Brazilian Thoracic Association Consensus on Sleep-disordered Breathing.

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing / Consenso em Distúrbios Respiratórios do Sono da Sociedade Brasileira de Pneumologia e Tisiologia

ABSTRACT Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

RESUMO O sono é essencial para o adequado funcionamento de todos os indivíduos. Os distúrbios respiratórios do sono ocorrem em todas as faixas etárias, constituindo motivo frequente de consulta médica. O objetivo deste consenso foi atualizar os conhecimentos sobre os principais distúrbios respiratórios do sono tanto na população adulta quanto na pediátrica, com ênfase na apneia obstrutiva do sono. A apneia obstrutiva do sono é uma doença extremamente prevalente, porém frequentemente subdiagnosticada. Associa-se frequentemente a uma série de comorbidades, notadamente cardiovasculares, metabólicas e neurocognitivas, que impactam significativamente na qualidade de vida e na mortalidade. Por conta disso, o Departamento de Distúrbios Respiratórios do Sono da Sociedade Brasileira de Pneumologia e Tisiologia reuniu 14 especialistas com reconhecida e comprovada experiência em distúrbios respiratórios do sono para a elaboração deste documento.

Long term oral appliance therapy decreases stress symptoms in patients with upper airway resistance syndrome.

STUDY OBJECTIVES: To evaluate the long-term effects of a mandibular advancement device (MAD) on stress symptoms and cognitive function in patients with upper airway resistance syndrome (UARS) compared with placebo. METHODS: This study was a randomized placebo-controlled clinical trial. Thirty UARS patients were randomized into 2 groups: placebo and MAD groups. UARS criteria were the presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea-hypopnea index ≤ 5 events/h and a respiratory disturbance index > 5 events/h of sleep, and/or flow limitation in more than 30% of total sleep time. All patients completed the Rey Auditory-Verbal Learning Test, the Logical Memory test, the Stroop Color Test, the Trail Making Test, the Digit Symbol Substitution Test, and Inventory of Stress Symptoms. Cognition protocol was defined based on the most used neuropsychological tests in the literature. Evaluations were performed before and after 1.5 years of treatment. RESULTS: Mean adherence to placebo and to MAD was 6.6 ± 2.6 and 6.1 ± 2.4 h/night, respectively. Side effects reported by MAD group were minor and short-term. There was no statistically significant difference in Rey Auditory-Verbal Learning Test, Logical Memory test, Stroop Color Test, Trail Making Test, and Digit Symbol Substitution Test before and after 1.5 years of treatment in both groups. Inventory of Stress Symptoms score decreased at the alert phase and the resistance phase after 1.5 years of MAD treatment compared to the placebo. CONCLUSIONS: Mandibular advancement devices were effective in decreasing stress symptoms in UARS patients after 1.5 years of treatment. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Efficacy of Oral Appliance for Upper Airway Resistance Syndrome; URL: https://clinicaltrials.gov/ct2/show/record/NCT02636621; Identifier: NTC02636621.

Treatment of obstructive sleep apnea syndrome associated with stroke.

The association between sleep-disordered breathing and stroke has been a subject of increased interest and research. Obstructive sleep apnea (OSA) is an important risk factor for stroke incidence and mortality. Moreover, OSA is a common clinical outcome after stroke, directly influencing the patient's recovery. The treatment of choice for OSA is positive airway pressure (PAP) support and the PAP appliance is considered the most recommended clinical management for the treatment of patients with cardiovascular complications. However, the implementation of PAP in stroke patients remains a challenge, considering the increased frequency of motor and language impairments associated with the cerebrovascular event. In the present study, we reviewed the main findings describing the association between stroke and OSA treatment with continuous positive airway pressure. We also discussed the types of OSA treatment, the different options and indications of PAP treatment, PAP adherence and the clinical outcomes after treatment.

[Pathophysiology of sleep-disordered breathing]. / Fisiopatologia dos distúrbios respiratórios do sono.

Sleep is a phase during which the respiratory system undergoes major changes. These changes lead to greater vulnerability and a greater risk of abnormalities, even in normal individuals. In the transition from wakefulness to sleep, there is commonly an increase in upper airway resistance and impairment of various protective responses and reflexes, which are efficient in promoting and maintaining upper airway patency during wakefulness. In individuals who present risk factors, such as anatomical abnormalities in the upper airway, these sleep-related changes cannot be efficaciously compensated, which increases the chances that sleep-disordered breathing will occur. Sleep-disordered breathing is characterized by a reduction in the size of upper airways, although the degree of the reduction varies. This reduction has multifactorial causes, which include anatomical abnormalities in the upper airway, alterations in the neuromuscular response and impairment of receptors in the upper airway. Upper airway functional and anatomical changes are likely to have genetic components, and, therefore, individuals exposed to certain environmental factors, such as allergies, have a greater chance of developing sleep-disordered breathing.

[Diagnostic criteria and treatment for sleep-disordered breathing: RERA]. / Critérios diagnósticos e tratamento dos distúrbios respiratórios do sono: RERA.

In polysomnography, RERA is defined as a respiratory parameter that indicates an arousal associated with a respiratory event and an increase in respiratory effort. Initially, RERA was described by means of esophageal manometry for the evaluation of respiratory effort. This greater respiratory effort occurs as a response to an increase in upper airway resistance, which is a factor present in the pathophysiology of sleep-disordered breathing, such as obstructive sleep apnea syndrome and upper airway resistance syndrome. Later, the use of a nasal pressure cannula was reported to be a reliable means of identifying airflow limitation and one that is more sensitive than is a thermistor. In addition, the nasal pressure cannula method has been used as a surrogate for esophageal manometry in the identification of periods in which upper airway resistance increases. Consequently, the American Academy of Sleep Medicine recommend the use of either method for the identification of RERA, which is defined by the flattening of the inspiratory curve, characteristic of airflow limitation. Although RERA has been identified and evaluated in current medical practice, it has yet to be standardized. Therefore, it is recommended that polysomnographic reports indicate which abnormal respiratory events were taken into consideration in the evaluation of the severity of sleep-disordered breathing.

Critérios diagnósticos e tratamento dos distúrbios respiratórios do sono: RERA / Diagnostic criteria and treatment for sleep-disordered breathing: RERA

Na polissonografia, RERA é definido como um parâmetro respiratório que indica um despertar associado a um evento respiratório e um aumento do esforço respiratório. Inicialmente, RERA foi descrito com o uso da manometria esofágica utilizada para avaliação do esforço respiratório. Esse maior esforço respiratório ocorre como resposta a um aumento da resistência da via aérea superior, aspecto presente na fisiopatologia dos distúrbios respiratórios do sono, entre esses, SAOS e SRVAS. Posteriormente, o uso de cânula de pressão nasal foi relatado como uma maneira confiável e mais sensível que o termistor para a identificação de eventos de redução do fluxo aéreo e também como um substituto da manometria esofágica para a identificação de períodos de aumento da resistência na via aérea superior. Consequentemente, a American Academy of Sleep Medicine recomenda o uso de um dos métodos para a identificação de RERA, que é definido por um padrão de achatamento da curva inspiratória, característico da limitação ao fluxo aéreo. Embora RERA seja identificado e avaliado na pratica médica, sua padronização ainda é necessária. Portanto, recomenda-se que os laudos de polissonografia indiquem quais eventos respiratórios anormais foram considerados na avaliação do grau de gravidade do distúrbio respiratório.

In polysomnography, RERA is defined as a respiratory parameter that indicates an arousal associated with a respiratory event and an increase in respiratory effort. Initially, RERA was described by means of esophageal manometry for the evaluation of respiratory effort. This greater respiratory effort occurs as a response to an increase in upper airway resistance, which is a factor present in the pathophysiology of sleep-disordered breathing, such as obstructive sleep apnea syndrome and upper airway resistance syndrome. Later, the use of a nasal pressure cannula was reported to be a reliable means of identifying airflow limitation and one that is more sensitive than is a thermistor. In addition, the nasal pressure cannula method has been used as a surrogate for esophageal manometry in the identification of periods in which upper airway resistance increases. Consequently, the American Academy of Sleep Medicine recommend the use of either method for the identification of RERA, which is defined by the flattening of the inspiratory curve, characteristic of airflow limitation. Although RERA has been identified and evaluated in current medical practice, it has yet to be standardized. Therefore, it is recommended that polysomnographic reports indicate which abnormal respiratory events were taken into consideration in the evaluation of the severity of sleep-disordered breathing.

Fisiopatologia dos distúrbios respiratórios do sono / Pathophysiology of sleep-disordered breathing

O sono representa uma fase na qual o sistema respiratório sofre importantes mudanças que levam a uma maior vulnerabilidade e maior chance de ocorrência de anormalidades, mesmo em indivíduos normais. Na transição da vigília para o sono, existe normalmente um aumento da resistência de via aérea superior e prejuízo de diferentes respostas e reflexos protetores, os quais são eficientes em promover e manter a patência da via aérea superior durante a vigília. Em indivíduos que apresentam fatores de risco, tais como anormalidades anatômicas em via aérea superior, essas mudanças associadas ao sono não conseguem ser compensadas de forma eficaz e, com isso, ocorre uma maior chance de ocorrer um distúrbio respiratório do sono. Os distúrbios respiratórios do sono são caracterizados por diferentes graus de diminuição do espaço das vias aéreas superiores. Essa diminuição tem causas multifatoriais, que incluem anormalidades da anatomia de via aérea superior, alteração da resposta neuromuscular e de alterações em receptores de via aérea superior. Provavelmente muitas alterações funcionais e anatômicas em via aérea superior são de característica genética, tornando o individuo com maior risco quando exposto a determinados fatores ambientais, tais como alergias, e a partir da combinação destes fatores haverá uma maior chance de desenvolver distúrbios respiratórios do sono.

Sleep is a phase during which the respiratory system undergoes major changes. These changes lead to greater vulnerability and a greater risk of abnormalities, even in normal individuals. In the transition from wakefulness to sleep, there is commonly an increase in upper airway resistance and impairment of various protective responses and reflexes, which are efficient in promoting and maintaining upper airway patency during wakefulness. In individuals who present risk factors, such as anatomical abnormalities in the upper airway, these sleep-related changes cannot be efficaciously compensated, which increases the chances that sleep-disordered breathing will occur. Sleep-disordered breathing is characterized by a reduction in the size of upper airways, although the degree of the reduction varies. This reduction has multifactorial causes, which include anatomical abnormalities in the upper airway, alterations in the neuromuscular response and impairment of receptors in the upper airway. Upper airway functional and anatomical changes are likely to have genetic components, and, therefore, individuals exposed to certain environmental factors, such as allergies, have a greater chance of developing sleep-disordered breathing.