Guía española de práctica clínica utilización de los dispositivos de avance mandibular (DAM) en el tratamiento de pacientes adultos con síndrome de apneas-hipopneas del sueño / Spanish guide to clinical practice using mandibular advancement devices (MAD) in the treatment of adult patients with sleep apnea-hypopnea syndrome

Objetivos: La GPC se orienta a los profesionales encuadrados en unidades de sueño en el diagnóstico del SAOS y de su tratamiento, especialmente con CPAP nasal. Asimismo el presente documento aspira a ser de utilidad para las distintas especialidades involucradas en el seguimiento de pacientes con SAOS. Objetivos: - Valorar la eficacia de los dispositivos de avance mandibular en el tratamiento de los pacientes adultos con síndrome de apneas-hipopneas obstructivas del sueño (SAOS). - Valorar los factores predictores de buena respuesta al tratamiento con dispositivos de avance mandibular en pacientes adultos diagnosticados de SAOS. - Valorar la metodología de implementación y seguimiento del tratamiento con DAM en pacientes adultos diagnósticados de SAOS. Finalmente, pretende aportar información de interés para los pacientes adultos diagnosticados de SAOS.

Measuring therapeutic efficacy in the treatment of central sleep apnoea in patients with heart failure.

The goal of treating sleep disordered breathing (SDB) has traditionally focused on improving daytime sleepiness and fatigue. In heart failure (HF) patients with SDB, this is not as easy to ascertain as their symptoms overlap with HF. Thus, improvement in treating SDB in HF patients must focus more on overall quality of life. Over the past 5 years, there has been a shift in sleep medicine from only improving symptoms in SDB, to preventing the long term consequences. The specialist Heart Failure community is, however, desirous of also seeing benefit in reduction of major clinical events for their patients with interventions, such as effects on mortality or re-hospitalisation rates and so may wish to see other benefits beyond a reduction in sleep apnea events before either commencing therapy or referring their patients for sleep study evaluation and further management. To expect lower mortality as well may be asking for too much. Consequently, success in the treatment in SDB should focus on three items: 1) proof that the underlying disease is treated, 2) symptomatic benefit and 3) demonstration that the pathological consequences are prevented. These benefits must then be balanced with a strong safety profile. Here we evaluate a variety of end-points of value to our CSA patients, in an effort to see what may reasonably be required for treating physicians to recommend an intervention for their CHF patients with CSA by looking at candidate measures of treatment success in CSA within a heart failure population.

[Central sleep apnea in multiple sclerosis]. / Zentrales Schlafapnoe-Syndrom bei multipler Sklerose.

Fatigue is a common problem in patients suffering from multiple sclerosis (MS). The presented case demonstrated concomitant severe central sleep apnea. Selection of the optimal ventilation modus was complex but proved successful. Given that daytime sleepiness is a frequent symptom in MS patients and that effective treatment options are available, sleep apnea should be considered and further classified by polysomnography in order to improve patients' quality of life.

Effects of exercise training in patients with chronic heart failure and sleep apnea.

STUDY OBJECTIVES: To test the effects of exercise training on sleep and neurovascular control in patients with systolic heart failure with and without sleep disordered breathing. DESIGN: Prospective interventional study. SETTING: Cardiac rehabilitation and exercise physiology unit and sleep laboratory. PATIENTS: Twenty-five patients with heart failure, aged 42 to 70 years, and New York Heart Association Functional Class I-III were divided into 1 of 3 groups: obstructive sleep apnea (n=8), central sleep apnea (n=9) and no sleep apnea (n=7). INTERVENTIONS Four months of no-training (control) followed by 4 months of an exercise training program (three 60-minute, supervised, exercise sessions per week). MEASURES AND RESULTS: Sleep (polysomnography), microneurography, forearm blood flow (plethysmography), peak VO2, and quality of life were evaluated at baseline and at the end of the control and trained periods. No significant changes occurred in the control period. Exercise training reduced muscle sympathetic nerve activity (P < 0.001) and increased forearm blood flow (P < 0.01), peak VO2( P < 0.01), and quality of life (P < 0.01) in all groups, independent of the presence of sleep apnea. Exercise training improved the apnea-hypopnea index, minimum 0O saturation, and amount stage 3-4 sleep (P < 0.05) in patients with obstructive sleep apnea but had no significant effects in patients with central sleep apnea. CONCLUSIONS: The beneficial effects of exercise training on neurovascular function, functional capacity, and quality of life in patients with systolic dysfunction and heart failure occurs independently of sleep disordered breathing. Exercise training lessens the severity of obstructive sleep apnea but does not affect central sleep apnea in patients with heart failure and sleep disordered breathing.

[Central sleep apnea syndrome as the first sign of type I Chiari malformation]. / Síndrome de apnea central del sueño como primera manifestación de malformación de Chiari tipo I.

INTRODUCTION: Type I Chiari malformation consists on the caudal displacement of cerebellar tonsils through the foramen magnum. It is often asymptomatic, although it may display symptoms as a result of cerebellum, brainstem, high cervical spinal cord or the lower cranial nerve, involvement. OBJECTIVE: We report our experience over the last 16 years. We have identified 16 patients with type I Chiari malformation. Only 2 cases showed common type I Chiari symptoms and just one had respiratory disorder as the first clinical sign. CLINICAL CASE: A 15 year old girl presented with a 5 years' history of chronic daily cough aggravated by exercise. Snoring and sleep apnea had been noted by her mother for 1 year. The girl eventually suffered from migraine and diurnal hypersomnolence. The physical and neurological examination was normal with the only exception being the absence of bilateral nauseous reflex. A nocturnal polysomnography study demonstrated a pseudoperiodic pattern with apnea pauses associated to cycles of deep breathing, resulting in severe gasometric repercussion and bradycardia. Magnetic resonance imaging of the brain showed Chiari I malformation. Non-invasive mechanical ventilation treatment significantly improved the clinical symptoms and gasometric analysis. DISCUSSION: Surgical posterior fossa decompression is discussed. Early decompression before appearance of irreversible neurological damage is recommended. It is associated with a significant reduction in the number of central apneas and sleep arousals. Surgical intervention is recommended in symptomatic patients and in cases of radiographic Chiari malformation or syrinx progression.

Six-month aerobic exercise training ameliorates central sleep apnea in patients with chronic heart failure.

BACKGROUND: Sleep-disordered breathing (SDB) is common in patients with heart failure and carries an independent risk for poor long-term prognosis. We aimed to study the effects of supervised, aerobic exercise training for 6 months on SDB in patients with chronic heart failure. METHODS AND RESULTS: We enrolled 18 patients having both systolic dysfunction (left ventricular ejection fraction <45%) and SDB (apnea-hypopnea index [AHI] >10). The exercise group comprised 10 patients who participated in our cardiac rehabilitation program for 6 months, and the remaining 8 patients served as control. AHI (median [interquartile range]) was unchanged in the control group patients at 6-month intervals (30.4 [19.9-36.3] versus 36.6 [8.6-39.4], NS). In contrast, AHI was significantly decreased in the exercise group from 24.9 [19.2-37.1] to 8.8 [5.3-10.1] (P < .01). In the exercise group, the numbers of central sleep apnea per night was significantly decreased (152 [124-244] versus 50 [24-67], P < .01) after exercise training, but those of obstructive apnea/hypopnea were unchanged (42 [7-94] versus 18 [7-54], NS). In addition, exercise training significantly increased peak oxygen consumption and decreased minute ventilation to carbon dioxide production slope (both P < .01). CONCLUSIONS: Six-month, aerobic exercise training increased exercise capacity and improved central sleep apnea in patients with chronic heart failure from systolic dysfunction.

[Treatment of central sleep apnea syndrome of multifactorial origin by home ventilatory support]. / Síndrome de apnea central de origen multifactorial tratado mediante soporte ventilatorio domiciliario.

We report the case of a patient with chronic renal failure and primary hyperparathyroidism who developed nonhypercapnic central sleep apnea syndrome (CSAS), which was multifactorial in origin and attributed to metabolic factors. Given an inadequate response to oxygen therapy and continuous positive airway pressure (CPAP) revealed by several polygraph studies, the patient was treated with bilevel positive airway pressure ventilatory support. Three months after treatment commenced, a parathyroidectomy was performed and hemodialysis was initiated. At this point it was observed that the patient no longer experienced somnolence; moreover, polysomnography revealed partial improvement in the CSAS and normalization of ventilatory patterns on application of nasal CPAP at 7 cm H2O. We discuss the pathogenesis of CSAS associated with chronic kidney failure along with the treatment options and conclude that treatment should be customized due to the lack of predictability of patient response.