Patients' estimates of their sleep times: reliability and impact on diagnosis of obstructive sleep apnoea.

BACKGROUND: Home polysomnography (PSG) is an alternative method for diagnosis of obstructive sleep apnoea (OSA). Some types 3 and 4 PSG do not monitor sleep and so rely on patients' estimation of total sleep time (TST). AIM: To compare patients' subjective sleep duration estimation with objective measures in patients who underwent type 2 PSG for probable OSA. METHODS: A prospective clinical audit of 536 consecutive patients of one of the authors between 2006 and 2013. A standard questionnaire was completed by the patients the morning after the home PSG to record the time of lights being turned off and estimated time of sleep onset and offset. PSG was scored based on the guidelines of the American Academy of Sleep Medicine. RESULTS: Median estimated sleep latency (SL) was 20 min compared with 10 min for measured SL (P < 0.0001). There was also a significant difference between the estimated and measured sleep offset time (median difference = -1 min, P = 0.01). Estimated TST was significantly shorter than the measured TST (median difference = -18.5 min, P = 0.002). No factors have been identified to affect patients' accuracy of sleep perception. Only 2% of patients had a change in their diagnosis of OSA based on calculated apnoea-hypopnoea index. CONCLUSIONS: Overall estimated TST in the patients with probable OSA was significantly shorter than measured with significant individual variability. Collectively, inaccurate sleep time estimation had not resulted in significant difference in the diagnosis of OSA.

Changes in brain morphology in patients with obstructive sleep apnoea.

BACKGROUND: Obstructive sleep apnoea (OSA) is a common disease that leads to daytime sleepiness and cognitive impairment. Attempts to investigate changes in brain morphology that may underlie these impairments have led to conflicting conclusions. This study was undertaken to aim to resolve this confusion, and determine whether OSA is associated with changes in brain morphology in a large group of patients with OSA, using improved voxel-based morphometry analysis, an automated unbiased method of detecting local changes in brain structure. METHODS: 60 patients with OSA (mean apnoea hypopnoea index 55 (95% CI 48 to 62) events/h, 3 women) and 60 non-apnoeic controls (mean apnoea hypopnoea index 4 (95% CI 3 to 5) events/h, 5 women) were studied. Subjects were imaged using T1-weighted 3-D structural MRI (69 subjects at 1.5 T, 51 subjects at 3 T). Differences in grey matter were investigated in the two groups, controlling for age, sex, site and intracranial volume. Dedicated cerebellar analysis was performed on a subset of 108 scans using a spatially unbiased infratentorial template. RESULTS: Patients with OSA had a reduction in grey matter volume in the right middle temporal gyrus compared with non-apnoeic controls (p<0.05, corrected for topological false discovery rate across the entire brain). A reduction in grey matter was also seen within the cerebellum, maximal in the left lobe VIIIb close to XI, extending across the midline into the right lobe. CONCLUSION: These data show that OSA is associated with focal loss of grey matter that could contribute to cognitive decline. Specifically, lesions in the cerebellum may result in both motor dysfunction and working memory deficits, with downstream negative consequences on tasks such as driving.

Routine use of humidification with nasal continuous positive airway pressure.

BACKGROUND: Heated humidification can reduce nasal symptoms caused by continuous positive airway pressure (CPAP) treatment, but its routine use has not been studied over the medium term in a randomized controlled trial. The aim of this study is to determine if heated humidification would reduce nasal symptoms and improve adherence with CPAP treatment in all patients with sleep apnoea irrespective of whether they had nasal symptoms initially. METHODS: A randomized, parallel group design. Patients were treated for 3 months with a Fisher & Paykel HC201 pump with built-in heated humidification, or with the heater disabled and without water. Adherence was measured with a timer built into the pumps. Nasal symptoms were measured with a 10-cm visual analogue scale. RESULTS: There were 25 in the humidification group and 29 in the non-humidification group. After 12 weeks mean (standard deviation) adherence with CPAP was 4.7 (2.4) and 4.5 (2.2) hours per night respectively. Nasal symptoms that were reduced were nose blocked* 6 (12), 18 (26); sneezing* 4 (8), 15 (25); dry nose* 8 (12), 24 (33); stuffy nose* 7 (14), 22(31); dry mouth* 13 (18), 33(36); and runny nose* 6 (17), 14 (29). Parameters marked with an asterisk '*' had P < 0.05 with t-tests. CONCLUSION: The routine use of heated humidification with CPAP in all patients with sleep apnoea reduced nasal symptoms, but did not improve adherence.

Measurement variability in sleep disorders medicine: the Victorian experience.

BACKGROUND: Surveys of laboratories in North America have documented significant diversity in the working definitions used for reporting respiratory events in sleep studies. AIM: To assess sources of variability in the measurement of sleep-disordered breathing (as defined by the Apnoea-Hypopnoea Index) between sleep laboratories in Victoria, Australia. METHODS: A self-complete written questionnaire was constructed following literature review and interviews with staff at three separate sleep laboratories. The survey was sent to all laboratories listed in Victoria by the Australasian Sleep Association. The first part of the survey related to the type of equipment used to record sleep and other variables during overnight polysomnography and the second part related to the definitions and methods used to report results. RESULTS: Seventeen out of 18 laboratories returned the surveys. There were variations identified in the types of sensors used to measure particular signals. There were also inconsistencies identified in the criteria used to score arousals, apnoeas and hypopnoeas by different laboratories. The variability was greatest for hypopnoea definitions. CONCLUSIONS: There is considerable variation in the methods used to measure and define sleep-disordered breathing between sleep laboratories in Victoria. The extent to which these variations influence the comparability of reported results between laboratories requires further evaluation. The survey findings may assist the process of developing and implementing local guidelines for the performance and reporting of polysomnography.

Impact of different criteria for defining hypopneas in the apnea-hypopnea index.

OBJECTIVES: To explore the effect of using different scoring criteria for hypopneas in the scoring of polysomnographic studies: (1) by estimating the level of agreement between apnea-hypopnea index (AHI) scores derived from different scoring methods, and (2) by examining the effect on the point prevalence of disease using different threshold values of the AHI. DESIGN: Retrospective analysis of 48 diagnostic polysomnographic records. SETTING: Tertiary-hospital sleep-disorders clinic. MEASUREMENTS: AHIs were derived from three different methods for scoring hypopneas. The hypopnea definitions used incorporated different combinations and threshold values of respiratory signal changes in addition to differences in the requirement for associated oxygen desaturation or arousal. The level of agreement between different scoring methods was assessed by constructing Bland-Altman plots and calculating intraclass correlation coefficients (ICCs). kappa statistics were used to assess agreement between the different methods using varying thresholds of AHI to categorize sleep apnea (AHI > 5, AHI > 15, and AHI > 20). RESULTS: The random-effects ICC for the three methods was 0.89, suggesting that the different scoring methods tended to rank patients fairly consistently. However, the point prevalence of disease estimated by using different thresholds of AHI was found to vary depending on the method used to score sleep studies (kappa, 0.30 to 0.95). CONCLUSIONS: These findings have implications for case finding, population-prevalence estimates, and grading of disease severity for access to government-funded continuous positive airway pressure services. Guidelines for standardizing the measurement and reporting of sleep studies in clinical practice should be implemented.

Cardiac and respiratory activity at arousal from sleep under controlled ventilation conditions.

Arousal from sleep is associated with elevated cardiac and respiratory activity. It is unclear whether this occurs because of homeostatic mechanisms or a reflex activation response associated with arousal. Cardiorespiratory activity was measured during spontaneous arousals from sleep in subjects breathing passively on a ventilator. Under such conditions, homeostatic mechanisms are eliminated. Ventilation, end-tidal PCO2, mask pressure, diaphragmatic electromyograph, heart rate, and blood pressure were measured in four normal subjects under two conditions: assisted ventilation and a normal ventilation control condition. In the control condition, there was a normal, sleep-related fall in ventilation and rise in end-tidal PCO2. Subsequently, at an arousal, there was an increase in respiratory and cardiac activity. In the ventilator condition, a vigorous cardiorespiratory response to a spontaneous arousal from sleep remained. These results indicate that sleep-related respiratory stimuli are not necessary for the occurrence of elevated cardiorespiratory activity at an arousal from sleep and are consistent with the hypothesis that such activity is at least in part due to a reflex activation response.

Flow-volume curve changes in patients with obstructive sleep apnoea and brief upper airway dysfunction.

OBJECTIVE: Patients with obstructive sleep apnoea (OSA) and those with brief upper airway dysfunction (BUAD) have been reported to have abnormalities of maximal flow-volume curves. This study was designed to assess the ability of flow-volume curves to predict the presence of OSA or BUAD. METHODOLOGY: Four maximal flow-volume manoeuvres performed by 33 OSA patients and 16 BUAD patients were compared with those of 36 normal subjects. Flow-volume indices, their variability, saw-toothing in the curve and an algorithm based on the flow ratios and shape of the curves were assessed. RESULTS: When the confounding factors, body mass index (BMI), age, gender and smoking status were taken into account, there was no significant difference in a variety of indices derived from the flow-volume curves between OSA and normal subjects. No BUAD patient had normal flow-volume curves as determined with the algorithm. After BMI, age, gender and smoking status were accounted for, decreased forced expiratory volume in 1 s (FEV1), and increased variability of peak expiratory flow (PEF)/peak inspiratory flow (PIF) and FEV1/PEF remained significantly associated with BUAD. CONCLUSIONS: These findings suggest that flow-volume curve indices have no value in predicting OSA. Some abnormalities are found in patients with BUAD; a normal flow-volume curve makes the diagnosis of BUAD unlikely.

Effect of breathing circuit resistance on the measurement of ventilatory function.

BACKGROUND: The American Thoracic Society (ATS) has set the acceptable resistance for spirometers at less than 1.5 cm H2O/l/s over the flow range 0-14 l/s and for monitoring devices at less than 2.5 cm H2O/l/s (0-14 l/s). The aims of this study were to determine the resistance characteristics of commonly used spirometers and monitoring devices and the effect of resistance on ventilatory function. METHODS: The resistance of five spirometers (Vitalograph wedge bellows, Morgan rolling seal, Stead Wells water sealed, Fleisch pneumotachograph, Lilly pneumotachograph) and three monitoring devices (Spiro 1, Ferraris, mini-Wright) was measured from the back pressure developed over a range of known flows (1.6-13.1 l/s). Peak expiratory flow (PEF), forced expiratory flow in one second (FEV1), forced vital capacity (FVC), and mid forced expiratory flow (FEF25-75%) were measured on six subjects with normal lung function and 13 subjects with respiratory disorders using a pneumotachograph. Ventilatory function was then repeated with four different sized resistors (approximately 1-11 cmH2O/l/s) inserted between the mouthpiece and pneumotachograph. RESULTS: All five diagnostic spirometers and two of the three monitoring devices passed the ATS upper limit for resistance. PEF, FEV1 and FVC showed significant (p < 0.05) inverse correlations with added resistance with no significant difference between the normal and patient groups. At a resistance of 1.5 cm H2O/l/s the mean percentage falls (95% confidence interval) were: PEF 6.9% (5.4 to 8.3); FEV1 1.9% (1.0 to 2.8), and FVC 1.5% (0.8 to 2.3). CONCLUSIONS: The ATS resistance specification for diagnostic spirometers appears to be appropriate. However, the specification for monitoring devices may be too conservative. PEF was found to be the most sensitive index to added resistance.

Is normobaric simulation of hypobaric hypoxia accurate in chronic airflow limitation?

Hypobaric hypoxemia is experienced by passengers during commercial aircraft flight. In order to assess the extent of hypoxemia and to test whether hypobaric hypoxia can be accurately estimated at sea level, the results of the normobaric hypoxia altitude simulation test (N-HAST) were compared with those of the hypobaric hypoxia altitude simulation test (H-HAST) in six normal control subjects and nine patients with chronic airflow limitation (CAL) at simulated cabin altitudes of 6,000 ft (1,829 m) and both at rest and during exercise at 8,000 ft (2,438 m). Serial arterial blood samples were drawn during the breathing of 15.1 and 16.3% inspired oxygen at sea level (N-HAST) at rest and during light exercise, and during the breathing of room air at simulated cabin altitudes (H-HAST) of 609 mm Hg (6,000 ft) and 565 mm Hg (8,000 ft) at rest and during light exercise. As measured with the H-HAST technique, the mean (+/- SD) PaO2 of the normal group fell from 96.2 +/- 6.2 mm Hg (sea level) to 70.1 +/- 6.0 mm Hg (6,000 ft), and to 61.7 +/- 1.6 mm Hg (8,000 ft at rest) and 54.8 +/- 7.1 mm Hg (8,000 ft during exercise) (p < 0.005 by analysis of variance [ANOVA]). In the CAL group, the mean (+/- SD) PaO2 fell from 75.8 +/- 8.2 mm Hg (sea level) to 57.0 +/- 6.3 mm Hg (6,000 ft), and 49.5 +/- 6.1 mm Hg (8,000 ft at rest), and 38.6 +/- 7.5 mm Hg (8,000 ft during exercise) (p < 0.005 by ANOVA).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of sample storage time, temperature and syringe type on blood gas tensions in samples with high oxygen partial pressures.

BACKGROUND: Although plastic arterial sampling syringes are now commonly used, the effects of sample storage time and temperature on blood gas tensions are poorly described for samples with a high oxygen partial pressure (PaO2) taken with these high density polypropylene syringes. METHODS: Two ml samples of tonometered whole blood (PaO2 86.7 kPa, PaCO2 4.27 kPa) were placed in glass syringes and in three brands of plastic blood gas syringes. The syringes were placed either at room temperature or in iced water and blood gas analysis was performed at baseline and after 5, 10, 20, 40, 60, 90, and 120 minutes. RESULTS: In the first 10 minutes measured PaO2 in plastic syringes at room temperature fell by an average of 1.21 kPa/min; placing the sample on ice reduced the rate of PaO2 decline to 0.19 kPa/min. The rate of fall of PaO2 in glass at room temperature was 0.49 kPa/min. The changes in PaCO2 were less dramatic and at room temperature averaged increases of 0.47 kPa for plastic syringes and 0.71 kPa for glass syringes over the entire two hour period. These changes in gas tension for plastic syringes would lead to an overestimation of pulmonary shunt measured by the 100% oxygen technique of 0.6% for each minute left at room temperature before analysis. CONCLUSIONS: Glass syringes are superior to plastic syringes in preserving samples with a high PaO2, and prompt and adequate cooling of such samples is essential for accurate blood gas analysis.

An evaluation of the Breath-Taker peak flow meter.

This study was designed to evaluate the Breath-Taker peak flow meter, recently released by the Asthma Foundation of Victoria. The performance characteristics of five Breath-Taker units were compared with those of five Wright and five mini-Wright peak flow meters. The between-unit reproducibility of each type of peak flow meter was measured using an explosive decompression device with a peak flow reproducibility of better than 1%. Each individual meter was used to measure the peak flow delivered by the decompression device three times for each of six flow rates (97-622 L/min). The coefficient of variation (CV) was lowest for the Wright meters (mean CV, 4.8%) and, similarly to the Breath-Taker units (mean CV, 8.4%), this decreased with increasing flow. The CV of the mini-Wright meters, however, increased as flow increased (mean CV, 7.5%). The Breath-Taker meter had less inter-unit variability than the mini-Wright meter at peak flows above 200 L/min. The accuracy of the three meter types was assessed by comparing measurements of peak expiratory flow rate (PEFR) made with each type and also with a computerized pneumotachograph system in 30 subjects with various degrees of irreversible airflow obstruction. Each subject performed at least three reproducible PEFR manoeuvres on the pneumotachograph and on each type of meter, in randomized order. The results showed that in comparison with the pneumotachograph system the Breath-Taker meter underestimated PEFRs by a mean of 27 L/min and the mini-Wright meter overestimated PEFRs by a mean of 45 L/min, whereas the Wright meter was not significantly different. Since the differences between the Breath-Taker meter and the pneumotachograph were independent of flow rate, a scale offset would suffice to "correct" the Breath-Taker readings.

Cardiopulmonary response to oxygen therapy in hypoxaemic chronic airflow obstruction.

The acute change in pulmonary artery pressure in response to oxygen may have prognostic value for patients with chronic obstructive pulmonary disease treated with long term domiciliary oxygen. A study was carried out to elucidate the mechanism of the acute cardio-respiratory response to oxygen in such patients and to determine whether it can be quantified non-invasively. The effects of acute oxygen administration (100% for 20 minutes and 28% oxygen for 24 hours) were assessed by non-invasive means and right heart catheterisation in 17 patients with severe stable hypoxaemic chronic obstructive pulmonary disease. Measurements included change in the ratio of dead space to tidal volume (VD/VT), effective pulmonary capillary blood flow (by rebreathing and single breath soluble gas uptake: QRB, QSB), left ventricular ejection fraction (radionuclide ventriculography), and M mode echocardiographic estimates of ventricular diameters and fractional shortening. These values were compared with those obtained from right heart catheter measurements of pulmonary artery pressure, cardiac index (thermodilution and direct carbon dioxide Fick: QTD, QFICK), and pulmonary vascular resistance. Oxygen administration resulted in a significant fall in pulmonary artery pressure, QTD, and QRB and a significant increase in VD/VT. The fall in QRB after 100% oxygen breathing for 20 minutes correlated strongly with the fall in pulmonary artery pressure (r = 0.86). There was no correlation between the fall in pulmonary artery pressure and the fall in QSB or the risen in VD/VT. Left ventricular ejection fraction did not change significantly. Echocardiography was technically unsatisfactory because of lung hyperinflation. Apart from a possible relation between VO2max and fall in pulmonary artery pressure after 24 hours of 28% oxygen breathing (r = 0.49, p less than 0.1) none of the baseline respiratory function measurements predicted the fall in pulmonary artery pressure or QRB. It is concluded that the cardiopulmonary response to acute oxygen breathing in patients with hypoxic chronic obstructive pulmonary disease includes a reduction in pulmonary artery pressure and cardiac output and a redistribution of pulmonary blood flow, and that rebreathing measurements of effective pulmonary blood flow can be used to quantify this response non-invasively.

Threshold pressure training, breathing pattern, and exercise performance in chronic airflow obstruction.

The effects of six weeks of threshold pressure inspiratory muscle training (IMT) on inspiratory muscle performance, breathing pattern and exercise performance were studied in eight patients with severe airflow obstruction. The results indicated that IMT improved inspiratory muscle performance but did not affect exercise performance or breathing pattern during maximal exercise.

Measurement of effective pulmonary blood flow by soluble gas uptake in patients with chronic airflow obstruction.

A study was designed to assess the accuracy and reproducibility of rebreathing and single breath soluble gas uptake measurements of effective pulmonary blood flow (Q) in patients with airways obstruction. Both rebreathing (RB) and single breath (SB) estimates of Q were compared with direct Fick and thermodilution (TD) measurements of cardiac output at rest and during exercise in eight patients with chronic, poorly reversible airflow obstruction with mean FEV1 65% predicted and mean FEV1/FVC 53%. The mean (SD) resting values obtained were QRB 3.47 (0.46), QSB 4.75 (1.15), QFick 4.77 (0.97), and QTD 5.15 (0.98). QRB was significantly lower than the other three estimates, which did not differ significantly from each other. Exercise produced significant increases in all four estimates for the group. The mean exercise values were QRB 6.23 (1.19), QSB 7.62 (1.97), QFick 8.97 (1.96), and QTD 9.09 (1.00), both QRB and QSB being significantly less than QFick and QTD. Analysis of variance of the rest, exercise, and combined data showed highly significant relationships with the TD and Fick measurements for both QRB and QSB over the range of values studied. In addition, the reproducibility of QRB and QSB was assessed in 15 other patients with chronic airflow obstruction (mean FEV1 42% predicted, FEV1/FVC 43%) and in 10 normal subjects. The coefficients of intrasubject variability for a single measurement for QRB were 8.7% in normal subjects and 10.2% in patients and for QSB were 11.7% in normal subjects and 16.1% in patients. The group differences from morning to afternoon, between days, and over a month were not significant in the normal subjects. In the patients QRB was slightly higher in the afternoon than in the morning of the same day, but the differences between days and over a month were not significant for either test. Although both tests detected the increase in pulmonary blood flow during exercise, the single breath test was more accurate at rest. Some underestimation was present for rebreathing at rest and for both tests during exercise, but this can be allowed for. In patients with mild airflow obstruction the reproducibility of the soluble gas uptake methods was similar to that of invasive catheter methods of cardiac output estimation. The single breath test in particular was, however, less reproducible in patients with more severe airflow obstruction, and the rebreathing method may be more useful for detecting increases in pulmonary blood flow in these patients.

Lobar occlusion in the preoperative assessment of patients with lung cancer.

Bronchial occlusion during exercise was used to predict the functional effects of subsequent pulmonary resection in six high risk patients with lung cancer and severe airflow obstruction. Each patient underwent transnasal fibreoptic bronchoscopy whilst cycling in steady state at a load which had been selected as equivalent to walking at a brisk pace for that patient. The effects on minute ventilation and oxygen uptake were observed during occlusion of the bronchus to the diseased lobe. If the patient was able to continue cycling and maintain the same work load during occlusion this was regarded as indicating that he would withstand resection of the occluded lung tissue. In five of the patients, postoperative studies were performed. All were able to maintain the same level of steady state exercise postoperatively as that maintained during bronchial occlusion preoperatively. Resection resulted in a decrease in static lung volumes. Other routine whole lung function tests, walking capacity and incremental exercise indices, however, were largely unchanged.

Evaluation of six oxygen concentrators.

Examples of six oxygen concentrators (DeVO2, Dom 10, Econo 2, Hudson, Permox, and Roomate) were evaluated over a 9-28 day period to determine (1) the oxygen yield (% O2) over the flow range 1-4 l min-1; (2) 90% oxygen rise time (90% RT) from a cold start when they were operated at 2 l min-1; (3) accuracy and readability of the flow device; (4) static outlet pressure; (5) major components comprising the product gas (Hudson only); and (6) general characteristics. At an outlet flow of 2 l min-1 the mean % O2 generated by all models, except the Permox (which was lower, mean (SD) 90.5% (3.1%), were between 94% and 95% with a range of less than +/- 0.5%. The Dom 10, Econo 2, and Hudson consistently generated higher oxygen concentrations than the other models at flow rates greater than 2 l min-1. The 90% RT was less than 10.5 minutes for all models. Deviations of up to 22% were observed between predicted and measured flow rates in all models except the DeVO2, Hudson, and Permox. It was possible to set the orifice type flow devices fitted to the Permox and Roomate between indicated flow settings, resulting in cessation of flow. Spectral analysis of the output of one device showed that argon and oxygen were concentrated to similar extents, indicating that the maximal attainable oxygen yield for a molecular sieve concentrator is about 96%.

An air-entrainment device for preparing precision gas mixtures.

Three low-cost venturi's built from readily available materials are described and evaluated to determine whether they can be used to prepare precision gas mixtures for the calibration of gas analysers. Using pure oxygen (O2) and nitrogen as the priming gases the venturi's generated mixtures with an O2 concentration within the range 12-53% O2. Over a two-week period, the variability was found to be less than 0.25% O2. The mixtures produced were found to vary according to the density of the priming gas, but were virtually independent of the priming flow rate. We conclude that the venturi may offer a simple and inexpensive method of preparing precision gas mixtures suitable for the calibration of gas analysers.