O avançar da idade é reconhecidamente um fator de risco para a Síndrome da Apneia Obstrutiva do Sono (SAOS). O motivo dessa constatação está associado à diminuição do tônus da musculatura orofaringeana e à redução da Dimensão Vertical de Oclusão (DVO), esta última atribuída às perdas dentárias. A abordagem odontológica, no tratamento da SAOS, refere-se ao uso de Aparelho de Avanço Mandibular (AAM), que impede a obstrução, parcial ou total, da passagem do ar pela via respiratória alta, durante o sono. Os pacientes desdentados, no entanto, têm sido negligenciados, nos estudos atualmente realizados. Pelo exposto, este trabalho objetivou avaliar os efeitos do tratamento em variáveis polissonográficas, ronco, sonolência, qualidade do sono e ainda os efeitos colaterais pelo uso do AAM titulável, em pacientes idosos e desdentados portadadores de SAOS. A metodologia envolveu inicialmente, cinquenta pacientes, dos quais dezesseis realizaram polissonografia de noite inteira, com gravação do ronco, por meio de um Roncômetro, visando investigação objetiva do sono. Analisaram-se subjetivamente frequência e intensidade do ronco, por questionários. A Escala Visual Analógica de Ronco (EVAR), aplicada ao parceiro de quarto, permitiu, igualmente, que fosse avaliada a intensidade desse sintoma. A sonolência diurna foi quantificada pela Escala de Sonolência de Epworth e a qualidade do sono, pelo Índice de Qualidade do Sono de Pittsburgh. Confecção individualizada dos AAMs respeitou os princípios biológicos relativos à DVO. Durante uma semana após a instalação, os pacientes utilizavam o AMM sem qualquer avanço mandibular, visando redução de quaisquer desconfortos. Subsequentemente, o protocolo estabelecia titulação gradual e progressiva (30%, 50% e 70%) do aparelho. Transposta a etapa de adaptação, após um período superior a quinze dias, as avaliações iniciais foram repetidas Os efeitos colaterais pelo uso do AAM e adesão ao tratamento foram investigados, a partir de questionários. Doze pacientes completaram o estudo (83,3% mulheres), sendo a media de idade 68 anos e índice de massa corporal médio de 28,3 kg/m2. Os resultados permitiram observar reduções significantes no índice de dessaturação de O2 (17,710,1 eventos/h, p=0,05) e índice de apneia (3,10,9 eventos/h, p=0,02). O uso do AAM evidenciou também diminuições na latência do sono REM, movimentos períodicos de perna, saturação mínima de O2, índice de apneia e hipopneia, na posição supina (p>0,05). O estudo objetivo do ronco apontou redução de 49,522,6 eventos/h (p=0,07). Além do mais, as avaliações subjetivas de frequência (p=0,024) e intensidade (p=0,007) do ronco, EVAR (p=0,003), qualidade do sono (p=0,008), efeitos colaterais e adesão ao AAM foram estatisticamente significantes. Foi possível concluir pela eficácia do tratamento sobre algumas variáveis polissonográficas estudadas, parâmetros subjetivos do ronco e qualidade do sono. Ademais, os sintomas relatados, pelo uso do AAM, reduziram-se ao longo do tempo, o que permitiu, com vantagem, que houvesse maior adesão ao tratamento por parte dos pacientes inseridos nesta pesquisa. / Aging process is well known as a risky factor to Obstructive Sleep Apnea Syndrome (OSAS). Concomitant with this process, the reduction of orofacial and pharyngeal musculature tone, as well as the decrease of Vertical Occlusion Dimension (VOD), the latter attributed to tooth loss, have been considered as probable causal agents involved in OSAS pathogenesis. The Dentistry approach for OSAS treatment is commonly related to the use of Mandibular Advancement Devices (MAD), which could prevent partial or complete upper airway obstruction during sleep. However, this treatment has been scarcely used in toothless patients. The aim of this study was to assess the effects of a titratable MAD in polysomnographic (PSG) variables, snoring, sleepiness, sleep quality and side effects, in edentulous elderly patients with OSAS. Sixteen out of fifty patients assessed have been selected and have undergone an overnight polysomnographic study. Snoring was recorded by using suitable equipment, so that an objective assessment of sleep patterns could be made. The frequency and intensity of snoring have also been subjectively assessed by means of questionnaires. The Snoring Visual Analogic Scale (SVAS), posed to a bed partner, was also assessed to evaluate snoring intensity. Excessive daytime sleepiness and the quality of sleep have also been investigated by Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index, respectively. The patients went through the whole process for individually manufacturing of the MAD following the biological principles of the VDO. A week after using the MAD, at 0% of mandibular advancement, the patients were invited to return in order to undergo a new evaluation according to their adaptation to MAD. Subsequently, a titration protocol was gradually established at 30%, 50% and 70% for mandibular advancement. After a period of at least fifteen days, which should correspond to an adjustment of patients to their devices, the same initial assessment procedures were repeated. The MAD collateral effects as well as the treatment acceptance have been investigated through questionnaires. Twelve patients (83,3% females) completed the study, with an average age of 68 years, body mass index of 28,3 kg/m2. The results showed a significant reduction in O2 desaturation index (17,710,1 event/h, p=0,05) and also in AI (3,10,9 events/h, p=0,02). The use of the MAD also represented reductions in the latency to REM sleep, periodical leg movements, minimum O2 saturation, apnea and hypopnea index (AHI) in supine position (p>0,05). The objective assessment of snoring showed a reduction, with no statistical relevance of the Snoring Index (49,522,6 events per hour of recording, p=0,07). The subjective assessment of frequency (p=0,024) and intensity of snoring (p=0,007), EVAR (p=0,003), sleep quality (p=0,008) and the MAD collateral effects as well as the treatment acceptance were also statistically significant. We observed that the OSAS treatment with MAD was effective in some polysomnografic variables studied as well as in the subjective parameters of snoring and sleep quality in edentulous elderly patients. The reported symptoms due to MAD use decreased over the time.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Os objetivos deste estudo foram avaliar o efeito do aparelho de avanço mandibular (Twin block - TB) no volume das vias aéreas superiores, por meio de tomografia computadorizada cone beam (CBCT); analisar, por meio da polissonografia, as mudanças no índice de apneia e hipopneia (IAH) e índice de apneia por hora de sono (IA), saturação de oxi-hemoglobina e eficiência do sono; e correlacionar o volume na CBCT e as polissonografias. Dezesseis pacientes portadores de apneia obstrutiva do sono, idade média de 47,06 anos, participaram deste estudo prospectivo, com acompanhamento médio de 7 meses. Foram feitas polissonografias iniciais (T1) e de acompanhamento (T2) com o TB em posição, e CBCT sem e com TB em posição. A segmentação e obtenção dos volumes das vias aéreas superiores foram realizadas e utilizados os testes t de Student pareado, de Wilcoxon e o índice de correlação de Spearman, com 5% de significância. Os resultados das polissonografias mostraram diferenças estatisticamente significativas entre T1 e T2 apenas para IAH (p<0,05). Houve aumento do volume da via aérea superior com TB quando comparado com o volume sem TB (p<0,05). Foi possível estabelecer-se correlação positiva entre volume da via aérea superior sem TB e IAH e IA em T1 (p<0,05), mas não houve correlação entre o volume da via aérea com TB e índices polissonográficos em T2. Pode-se concluir que, houve aumento de volume da via aérea superior com o TB e houve redução do IAH em T2 porém, sem correlação entre estes dados. / The aim of this study were to evaluate the effect of a mandibular advancement device (Twin Block TB) in the upper airway volume, with cone beam computed tomography (CBCT); to analyze, by polysomnographys, changes in apnea and hipopnea index per hour (AHI), apnea index per hour of sleep (AI), oxyhemoglobin saturation and sleep efficiency; and correlate changes in volume in CBCT and the results of polysomnography. Sixteen OSA patients, mean age of 47.07 years, participated in this prospective study, with follow up of 7 months. Initial polysomnography (T1) and follow up polysomnography (T2) were taken with TB in position, and CBCT with and without TB were taken. Upper airway segmentations and volumes were performed and were evaluated by the Student t test, the Wilcoxon test, and Spearman correlation, with 5% significance level. The results of the polysomnographs showed statistically significant differences between T1 and T2, only for AHI (p<0.05). There was an increased airway volume with TB in position when compared to volume without TB (p<0.05). A positive correlation between upper airway volume without TB and T1 AHI and AI was established (p<0.05), but there was no correlation between upper airway volume with TB and T2 polysomnography indexes. In conclusion, there was an increase in volume of the upper airway with the TB and reduction of AHI in T2 but without correlation with these data.

Made available in DSpace on 2014-06-11T19:30:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2006Bitstream added on 2014-06-13T19:00:53Z : No. of bitstreams: 1 weber_sat_dr_botfm.pdf: 3273036 bytes, checksum: 67d29dc2b1ad60f35ef629647ca4572e (MD5) / A Síndrome de Apnéia Hipopnéia Obstrutiva do Sono é um distúrbio caracterizado por episódios repetidos de obstrução parcial ou completa da via aérea superior durante o sono, resultando em hipóxia intermitente, hipercapnia e fragmentação do sono. Afeta 0,7% a 3% das crianças na faixa etária pré-escolar, e está, nas crianças, relacionada com a hipertrofia das tonsilas palatina e/ou faríngeas. Em adultos, a SAHOS foi relacionada como fator de risco para doenças cardiovasculares e distúrbios metabólicos. Em crianças, há poucos relatos de alterações cardíacas como cor pulmonale ou HAS. Porém, as evidências fisiopatológicas da SAHOS permitem suspeitar que haja alterações estruturais e funcionais cardíacas, notadamente do ventrículo direito. Avaliar a função cardíaca de crianças com distúrbios respiratórios obstrutivos por hipertrofia das tonsilas, antes e após a cirurgia de adeno- e/ou tonsilectomia. Foram estudadas 40 crianças, de ambos os sexos, com idade entre 3 a 11 anos, das quais 30 estavam em seguimento no Ambulatório de Distúrbios do Sono, da disciplina de Otorrinolaringologia, FMB - UNESP, aguardando cirurgia de adeno- e/ou tonsilectomia por hipertrofia das tonsilas e distúrbios respiratórios obstrutivos, caracterizados por roncos, pausas respiratórias referidas e sono agitado. As outras 10 crianças eram controles saudáveis, os dois grupos estando homogêneos em relação ao sexo, idade, peso e altura. Todas as 40 crianças foram submetidas a ecocardiograma, visando as 4 câmaras em sístole e diástole... / Obstructive sleep apnea is characterized by intermittent partial or complete obstruction of the upper airway, causing hypoxemia, hypercapnia and sleep fragmentation. It affects 0,7% to 3% of the pre-school children, and in children it is closely related to enlarged tonsils. In adults, sleep apnea has been described as na independent risk factor for cardiovascular disease and metabolic disorders. In children, there a few studies for cardiovascular disfunction, most of them related to cor pulmonale or hypertension. Even though, the pathophysiologic mechanism of OSA permit to suspect of structural and functional cardiac changes, mostly of the right chambers. To study the heart function in children with sleep-related breathing disorders and enlarged tonsils, before and after adeno- and/or tonsillectomy. We studied 40 children, of both genders, aged between 3 and 11 years. Thirty children were at follow-up of Botucatu Medical School - State University of São Paulo due to hypertrophy of the tonsils and clincal complaints of Obstructive Sleep Apnea, as snoring, referred apneas and restless sleep. The other ten children were healthy controls; both groups were homogeneous in gender, age, weight and height. All 40 children were submitted to echocardiogram, analysing the four chambers, in systole and diastole... (Complete abstract click electronic access below)

研究背景與目的：近年來，有不少研究指出阻塞性睡眠呼吸中止疾患（簡稱OSA）患者呈現出高比例的憂鬱情緒，但其盛行率結果分歧，回顧過往文獻也發現OSA與憂鬱情緒的關聯性之結果亦呈現分歧的結果。值得注意的是，OSA與憂鬱情緒之間存在著類似的症狀表現——白天嗜睡，OSA患者可能依據OSA伴隨的嗜睡症狀，回應憂鬱問卷或診斷中的問題，而使其受到誤診或是使盛行率受到高估。為探討此議題，本研究進行兩項研究，分別以橫斷及長期追蹤的資料，探討（一）OSA患者的憂鬱情緒是否聚焦於身體面向，且OSA與憂鬱情緒之間是否受到白天嗜睡中介，以及（二）OSA患者睡眠檢查長期追蹤資料中憂鬱情緒的改變，是否與白天嗜睡程度有關。 研究方法：研究一以台北醫學大學附設醫院睡眠中心資料庫中，2010至2015年到台北醫學大學附設醫院睡眠中心看診並進行PSG檢測時所收集的資料（AHI、醒覺指標、缺氧指標、平均血氧飽和度、最低血氧飽和度、BDI-IA、ESS）進行分析，在排除小於20歲與睡眠疾患共病之後，共有2140位OSA（364女、1776男）患者資料被納入分析。本研究針對OSA患者的憂鬱情緒（BDI-IA）分數進行探索性因素分析，並以此因素結構與Beck與Steer（1993）所得之憂鬱情緒面向結構進行模型競爭，以求更適配於OSA患者之因素結構。再者，本研究取具輕度以上憂鬱情緒的OSA患者資料，以線性迴歸分析了解OSA嚴重度（AHI）、嗜睡程度（ESS得分）與憂鬱情緒（BDI-IA、身體面向、認知面向）之間的關聯性，並以拔靴法進行中介模型的檢定。此外，欲探討OSA患者的憂鬱情緒可能聚焦於身體面向，本研究亦將OSA患者依症狀嚴重度分組，並比較不同症狀嚴重度OSA患者的認知面向與身體面向憂鬱分數。研究二則是以台北醫學大學附設醫院睡眠中心資料庫追蹤一年至兩年間的OSA患者的資料進行資料分析，由於女性人數過少，因此僅納入81位男性OSA患者資料進行統計分析。 研究結果：研究一探索性因素分析結果顯示，「體重減輕」與「煩躁易怒」在因素分析結果的負荷量相當低，無法歸類至其一面向，予以排除，且「不滿自我」、「社交退縮」、「優柔寡斷」三題（原認知面向題項）在OSA患者樣本中被歸類至身體面向。競爭模型結果顯示，本研究所得之因素結構AIC值較低，因此以本研究所得之因素結構進行後續分析中認知面向與身體面向憂鬱情緒之計分與分析。以具憂鬱情緒的OSA患者資料進行相關分析結果發現，AHI 、覺醒指標、 缺氧指標、平均血氧飽和度、最低血氧飽和度皆與ESS呈現顯著相關；且ESS與BDI、身體面向、認知面向憂鬱情緒皆呈現顯著正相關。值得注意的是，OSA症狀嚴重度AHI雖未與BDI呈現顯著關聯性，但與身體面向憂鬱情緒達顯著正相關，且OSA病理機轉——醒覺指標、缺氧指標、平均血氧飽和度亦與身體面向憂鬱情緒達顯著關聯性。拔靴法結果顯示，在控制年齡與BMI後，ESS僅中介於醒覺指標與身體面向憂鬱情緒間的關聯性。將男女性分組後，女性患者的ESS中介於AHI與身體面向憂鬱情緒、醒覺指標與身體面向憂鬱情緒、以及缺氧指標與身體面向憂鬱情緒之間的關聯性，但男性OSA患者則無此中介效果。將OSA患者依症狀嚴重度分組，針對不同症狀嚴重度OSA患者的認知面向與身體面向憂鬱分數進行重複量數檢定，發現不論AHI為輕、中、重度，身體面向憂鬱分數皆較認知面向來得高。研究二檢視OSA患者一年至兩年間追蹤的結果，發現AHI改變量與BMI改變量，無論對於ESS的改變量、BDI-IA總分的改變量、認知面向以及身體面向憂鬱情緒的改變量，皆無顯著相關性；而ESS改變量則與BDI-IA總分的改變量、認知面向憂鬱情緒的改變量、身體面向憂鬱情緒的改變量呈現顯著相關性。依ESS改變量分組後，進一步以單因子變異數分析對BDI-IA改變量、認知面向憂鬱情緒改變量、身體面向憂鬱情緒改變量進行檢定，結果顯示，無論在BDI-IA改變量、認知面向憂鬱情緒改變量、或身體面向憂鬱情緒改變量，皆達顯著差異；而事後檢定顯示，無論在BDI-IA改變量、認知面向、身體面向憂鬱情緒，ESS升高組與ESS無變化組、ESS降低組呈現顯著差異，而ESS無變化組則與ESS降低組無顯著差異。 結論：本研究OSA患者自評BDI-IA的結果發現有高達35%的患者至少有輕度以上的憂鬱情緒，且本研究發現在女性OSA患者身上，OSA嚴重度、睡眠片段化病理機轉，與憂鬱情緒間，受到白天嗜睡程度中介；且OSA患者的憂鬱情緒明顯聚焦於身體面向上，此結果說明OSA患者的憂鬱情緒可能受到白天嗜睡程度所影響，本研究在於提醒臨床工作者對OSA患者進行憂鬱症臨床診斷時，需注意與釐清OSA患者是否以白天嗜睡的情況，來回應憂鬱症狀相關的嗜睡表現，以降低誤判OSA患者憂鬱情緒的可能性。 / Aims: Recent years, researchers found high prevalence of depression occurred in OSA patients. However, the inconsistency was also found in depression prevalence and in the association between OSA and depressive mood. Notably, excessive daytime sleepiness is one of common symptoms of both OSA and depression. High prevalence of depression might be an overestimation due to excessive daytime sleepiness reported by OSA patients. Two studies (cross-sectional and longitudinal studies) were conducted to examine (1) whether the depressive symptoms in OSA patients are more somatic in nature and whether mediation effect between OSA and depression exist, and (2) whether the changes in depressive mood correlate with the changes in excessive daytime sleepiness showed in long term follow-up data. Methods: Sleep test data (including AHI, arousal index, desaturation index, mean SaO2, lowest SaO2, BDI-IA, ESS) retrieved from database of Taipei Medical University Hospital Sleep Center from year 2010 to 2015 was used in Study 1. 2140 OSA patients (364 F、1776 M) were included after rule out patients who is under 20 year-old or comorbid with other sleep disorders. Exploratory factor analysis was conducted to extract the dimensions of depressive mood in OSA patients and the dimensions obtained were further compared with those of Beck and Steer (1993) through competing models. Furthermore, correlations between OSA severity, OSA pathological mechanism, excessive daytime sleepiness, and depressive mood were analyzed in the data of OSA patients with depressive mood, and boostrapping method was conducted to test mediation effect. For examining whether the depressive symptoms in OSA patients are more somatic in nature, cognitive dimension and somatic dimension were compared within different OSA severity. One to two year follow-up sleep test data retrieved from database of Taipei Medical University Hospital Sleep Center was analyzed in Study 2. There were only 81 male OSA patient data included due to the small numbers of female patients. Results: Exploratory factor analysis in Study 1 showed that “weight loss” and “irritability” should be excluded due to low factor loading in depressive mood of OSA patients. “Dissatisfaction”, “social withdrawal” and “indecisiveness” were categorized into somatic dimension in OSA patients. Competing models indicated the factors obtained in exploratory factor analysis were preferred due to lower AIC value, which suggested the model was better fit to OSA patients. Correlation analysis showed that AHI, arousal index, desaturation index, mean SaO2, lowest SaO2, BDI-IA score, somatic dimension and cognitive dimension significantly correlated with ESS. Notably, although the correlation between AHI and BDI-IA was non-significant, AHI positively correlated with somatic dimension. OSA pathological mechanism (arousal index, desaturation index, mean SaO2) also significantly correlated with somatic dimension on BDI-IA. After controlling age and BMI, mediation effects of excessive daytime sleepiness were only found on the relation of arousal index and somatic dimension. Mediation effects were also found on the relation of AHI and somatic dimension, on the relation of desaturation index and somatic dimension, and on the relation of arousal index and somatic dimension in female OSA patients, but the mediation effect was not found in male OSA patients. Furthermore, 3 X 2 ANOVA repeated measurement showed somatic dimension was significantly higher than cognitive dimension on BDI-IA in different AHI severity group. Follow-up data in Study 2 showed the change of AHI and BMI were not correlated with the change of ESS, BDI-IA, cognitive dimension and somatic dimension on BDI-IA. However, the change of ESS was significantly correlated with the change of BDI-IA, cognitive dimension and somatic dimension on BDI-IA. Furthermore, the change of BDI-IA, cognitive dimension and somatic dimension on BDI-IA were tested in different ESS change group. Results showed that the change of BDI-IA, cognitive dimension and somatic dimension on BDI-IA were significant in different ESS change group. Post-hoc analysis indicated the change of BDI-IA, cognitive dimension and somatic dimension in ESS elevated group were significantly different from ESS maintained group and ESS descend group but the difference between ESS maintained group and ESS descend group was non-significant. Conclusion: 35% of OSA patients were classified as co-occurring depressive mood using BDI-IA. However, mediation effect of excessive daytime sleepiness was found in female patients on the relation of OSA severity and depressive mood, and also on the relation of sleep fragmentation and depressive mood. Furthermore, depressive symptoms in OSA patients are more somatic in nature. The results showed depressive mood in OSA patients was probably affected by the excessive daytime sleepiness. The findings suggested the need to clarify the effect of excessive daytime sleepiness to prevent the overestimation of depressive mood in OSA patients.

Introdução: A apnéia obstrutiva do sono é um problema de saúde pública dada sua alta prevalência e morbidade. O tratamento de escolha para casos graves é o uso de máscara ligado à pressão positiva contínua na via aérea (CPAP). Nos casos de apnéia obstrutiva do sono moderada, a adesão ao CPAP é variável, e outras formas alternativas de tratamento são necessárias. A disfunção da musculatura de via aérea superior participa na gênese da apnéia obstrutiva do sono. Exercícios orofaríngeos (terapia miofuncional) são derivados da terapia fonoaudiológica dentro da especialidade de motricidade orofacial, e foram desenvolvidos para o tratamento da apnéia obstrutiva do sono. A terapia miofuncional consiste em exercícios isométricos e isotônicos dirigidos para a língua, palato mole e paredes laterais faríngeas, incluindo a adequação das funções de sucção, deglutição, mastigação, respiração e fala. Objetivo: Testar a hipótese de que a terapia miofuncional reduz a gravidade da apnéia obstrutiva do sono. Métodos: Pacientes com apnéia obstrutiva do sono moderada, determinada através de polissonografia (índice de apnéia-hipopnéia entre 15 e 30 eventos/hora) foram sorteados para 3 meses de medidas gerais incluindo lavagem nasal, orientação da mastigação bilateral alternada e exercícios de inspiração e expiração nasal na posição sentado (grupo controle), ou tratamento com terapia miofuncional. Além das orientações recebidas pelo grupo controle, a terapia miofuncional incluiu exercícios orofaríngeos diários sem supervisão e sob supervisão uma vez por semana (sessões de 20 minutos). Foram realizadas na entrada e final do estudo medidas antropométricas, questionários avaliando a freqüência e intensidade do ronco, sonolência subjetiva diurna (Epworth), qualidade do sono (Pittsburgh) e polissonografia completa. Resultados: Foram incluídos no estudo 45 pacientes; 8 foram excluídos por falta de adesão ao protocolo. O grupo final se constituiu de 37 pacientes com idade (média ± desvio padrão) = 51±9 anos, índice de massa corpórea = 30±4 Kg/m2 e índice de apnéia e hipopnéia = 23±5 apnéias/hora, sendo 17 do grupo controle e 20 do grupo tratamento. O grupo controle não teve mudança significativa em todos os parâmetros. Em contraste, os pacientes tratados com terapia miofuncional apresentaram melhora significante (p<0.05) na circunferência cervical (39.5±3.4 vs. 38.3±3.7 cm), na sonolência diurna (13.2±5.4 vs. 8.2±6.0), na qualidade do sono (10.3±3.5 vs. 7.1±2.3), na freqüência do ronco (3.9±0.5 vs. 2.7±1.1), na intensidade do ronco (3.4±0.5 vs. 1.8±0.9) e no índice de apnéia e hipopnéia (23.2±4.8 vs. 14.6±8.1 eventos/hora; p<0.01). Considerando todo o grupo, as mudanças na circunferência cervical se correlacionaram com as mudanças no índice de apnéia e hipopneia (r=0.55; p<0.001). Conclusões: A terapia miofuncional por 3 meses reduz os sintomas e a gravidade da apnéia obstrutiva do sono moderada. A melhora da apnéia se correlaciona com a diminuição do diâmetro cervical, sugerindo que o tônus da musculatura da via aérea superior durante a vigília se correlaciona com a gravidade da apnéia obstrutiva do sono e pode ser modificada com a terapia miofuncional. / Introduction: Obstructive sleep apnea is a public health problem due to the high prevalence and high morbidity. Continuous positive airway pressure (CPAP) is the treatment of choice for severe cases. However, adherence to CPAP is variable among moderate obstructive sleep apnea patients and alternative treatments are necessary. Upper airway muscle weakness plays an important role in the genesis of obstructive sleep apnea. Oropharyngeal exercises (myofunctional therapy) are derived from phonoaudiological therapy within orofacial motricity specialty, and were developed for the treatment of sleep obstructive apnea. The myofunctional therapy consists of isometric and isotonic exercises directed to tongue, soft palate and lateral pharyngeal wall, including adequate functioning of suction, swallowing, chewing, breathing and speech. Objective: To test the hypothesis that myofunctional therapy will attenuate obstructive sleep apnea syndrome severity. Methods: We included 37 moderate obstructive sleep apnea patients apnea-hypopnea index (AHI) between 15 and 30 events/hour that were randomized to 3 months of general measures, including nasal lavage, orientation of alternated bilateral chewing and exercises of inspiration and expiration in the seated position (control group). The treatment with myofunctional therapy consisted of oropharyngeal exercises performed without supervision daily and under supervision once a week (20 minutes), in adition to the orientations given to the control group. Anthropometric measurements, questionnaires evaluating snoring frequency and intensity (Berlin), daytime subjective sleepiness (Epworth), sleep quality (Pittsburgh) and full polysomnography were performed at baseline and in the end of the study. Results: 45 patients were included in the study, 8 were excluded because they failed to return regularly. The final group consisted of 37 patients age (mean ± SD) = 51±9 years, body mass index = 30±4 Kg/m2 and apnea hypopnea index = 23±5 apneas/hour), seventeen were randomized to the control group and twenty to the treatment group. The control group did not changes in all parameters along the study. In contrast, the patients treated with myofunctional therapy presented a significant decrease (p<0.05) in neck circumference (39.5±3.4 vs. 38.3±3.7 cm), daytime somnolence (13.2±5.4 vs. 8.2±6.0), sleep quality (10.3±3.5 vs. 7.1±2.3), snoring frequency (3.9±0.5 vs. 2.7±1.1), snoring intensity (3.4±0.5 vs. 1.8±0.9) and apnea hypopnea index (23.2±4.8 vs. 14.6±8.1 events/hour; p<0.01). Considering the entire group, changes in neck circumference correlated with the changes in AHI (r=0.55; p <0.001). Conclusions: Myofunctional therapy, over 3 months, reduce symptons and severity of moderate obstructive sleep apnea. The improvement correlates with the decrease of cervical diameter, suggesting that the musculature tonus of upper airway while awake correlates with the severity of obstructive sleep apnea and can be modified with myofunctional therapy.

Introdução: A apneia obstrutiva do sono (AOS) é caracterizada por episódios recorrentes de colapso parcial ou completo da faringe responsáveis por roncos e eventos de hipopneia ou apneia, respectivamente, associados à queda de saturação de oxigênio e despertares frequentes durante o sono. A AOS está associada à doença arterial coronariana e é um fator de risco independente para complicações após cirurgia. Entretanto, a maioria dos pacientes com AOS submetidos à cirurgia não tem suspeita ou diagnóstico prévio de AOS. Objetivos: O principal objetivo do estudo foi determinar prevalência da AOS em candidatos à cirurgia de revascularização do miocárdio (RM) e compará-la à prevalência da AOS em candidatos à cirurgia abdominal eletiva (ABD-cirurgia). Como objetivo secundário, avaliamos os preditores clínicos e o desempenho do questionário de Berlin, que estratifica os pacientes em alto risco e baixo risco de AOS, como teste de triagem no pré-operatório, assim como os preditores clínicos de AOS em ambos os grupos. Métodos: Foram incluídos 40 pacientes consecutivos no grupo RM [29 homens; idade: 56±7 anos; índice de massa corporal (IMC): 30±4 kg/m2], e 41 pacientes no grupo ABD-cirurgia, que foram pareados para sexo, idade e IMC (28 homens; idade: 56±8 anos; IMC: 29±5 11 kg/m2). Todos os pacientes foram submetidos à polissonografia completa noturna (PSG) e à avaliação clínica e laboratorial pré-operatória, incluindo avaliação da sonolência diurna com a escala de sonolência Epworth (ESS) e com o questionário de Berlin. Resultados: A prevalência de AOS (índice de apneia hipopneia na PSG 15 eventos/hora) no grupo RM e ABD-cirurgia foi alta e semelhante (52% e 41%, respectivamente, p=0,32). O grupo RM apresentou menor nível de sonolência (ESS: 6±3 e 9±5; RM vs. ABD-cirurgia, respectivamente, p=0,008). A sensibilidade e a especificidade do Berlin no grupo RM foi 67% e 26%, e no grupo ABD-cirurgia, 82 e 62%, respectivamente. O IMC, as circunferências abdominal e cervical, a pressão arterial sistólica, a pressão arterial diastólica, os triglicerídeos, a lipoproteína de alta densidade sérica (HDL-c), a Diabetes Mellitus e o risco alto de AOS (de acordo com questionário de Berlin) se correlacionaram com a AOS na análise univariada. No entanto, a circunferência abdominal foi o único preditor independente associado à presença de AOS após regressão logística múltipla. Conclusão: A AOS é extremamente comum entre pacientes candidatos à cirurgia cardíaca e cirurgia abdominal. O questionário de Berlin apresentou baixa sensibilidade para detecção AOS em pacientes do grupo RM, mas a sensibilidade e a especificidade no grupo ABD-cirurgia foram semelhantes aos valores encontrados na literatura. A sonolência diurna não está associada à presença de AOS entre portadores de doença arterial coronariana com indicação de tratamento cirúrgico e entre candidatos à cirurgia abdominal eletiva, o que pode ajudar a explicar o subdiagnóstico de AOS na nossa população / Background: The obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the pharynx account for snoring and apnea or hypopnea events, respectively, associated with the decrease of oxygen saturation and frequent arousals during sleep. OSA is associated with coronary artery disease and is an independent risk factor for complications after surgery. However, most patients with OSA undergoing surgery is not suspected or previously diagnosed OSA. Objectives: The main objective of this study was to determine the prevalence of OSA in candidates for coronary arterial bypass grafting surgery (CABG) and compare it with the prevalence of OSA in candidates for elective abdominal surgery (ABD-surgery). As a secondary objective, we evaluated the clinical predictors and performance of the Berlin questionnaire, which stratifies patients into high risk and low risk for OSA, as a screening test in the preoperative as well as clinical predictors of OSA in both groups. Methods: We included 40 consecutive patients in the CABG group [29 men, age: 56 ± 7 years, body mass index (BMI): 30 ± 4 kg/m2] and 41 patients in the ABD-surgery, who were matched for gender, age and BMI (28 men, age: 56 ± 8 years, BMI: 29 ± 5 kg/m2 ¬). All patients underwent full nocturnal polysomnography (PSG) and clinical and laboratory pre-operative evaluation, 14 including assessment of daytime sleepiness with the Epworth Sleepiness Scale (ESS) and the Berlin questionnaire. Results: The prevalence of OSA (apnea hypopnea index in PSG 15 events/hour) in the RM group and ABD-surgery was high and similar (52% and 41% respectively, p = 0.32). Patients submitted to CABG presented lower levels of daytime somnolence than ABD-surgery patients (ESS: 6±3 vs. 9±5; p=0.008, respectively). The sensitivity and specificity of Berlin in the RM group was 67% and 26%, and ABD-surgery group, 82 and 62% respectively. The BMI, waist and neck circumference, systolic blood pressure, diastolic blood pressure, triglycerides, serum high density lipoprotein (HDL-C), Diabetes Mellitus and the high risk of OSA (according to questionnaire Berlin) correlated with OSA in univariate analysis. However, waist circumference was the only independent predictor associated with the presence of OSA after multiple logistic regression. Conclusion: OSA is extremely common among patients who are candidates for CABG and abdominal surgery. The Berlin questionnaire showed low sensitivity for detecting OSA in patients in the RM group, but the sensitivity and specificity in ABD-surgery group were similar to those found in the literature. Daytime sleepiness is not associated with the presence of OSA among patients with coronary artery disease with indication for surgical treatment and patients with indication for elective abdominal surgery, which may help explain the underdiagnosis of OSA in our population

No description available.

Ao considerar que os distúrbios respiratórios relacionados ao sono, apneia obstrutiva do sono (AOS) e dessaturação noturna de oxigênio (DNO), podem estar presentes em pacientes com doença pulmonar obstrutiva crônica (DPOC), este estudo teve como objetivos: (1) estimar a frequência de AOS e DNO na amostra e nos graus e categorias GOLD (Global Initiative for Chronic Obstructive Lung Disease); (2) avaliar a relação da presença de AOS e DNO no agravamento clínico de pacientes com DPOC. Estudo transversal em 56 pacientes com DPOC estável e pressão parcial arterial de oxigênio (PaO2) diurna > 60 mmHg, submetidos à coleta dos seguintes dados: demográficos, antropométricos e de hábito tabágico; relato de ronco e sonolência diurna; número de exacerbações e hospitalizações; escala de dispneia do Medical Reserch Council modificada; teste de avaliação da DPOC; escala de sonolência de Epworth; espirometria; gasometria arterial; hemograma; monitorização ambulatorial da pressão arterial e polissonografia. Os pacientes foram classificados em graus e categorias GOLD e divididos em 3 grupos de estudo: grupo DPOC pura, grupo síndrome de sobreposição (SS) e grupo dessaturador (D). Os resultados mostraram: 30 pacientes do sexo masculino (54%); idade: 63,7 (DP=7,3) anos; índice de massa corpórea (IMC): 25,2 (DP=4,3) Kg/m2; circunferência do pescoço: 38,4 (DP=3,2) cm; 46% tabagistas; carga tabágica: 50,0 (DP=20,7) anosmaço; volume expiratório forçado no primeiro segundo (VEF1): 56,4 (DP=19,8) % do previsto; PaO2: 78,3 (DP=8,0) mmHg; saturação arterial de oxigênio (SaO2): 95,5 (DP=1,4) %; 29 pacientes (52%) eram do grupo DPOC pura, 14 (25%) do grupo SS e 13 (23%) do grupo D; frequência de AOS e DNO na amostra: 25% e 23%, respectivamente; frequência de AOS nos GOLD 1234: 14%, 24%, 25%, 50% (p=0,34) e GOLD ABCD: 44%, 15%, 25%, 26% (p=0,31), respectivamente; frequência da DNO nos GOLD 1234: 29%, 24%, 19%, 25% (p=0,88) e GOLD ABCD: 11%, 20%, 25%, 30% (p=0,35), respectivamente. Evidências de diferença estatística entre os 3 grupos: sexo (DPOC pura: 48% de homens versus SS: 86% versus D: 31%; p<0,01); IMC (DPOC pura: 23,9 (DP=3,8) versus SS: 24,7 (DP=4,6) versus D: 28,6 (DP=3,5) Kg/m2; p<0,01); circunferência do pescoço (DPOC pura: 37,4 (DP=2,7) versus SS: 40,0 (DP=2,9) versus D: 38,9 (DP=3,9) cm; p=0,03); relato de sonolência diurna (DPOC pura: 17% versus SS: 0 versus D: 38%; p=0,03); SaO2 diurna (DPOC pura: 95,8 (DP=1,5) % versus SS: 95,8 (DP=1,1) % versus D: 94,7 (DP=1,3) %; p=0,04); descenso noturno diastólico (DPOC pura: 6,5 (DP=7,0) % versus SS: 2,3 (DP=7,3) % versus D: 5,6 (DP=7,0) %; p=0,04). Conclui-se que, em pacientes com DPOC, a frequência de AOS e DNO foi elevada na amostra e não sofreu influência dos graus ou categorias GOLD; encontrou-se associação entre a presença de AOS e o sexo masculino, maior circunferência do pescoço e menor descenso noturno diastólico; e a presença de DNO associou-se com o sexo feminino, maior IMC, maior relato de sonolência diurna e menor SaO2 diurna. Estas características podem contribuir para diferenciar clinicamente os grupos SS e D do grupo DPOC pura / While considering that the sleep-related breathing disorders, obstructive sleep apnea (OSA) and nocturnal oxygen desaturation (NOD) may be present in patients with chronic obstructive pulmonary disease (COPD), this study aimed to: (1) to estimate the frequency of OSA and NOD in the sample and in the GOLD degrees and categories (Global Initiative for Chronic Obstructive Lung Disease); (2) to assess the relationship of the presence of OSA and NOD in the clinical aggravation of patients with COPD. Transversal study in 56 patients suffering from stable COPD and daytime partial arterial oxygen tension (PaO2) > 60 mmHg, subjected to the collection of the following data: demographic and anthropometric data, and smoking habit; report of snoring and daytime sleepiness; number of exacerbations and hospitalizations; modified Medical Research Council dyspnea scale; COPD assessment test; Epworth Sleepiness Scale; spirometry; arterial gasometry; hemogram; ambulatory blood pressure monitoring and polysomnography. The patients were classified in GOLD degrees and categories and divided into 3 study groups: pure COPD group, overlap syndrome (OS) and desaturator group (D). The results showed: 30 male patients (54%); age 63,7 years old (DP=7,3); body mass index (BMI) 25,2 Kg/m2 (DP=4,3); neck circumference 38,4 cm (DP=3,2); 46% smokers; smoking load 50,0 pack years (DP=20,7); forced expiratory volume in the first second (FEV1) 56,4% of the expected (DP=19,8); PaO2 78,3 mmHg (DP=8,0); arterial oxygen saturation (SaO2) 95,5% (DP=1,4); 29 patients (52%) belonged to the pure COPD group, 14 (25%) to the OS group and 13 (23%) to the D group; frequency of OSA and NOD in the sample: 25% and 23%, respectively; frequency of OSA in the GOLD 1234: 14%, 24%, 25%, 50% (p=0,34) and GOLD ABCD: 44%, 15%, 25%, 26% (p=0,31), respectively; NOD frequency in the GOLD 1234: 29%, 24%, 19%, 25% (p=0,88) and GOLD ABCD: 11%, 20%, 25%, 30% (p=0,35), respectively. Evidences of statistical difference among the three groups: sex (pure COPD: 48% men versus OS: 86% versus D: 31%; p<0,01); BMI (pure COPD: 23,9 (DP=3,8) versus OS: 24,7 (DP=4,6) versus D: 28,6 (DP=3,5) Kg/m2; p<0,01); neck circumference (pure COPD: 37,4 (DP=2,7) versus OS: 40,0 (DP=2,9) versus D: 38,9 (DP=3,9) cm; p=0,03); report of daytime sleepiness (pure COPD: 17% versus OS: 0 versus D: 38%; p=0,03); daytime SaO2 (pure COPD: 95,8% (DP=1,5) versus OS: 95,8% (DP=1,1) versus D: 94,7% (DP=1,3); p=0,04); diastolic sleep dip (pure COPD: 6,5% (DP=7,0) versus OS: 2,3% (DP=7,3) versus D: 5,6% (DP=7,0); p=0,04). It was concluded that, in patients with COPD, the OSA and NOD frequency was high in the sample and was not influenced by GOLD grades or categories. An association between the presence of OSA and the male sex, a larger neck circumference and a smaller diastolic sleep dip was found; and the presence of the NOD was associated with the female sex, a larger BMI, a more significant report of daytime sleepiness and a smaller daytime SaO2. These characteristics may contribute to differentiate clinically the OS and D groups from the pure COPD group

Introdução: A apnéia obstrutiva do sono é um problema de saúde pública dada sua alta prevalência e morbidade. O tratamento de escolha para casos graves é o uso de máscara ligado à pressão positiva contínua na via aérea (CPAP). Nos casos de apnéia obstrutiva do sono moderada, a adesão ao CPAP é variável, e outras formas alternativas de tratamento são necessárias. A disfunção da musculatura de via aérea superior participa na gênese da apnéia obstrutiva do sono. Exercícios orofaríngeos (terapia miofuncional) são derivados da terapia fonoaudiológica dentro da especialidade de motricidade orofacial, e foram desenvolvidos para o tratamento da apnéia obstrutiva do sono. A terapia miofuncional consiste em exercícios isométricos e isotônicos dirigidos para a língua, palato mole e paredes laterais faríngeas, incluindo a adequação das funções de sucção, deglutição, mastigação, respiração e fala. Objetivo: Testar a hipótese de que a terapia miofuncional reduz a gravidade da apnéia obstrutiva do sono. Métodos: Pacientes com apnéia obstrutiva do sono moderada, determinada através de polissonografia (índice de apnéia-hipopnéia entre 15 e 30 eventos/hora) foram sorteados para 3 meses de medidas gerais incluindo lavagem nasal, orientação da mastigação bilateral alternada e exercícios de inspiração e expiração nasal na posição sentado (grupo controle), ou tratamento com terapia miofuncional. Além das orientações recebidas pelo grupo controle, a terapia miofuncional incluiu exercícios orofaríngeos diários sem supervisão e sob supervisão uma vez por semana (sessões de 20 minutos). Foram realizadas na entrada e final do estudo medidas antropométricas, questionários avaliando a freqüência e intensidade do ronco, sonolência subjetiva diurna (Epworth), qualidade do sono (Pittsburgh) e polissonografia completa. Resultados: Foram incluídos no estudo 45 pacientes; 8 foram excluídos por falta de adesão ao protocolo. O grupo final se constituiu de 37 pacientes com idade (média ± desvio padrão) = 51±9 anos, índice de massa corpórea = 30±4 Kg/m2 e índice de apnéia e hipopnéia = 23±5 apnéias/hora, sendo 17 do grupo controle e 20 do grupo tratamento. O grupo controle não teve mudança significativa em todos os parâmetros. Em contraste, os pacientes tratados com terapia miofuncional apresentaram melhora significante (p<0.05) na circunferência cervical (39.5±3.4 vs. 38.3±3.7 cm), na sonolência diurna (13.2±5.4 vs. 8.2±6.0), na qualidade do sono (10.3±3.5 vs. 7.1±2.3), na freqüência do ronco (3.9±0.5 vs. 2.7±1.1), na intensidade do ronco (3.4±0.5 vs. 1.8±0.9) e no índice de apnéia e hipopnéia (23.2±4.8 vs. 14.6±8.1 eventos/hora; p<0.01). Considerando todo o grupo, as mudanças na circunferência cervical se correlacionaram com as mudanças no índice de apnéia e hipopneia (r=0.55; p<0.001). Conclusões: A terapia miofuncional por 3 meses reduz os sintomas e a gravidade da apnéia obstrutiva do sono moderada. A melhora da apnéia se correlaciona com a diminuição do diâmetro cervical, sugerindo que o tônus da musculatura da via aérea superior durante a vigília se correlaciona com a gravidade da apnéia obstrutiva do sono e pode ser modificada com a terapia miofuncional. / Introduction: Obstructive sleep apnea is a public health problem due to the high prevalence and high morbidity. Continuous positive airway pressure (CPAP) is the treatment of choice for severe cases. However, adherence to CPAP is variable among moderate obstructive sleep apnea patients and alternative treatments are necessary. Upper airway muscle weakness plays an important role in the genesis of obstructive sleep apnea. Oropharyngeal exercises (myofunctional therapy) are derived from phonoaudiological therapy within orofacial motricity specialty, and were developed for the treatment of sleep obstructive apnea. The myofunctional therapy consists of isometric and isotonic exercises directed to tongue, soft palate and lateral pharyngeal wall, including adequate functioning of suction, swallowing, chewing, breathing and speech. Objective: To test the hypothesis that myofunctional therapy will attenuate obstructive sleep apnea syndrome severity. Methods: We included 37 moderate obstructive sleep apnea patients apnea-hypopnea index (AHI) between 15 and 30 events/hour that were randomized to 3 months of general measures, including nasal lavage, orientation of alternated bilateral chewing and exercises of inspiration and expiration in the seated position (control group). The treatment with myofunctional therapy consisted of oropharyngeal exercises performed without supervision daily and under supervision once a week (20 minutes), in adition to the orientations given to the control group. Anthropometric measurements, questionnaires evaluating snoring frequency and intensity (Berlin), daytime subjective sleepiness (Epworth), sleep quality (Pittsburgh) and full polysomnography were performed at baseline and in the end of the study. Results: 45 patients were included in the study, 8 were excluded because they failed to return regularly. The final group consisted of 37 patients age (mean ± SD) = 51±9 years, body mass index = 30±4 Kg/m2 and apnea hypopnea index = 23±5 apneas/hour), seventeen were randomized to the control group and twenty to the treatment group. The control group did not changes in all parameters along the study. In contrast, the patients treated with myofunctional therapy presented a significant decrease (p<0.05) in neck circumference (39.5±3.4 vs. 38.3±3.7 cm), daytime somnolence (13.2±5.4 vs. 8.2±6.0), sleep quality (10.3±3.5 vs. 7.1±2.3), snoring frequency (3.9±0.5 vs. 2.7±1.1), snoring intensity (3.4±0.5 vs. 1.8±0.9) and apnea hypopnea index (23.2±4.8 vs. 14.6±8.1 events/hour; p<0.01). Considering the entire group, changes in neck circumference correlated with the changes in AHI (r=0.55; p <0.001). Conclusions: Myofunctional therapy, over 3 months, reduce symptons and severity of moderate obstructive sleep apnea. The improvement correlates with the decrease of cervical diameter, suggesting that the musculature tonus of upper airway while awake correlates with the severity of obstructive sleep apnea and can be modified with myofunctional therapy.

ABSTRACT ASSESSING BASELINE AND POST-DISCHARGE RISK FACTORS IN SUBJECTS WITH AND WITHOUT SLEEP APNEA UNDERGOING ENDOSCOPY WITH DEEP SEDATION Background: Outpatient procedures encompass over 60% of all surgeries in the United States, and the prevalence of obstructive sleep apnea (OSA) remains high among adult surgical ambulatory patients. Ambulatory surgery poses problems for patients with OSA because narcotics and anesthetics used during surgery can complicate the negative effects of OSA, leading to cardiac events, brain hypoxia, and even death. This study was designed to evaluate the prevalence of cardiopulmonary risk factors among post endoscopic patients with diagnosed and undiagnosed sleep apnea. Methods: The study involved a prospective, descriptive cross-sectional design and incorporated a pre-test or post-test data collection approach, using Actigraphy, pulse oximetry and 24-hour ECG monitoring via Bluetooth technology to monitor outpatients undergoing endoscopy with deep Propofol sedation. Patients were recruited pre-procedure to obtain a resting baseline ECG, and pre-procedure values were then monitored post procedure continuously for 24 hours. A p-value less than 0.05 was considered to be statistically significant. A target sample included 50 adult outpatients from a Florida suburban endoscopy center. Results: Pulse oximetry and Actigraph scores revealed no difference based on OSA. The ANOVA for oxygen desaturation events and sleep quality indices reflected no differences across groups. Sleep quality had no measurable influence on adverse events and was similar across groups; participants diagnosed with OSA slept longer than those in the untreated or no OSA group. Regressions for sleep quality indices reflected no differences among groups. Conclusions: There remains a lack of literature on cardiopulmonary and ECG indicators of cardiac risks in patients with OSA in the 24 hours following discharge from ambulatory surgery. This dissertation characterized the ECG at baseline and post-discharge among post-endoscopy outpatients with OSA and without OSA. Further research is recommended.