Introduction : L'apnée obstructive du sommeil (AOS) et ses comorbidités (tel le bruxisme du sommeil (BS)) sont associées à des fluctuations du système nerveux autonome (SNA) chez les adultes et les enfants. La variabilité de la fréquence cardiaque (VFC), qui concerne, entre autres, la fluctuation des intervalles de temps entre les battements cardiaques adjacents, est une méthode non invasive et reproductible d'évaluation de la modulation du SNA. Objectif : Évaluer l'effet individuel et potentiellement cumulatif de ces conditions sur la VFC de la population pédiatrique. Méthodes : Des questionnaires dentaires et de bruxisme ont été remplis par les parents. Les enfants ont subi une évaluation dentaire et un enregistrement polysomnographique. La VFC a été analysée dans une fenêtre de référence de 5 minutes ainsi que dans des fenêtres de 4x3 minutes avant et après les événements d’AOS ou de BS. Résultats : Un total de 41 enfants ont été classés en sous-groupes : BS, contrôle et AOS+BS. Le rapport de puissance spectrale Basse Fréquence/Haute Fréquence (BF/HF), qui est connu pour utiliser les transformations de Fourier rapide, était plus élevé dans le groupe AOS + BS que dans le groupe contrôle (p = 0,01) et le groupe BS (p = 0,04) pour toutes les fenêtres d’analyse combinées (B0-B8). Dans le domaine temporel de la VFC, l'écart type des intervalles RR (SDNN) des fenêtres était plus élevé après chaque événement (B5 à B8) que la ligne de base (B0) pour les 3 groupes (p < 0,05). Conclusion : La VFC est différente entre les trois groupes. / Introduction: Obstructive sleep apnea (OSA) and its comorbid conditions (such as sleep bruxism (SB)) are associated with an autonomic nervous system (ANS) fluctuation in adults and children. Heart rate variability (HRV), which is concerned with, among other things, the fluctuation of the time intervals between adjacent heartbeats, is a non-invasive and reproducible method of assessing the modulation of the ANS. Aim: To assess the individual and potentially cumulative effect of these conditions on HRV in the pediatric population. Methods: Dental and bruxism questionnaires were completed by the parents. Children underwent a dental assessment and polysomnographic recording. HRV was analyzed in a 5-minute baseline windows as well as in 4x3-minute windows before and after OSA or SB events. Results: A total of 41 children were classified into subgroups: SB, control and OSA+SB. The Low Frequency/High Frequency (LF/HF) power ratio, which is known to use Fast Fourier Transforms, was higher in the AOS + SB group than in the control group (p = 0.01) and the SB group (p=0.04) for all analysis windows combined (B0-B8). In the time domain of the HRV, the standard deviation of the RR intervals (SDNN) of the windows was higher after each event (B5 to B8) than the baseline (B0) for the 3 groups (p < 0.05). Conclusion: HRV is different between the three groups.

Problématique à laquelle répond ce projet de recherche: Les troubles respiratoires obstructifs du sommeil (TROS) comprennent différentes anomalies allant du ronflement chronique au syndrome d’apnée obstructive du sommeil (SAOS). Le SAOS toucherait entre 1 et 5% d’une population pédiatrique générale avec un pic d’incidence entre 2 et 6 ans. Les enfants obèses sont particulièrement atteints avec une prévalence pouvant atteindre 40%. Chez les enfants atteints de malformations crânio-faciales sévères, la prévalence peut atteindre plus de 50%. Les conséquences du SAOS sur le développement de l’enfant peuvent être significatives en l’absence de traitement, tant au point de vue de la croissance que des performances cognitives, du comportement et des paramètres cardio-vasculaires, pulmonaires ou métaboliques. Chez l’adulte, la prévalence du SAOS est estimée, dans la population générale, à 3 à 7% des hommes et à 2 à 5% des femmes d’âge moyen. Cette prévalence serait plus élevée dans certains sous-groupes de la population, notamment les personnes en surpoids ou obèses, chez les femmes enceintes, dans certaines ethnies et chez les personnes âgées. Le SAOS peut entrainer une sur- morbidité cardiovasculaire (hypertension artérielle, accident vasculaire cérébral et infarctus du myocarde) et une augmentation des accidents de travail ou de la circulation imputables à la somnolence. Il est actuellement reconnu que le SAOS pédiatrique et le SAOS de l’adulte ont des causes, des présentations et des conséquences différentes. On ne sait cependant pas si le SAOS de l’adolescent est une poursuite de la forme pédiatrique ou une forme précoce du SAOS de l’adulte. On ne sait pas non plus si certains facteurs de risque sont présents précocement chez l’enfant et persistent jusqu’à l’âge adulte, ou si les deux formes SAOS pédiatrique / adulte ont une étiologie relativement indépendante. Objectifs: Comparer la distribution des caractéristiques morphologiques dento-faciales, fonctionnelles oro- nasales et de l’adiposité entre les membres d’une même famille, (quand à la fois) lorsqu’un enfant et un parent présentent des symptômes de troubles obstructifs du sommeil. Un des membres devra avoir reçu préalablement un diagnostic de SAOS. Type de recherche: Étude transversale observationnelle Méthodologie: Nous avons recruté des enfants afin de planifier un enregistrement du sommeil au CHU Sainte- Justine avec au minimum un de ses parents biologiques directs. Les procédures expérimentales qui ont été utilisées avec chacune de ces familles étaient : • Une évaluation crânio-faciale et fonctionnelle de l’enfant et d'au moins un de ses parents, incluant la prise de photos • Un questionnaire de dépistage du SAOS et un arbre généalogique sur 3 générations • Un enregistrement du sommeil de l’enfant • L'enregistrement du poids et de la taille, de la circonférence du cou, de la circonférence de la taille ainsi que des symptômes liés au SAOS Résultats: Nous avons inclus un groupe de 20 paires (un enfant couplé à un de ses parents). De ce groupe, 13 enfants ont été diagnostiqué du SAOS et 7 en étaient non atteints. Pour ce qui est de l'analyse des questionnaires des enfants, 100% des apnéiques rapportaient une obstruction nasale. Pour les caractéristiques crânio-faciales, 85% de tous les enfants avait la même classification du tonus labial et jugal, 90% de tous les enfants avait avaient la même forme d'arcade maxillaire et mandibulaire et 100% des enfants apnéiques présentaient la même classification de chevauchement dentaire que leur parent. Dans le cas de l'analyse anthropométrique sur photographies, les mesures de la hauteur faciale totale, de la hauteur du tier inférieur et la 2 position antéro-postérieure du maxillaire sont celles qui ont démontrées une certaine tendance d'héritabilité. La mesure N-Gn était plus grande chez les enfants apnéiques, ce qui signifie une hauteur faciale totale plus grande (Cohen d = 1,007). La mesure Sn-Gn était aussi plus grande chez les enfants apnéiques, ce qui signifie un tier inférieur plus long (Cohen d = 1,010). Enfin, l'angle T- N-Sn est plus petit chez les enfants apnéiques (Cohen d = 0,851). Conclusion: L'étude actuelle est une étude pilote constitué d'un échantillon limité. Seul un des deux parents de chaque famille a accepté de participer. Malgré cela, on peut voir une certaine tendance d'héritabilité au niveau du tonus labial et jugal, de la forme des arcades dentaires, de la classification du chevauchement dentaire et de l'obstruction nasale. Des études plus importantes seront cependant nécessaires afin d'obtenir des résultats statistiquement significatifs. / Problem addressed by this research project: Sleep Disordered Breathing (SDB) includes different abnormalities ranging from chronic snoring to obstructive sleep apnea syndrome (OSAS). OSAS would affect between 1 and 5% of a general pediatric population with a peak incidence between 2 and 6 years old. Obese children are particularly affected with a prevalence of up to 40%. In children with severe craniofacial malformations, the prevalence can reach more than 50%. The consequences of OSAS on child development can be significant in the absence of treatment, both in terms of growth and cognitive performance, behavior and cardiovascular, pulmonary or metabolic parameters. In adults, the prevalence of OSAS is estimated, in the general population, at 3 to 7% of men and 2 to 5% of middle-aged women. This prevalence would be higher in certain subgroups of the population, in particular overweight or obese people, in pregnant women, in certain ethnic groups and in the elderly. OSAS may lead to increased cardiovascular morbidity (arterial hypertension, stroke, myocardial infarction), and an increase in work or traffic accidents attributable to drowsiness. It is currently recognized that pediatric OSAS and adult OSAS have different causes, presentations and consequences. However, it is not known whether adolescent OSAS is a continuation of the pediatric form or an early form of adult OSAS. It is also unclear whether certain risk factors are present early in childhood and persist into adulthood, or whether the two pediatric/adult forms of OSAS have a relatively independent etiology. Aims: To compare the distribution of dentofacial morphological, oronasal functional characteristics and adiposity between members of the same family, when both child and parent present with symptoms of SDB. One of the members must have previously received a diagnosis of OSAS. Type of research: Observational cross-sectional study Methodology: We recruited children scheduled for sleep recording at CHU Sainte-Justine as well as at least one of their direct biological parents. The experimental procedures that were used with each of these families were: • A craniofacial and functional assessment of the child and at least one of his parents, including taking photos • An OSAS screening questionnaire and a 3-generation family tree • A sleep recording of the child • Records of weight and height, neck circumference, waist circumference and symptoms related to sleep apnea were also collected Results: We included a group of 20 pairs (a child coupled to one of his parents. Of this group, 13 children were diagnosed with OSAS and 7 were unaffected. Regarding the analysis of the children's questionnaires, 100% of apneic patients report nasal obstruction. For craniofacial features, 85% of all children had the same labial and jugal tone classification, 90% of all children had the same maxillary and mandibular arch shape, and 100% of apneic children had the same classification of the dental crowding as their parent. In the case of the anthropometric analysis on photographs, the measurements of the total facial height, the height of the lower third and the anteroposterior position of the maxilla are those that demonstrated a certain trend. The N-Gn measurement was greater in children with apnea, signifying greater total facial height (Cohen d = 1.007). The Sn-Gn measure was also greater in children with apnea, meaning one lower third longer (Cohen d = 1.010). Finally, the T-N-Sn angle is smaller in apneic children (Cohen d = 0.851). 5 Conclusion: The current study is a pilot study consisting of a limited sample. Only one parent from each family agreed to participate. Despite this, we can see a certain trend of heritability at the level of the labial and jugal tone, the shape of the dental arches, the classification of the dental crowding and the nasal obstruction. However, larger studies will be needed to obtain statistically significant results.

Le traitement de première ligne de l’apnée obstructive du sommeil est l’appareil à pression positive, soit le CPAP, qui est le plus souvent utilisé avec un masque nasal. Certains patients, incapables de tolérer le masque nasal, doivent se tourner vers le masque facial, qui peut parfois requérir une pression supérieure à celle utilisée avec le masque nasal pour éliminer tous les événements respiratoires. Nous supposons que l’ajustement serré du masque facial, dans le but de réduire les fuites, entraîne une pression de recul sur la mandibule; ceci diminuerait le calibre des voies aériennes supérieures, nécessitant donc une pression effective thérapeutique supérieure pour rétablir un passage de l’air. Nos objectifs étaient : 1) de démontrer s’il y avait une différence de pression effective entre le masque nasal et le masque facial, 2) de quantifier la fuite entre les deux masques, 3) d’évaluer l’effet d’une orthèse de rétention mandibulaire neutre (OMN), qui empêche le recul mandibulaire, sur la pression effective des deux masques et 4) d’évaluer s’il existait un lien entre la céphalométrie et les réponses variables des individus. Méthodologie : Lors de cette étude expérimentale croisée, huit sujets (2 femmes, 6 hommes) avec une moyenne d’âge de 56,3ans [33ans-65ans] ont reçu un examen orthodontique complet incluant une radiographie céphalométrique latérale. Ils ont ensuite passé deux nuits de polysomnographie au laboratoire du sommeil en protocole « split-night » où les deux masques ont été portés, seuls, la première nuit, et avec l’OMN, la deuxième nuit. Résultats : Nous avons trouvé que la pression effective thérapeutique était supérieure avec le masque facial comparativement au masque nasal de manière statistiquement significative. Nous avons observé une fuite supérieure avec le masque nasal, ce qui permet de dire que la fuite n’explique probablement pas cette différence de pression entre les deux masques. L’OMN n’a pas donné d’effet statistiquement significatif lorsque combinée au masque nasal, mais il aurait probablement été possible de trouver un effet positif avec le masque facial si le Bi-PAP avait été inclus dans le protocole de recherche. Conclusion : Nos résultats ne permettent pas de confirmer le rôle du recul mandibulaire, causé par la force exercée avec le masque facial, dans l’obtention de pressions supérieures avec ce masque, mais nous ne pouvons toutefois pas éliminer l’hypothèse. Les résultats suggèrent également que ce phénomène est peut-être plus fréquent qu’on ne le croit et qu’il pourrait y avoir un lien avec certains facteurs anatomiques individuels. / The first line of treatment for obstructive sleep apnea is continuous positive airway pressure or CPAP used via a nasal mask. Some patients, unable to tolerate the nasal mask, have to turn to the facial mask, which sometimes requires a superior level of pressure to eliminate all the respiratory events. We believe that the force applied on the chin from a tight adjustment of the facial mask may retrude the mandible and diminish the upper airway caliber. Our objectives for this study were to: 1) demonstrate that a difference of effective therapeutic pressure between the nasal and facial masks does exist, 2) quantify the leaks associated with each mask, 3) evaluate the effect of a neutral mandibular appliance (NMA), that prevents the retrusion of the mandible, on the effective pressure of both masks and 4) evaluate if a link between the cephalometric values and varied individual responses to both masks exists. Methods: Eight subjects (2 females, 6 males) mean age 56.3 years (33-65y) participated in the cross-over design pilot study. All subjects underwent a complete orthodontic examination including lateral cephalometric radiograph before spending two nights in a sleep laboratory for a polysomnography in split-night protocol, where both mask were worn alone on the first night and with the NMA on the second night. Results: We found that the therapeutic effective pressure was higher with the facial mask compared to the nasal mask, and this difference was statistically significant. The leak was more elevated with the nasal mask, thus eliminating this factor as a probable cause of the higher pressure with the facial mask. The NMA did not have any statistically significant effect on both masks; however a possible positive effect might be seen if the Bi-level PAP was included in the protocol. Conclusion: Our results cannot confirm the role of the retrusion of the mandible, caused by the force applied by the facial mask, in the necessity of a superior level of pressure with that mask, but we cannot eliminate that possibility either. Our results suggest that this phenomenon is more frequent that we may think and that a link with some anatomical factors may exist.

Introdução: A correta localização do sítio de obstrução nas vias aéreas superiores (VAS) possibilita melhores resultados de tratamento para os pacientes com Síndrome da Apneia Obstrutiva do Sono (SAOS). A endoscopia com sono induzido (DISE) com propofol permite esta avaliação, mas o sono induzido pelo propofol altera a arquitetura do sono, abolindo a presença do sono REM (rapid eye movement). Objetivos: Avaliar as alterações promovidas pelo propofol nos principais parâmetros respiratórios por meio do exame de polissonografia (PSG) nos pacientes portadores de SAOS com predomínio no sono REM (SAOS-R). Descrever os achados da DISE nesses pacientes, comparando-os aos achados da manobra de Müller e às descrições na literatura. Casuística e Métodos: Foram estudados 12 indivíduos não obesos com SAOS-R (confirmado por PSG noturna diagnóstica recente), submetidos a dois exames polissonográficos diurnos, com e sem indução do sono com propofol. O propofol foi utilizado via endovenosa em infusão contínua e controlada por bomba de infusão alvocontrolada (Diprifusor®). Os parâmetros comparados entre os exames foram: IAH (índice de apneia e hipopneia), IA (índice de apneia), IH (índice de hipopneia) e saturação de oxi-hemoglobina (SaO2) mínima e média. Além desses parâmetros, os sítios de obstrução das VAS encontrados na DISE foram comparados com os observados na avaliação ambulatorial com os indivíduos em estado de vigília. Resultados: Não foi evidenciado sono REM em nenhum exame realizado com propofol. O IAH, IA e IH do exame com propofol não apresentaram diferença estatística quando comparados com os exames diurnos sem indução e PSG noturna. A SaO2 média apresentou diferença estatística entre os três exames, sendo menor nas PSGs com indução do sono utilizando propofol, tanto em relação ao exame sem sedação (p<0,0001) quanto ao noturno (p=0,004). A SaO2 mínima foi semelhante entre as PSGs com sedação e noturnas, mas foi significativamente menor nos exames com sedação em relação aos sem sedação diurnos (p=0,011). Quando houve diferença significativa, esta ocorreu em torno de 2 a 3%. A análise de concordância para a classificação de VOTE (velum, oropharynx, tongue base and epiglottis) na avaliação ambulatorial e na DISE não demonstrou nenhuma concordância para todas as estruturas avaliadas (Kappa = - 0,029 em palato, 0,1 em orofaringe, 0,16 em base da língua e 0,0 em epiglote). Os resultados demonstraram que, apesar de o propofol influenciar a arquitetura do sono, abolindo o sono REM, os principais parâmetros utilizados na avaliação dos pacientes com SAOS-R, permaneceram inalterados, ou foram clinicamente irrelevantes. Conclusão: Assim, quando utilizado por infusão contínua, o propofol demonstrou ser uma droga segura na avaliação endoscópica dos indivíduos com SAOS-R para a determinação dos sítios de obstrução, acrescentando informações importantes para o correto tratamento. Ainda, a PSG sob sono induzido com propofol manteve os principais parâmetros ventilatórios em comparação à PSG sob sono espontâneo. / Introduction: The correct localization of upper airway obstruction induces the patients with obstructive sleep apnea syndrome (OSAS) to present better treatment results. Drug induced sleep endoscopy (DISE) with propofol allows this evaluation, but changes the sleep architecture, abolishing the presence of REM sleep. Objecives: To evaluate the changes promoted by propofol on the main respiratory parameters of polysomnography (PSG) in patients with REM-related OSAS (REM-OSAS). To describe the endoscopic findings in these patients, and to compare them to the outpatient Müller\'s maneuver and to the findings described in literature. Casuistic and Methods: In this study, 12 non-obese subjects with REM-OSAS (confirmed by recent nocturnal PSG) underwent two polysomnographic examinations during the day, with and without sleep induction with propofol. Propofol was used intravenously in continuous infusion controlled by target-controlled infusion pump (Diprifusor®). The parameters compared between the examinations were: AHI (apnea-hypopnea index), AI (apnea index), HI (hypopnea index) and both minimal and mean oxihemoglobin saturation (SaO2). Besides these parameters the sites of upper airway obstruction found in DISE were compared with those found in awake outpatient evaluation. Results: REM sleep was not achieved in any moment, in any patient, when propofol was infused. The AHI, AI and HI during infusion with propofol showed no statistical difference when compared with both diurnal test without propofol and diagnostic nocturnal PSG. Mean SaO2 showed statistical difference between the 3 tests, being lower in PSG with sleep induction with propofol, both for the exam without sedation (p<0.0001) as for and the diagnostic PSG (p=0.004). Minimum SaO2 was similar between examinations with sedation and diagnostic nocturnal PSG, but it was significantly lower in tests with propofol infusion compared with the diurnal exam without sedation (p=0,011). Mean difference, when significant, was about 2 to 3%. The analysis of agreement for the VOTE classification by patient evaluation and DISE showed no agreement in any measured structure (kappa = -0.029 for velum, 0,1 for oropharynx, 0,16 for tongue base and 0,0 for epiglottis). The results demonstrate that although propofol influences sleep architecture, abolishing REM sleep, the main respiratory parameters remained unchanged in patients with REMOSAS. Conclusions: Thus, target-controlled infusion of propofol is a safe method for endoscopic evaluation of patients with REM-OSAS, in order to determine the sites of obstruction, and it adds important information for proper treatment. Yet, PSG during DISE with propofol was related to manteinance of the most important ventilatory parameters when compared with PSG under spontaneous sleep.

A obesidade tornou-se um problema de saúde pública em todo o mundo, devido ao aumento significativo desta doença que é considerada crônica, complexa e multifatorial e responsável por muitos problemas cardiocirculatórios, locomotores, metabólicos e respiratórios, a exemplo da hipertensão arterial, a Síndrome da Apneia e Hipopneia Obstrutiva do Sono (SAHOS), dentre outras. Estudos apontam para uma relação importante, onde crianças e adolescentes com sobrepeso ou obesidade possuem uma maior chance de se tornarem adultos obesos. A presente pesquisa desenvolveu um Programa de Educação em Saúde (PES) com sete encontros a estudantes do 9º ano do Ensino Fundamental II e 1º ano do Ensino Médio de uma escola da rede pública do interior paulista, com o objetivo de sensibilizá-los sobre a importância da prática de atividades físicas e hábitos saudáveis na prevenção da SAHOS e obesidade. O programa foi dividido em três etapas: desenvolvimento, realização e avaliação do PES. Na 1ª etapa, o pesquisador organizou a estrutura básica do programa e elaborou o material. Na 2ª etapa, aconteceram os encontros presenciais com os alunos com aplicação de questionários, avaliação antropométrica, acesso à Plataforma de Aprendizagem Moodle, atividades lúdicas e ação social. Na 3ª etapa, houve a avaliação do PES. Os resultados apontaram que o programa proporcionou aprendizagem significativa aos estudantes sobre os conteúdos desenvolvidos, uma vez que houve a compreensão dos alunos sobre os benefícios da prática de atividade física implementada no cotidiano, assim como a importância dos hábitos alimentares e comportamentais saudáveis para prevenção da Síndrome de Apneia e Hipopneia Obstrutiva do Sono (SAHOS) e obesidade e, por fim, realizou-se a multiplicação do conhecimento à comunidade escolar por meio da ação social tendo como consequência a promoção da saúde com a disseminação das informações aprendidas. / Obesity has become a public health issue throughout the world, due to the significant increasing of this disease, which is considered chronic, complex, multifactorial, and liable for many cardiocirculatory, locomotors, metabolic and breathing problems, such as high blood pressure, Obstructive Sleep Apnea and Hypopnea Syndrome (OSAHS), among others. Studies indicate to an important relation, where children and adolescents overweight or obesity, have a greater chance to become obese adults. The present research has developed a Health Education Program (HEP) with seven meetings to the Ninth grade students of the regular Elementary School II and first year of the High School at a public school in the State of São Paulo, in order to sensitizing them about the Importance to practicing physical activities and healthy habits to the prevention of OSAHS and obesity. The program has been divided into 3 stages: development, implementation and evaluation of HEP. In the first stage, the researcher arranged the basic structure of the program and prepared the material. In the second stage, there were face-to-face meetings with students with questionnaires, anthropometric evaluation, access to the Moodle Learning Platform, playful activities and social action. In the third step, there was the HEP evaluation. The results showed that the program provided meaningful learning for the students about the content developed, since there was the students\' understanding about the benefits of physical activity practice implemented in daily life, as well as the importance of eating habits and healthy behavior for prevention of Obstructive Sleep Apnea and Hypopnea Syndrome (OSAHS) and obesity, and lastly, the multiplication of knowledge to the school community through social action resulting in health promotion with the information learned dissemination.

Introdução: Apneia obstrutiva do sono (AOS) é uma doença comum em pacientes com cardiomiopatia hipertrófica (CMH) e está associada de forma independente a piora nos seus parâmetros cardíacos. O tratamento da AOS com CPAP (continuous positive airway pressure) é considerado benéfico em pacientes sem CMH. Contudo, o CPAP pode agudamente piorar o desempenho cardíaco em pacientes com CMH e obstrução na via de saída do ventrículo esquerdo (VSVE). Métodos: Foram estudados 26 pacientes com CMH, estáveis, divididos em 12 não-obstrutivos (CMHN-Obst) e 14 obstrutivos (CMHObst), de acordo com seu gradiente de VSVE menor ou maior que 30mmHg, respectivamente. Pacientes foram continuamente monitorados pela pressão arterial (PA) batimento-a-batimento e eletrocardiograma, em vigília e posição supina. Um ecocardiograma bidimensional foi realizado durante o repouso (Basal) a após 20 minutos de CPAP nas pressões de 1,5cmH2O e 10cmH2O, que foram aplicadas em ordem randomizada, interpostas por 10 minutos de intervalo sem CPAP. Em outra data os pacientes foram submetidos a uma polissonografia completa para diagnóstico de AOS. Resultados: Variáveis hemodinâmicas como PA, débito cardíaco, volume sistólico, frequência cardíaca, fração de ejeção do ventrículo esquerdo e gradiente de VSVE permaneceram estáveis ao longo do estudo em ambos os grupos. Em pacientes não-obstrutivos, o CPAP em 10cmH2O reduziu área do átrio direito, a complacência do ventrículo esquerdo, bem como o relaxamento de ambos os ventrículos. Nos pacientes obstrutivos, o CPAP em 10cmH2O provocou efeitos similares no coração direito e também elevou as pressões na artéria pulmonar. No coração esquerdo, houve uma redução na área e volume do átrio esquerdo, com aumento nas áreas e volumes do jato e frações regurgitantes. A polissonografia completa demonstrou que a AOS (índice de apneia e hipopneia >= 15 eventos/hora) estava presente em 58% dos pacientes. Conclusões: O CPAP se mostrou uma alternativa segura para tratar AOS em pacientes com CMH, pois não alterou agudamente a hemodinâmica. Contudo, provocou algumas alterações na dinâmica cardíaca de pacientes obstrutivos, que devem ser considerados com cautela / Background: Obstructive sleep apnea (OSA) is a common disease and is independently associated with a worse in cardiac parameters among patients with hypertrophic cardiomyopathy (HCM). The treatment of OSA with CPAP (Continuous positive airway pressure) is beneficial among patients without CMH. However, CPAP may acutely impair cardiac performance in patients with HCM and left ventricular outflow tract (LVOT) obstruction. Methods: We studied 26 stable HCM patients divided in 12 nonobstructive-HCM and 14 obstructive-HCM according to their LVOT pressure gradient lower or higher than 30 mmHg, respectively. Patients were continuously monitored by beatto- beat blood pressure (BP) and electrocardiogram in the supine position while awake. A 2-dimensional echocardiography was performed at resting (Baseline) and after 20 minutes of nasal CPAP at 1.5cmH2O and 10cmH2O, that was applied in a random order interposed by 10 minutes without CPAP. In another day all patients underwent full Polysomnography for OSA diagnosis. Results: Hemodynamic variables such as BP, cardiac output, stroke volume, heart rate, left ventricular ejection fraction and LVOT gradient did not change along the study period in both groups. CPAP at 10cmH2O in nonobstructive-HCM patients decreased right atrial area, left ventricular compliance, right and left ventricular relaxation. In obstructive-HCM patients, CPAP at 10cmH2O promoted similar effects in the right heart, and also raised pulmonary artery pressure. In the left heart, there was a decrease in left atrial area and volume with increased area and volume of both, regurgitant jet and regurgitant fraction. Full Polysomnography showed that OSA (apneahypopnea index >=15 events/h) was present in 58% of HCM patients. Conclusions: CPAP showed to be safe to treat OSA and did not acutely change hemodynamics in patients with HCM. However, CPAP may acutely impair cardiac dynamics in obstructive-HCM patients and this finding should be carefully considered

Introdução: Apneia Obstrutiva do Sono (AOS) é prevalente em estados edematosos, especialmente em pacientes em hemodiálise (HD). Uma vez que o deslocamento noturno de fluidos (DNF) acarreta piora da AOS, nós elaboramos a hipótese de que a interferência na redistribuição de fluidos pelo uso de meias elásticas compressivas (MEC) atenuaria a gravidade da AOS, por mecanismos diferentes em comparação à terapia padrão para AOS, a pressão positiva em vias aéreas (CPAP). Métodos: este é um estudo randomizado e cross-over, que incluiu 14 pacientes dialíticos com AOS (índice de apneia/hipopneia - IAH > 5 eventos/hora) em exame de polissonografia (PSG), que era realizada em três momentos: basal, titulação de CPAP e após uma semana de uso diário de MEC. Circunferência cervical (CC), bioimpedância elétrica segmentar e variabilidade de frequência cardíaca (VFC) foram avaliadas antes e após cada exame de PSG. Resultados: A idade média foi 53±9 anos (57% de homens) e o índice de massa corporal foi 29,7±6,8 Kg/m². O IAH foi reduzido de 20,8 (14,2; 39,6) no exame basal para 7,9 (2,8; 25,4) durante titulação de CPAP e para 16,7 (3,5; 28,9) eventos/hora após uso de MEC (CPAP vs. basal, p=0,004; MEC vs. basal, p=0,017; e CPAP vs. MEC, p=0.017). Comparando basal, CPAP e MEC, o conteúdo de água noturna em membros inferiores foi menor com MEC (p=0,04), enquanto a água intracelular noturna em tronco foi maior (p=0,03). DNF basal, com CPAP e MEC foi de -183±72, -343±220, e -290±213ml, respectivamente (p=0,006). Houve aumento da circunferência cervical durante a noite durante o exame basal (0,7±0,4 cm), mas houve redução dessa circunferência após titulação com CPAP (-1,0±0,4 cm) e após uso de MEC (-0,4±0,8 cm) (CPAP vs. basal, p<0.0001; MEC vs. basal, p=0.001; CPAP vs. MEC, p=0.01). VFC, avaliada pelos componentes de alta e baixa frequência, demonstrou menor ativação simpática durante o exame de titulação de CPAP: OR: 11 (95% CI: 1,06 - 114,2), p=0,025, mas não com MEC: OR: 7,8 (95% CI: 0,75 - 82,2), p=0,059. Conclusões: tanto o CPAP quanto MEC melhoraram AOS em pacientes em HD, mas por mecanismos distintos: enquanto o CPAP reduziu o edema de vias aéreas superiores, ao exercer pressão local, o uso de MEC reduziu o DNF, ao evitar retenção de fluidos em membros inferiores, acumulando água no componente intracelular do tronco. Ativação simpática foi somente reduzida com uso de CPAP. / Background: Obstructive Sleep Apnea (OSA) is prevalent in edematous states, notably in hemodialysis (HD) patients. Once overnight fluid shift (OFS) augments OSA, we hypothesized that interfering in fluid redistribution by wearing compression stockings (CS) would attenuate OSA severity by different mechanisms in comparison to the standard treatment to OSA, the positive airway pressure (CPAP). Methods: This is a randomized crossover study that included 14 dialytic patients with OSA (apnea/hypopnea index - AHI >5 events/hour) by polysomnography (PSG), which was performed in three moments: at baseline, for CPAP titration, and one week after daily wearing of CS. Neck circumference (NC), segmental bioelectrical impedance and heart rate variability (HRV) were assessed before and after each PSG. Results: Mean age was 53±9 years (57% men) and body mass index was 29.7±6.8 kg/m2. AHI decreased from 20.8 (14.2; 39.6) at baseline to 7.9 (2.8; 25.4) during CPAP titration and to 16.7 (3.5; 28.9) events/hour after wearing CS (CPAP vs. baseline, p=0.004; CS vs. baseline, p=0.017; and CPAP vs. CS, p=0.017). Comparing baseline, CPAP and CS, nocturnal lower limbs water content was lower with CS (p=0.04), while nocturnal intracellular trunk water was higher (p=0.03). OFS at baseline, CPAP and CS was -183±72, -343±220, and -290±213ml, respectively (p=0.006). Overnight NC variation increased at baseline (0.7±0.4 cm), but decreased after CPAP titration (-1.0±0.4 cm) and while wearing CS (-0.4±0.8 cm) (CPAP vs. baseline, p<0.0001; CS vs. baseline, p=0.001; CPAP vs. CS, p=0.01). HRV, assessed by both high and low frequency components, showed a lower sympathetic activation during CPAP titration: OR: 11 (95% CI: 1.06 - 114.2), p=0.025, but not with CS: OR: 7,8 (95% CI: 0.75 - 82.2), p=0.059 Conclusions: Both CPAP and CS improved OSA in HD patients by different mechanisms: while CPAP reduced edema in upper airways by exerting local pressure, wearing CS reduced OFS by avoiding fluid retention in the legs, accumulating water in the intracellular component of the trunk. Sympathetic activation was decreased only with CPAP.

Introdução: A Apneia obstrutiva do sono (AOS) é uma doença comum na população geral e sua presença pode ser parcialmente explicada por um componente genético. No entanto, existe uma interação grande entre AOS com fatores de confusão, incluindo obesidade. O objetivo principal desse estudo é determinar a herdabilidade da AOS em uma população rural brasileira. Métodos: Foram estudados famílias provenientes de coorte (Corações de Baependi). Os participantes foram avaliados quanto a medidas antropométricas, circunferência de cintura, quadril e pescoço. Aplicamos os questionários de Berlim para determinar o risco de ter AOS, escala de sonolência de Epworth para verificar sonolência excessiva diurna e o questionário de Pittsburgh para verificar a qualidade do sono. Realizamos poligrafia noturna para determinar a presença e gravidade da AOS utilizando o índice de apneia-hipopneia (IAH, definido positivo quando >= 15 eventos/hora). Foi realizada medida de pressão arterial (PA) por meio da monitorização ambulatorial da pressão arterial (MAPA) e velocidade de onda de pulso (VOP) para avaliar rigidez arterial. Resultados: A amostra foi composta de 587 participantes (188 homens e 399 mulheres), com mediana de idade e intervalo interquartil = 44 (29 - 55) anos e IMC = 25,0 (22,1-28,6) kg/m2. Os sintomas sugestivos de AOS derivados dos questionários de Epworth, Berlim e Pittsburgh não se associaram com a presença de AOS; A AOS foi diagnosticada em 18,6% eventos/hora da população, A herdabilidade foi estimada em 26%, independente da obesidade e outros fatores de confusão. A mediana da PA foi mais alta, a ausência de descenso noturno da PA foi mais comum e o VOP mais alto em participantes com AOS do que sem AOS. Na regressão logística multivariada apenas a idade e a PA se associaram de forma significante com o VOP. Conclusões: A herdabilidade da AOS foi moderada (26%) em uma população rural. As alterações cardiovasculares presentes na AOS estão associadas a fatores de confusão em estudos familiares / Introduction: Obstructive sleep apnea (OSA) is a common disease in the general population and the presence can be partially explained by a genetic component. However, there is a strong interaction between OSA with confounding factors, including obesity. The main objective of this study is to determine the heritability of OSA in a Brazilian rural population. Methods: We studied families from the Baependi Heart Study. Participants were assessed for anthropometric measurements, waist, hip and neck circumferences. We used the Berlin questionnaire to determine the risk of having OSA, Epworth sleepiness scale to evaluated the presence of excessive daytime sleepiness and the questionnaire of Pittsburgh to verify the quality of sleep. Overnight Polygraph night was conducted to determine the presence and severity of OSA through the apnea-hypopnea index. Blood pressure was measured (BP) by ambulatory blood pressure (ABP) and pulse wave velocity (PWV) to assess arterial stiffness. Results: The sample consisted of 587 participants (188 men and 399 women), median and interquartile range of age = 44 (29-55) years and BMI = 25.0 (22.1 to 28.6) kg / m2. Symptoms suggestive of OSA derived from Epworth, Berlin and Pittsburgh questionnaires were not associated with the presence of OSA; OSA was diagnosed in 18.6% events/hour of the population, the heritability was estimated at 26%, independent of obesity and other confounding factors. BP was higher, the absence of nocturnal BP was more common and the highest VOP in participants with OSA than without OSA. Using multivariate logistic regression only age and BP were associated significantly with PWV. Conclusions: OSA heritability is moderate (26%) in a rural population. The cardiovascular alterations associated with OSA were explained by confounding factors

Introdução: A parede lateral da faringe tem importante papel no colapso da via aérea superior nos episódios de apneia obstrutiva do sono (AOS). Os dois principais músculos que formam esta região são o músculo palatofaríngeo (MPF) e o músculo constritor superior da faringe (MCSF). Estes músculos são classificados como esqueléticos e não possuem um padrão histológico de normalidade estabelecido. Os objetivos do estudo foram verificar a estrutura histológica das fibras do MPF e do MCSF em indivíduos controles sem síndrome da apneia obstrutiva do sono (SAOS), e avaliar se indivíduos portadores de SAOS apresentam alterações histológicas nestes músculos em comparação aos controles. Métodos: Foram avaliados 28 indivíduos adultos (faixa etária entre 18 e 55 anos de idade), sendo 17 portadores de SAOS grave e 11 controles. Destes 11 controles, 7 eram portadores de ronco primário, e 4 não apresentavam roncos e AOS. Coletaram-se fragmentos de MPF e de MCSF em cirurgia de faringoplastia lateral para os roncadores primários e apneicos graves, e em cirurgia de tonsilectomia das palatinas para os indivíduos com tonsilite crônica caseosa. Os espécimes musculares coletados foram congelados em nitrogênio líquido em até 3 horas após o procedimento cirúrgico. Por meio de colorações histológicas e imuno-histoquímicas, avaliou-se a histologia das fibras musculares no que tange a sua morfologia, a distribuição dos tipos de fibras, as dimensões do espaço intercelular, e a prevalência de fibras híbridas nos 2 músculos e em ambos os grupos. Resultados: O grupo-controle apresenta predomínio de fibras do tipo II, de contração rápida e alta fatigabilidade, nos MPF e MCSF, não havendo diferença estatística entre os dois músculos. Encontramos prevalência elevada de fibras híbridas no grupo-controle (45,45% no MPF e 27,27% no MCSF), sem diferença estatística entre os dois músculos. Quanto à comparação entre os grupos controle e SAOS, verificamos redução do percentual de fibras do tipo II do MCSF nos indivíduos com SAOS (p=0,04) quando comparados aos controles. Não houve diferença estatística na distribuição dos tipos de fibras musculares entre os 2 grupos no MPF. Conclusões: Os MPF e MCSF possuem composição histológica com predomínio de fibras do tipo II e prevalência elevada de fibras híbridas nos indivíduos sem SAOS. Os indivíduos portadores de SAOS possuem redução do percentual de fibras do tipo II no MCSF em comparação aos indivíduos sem SAOS, e isso pode ter implicações na redução da eficiência desta musculatura, podendo contribuir na etiopatogenia da AOS / Introduction: The lateral pharyngeal muscular wall plays an important role in upper airway collapse in obstructive sleep apnea (OSA) episodes. The two main muscles that form this anatomical site are the palatopharyngeal muscle (PPM) and the superior pharyngeal constrictor muscle (SPCM). These muscles are classified as skeletal and do not have an established normal histological pattern in literature. The objectives of the study were: verify the histological structure of PPM and SPCM fibers in control subjects without obstructive sleep apnea syndrome (OSAS), and evaluate whether OSAS individuals demonstrate histological changes in these muscles compared to controls. Methods: Twenty-eight adults (age range between 18 to 55 years old) were evaluated, 17 with severe OSAS and 11 controls. On the control group, 7 had primary snoring and 4 had no snoring or OSA. PPM and SPCM fragments were collected in lateral pharyngoplasty surgery for the primary snoring and severe OSAS patients and a palatine tonsillectomy was executed in individuals with chronic caseous tonsillitis. The collected muscles specimens were frozen in liquid nitrogen within 3 hours after the surgical procedure. Histological and immunohistochemical staining were used to evaluate the histology of muscle fibers concerning their morphology, the distribution of fiber types, the size of the intercellular space and the prevalence of hybrid fibers in the two muscles in both groups. Results: The control group showed predominance of type II fibers (fast contraction and high fatigability) in PPM and SPCM, without statistical difference between the two muscles. We found a high prevalence of hybrid fibers in the control group (45.45% in PPM and 27.27% in SPCM), without statistical difference between the two muscles. Regarding the comparison between the control and OSAS groups, we verified a reduction in the percentage of SPCM type II fibers in individuals with OSAS (p = 0.04) when compared to controls. There was no statistical difference in the percentage of muscle fiber types between the 2 groups in PPM. Conclusions: PPM and SPCM have histological composition with predominance of type II fibers and high prevalence of hybrid fibers in individuals without OSAS. Patients with OSAS have a reduction in the percentage of type II fibers in SPCM compared to controls, and this may have implications in the efficiency of this muscular function, which may contribute to the etiopathogenesis of OSAS

Introdução: A parede lateral da faringe tem importante papel no colapso da via aérea superior nos episódios de apneia obstrutiva do sono (AOS). Os dois principais músculos que formam esta região são o músculo palatofaríngeo (MPF) e o músculo constritor superior da faringe (MCSF). Estes músculos são classificados como esqueléticos e não possuem um padrão histológico de normalidade estabelecido. Os objetivos do estudo foram verificar a estrutura histológica das fibras do MPF e do MCSF em indivíduos controles sem síndrome da apneia obstrutiva do sono (SAOS), e avaliar se indivíduos portadores de SAOS apresentam alterações histológicas nestes músculos em comparação aos controles. Métodos: Foram avaliados 28 indivíduos adultos (faixa etária entre 18 e 55 anos de idade), sendo 17 portadores de SAOS grave e 11 controles. Destes 11 controles, 7 eram portadores de ronco primário, e 4 não apresentavam roncos e AOS. Coletaram-se fragmentos de MPF e de MCSF em cirurgia de faringoplastia lateral para os roncadores primários e apneicos graves, e em cirurgia de tonsilectomia das palatinas para os indivíduos com tonsilite crônica caseosa. Os espécimes musculares coletados foram congelados em nitrogênio líquido em até 3 horas após o procedimento cirúrgico. Por meio de colorações histológicas e imuno-histoquímicas, avaliou-se a histologia das fibras musculares no que tange a sua morfologia, a distribuição dos tipos de fibras, as dimensões do espaço intercelular, e a prevalência de fibras híbridas nos 2 músculos e em ambos os grupos. Resultados: O grupo-controle apresenta predomínio de fibras do tipo II, de contração rápida e alta fatigabilidade, nos MPF e MCSF, não havendo diferença estatística entre os dois músculos. Encontramos prevalência elevada de fibras híbridas no grupo-controle (45,45% no MPF e 27,27% no MCSF), sem diferença estatística entre os dois músculos. Quanto à comparação entre os grupos controle e SAOS, verificamos redução do percentual de fibras do tipo II do MCSF nos indivíduos com SAOS (p=0,04) quando comparados aos controles. Não houve diferença estatística na distribuição dos tipos de fibras musculares entre os 2 grupos no MPF. Conclusões: Os MPF e MCSF possuem composição histológica com predomínio de fibras do tipo II e prevalência elevada de fibras híbridas nos indivíduos sem SAOS. Os indivíduos portadores de SAOS possuem redução do percentual de fibras do tipo II no MCSF em comparação aos indivíduos sem SAOS, e isso pode ter implicações na redução da eficiência desta musculatura, podendo contribuir na etiopatogenia da AOS / Introduction: The lateral pharyngeal muscular wall plays an important role in upper airway collapse in obstructive sleep apnea (OSA) episodes. The two main muscles that form this anatomical site are the palatopharyngeal muscle (PPM) and the superior pharyngeal constrictor muscle (SPCM). These muscles are classified as skeletal and do not have an established normal histological pattern in literature. The objectives of the study were: verify the histological structure of PPM and SPCM fibers in control subjects without obstructive sleep apnea syndrome (OSAS), and evaluate whether OSAS individuals demonstrate histological changes in these muscles compared to controls. Methods: Twenty-eight adults (age range between 18 to 55 years old) were evaluated, 17 with severe OSAS and 11 controls. On the control group, 7 had primary snoring and 4 had no snoring or OSA. PPM and SPCM fragments were collected in lateral pharyngoplasty surgery for the primary snoring and severe OSAS patients and a palatine tonsillectomy was executed in individuals with chronic caseous tonsillitis. The collected muscles specimens were frozen in liquid nitrogen within 3 hours after the surgical procedure. Histological and immunohistochemical staining were used to evaluate the histology of muscle fibers concerning their morphology, the distribution of fiber types, the size of the intercellular space and the prevalence of hybrid fibers in the two muscles in both groups. Results: The control group showed predominance of type II fibers (fast contraction and high fatigability) in PPM and SPCM, without statistical difference between the two muscles. We found a high prevalence of hybrid fibers in the control group (45.45% in PPM and 27.27% in SPCM), without statistical difference between the two muscles. Regarding the comparison between the control and OSAS groups, we verified a reduction in the percentage of SPCM type II fibers in individuals with OSAS (p = 0.04) when compared to controls. There was no statistical difference in the percentage of muscle fiber types between the 2 groups in PPM. Conclusions: PPM and SPCM have histological composition with predominance of type II fibers and high prevalence of hybrid fibers in individuals without OSAS. Patients with OSAS have a reduction in the percentage of type II fibers in SPCM compared to controls, and this may have implications in the efficiency of this muscular function, which may contribute to the etiopathogenesis of OSAS