Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification.

Nasal continuous positive airway pressure (CPAP) can cause undesirable nasal symptoms, such as congestion to obstructive sleep apnoea (OSA) patients, whose symptoms can be attenuated by the addition of heated humidification. However, neither the nature of nasal symptoms nor the effect of heated humidification on nasal pathophysiology and pathology are convincingly known. 20 patients with OSA on nasal CPAP who exhibited symptomatic nasal obstruction were randomised to receive either 3 weeks of CPAP treatment with heated humidification or 3 weeks of CPAP treatment with sham-heated humidification, followed by 3 weeks of the opposite treatment, respectively. Nasal symptom score, nasal resistance, nasal lavage interleukin-6, interleukin-12 and tumour necrosis factor-α and nasal mucosa histopathology were assessed at baseline and after each treatment arm. Heated humidification in comparison with sham-heated humidification was associated with decrease in nasal symptomatology, resistance and lavage cytokines, and attenuation of inflammatory cell infiltration and fibrosis of the nasal mucosa. In conclusion, nasal obstruction of OSA patients on CPAP treatment is inflammatory in origin and the addition of heated humidification decreases nasal resistance and mucosal inflammation.

Predictors of residual sleepiness in adequately treated obstructive sleep apnoea patients.

Some patients with obstructive sleep apnoea syndrome (OSAS; respiratory distress index (RDI) of >5 events.h(-1)) experience residual excessive daytime subjective sleepiness (Epworth Sleepiness Scale (ESS) score of >10), despite adequate use of continuous positive airway pressure (CPAP) therapy. The aim of the present study was to identify clinical and polysomnographic predictors of this sleepiness. Clinical and polysomnographic variables and ESS score were evaluated in 208 OSAS patients with an ESS score of >10 before (initial assessment) and after > or =6 months of adequate (> or =4 h.day(-1)) CPAP use. Following CPAP treatment, 114 (55%) patients showed an abnormal ESS score (>10; CPAP nonresponders), whereas 94 (45%) showed a normal ESS score (<11; CPAP responders). Of the CPAP responders, none had a history of depression, whereas the converse was true for 38.8% of CPAP nonresponders. In addition, multivariate logistic regression analysis revealed that the independent predictors of residual excessive daytime sleepiness following CPAP therapy were a history of diabetes and heart disease, and a higher ESS score and lower RDI on initial assessment. In conclusion, predictors of residual excessive sleepiness in adequately CPAP-treated OSAS were a history of depression, diabetes and heart disease, and a higher ESS score and lower RDI on initial assessment.

Randomised trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea.

Although nasal surgery has limited efficacy in obstructive sleep apnoea (OSA) treatment, some patients experience improvement. The present study tested the hypothesis that post-surgery improvement is associated with increased nasal breathing epochs. A total of 49 OSA patients (mean apnoea/hypopnoea index (AHI) 30.1+/-16.3 events x h(-1)) with symptomatic fixed nasal obstruction due to deviated septum were randomly assigned to either septoplasty (surgery group; 27 patients) or sham surgery (placebo group; 22 patients). The breathing route was examined during overnight polysomnography. All patients in the placebo group were nonresponders, whereas in the surgery group four (14.8%) patients were responders and exhibited considerable increase in nasal breathing epochs (epochs containing more than three consecutive phasic nasal signals), and 23 patients were nonresponders, presenting a modest increase in nasal breathing epochs. The change in AHI was inversely related to the change in nasal breathing epochs, with responders exhibiting among the greatest increases in nasal breathing epochs. Baseline nasal breathing epochs were positively related to per cent change in AHI. Responders had among the lowest baseline nasal breathing epochs; a cut-off value of 62.4% of total sleep epochs best separated (100% sensitivity, 82.6% specificity) responders/nonresponders. In conclusion, nasal surgery rarely treats obstructive sleep apnoea effectively. Baseline nasal breathing epochs can predict the surgery outcome.

Obstructive sleep apnoea and oral breathing in patients free of nasal obstruction.

Although there is an association between nasal obstruction, oral breathing and obstructive sleep apnoea syndrome (OSAS), it remains unknown whether increased oral breathing occurs in patients with OSAS who are free of nasal obstruction. The present study evaluated the relationship between breathing route and OSAS in patients without nasal obstruction. The breathing route of 41 snorers (25 male; aged 26-77 yrs) with normal nasal resistance was examined during overnight polysomnography using a nasal cannula/pressure transducer and an oral thermistor. In total, 28 patients had OSAS (apnoeics) and 13 patients were simple snorers. Apnoeics had a higher percentage of oral and oro-nasal breathing epochs. Oral and oro-nasal breathing epochs were positively related with apnoea/hypopnoea index (AHI) and duration of apnoeas/hypopnoeas and inversely related to oxygen saturation. Additionally, oro-nasal breathing epochs correlated with body mass index (BMI). In multiple linear regression analysis, oral breathing epochs were independently related only to AHI (r2 = 0.443), and oro-nasal breathing epochs were independently related to AHI (r2 = 0.736) and BMI (r2 = 0.036). In conclusion, apnoeics spent more time breathing orally and oro-nasally than simple snorers, and the apnoea/hypopnoea index is a major determinant of the time spent breathing orally and oro-nasally.

Gender differences on polysomnographic findings in Greek subjects with obstructive sleep apnea syndrome.

BACKGROUND AND PURPOSE: Studies from North American clinics have reported that females with obstructive sleep apnea syndrome (OSAS) are about the same age as males but are heavier, have less severe apnea and make up a much smaller proportion of cases. We examined polysomnographic differences between Greek men and women with OSAS in order to study the influence of gender on clinical presentation and laboratory findings. PATIENTS AND METHODS: This retrospective study included a cohort of 1,010 Greek patients (844 males, 166 females) diagnosed with OSAS by overnight polysomnography (PSG), who were referred to the Sleep Disorders Center of Evangelismos Hospital, Athens Medical School, University of Athens. All patients were studied over a period of three consecutive years, during which time clinical and polysomnography (PSG) findings were compared. RESULTS: Body mass index (BMI) was similar in men and women with OSAS (BMI=31.6+/-5.5kg/m(2) in men versus BMI=32.5+/-8.1 (SD) kg/m(2) in women). Female patients were significantly older than male patients (56.9+/-10.6 versus 50.6+/-11.7 year, P=0.001). The mean apnea-hypopnea index (AHI) during total sleep time was higher in men than in women (42.4+/-28.2 versus 33.2+/-27.7 events/h, P<0.001). The AHI in non-rapid eye movement (NREM) sleep was higher in men than in women (42.9+/-28.9 versus 32.6+/-28.7 events/h, P<0.001), but in rapid eye movement (REM) sleep AHI was similar in men and women (36.0+/-23.3 versus 34.9+/-25.4 events/h). Forty percent of men had AHI-REM sleep >AHI-NREM compared to 62% of women, and the difference between REM and NREM-AHI was significantly less in men than in women (14.21+/-11.18 versus 19.76+/-13.43 events/h, P<0.001)). Several aspects of sleep were worse in women versus men: sleep efficiency index was lower (79.4+/-16.1% versus 85.1+/-12.5%, P<0.001); sleep onset latency (27.7+/-27.7 versus 17.9+/-18.1min, P<0.001), and REM onset latency (161.5+/-76.2 versus 145.7+/-71.4min, P<0.018) were longer; wake time after sleep onset (WASO) was also greater in women (42.6+/-46.5 versus 30.7+/-34.9min, P<0.003). CONCLUSIONS: In Greek subjects with OSAS, there was no difference in BMI, and female patients were significantly older than male patients. OSAS was diagnosed in men five times more often than in women. AHI was greater in men than in women, but women are more likely than men to have a higher AHI in REM than NREM. Sleep quality is worse in female than in male patients.

An unusual case of insomnia associated with Whipple encephalopathy: first case reported from Greece.

Whipple disease is a relapsing systemic illness caused by Tropheryma whippelii. Central nervous system involvement occurs in 5%-40% of all patients. Hypothalamic manifestations occur in 31% of Whipple encephalopathy, including polydipsia, hyperphagia, change in libido and insomnia. We report a case of a 48-year-old man with severe insomnia, depression, dementia, dysarthria, myoclonic movements of the limbs and ophthalmoplegia. The diagnosis of Whipple encephalopathy was confirmed by PCR analysis of blood and faeces. He received a full dose of antibiotic treatment. Despite clinical improvement, resolution of the lesions detected in MRI scan of the brain and negative results of the PCR in blood, faeces and cerebrospinal fluid six months later, insomnia persisted and finally subsided after the administration of carbamazepine (600 mg/day). Our case supports the finding that carbamazepine might be useful in the treatment of insomnia associated with Whipple encephalopathy.