areas under the ROC curve, presented a good discrimination. CONCLUSIONS: Findings revealed an integrative heuristic model that accounted for the joint influence of demographic, clinical, psychological, and family coping factors on poor, moderate, and optimal adherence patterns.

Clinical assessment of pediatric obstructive sleep apnea: a systematic review and meta-analysis.

OBJECTIVES/HYPOTHESIS: Clinical symptoms and signs are routinely used to investigate pediatric obstructive sleep apnea (OSA). This study aimed to systematically assess the evidence for the diagnostic accuracy of individual or combined clinical symptoms and signs in predicting pediatric OSA. STUDY DESIGN: A systematic review of the literature and diagnostic meta-analysis. METHODS: Four medical databases were searched (from inception to August 2011). Studies were included that compared the clinical assessment with the current gold standard (full polysomnography). The study quality was assessed using the quality assessment tool for diagnostic accuracy studies. Summary estimates of diagnostic accuracy were determined using the sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and hierarchical summary receiver operating characteristic (HSROC) model for meta-analyses. RESULTS: Ten diagnostic studies with 1,525 patients were included in the review. There was substantial variation in the sensitivity and specificity among different symptoms and signs, as well as across studies. Tonsillar size and snoring reported by parents or caregivers had high sensitivity but low specificity. In contrast, excessive daytime somnolence, observed apnea, and difficulty in breathing during sleep had high specificity but low sensitivity. Seven models of a combination of symptoms and signs presented moderate sensitivity (range, 0.04-0.94) and specificity (range, 0.28-0.99). The HSROC indicates poor diagnostic performance of the symptoms and signs in predicting pediatric OSA. CONCLUSIONS: Neither single nor combined symptoms and signs have satisfactory performance in predicting pediatric OSA. Alternative diagnostic models are necessary to improve the accuracy.

Obstructive sleep apnea symptoms beyond sleepiness and snoring: effects of nasal APAP therapy.

OBJECTIVE: The purpose of this study was to evaluate the prevalence and assess the response to nasal automatic positive airway pressure (APAP) therapy of less typical symptoms in patients diagnosed with obstructive sleep apnea (OSA), like fatigue, gasping, nocturia, nocturnal sweating, morning headaches, heartburn, and erectile dysfunction. METHODS: Ninety-eight male patients with moderate to severe OSA were included in the study (n = 98). In the beginning of the study, an overnight sleep study was performed to all subjects using a five-channel recording device. Patients started APAP therapy with pre-determined minimum and maximum pressures of 4 and 15 cmH(2)0, respectively. The total Sleep Disorders Questionnaire was answered by all subjects before and 6 months after APAP therapy. Questions 4, 18, 23, 25, 58, 88, and 148 were used in this study. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) 17.0 software. RESULTS: Subjects had a mean (SD) age of 55.1 (10.8) years and an average of 52.2 (21.4) apnea-hypopnea events per hour of sleep. At baseline, nocturia was the most prevalent symptom (38%), followed by nocturnal sweating (34%), gasping (30%), erectile dysfunction (25%), fatigue (23%), heartburn (15%), and morning headaches (10%). After 6 months of APAP therapy, a statistically significant reduction on the prevalence of all symptoms was observed, except for erectile dysfunction and morning headaches. CONCLUSION: The findings suggest that APAP therapy is effective in controlling the majority of OSA symptoms beyond sleepiness and snoring.

Psychological morbidity, illness representations, and quality of life in female and male patients with obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder that affects both women and men. The aim of this study was to characterize and investigate the differences in terms of anxiety, depression, illness perception, and quality of life between female and male OSAS patients from a total of 111 patients (33 women and 78 men) who were recently diagnosed with OSAS in an outpatient clinic of a University Hospital in Portugal. They underwent a standardized protocol that included evaluation to assess of psychological morbidity (anxiety and depression - Hospital Anxiety and Depression Scale), illness representations (Brief Illness Perception Questionnaire), and quality of life (Sleep Apnea Quality of Life Index). The most significant differences between female and male OSAS patients result of apnea/hypopnea index (AHI), after controlling for body mass index (p < 0.05); anxiety (p = 0.000) and depression (p < 0.005); consequences (p < 0.005), identity (p = 0.000), coherence (p < 0.01), and emotional representation (p < 0.005) of OSAS; and for daily functioning (p = 0.000), emotional (p = 0.001), and symptoms (p < 0.05) domains of quality of life. Data suggest that women revealed more psychological morbidity associated with OSAS. Therefore, it seems extremely important to look at women as potential patients for sleep apnea and avoid looking up for a pattern of symptoms that rely on men as a norm to which women are compared.

At home and on demand mechanical cough assistance program for patients with amyotrophic lateral sclerosis.

OBJECTIVE: To establish a cost-effective telephone-accessed consultation and mechanical in-exsufflation (MI-E) and manually assisted coughing, oximetry feedback program for 39 patients with amyotrophic lateral sclerosis. DESIGN: Rapid access to healthcare consultation and to MI-E was provided to treat episodes of distress as a result of secretion encumbrance not reversed by suctioning and associated with a decrease in oxyhemoglobin saturation (SpO(2)) baseline. Avoided hospitalizations, defined by relief of respiratory distress and return of SpO(2) baseline to >or=95% by continuous ventilator use and assisted coughing, were recorded. Patient satisfaction was queried at 6 mos, and a cost analysis was performed of continuous vs. on demand MI-E use. RESULTS: Thirty-nine patients made a total of 1661 calls in 7.46 +/- 5.8 mos of follow-up. Twenty-seven patients had 66 home care visits by a respiratory therapist for a total time commitment of 89.7 +/- 99.3 min/patient/mo. Twelve patients, all ventilator users, were also brought mechanical in-exsufflators for mechanically assisted coughing for 47 respiratory episodes. Thirty hospitalizations were avoided. Seventy-five percent of the patients were extremely satisfied. Mean monthly cost per patient for on-demand telephone consultation, professional home healthcare visits, and MI-E as deemed necessary was euro403 +/- euro420 or 59% less than for continuous MI-E rental. Hospitalization costs were also spared. CONCLUSIONS: An on-demand consult and MI-E access program can avoid hospitalizations for patients with amyotrophic lateral sclerosis with significant cost savings.

Autoadjusting-CPAP effect on serum leptin concentrations in obstructive sleep apnoea patients.

BACKGROUND: Leptin is an hormone that regulates body weight. Studies have shown increasing leptin concentrations according to body mass index (BMI) and intermittent hypoxia. Our aim is to evaluate the basal leptin levels in OSA patients and its possible relation to OSA severity, independently of confounders and investigate the Autoadjusting-CPAP effect on leptin values. METHODS: In ninety eight male patients with moderate to severe OSA leptin serum levels were evaluated before therapy, 9 days and 6 months after therapy. RESULTS: In this group mean age was 55.3 years, mean BMI was 33.2 Kg/m2 and mean Apnoea- Hypopnea Index (AHI) was 51.7/h. Mean basal serum leptin value was 12.1 ug/L. Univariate analysis showed a significant correlation between serum leptin values and BMI (R = 0.68; p < 0.001), waist-hip ratio (R = 0.283; p = 0.004) and AHI (R = 0.198; p = 0.048); in stepwise multiple regression analysis only BMI (p < 0.001) was a predictor of serum leptin values. One week after therapy, mean leptin serum level decreased to 11.0 ug/L and 6 months after it was 11.4 ug/L. (p = 0.56 and p = 0.387, respectively) CONCLUSION: Baseline leptin serum levels positively correlate with BMI, fat distributio and OSA severity. BMI is the only predictor of basal leptin levels.Treatment with Autoadjusting-CPAP has a small effect on leptin levels.

Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema--a systematic review and meta-analysis.

INTRODUCTION: Continuous positive airway pressure ventilation (CPAP) and non-invasive positive pressure ventilation (NPPV) are accepted treatments in acute cardiogenic pulmonary edema (ACPE). However, it remains unclear whether NPPV is better than CPAP in reducing the need for endotracheal intubation (NETI) rates, mortality and other adverse events. Our aim was to review the evidence about the efficacy and safety of these two methods in ACPE management. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials on the effect of CPAP and/or NIPV in the treatment of ACPE, considering the outcomes NETI, mortality and incidence of acute myocardial infarction (AMI). We searched six electronic databases up to May 2005 without language restrictions, reviewed references of relevant articles, hand searched conference proceedings and contacted experts. RESULTS: Of 790 articles identified, 17 were included. In a pooled analysis, 10 studies of CPAP compared to standard medical therapy (SMT) showed a significant 22% absolute risk reduction (ARR) in NETI (95% confidence interval (CI), -34% to -10%) and 13% in mortality (95%CI, -22% to -5%). Six studies of NPPV compared to SMT showed an 18% ARR in NETI (95%CI, -32% to -4%) and 7% in mortality (95%CI, -14% to 0%). Seven studies of NPPV compared to CPAP showed a non-significant 3% ARR in NETI (95%CI, -4% to 9%) and 2% in mortality (95%CI, -6% to 10%). None of these methods increased AMI risk. In a subgroup analysis, NPPV did not lead to better outcomes than CPAP in studies including more hypercapnic patients. CONCLUSION: Robust evidence now supports the use of CPAP and NPPV in ACPE. Both techniques decrease NETI and mortality compared to SMT and none shows increased AMI risk. CPAP should be considered a first line intervention as NPPV did not show a better efficacy, even in patients with more severe conditions, and CPAP is cheaper and easier to implement in clinical practice.

Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance.

STUDY OBJECTIVES: To analyze the physiologic effects and tolerance of mechanical insufflation-exsufflation (MI-E) for patients with chronic ventilatory failure of various etiologies. DESIGN: Prospective clinical trial. SETTING: Rehabilitation unit of a university hospital. PATIENTS OR PARTICIPANTS: Thirteen patients with amyotrophic lateral sclerosis (ALS), 9 patients with severe COPD, and 7 patients with other neuromuscular disorders (oNMDs) with chronic airway secretion encumbrance and decreases in oxyhemoglobin saturation (Spo(2)). INTERVENTIONS: Pressures of MI-E of 15 cm H(2)O, 30 cm H(2)O, and 40 cm H(2)O were cycled to each patient, with 3 s for insufflation and 4 s for exsufflation. One application was six cycles at each pressure for a total of three applications. MEASUREMENTS AND RESULTS: We continuously evaluated respiratory inductance plethysmography (RIP) and Spo(2) during every application. Peak cough flow (PCF) and dyspnea (Borg Scale) were also measured before the first and after the last application. The technique was well tolerated in all patient groups. Median Spo(2) improved significantly (p < 0.005) in all patient groups. Median PCF improved significantly (p < 0.005) in the ALS and oNMD groups from 170 to 200 L/min and from 180 to 220 L/min, respectively, and dyspnea improved significantly in the patients with oNMDs and patients with COPD from 3 to 1 and from 2 to 0.75, respectively. Breathing pattern characteristics (RIP) did not deteriorate after MI-E in any patient groups. Inspiratory flow limitation significantly decreased at the highest MI-E pressures for the ALS group. CONCLUSIONS: Our results confirm good tolerance and physiologic improvement in patients with restrictive disease and in patients with obstructive disease, suggesting that MI-E may be a potential complement to noninvasive ventilation for a wide variety of patient groups.

Cork workers' occupational asthma: lack of association with allergic sensitisation to fungi of the work environment.

OBJECTIVES: To evaluate allergic sensitisation to Chrysonilia sitophila, Penicillium glabrum, and Trichoderma longibrachiatum in cork workers with asthma. METHODS: Skin prick tests with a battery of common allergens and with the three fungi were performed on ten cork workers with asthma and eight non-exposed asthmatics. Based on serial peak expiratory flow measurements, five were classified as having occupational asthma (AO) and five as having non-occupational asthma (NOA). In exposed patients, specific antibodies for the three fungi were also studied by immunoblotting RESULTS: Two out of ten patients with occupational exposure and four out of eight of the control group showed positive results for skin prick tests for common allergens. Moreover, two out of five patients with OA and three out of eight controls exhibited sensitisation to storage mites. All exposed patients (with OA or NOA) had negative skin prick test results for the fungal extracts. In patients with asthma and occupational exposure, immunoblotting results confirmed the absence of specific IgE. However, specific IgG4 was present in some cases. CONCLUSIONS: Atopy does not seem to characterise occupational asthma in cork workers. Despite their long exposure to moulds, we could not find evidence of IgE sensitisation to the three most prevalent cork fungi in patients with OA, which points to the search for other causative agents, such as cork chemical compounds or contaminants.

Heated humidification during nasal continuous positive airway pressure for obstructive sleep apnea syndrome: objective evaluation of efficacy with nasal peak inspiratory flow measurements.

BACKGROUND: Nasal obstruction is one of the most frequent and sometimes troublesome side effects of nasal continuous positive airway pressure (nCPAP) therapy for obstructive sleep apnea syndrome (OSAS). METHODS: We describe a 60-year-old man with allergic seasonal rhinitis and OSAS, with worsening nasal symptoms 1 week after beginning home nCPAP, making nCPAP use difficult (nasal peak inspiratory flow [nPIF], 80 L/minute [57% of his best]). RESULTS: No significant improvement was obtained with topical steroids or cold humidification. Heated humidification was then considered, achieving an improvement in mean nPIF and symptom scores. An acceptable compliance with CPAP could be obtained during the heated humidification period (3.9 hours of mean daily use). CONCLUSION: In this patient with moderately severe OSAS and allergic rhinitis, monitoring nasal symptoms and nasal PIF objectively showed the benefit of heated humidification to overcome nasal intolerance and increase compliance to nCPAP treatment.