Correlation between nasal anatomical characteristics in newborns and short binasal prong dimensions

Abstract Objective: To correlate the nasal anatomical characteristics of newborns with the dimensions of short binasal prongs. Method: Observational, cross-sectional study carried out in two hospitals in southern Brazil. The authors evaluated 1620 newborns with neonatal data and nasal dimensions. To measure the dimensions of the nasal region, the authors considered the width of the medial columella, the right nostril diameter, and the left nostril diameter. These data were correlated with the dimensions of two models of short binasal prongs. Results: Of the total newborns evaluated, 807 were female (49.8%), and 813 were male (50.2%). The majority were white (96.2%). The mean gestational age was 37.4 ± 2.9 weeks, ranging from 22 to 42 weeks. The birth weight was 2946.8 ± 699.3 g, ranging from 490.0 to 4740.0 g. Most of the nasal measures were significantly larger than both prong model measurements. Conclusion: The sizes of short binasal prongs available on the Brazilian market do not match the nasal anatomical characteristics of newborns.

CPAP Treatment Improves Quality of Life and Self-perception of Voice Impairment in Patients with OSA.

OBJECTIVE: The purpose of this study is to examine vocal fatigue and impairment, gastroesophageal symptoms, dysphagia risk, and sleep-related quality of life in individuals with obstructive sleep apnea (OSA) who have been treated with continuous positive airway pressure (CPAP) compared to those who have not received treatment. METHODS: Fifty-four participants diagnosed with OSA completed an online research form. Of these, 29 were receiving CPAP treatment, while 25 were not undergoing treatment. The following instruments were used: Vocal Fatigue Index, Voice Handicap Index, Gastroesophageal symptoms, Eating Assessment Tool, and Quebec Sleep Questionnaire. RESULTS: The group that received CPAP treatment had significantly lower scores in the functional domain and total Voice Handicap Index. They also experienced fewer symptoms of regurgitation, reduced daytime sleepiness, fewer nocturnal symptoms, and better emotional and social interactions in their quality of life compared to the untreated group. There were no significant differences in voice fatigue and dysphagia risk between the groups. CONCLUSION: Individuals treated with CPAP experience reduced vocal impairment, fewer regurgitation symptoms, and improvement in the emotional and social interactions domains of their quality of life compared to individuals without treatment.

Inequalities in the access to diagnosis and treatment of obstructive sleep apnea in Brazil: a cross-sectional study.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is highly prevalent, and positive airway pressure (PAP) therapy is the primary treatment. This study aimed to assess the diagnostic and PAP treatment resources for OSA within Brazil's Unified Health System and to identify potential inequalities and gaps. METHODS: A structured survey was sent to members of the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine to identify sleep laboratories providing OSA diagnosis and/or treatment within Brazil's Unified Health System. The numbers of centers, care team structure, sleep studies availability, PAP accessibility, and follow-up services were characterized in all 5 Brazilian regions. RESULTS: Forty-seven centers were identified: Midwest (n = 4), Northeast (n = 10), North (n = 3), Southeast (n = 22), and South (n = 8). Most centers (70%) provided both OSA diagnosis and treatment, mainly in capitals and/or metropolises (87%). Ten out of 27 Brazilian Federal Units lacked sleep services for OSA management, with the North having the highest proportion of states without a sleep service (71%). The annual number of diagnostic exams for OSA was 14,932, with significant heterogeneity across regions (Midwest: 240; North: 400; Northeast: 3,564; South: 4,380; Southeast: 6,348). Mean waiting times for diagnosis and treatment were 11 and 8 months, respectively. Only 46% of PAP treatments were publicly funded, making legal injunctions and out-of-pocket expenditure common practices. CONCLUSIONS: This study revealed significant disparities in OSA diagnosis and treatment resources across Brazil, with the North region being particularly underserved. The findings underscore an urgent need for strategies to improve sleep care nationwide. CITATION: Drager LF, Santos RB, Pachito D, Albertini CS, Sert Kuniyoshi FH, Eckeli AL. Inequalities in the access to diagnosis and treatment of obstructive sleep apnea in Brazil: a cross-sectional study. J Clin Sleep Med. 2024;20(5):735-742.

Hallucinations in patients with obstructive sleep apnea-hypopnea syndrome: report of 3 cases.

Hallucinations are false sensory perceptions that occur in the absence of an external stimulus. Three cases of hallucinations related to obstructive sleep apnea-hypopnea syndrome are reported, 2 of which improved with the initiation of continuous positive airway pressure therapy. So far there are no published reports in the literature that account for this relationship in the absence of primary or structural mental pathology. All 3 reported patients had visual hallucinations that were uncomfortable and frightening. Polysomnography showed moderate-to-severe obstructive sleep apnea-hypopnea syndrome with severe oxygen desaturation. Initiation of continuous positive airway pressure therapy achieved control of hallucinations in 2 patients during follow-up. Very little information is available on the coexistence of obstructive sleep apnea-hypopnea syndrome and hallucinations. Observational and experimental studies are required to clarify whether there is a causal relationship between the 2 pathologies as well as the therapeutic role that continuous positive airway pressure may have. CITATION: Venegas MA, Montoya JS. Hallucinations in patients with obstructive sleep apnea-hypopnea syndrome: report of 3 cases. J Clin Sleep Med. 2024;20(1):165-167.

Cost-Utility Analysis of Continuous Positive Airway Pressure Therapy Compared With Usual Care for Obstructive Sleep Apnea in the Public Health System in Brazil.

OBJECTIVES: This study aimed to conduct a cost-utility analysis of continuous positive airway pressure (CPAP) therapy compared with usual care as treatment of moderate to severe cases of obstructive sleep apnea (OSA) in Brazil, where decentralized policies of CPAP provision are in place. METHODS: Markov cohort model comparing CPAP therapy with usual care, that is, no specific treatment for OSA, for moderate to severe cases was used. The payer perspective from the Unified Health System, Brazil, was adopted. Effectiveness parameters and costs related to health states were informed by literature review. Resource use related to CPAP therapy was defined by specialists and costs informed by recent purchase and leasing contracts. Incremental cost-effectiveness ratios were generated for purchase and leasing contracts to reflect current practices. A conservative willingness-to-pay threshold was set at 1 gross domestic product per capita per quality-adjusted life-year (QALY) (Brazilian reais [BRL] 40 712/QALY). Uncertainties were explored in deterministic and probabilistic sensitivity analyses. RESULTS: Incremental cost-effectiveness ratio for the purchase modality was 8303 BRL/QALY and for leasing 45 192 BRL/QALY. Considering the adopted willingness-to-pay threshold, provision of CPAP by the purchase modality was considered cost-effective but not the leasing modality. The parameter related to the greatest uncertainty was the reduction in the risk of having a stroke attributable to CPAP. Probabilistic analysis confirmed the robustness of results. CONCLUSIONS: CPAP therapy is a cost-effective alternative compared with usual care for moderate to severe OSA for the purchase modality. These results should help underpinning the decision making related to a uniform policy of CPAP provision across the country.

Actualización sobre apnea obstructiva del sueño en la etapa de movimientos oculares rápidos / Update on obstructive sleep apnea in the rapid eye-movement stage

La apnea obstructiva del sueño durante los movimientos oculares rápidos del sueño (AOS REM), se define como la presencia de episodios de apnea y/o hipopnea obstructivos en la etapa del sueño REM. La epidemiología de esta patología es compleja y no existe una definición estandarizada actualmente. Aunque no se ha logrado llegar a un consenso para definir AOS REM, la evidencia señala que está asociada a factores de riesgos cardiovasculares, metabólicos y neurocognitivos de forma independiente. A pesar que su tratamiento principal es la presión positiva continua de las vías respiratorias (CPAP), los criterios de un adecuado uso de CPAP en la AOS, no son suficientes para tratar de forma adecuada la AOS REM. Es necesario estandarizar una definición universal y realizar estudios prospectivos diseñados para buscar estrategias de tratamientos específicos para la AOS REM.

Obstructive sleep apnea during rapid eye movement sleep (REM OSA) is defined as the presence of obstructive episodes of apnea and/or hypopnea in REM sleep. The epidemiology of this pathology is complex and there is currently no standardized definition. Although no consensus has been reached to define REM OSA, the evidence indicates that it is independently associated with cardiovascular, metabolic and neurocognitive risk factors. Although its main treatment is continuous positive airway pressure (CPAP), the criteria for an adequate use of CPAP in OSA are not sufficient to adequately treat REM OSA. It is necessary to standardize a universal definition and carry out prospective studies designed to search for specific treatment strategies for REM OSA.

Impact of treating obesity hypoventilation syndrome on body mass index.

STUDY OBJECTIVES: To evaluate the impact of positive airway pressure (PAP) therapy on body mass index (BMI) in patients with obesity hypoventilation syndrome (OHS) associated with obstructive sleep apnea (OSA). METHODS: A systematic review using the following terms: "obesity hypoventilation syndrome" AND "treatment" AND "randomized" using Cochrane Central Register of Controlled Trials, Medline and Web of Science was performed from the first data available until February 10, 2023. The inclusion criteria were: (1) original article; (2) adult OHS with concomitant OSA (apnea-hypopnea index or AHI ≥5 events/h); (3) randomized trial with PAP arm and standard care (control); (4) BMI evaluation at baseline and after the first months. We performed an individual participant data meta-analysis of randomized controlled trials. RESULTS: Our initial search retrieved 32 articles and 3 randomized studies fulfilled study criteria and were included in the final analysis, leading to a total of 342 participants. Patients were predominantly females (62%) and had OHS associated with at least mild OSA. As compared to baseline, a decrease in BMI was observed at study endpoint but this difference was not different intergroups (-0.50 ± 1.49 and -0.50 ±1.83, in control and PAP groups respectively (p=0.939)). Weight change was not associate with PAP adherence, OSA severity or use of supplemental oxygen. CONCLUSIONS: In contrast to treatment of eucapnic OSA with PAP that is associated with weight gain, treatment of OSA+OHS patients with or without PAP is associated with weight loss. Future studies are necessary to elucidate the mechanism by which weight loss occurs.

Evaluation and Performance of a Positive Airway Pressure Device (CPAP-AirFlife™): A Randomized Crossover Non-Inferiority Clinical Study in Normal Subjects.

Background and Objectives: During the COVID-19, the demand for non-invasive ventilatory support equipment significantly increased. In response, a novel non-invasive ventilatory support model called CPAP-AirFlife™ was developed utilizing existing technologies. This model offers technological advantages, including an aerosol-controlled helmet suitable for high-risk environments such as ambulances. Additionally, it is cost-effective and does not require medical air, making it accessible for implementation in low-level hospitals, particularly in rural areas. This study aimed to assess the efficacy of CPAP-AirFlife™ by conducting a non-inferiority comparison with conventional ventilation equipment used in the Intensive Care Unit. Materials and Methods: A clinical study was conducted on normal subjects in a randomized and sequential manner. Parameters such as hemoglobin oxygen saturation by pulse oximetry, exhaled PCO2 levels, vital signs, and individual tolerance were compared between the CPAP-AirFlife™ and conventional equipment. The study population was described in terms of demographic characteristics and included in the analysis. Results: It was shown that the CPAP-AirFlife™ was not inferior to conventional equipment in terms of efficacy or tolerability. Hemoglobin oxygen saturation levels, exhaled PCO2 levels, vital signs, and individual tolerance did not significantly differ between the two models. Conclusions: The findings suggest that CPAP-AirFlife™ is a practical and cost-effective alternative for non-invasive ventilatory support. Its technological advantages, including the aerosol-controlled helmet, make it suitable for high-risk environments. The device's accessibility and affordability make it a promising solution for implementation in low-level hospitals, particularly in rural areas. This study supports using CPAP-AirFlife™ as a practical option for non-invasive ventilatory support, providing a valuable contribution to respiratory care during the COVID-19 pandemic and beyond.

Adherence to Positive Airway Pressure Therapy in a Cohort of Colombian Patients with Obstructive Sleep Apnea Syndrome.

Objective To describe the adherence to the use of positive air pressure (PAP) devices in a cohort of patients with sleep apnea syndrome in Colombia. Material and Methods Descriptive cross-sectional study of adult patients treated between January 2018 and December 2019 in the sleep clinic of a private insurer in Colombia. Results The analysis included 12,538 patients (51.3% women) with a mean age of 61.3 years; 10,220 patients (81.5%) use CPAP and 1,550 (12.4%) BIPAP. Only 37% are adherent (> 70% of use for 4 hours or more), adherence rates were highest in the >65 years age groups. 2,305 patients (18.5%) were hospitalized, on average 3.2 times; 515 of these (21.3%) had one or more cardiovascular comorbidities. Conclusion Adherence rates in this sample are lower than those reported elsewhere. They are similar in males and females and tend to improve with age.

Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial.

STUDY OBJECTIVE: To determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy. DESIGN: Single-center prospective randomized controlled trial. SETTING: Tertiary academic center. PATIENTS: We enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation. INTERVENTION: Patients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask. MEASUREMENTS: The primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores. MAIN RESULTS: 54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003). CONCLUSIONS: A nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings. TRIAL REGISTRATION: Clinicaltrials.gov, identifier: NCT05175573.

Respiratory muscle training for obstructive sleep apnea: Systematic review and meta-analysis.

Obstructive sleep apnea is the most common sleep disorder. This review aims to evaluate the effectiveness and safety of respiratory muscle training in the treatment of patients with obstructive sleep apnea. The study protocol was registered in Prospero Platform (CRD42018096980). We performed searches in the main databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed; Excerpta Medica dataBASE (Embase) via Elsevier; Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Library; Latin American and Caribbean Literature on Health Sciences (LILACS) through the Portal of the Virtual Health Library and Physiotherapy Evidence Database (PEDro) for all randomised-controlled trials published before July 2022. The randomised-controlled trials were assessed for risk of bias and certainty of evidence. Thirteen randomised-controlled trials were included. All studies had an overall high risk of bias. Inspiratory muscle training probably improves systolic blood pressure and sleepiness when compared with sham. However, inspiratory muscle training probably does not improve diastolic blood pressure and maximum expiratory pressure, and may not be superior to sham for apnea-hypopnea index, forced expiratory volume in 1 s, forced vital capacity, sleep quality and quality of life. In addition, it is uncertain whether there is any effect of inspiratory muscle training on maximum inspiratory pressure and physical capacity. Inspiratory muscle training may also improve maximum inspiratory pressure and maximum expiratory pressure compared with oropharyngeal exercises. However, it may not be superior for apnea-hypopnea index, sleep quality, sleepiness, quality of life and functional capacity. When associated with physical exercise, inspiratory muscle training may not be superior to physical exercise alone for maximum inspiratory pressure, maximum expiratory pressure, systolic and diastolic blood pressure, and functional capacity. At the same time, when associated with cardiac rehabilitation exercises, inspiratory muscle training may reduce apnea-hypopnea index, improve inspiratory muscle strength, sleepiness and sleep quality compared with cardiac rehabilitation alone. However, it may not be superior for improving quality of life. Regarding expiratory muscle training, it may improve expiratory muscle strength and sleep quality, but not sleepiness when compared with sham. The evidence on the effects of expiratory muscle training in apnea-hypopnea index is very uncertain.

Cost-utility and budget impact analysis of CPAP therapy compared to no treatment in the management of moderate to severe obstructive sleep apnea in Colombia from a third-party payer perspective.

OBJECTIVES: To conduct cost-utility and budget impact analysis of providing Continuous Positive Airway Pressure (CPAP) therapy versus no treatment for moderate to severe obstructive sleep apnea (OSA) in Colombia from a third-party payer perspective. METHODS: We used a Markov model to assess the cost-utility and budget impact analysis of CPAP in patients over 40 years old with moderate to severe OSA. Data on effectiveness and utility values were obtained from published literature. A discount rate of 5% was applied for outcomes and costs. ICER was calculated and compared against the threshold estimated for Colombia, which is 86% of the GDP per capita. RESULTS: Over a lifetime horizon, the base case analysis showed the incremental cost per quality-adjusted life-years (QALYs) gained with CPAP therapy was COP$3,503,804 (USD$1,011 in 2020 prices). The budget impact analysis showed that the adoption of CPAP therapy in the target population would lead to a cumulative net budget impact of COP$411,722 million (USD$118,784,412 in, 2020 prices) over five years of time horizon. CONCLUSIONS: CPAP was cost-effective compared to no-treatment in OSA. According to the budget impact analysis, adopting this technology would require a budget allocation that is partially offset by reduced number of strokes and traffic accident events.

Prognostic importance of obstructive sleep apnea and CPAP treatment for cardiovascular and mortality outcomes in patients with resistant hypertension: a prospective cohort study.

The prognostic importance of obstructive sleep apnea (OSA) severity and other polysomnographic parameters in patients with resistant hypertension (RHT) has never been evaluated. We aimed to assess it in a prospective cohort of 422 individuals with RHT. OSA presence/severity was ascertained by complete polysomnography (PSG) at baseline. Multivariable Cox regressions assessed the risks associated with OSA severity and other PSG parameters (apnea-hypopnea index, sleep duration, nocturnal hypoxemia and periodic limb movements) for the primary (total cardiovascular events [CVEs] and all-cause mortality) and secondary outcomes (major CVEs). In the subgroup of patients with moderate/severe OSA, the risks associated with CPAP treatment were also estimated in relation to untreated individuals. One-hundred and eighty-six participants (44%) had no/mild OSA and 236 (56%) had moderate/severe OSA, and 67 of them were CPAP-treated. Over a mean follow-up of 5 years, there were 46 CVEs (37 major ones) and 44 all-cause deaths. Neither the presence of moderate/severe or severe OSA, nor being untreated during follow-up, was associated with significant excess risks for any outcome in relation to the subgroup with no/mild OSA. Similarly, no other PSG-derived parameter predicted any adverse outcome. Otherwise, CPAP treatment was associated with non-significant risk reductions of 37% for total CVEs, 49% for major CVEs and 63% for all-cause mortality in relation to those who remained untreated during follow-up. In conclusion, the presence/severity of OSA and its related PSG parameters were not associated with worse cardiovascular/mortality prognosis in patients with RHT. However, CPAP treatment might be protective in individuals with moderate/severe OSA.

Relationship between level CPAP titration, anthropometric variables, and drug-induced sleep endoscopy DISE.

INTRODUCTION: Subjects with palatal obstruction alone vs. multilevel obstruction on DISE had better outcomes after palate surgery. We asked ourselves if the therapeutic level positive airway pressure (PAP) titration could predict the level of airway obstruction and its complexity. PURPOSE: The aim of this study was to identify possible relationships between therapeutic level of positive airway pressure initial titration and levels of collapse in drug-induced sleep endoscopy (DISE). A secondary objective was to establish the relationship the other variables and DISE. METHODS: We analyzed retrospective clinical histories between March 2020 to March 2022 of 37 patients with polysomnography or cardiorespiratory polygraphy studies and PAP initial titration who were taken to drug-induced sleep endoscopy. Sleep study data, anthropometric variables, and patterns of airway collapse during DISE were analyzed with PAP initial titration levels. RESULTS: Most of the patients with complex collapse had concentric velum collapse (p < 0.006). A significant association was found between the apnea-hypopnea index (AHI) and oropharyngeal collapse; (p < 0.0030) and finally we demonstrated relationship between neck circumference and gender with epiglottis collapse (p < 0.046), (p < 0.037), respectively. CONCLUSIONS: Our findings show a strong relationship between that complex collapses and concentric velum collapse; patients with greater oropharyngeal collapse have a higher mean AHI. Patients without epiglottic collapse have a higher mean neck circumference. An association between mean pressure initial titration and complex collapse could not be established.

The use of a noninvasive positive pressure system to facilitate tracheal intubation in a difficult pediatric airway: a case report.

Patients with burns to the head and neck may be difficult to intubate or ventilate via facemask. Furthermore, post-burn scarring and microstomia may reduce the success of rescue supraglottic airway placement. While awake tracheal intubation using a flexible intubation scope is considered the optimal technique for these patients, it may not always be feasible in the pediatric population. We report a case of successful management of a difficult airway in a child with extensive post-burn head and neck deformity using a noninvasive positive pressure system to aid with inhalational induction and deep sedation during intubation using a flexible scope.

Comparison of different methods of obtaining the rapid shallow breathing index.

OBJECTIVE: To compare the Rapid Shallow Breathing Index (RSBI) obtained by the ventilometer and from mechanical ventilation parameters. METHODS: Randomized crossover trial, including 33 intubated patients, on mechanical ventilation for at least 24 hours, undergoing spontaneous breathing test. Patients were submitted to the measurement of RSBI by four methods: disconnected from the ventilator through the ventilometer; in Pressure Support Ventilation (PSV) mode at a pressure of 7.ßcm H2O; in Continuous Positive Airway Pressure (CPAP) mode at a pressure of 5.ßcmH2O with flow trigger; in CPAP mode at a pressure of 5.ßcmH2O with pressure trigger. RESULTS: No significant difference was detected between the RSBI obtained by the ventilometer and in the CPAP mode with flow and pressure triggers, however, in the PSV mode, the values were lower than in the other measurements (p.ß<.ß0.001). By selecting patients from the sample with higher RSBI (... 80 cycles.min-1.L-1), the value of the index obtained by the ventilometer was higher than that obtained in the three options of ventilation methods. CONCLUSION: The RSBI obtained in the CPAP mode at a pressure of 5.ßcmH2O, in both triggers types, did not differ from that measured by the ventilometer; it is, therefore, an alternative when obtaining it from mechanical ventilation parameters is necessary. However, in the presence of borderline values, the RSBI measured by ventilometer is recommended, as in this method the values are significantly higher than in the three ventilation modalities investigated.

Legal action for access to resources inefficiently made available in health care systems in Brazil: a case study on obstructive sleep apnea / Judicialização para acesso a recursos disponibilizados de forma ineficiente nos sistemas de saúde do Brasil: estudo de caso sobre apneia obstrutiva do sono

ABSTRACT Objective: Obstructive sleep apnea (OSA) is a highly prevalent chronic disease, associated with morbidity and mortality. Although effective treatment for OSA is commercially available, their provision is not guaranteed by lines of care throughout Brazil, making legal action necessary. This study aimed at presenting data related to the volume of legal proceedings regarding the access to diagnosis and treatment of OSA in Brazil. Methods: This was a descriptive study of national scope, evaluating the period between January of 2016 and December of 2020. The number of lawsuits was analyzed according to the object of the demand (diagnosis or treatment). Projections of total expenses were carried out according to the number of lawsuits. Results: We identified 1,462 legal proceedings (17.6% and 82.4% related to diagnosis and treatment, respectively). The projection of expenditure for OSA diagnosis in the public and private spheres were R$575,227 and R$188,002, respectively. The projection of expenditure for OSA treatment in the public and private spheres were R$2,656,696 and R$253,050, respectively. There was a reduction in the number of lawsuits between 2017 and 2019. Conclusions: Legal action as a strategy for accessing diagnostic and therapeutic resources related to OSA is a recurrent practice, resulting in inefficiency and inequity. The reduction in the number of lawsuits between 2017 and 2019 might be explained by the expansion of local health care policies or by barriers in the journey of patients with OSA, such as difficulties in being referred to specialized health care and low availability of diagnostic resources.

RESUMO Objetivo: A apneia obstrutiva do sono (AOS) é uma doença crônica altamente prevalente, associada a morbidade e mortalidade. Embora tratamentos efetivos para a AOS estejam disponíveis comercialmente, seu fornecimento não é garantido pelos fluxos de atendimento em todo o Brasil, tornando necessária a judicialização. Este estudo teve como objetivo apresentar dados referentes ao volume de processos judiciais relacionados ao acesso ao diagnóstico e tratamento da AOS no Brasil. Métodos: Estudo descritivo de abrangência nacional, avaliando o período entre janeiro de 2016 e dezembro de 2020. O número de demandas judiciais foi analisado de acordo com o objeto da demanda (diagnóstico ou tratamento). As projeções das despesas totais foram realizadas de acordo com o número de demandas judiciais. Resultados: Foram identificados 1.462 processos judiciais (17,6% e 82,4% referentes a diagnóstico e tratamento, respectivamente). A projeção dos gastos com o diagnóstico da AOS nas esferas pública e privada foi de R$ 575.227 e R$ 188.002, respectivamente. A projeção dos gastos com o tratamento da AOS nas esferas pública e privada foi de R$ 2.656.696 e R$ 253.050, respectivamente. Houve redução do número de demandas judiciais entre 2017 e 2019. Conclusões: A judicialização como estratégia de acesso a recursos diagnósticos e terapêuticos relacionados à AOS é uma prática recorrente, resultando em ineficiência e iniquidade. A redução do número de demandas judiciais entre 2017 e 2019 pode ser explicada pela expansão das políticas locais de saúde ou por barreiras na jornada dos pacientes com AOS, como dificuldades de encaminhamento para atendimento especializado e a baixa disponibilidade de recursos diagnósticos.

Effects of CPAP on cardiorespiratory outcomes in patients with obstructive sleep apnea and heart failure: a systematic review / Efectos de la presión positiva continua en las vías aéreas en los resultados cardiorrespiratorios en pacientes con apnea obstructiva del sueño e insuficiencia cardíaca: una revisión sistemática / Efeitos da pressão positiva contínua nas vias aéreas nos desfechos cardiorrespiratórios em pacientes com apneia obstrutiva do sono e insuficiência cardíaca: uma revisão sistemática

ABSTRACT Obstructive sleep apnea (OSA) is a public health problem with a great economic impact. It is estimated that the prevalence of patients with OSA ranges from 4% to 6% of men and 2% to 4% of women in the general population. Strong evidence suggests that both sleep disorders and heart failure (HF) are related. Continuous positive airway pressure (CPAP) is the gold standard non-pharmacological treatment for this population. However, there is still a gap in the literature and its effects in patients with OSA and HF are not entirely clear. This study aimed to evaluate, by randomized clinical trials, the effects of positive pressure on cardiorespiratory function in patients with OSA and HF. Randomized clinical trials were included, with publication in the MEDLINE, PEDro, Cochrane Library, SciELO and PubMed databases and the risk bias was assessed using the PEDro scale. Six articles were included in this study, involving 165 participants. Our findings demonstrate that CPAP in the treatment of OSA in patients with HF promotes an increase in left ventricular ejection fraction, oxygen saturation and a reduction in blood pressure, apnea/hypopnea indices and awakenings from sleep during the night. We conclude that treatment with CPAP promotes an improvement in cardiorespiratory outcomes in patients with OSA and HF, improving the prognosis and reducing the risk of sudden death. However, their data must be cautiously interpreted considering the bias of the studies and their limitations.

RESUMEN La apnea obstructiva del sueño (APS) es un problema de salud pública con gran impacto económico. Se estima que la prevalencia de portadores de AOS es del 4% al 6% en los hombres y del 2% al 4% en las mujeres en la población general. Existe una fuerte evidencia de que tanto los trastornos del sueño como la insuficiencia cardíaca (IC) tienen una asociación entre sí. La presión positiva continua en las vías respiratorias (CPAP) es el tratamiento no farmacológico estándar de oro para esta población. Sin embargo, aún existe un vacío en la literatura y sus efectos en pacientes con AOS e IC no están del todo claros. Ante esto, el objetivo de este estudio es evaluar, mediante ensayos clínicos aleatorizados, los efectos de la CPAP sobre la función cardiorrespiratoria en pacientes con AOS e IC. Se incluyeron seis ensayos clínicos aleatorizados, con publicación en las bases de datos MEDLINE, PEDro, Cochrane Library, SciELO y PubMed, con un total de 165 participantes. El riesgo de sesgo se evaluó mediante la escala PEDro. Nuestros hallazgos demuestran que la CPAP en el tratamiento de la AOS en pacientes con IC promueve un aumento de la fracción de eyección del ventrículo izquierdo y de la saturación de oxígeno, y una reducción de la presión arterial, de los índices de apnea/hipopnea y de los despertares nocturnos. Se concluye que el tratamiento con CPAP promueve una mejora en los resultados cardiorrespiratorios en pacientes con AOS e IC, mejorando el pronóstico y reduciendo el riesgo de muerte súbita. Sin embargo, sus datos deben interpretarse con cautela considerando el sesgo de los estudios y sus limitaciones.

RESUMO A apneia obstrutiva do sono (AOS) é um problema de saúde pública de grande impacto econômico. Estima-se que a prevalência de portadores de AOS seja de 4% a 6% entre os homens e de 2% a 4% entre as mulheres da população em geral. Há fortes evidências de que os distúrbios do sono e a insuficiência cardíaca (IC) estão relacionados. A pressão positiva contínua nas vias aéreas (CPAP) é o tratamento não farmacológico padrão ouro para essa população. No entanto, ainda há uma lacuna na literatura, e seus efeitos em pacientes com AOS e IC não estão plenamente estabelecidos. Assim, o objetivo deste estudo foi avaliar através da revisão de ensaios clínicos randomizados os efeitos da CPAP na função cardiorrespiratória em pacientes com AOS e IC. Foram incluídos seis ensaios clínicos randomizados, publicados nas bases de dados MEDLINE, PEDro, Cochrane Library, SciELO e PubMed, totalizando 165 participantes. O risco de viés foi avaliado através da escala PEDro. Nossos achados demonstraram que a CPAP no tratamento da AOS em pacientes com IC promove um aumento da fração de ejeção do ventrículo esquerdo e da saturação de oxigênio e uma redução da pressão arterial, dos índices de apneia/hipopneia e dos despertares durante a noite. Concluímos que o tratamento com CPAP promove uma melhora nos desfechos cardiorrespiratórios em pacientes com AOS e IC, beneficiando o prognóstico e reduzindo os riscos de morte súbita. Porém, os resultados devem ser interpretados com cautela, considerando o viés dos estudos e suas limitações.

Demoras y adherencia al tratamiento de las apneas del sueño dentro de un sistema de provisión universal en un hospital público / Delays and Adherence to the Treatment of Sleep Apnea within a Universal Provision System in a Public Hospital

Introducción: El tratamiento con presión positiva es uno de los pilares del manejo de las apneas obstructivas del sueño, sin embargo, el acceso a los equipos y la adherencia a su uso no son fáciles de lograr. Objetivo: Evaluar la adherencia de los pacientes del sistema público de salud que reciben equipos de presión continua de forma gratuita para el tratamiento de las apneas obstructivas del sueño. Material y métodos: Se evaluó retrospectivamente a los pacientes con diagnóstico de apnea obstructiva del sueño que recibieron equipos de CPAP entre 2013 y 2018 a través de PAMI, Incluir Salud y Cobertura Porteña de Salud. Resultados: Los pacientes de PAMI fueron de mayor edad y tenían un Epworth más bajo. La demora entre consulta y diagnóstico fue de 1,4 ± 2,4 meses. El tiempo de diagnóstico a provisión del equipo fue de 10,2 ± 9,9 meses. Los pacientes de PAMI recibieron los equipos más rápido (2,7 ± 2,5 meses) y fueron más adherentes a las visitas de control. La adherencia a los controles clínicos el primer año fue del 46 %. Los pacientes de mayor edad, con Epworth más bajo y que usan auto-CPAP tenían una tendencia no significativa a favorecer esta adherencia. La adherencia objetiva medida por tarjeta de memoria o telemonitoreo fue del 40 %. El mayor IMC fue el único factor que la favorecía. Conclusiones: Superando la limitación económica al acceso a los equipos, no cambia la actitud hacia la adherencia y control.

Introduction: Treatment with positive airway pressure is one of the cornerstones in managing obstructive sleep apnea (OSA). However, access to the equipment and ad herence to their use are not easy to achieve. Objective: to evaluate the adherence of patients from the public health system who receive continuous pressure devices free of charge for the treatment of OSA. Materials and methods: Patients diagnosed with OSA who received continuous positive airway pressure (CPAP) devices between 2013 and 2018 through PAMI (Programa de Atención Médica Integral, Medical Services Program) , Incluir Salud, and Cobertura Porteña de Salud were retrospectively evaluated. Results: Patients from PAMI were older and had a lower score in the Epworth scale. The delay between the consultation and the diagnosis was 1.4 ± 2.4 months. The time from the diagnosis until the equipment was provided was 10.2 ± 9.9 months. Patients from PAMI received the equipment faster (2.7 ± 2.5 months) and were more adherent to follow-up visits. Adherence to clinical follow-up visits in the first year was 46%. Older patients with a lower Epworth score and those using AutoCPAP had a non-significant trend favoring this adherence. The objective adherence measured by memory card or telemonitoring was 40%. The higher body mass index (BMI) was the only factor favor ing objective adherence. Conclusions: Overcoming the economic limitation to access the equipment does not change the attitude towards adherence and follow-up.

The use of a noninvasive positive pressure system to facilitate tracheal intubation in a difficult pediatric airway: a case report

Abstract Patients with burns to the head and neck maybe difficult to intubate or ventilate via facemask. Furthermore, post-burn scarring and microstomia may reduce the success of rescue supraglottic airway placement. While awake tracheal intubation using a flexible intubation scope is considered the optimal technique for these patients, it may not always be feasible in the pediatric population. We report a case of successful management of a difficult airway in a child with extensive post-burn head and neck deformity using a noninvasive positive pressure system to aid with inhalational induction and deep sedation during intubation using a flexible scope.