[Obstructive sleep apnea, CPAP treatment and adverse health effects. Counterpoint].
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Evidence-Based Medicine↗
Biomedical subjects
M Gugger
Publications and source records attributed to M Gugger.
Video-assisted thoracoscopic surgery for fibrinopurulent pleural empyema in 67 patients.
BACKGROUND: The roles of different drainage procedures in the management of empyema have to be redefined now that video-assisted thoracoscopic surgery (VATS) has been introduced. The debridement of fibrinopurulent stage II empyema with the use of VATS was assessed prospectively in regard to control of infection and restoration of pulmonary function. METHODS: Between January 1992 and May 1996, all patients at our institution with fibrinopurulent empyema that did not respond to chest tube drainage and antibiotic therapy were treated by debridement with the use of VATS. The patients were followed up prospectively by clinical and radiologic assessments 3 and 6 months after the operation and by spirometry 6 months after the operation. RESULTS: Video-assisted thoracoscopic surgery was initiated in 67 patients, but conversion to open decortication was required because of the finding of advanced disease in 19 patients (28%). Forty-eight patients underwent successful debridement with the use of VATS. The mean operative time was 82.1 minutes (range, 50 to 135 minutes), the mean duration of postoperative chest tube placement was 4.1 days (range, 2 to 8 days), and the mean duration of postoperative hospitalization was 12.3 days (range, 4 to 42 days). No wound infections were observed during the postoperative course. Both the 30-day mortality rate and the recurrence (ie, need for thoracotomy) rate were 4%. The mean predicted vital capacity was 84.8% +/- 14.9% and the mean predicted forced expiratory volume in 1 second was 88.6% +/- 19.2% 6 months after the operation. CONCLUSIONS: Debridement with the use of VATS is safe and efficient for stage II empyema, but open decortication should be used for more advanced disease.
Adult↗
Peliosis of the spleen: an immune-complex disease?
AIMS: To determine the pathogenesis of splenic peliosis by further morphological and immunohistochemical examination. METHODS AND RESULTS: Histological, electron microscopic and immunohistochemical examination revealed evidence for an inflammatory genesis of splenic peliosis with destruction of reticular fibres and local deposits of IgG and activated complement C3. CONCLUSION: Our findings indicate that the peliotic lesion in the spleen may be mediated by immune-complex deposits.
Female↗
Characteristic lesions on CT scan and progressive dyspnea.
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Dyspnea↗
[Progress in surgical therapy of bronchus carcinoma].
Surgical progresses in the treatment of lung cancer are not only related to technical details of surgery itself, but rely much upon an interdisciplinary approach before and after the operation. This will improve patient selection, multimodality treatment concepts and morbidity and mortality with overall improvement of quality of life in these patients.
Carcinoma, Bronchogenic↗
[Is preoperative chemotherapy in locally advanced non-small-cell bronchial carcinoma of value?].
Although surgeons are able to resect completely locally advanced non-small cell lung cancer with mediastinal lymph node involvement (stage IIIA), the majority of patients succumb from metastatic disease. Therefore, neoadjuvant therapy was introduced in the management of this disease in order to eradicate distant metastases at an early stage. Phase II trials with preoperative chemotherapy in stage IIIA patients have shown that the pathological response (amount of tumour necrosis) and the clearance of mediastinal lymph node correlate with a better survival and is the best predictor for eradication of distant metastases. Indeed, three small randomised phase III studies have demonstrated a survival advantage for preoperative chemotherapy compared to surgery alone. Further studies are required to determine the best neoadjuvant regimen inducing the largest amount of tumour necrosis.
Carcinoma, Non-Small-Cell Lung↗
[Impaired kidney function in lithium therapy].
Long-term therapy with lithium may be associated with a broad spectrum of functional and structural side-effects in the kidney. Among these features, nephrogenic diabetes insipidus is the most frequent and it can be expected to occur in 20-70% of the patients. Diabetes insipidus is the result of a lithium induced resistance of collecting ducts to antidiuretic hormone. Additional functional disturbances are represented by renal tubular acidosis and consequences of hypercalcemia. Structural alterations of the kidney have a rare occurrence. In the literature, there are accounts of chronic tubulo-interstitial nephritis, acute tubular necrosis and few cases of glomerulopathies. Our report of a patient with chronic interstital nephritis is supplemented by a brief discussion of the diverse picture of the nephrotoxicity of lithium.
Antimanic Agents↗
[Progress in pneumology].
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Health Promotion↗
[Surgical aspects of mycobacterioses. Evolution during the last 20 years].
INTRODUCTION: Tuberculosis remains one of the major infectious diseases. Its incidence has grown in immigrants and in immunosuppressed patients, and, moreover, cases of drug resistance are on the increase. The goal of this study was to analyze the implications of these new developments and surgical experience in our patients. METHODS: The cases of 104 patients with tuberculosis hospitalized between 1975 and 1995 were reviewed retrospectively. RESULTS: 22% of the patients (23/104) were immigrants. No HIV-positive patients were described but association with debilitating diseases was frequent. Diagnosis was chiefly by histology. The culture was positive in only 30/104 patients (29%). Drug resistance was seen in only one patient (1%). 72/104 patients (69.2%) presented with an infection of the pulmonary parenchyma, 21/104 (20.2%) with pleural tuberculosis including tuberculous empyema, 3/104 (2.9%) with tuberculosis of the chest wall and 8/104 (7.7%) with mediastinal tuberculosis. Surgery was performed in 84/104 patients (80.8%). The chief indications were suspected carcinoma in 39/84 cases (46.4%), destroyed lung in 11/84 (13.1%), empyema combined with bronchopleural fistula in 10/84 (11.9%), enlarged mediastinal lymph-nodes of unknown dignity in 7/84 (8.3%), recurrent pleural effusion in 5/84 (5.9%) and bronchial stenosis in 4/84 (4.8%). CONCLUSION: The number of surgical patients with tuberculosis has remained fairly stable over the last 20 years, but the proportion of immigrants has grown since 1990. Thoracoscopy is playing an increasingly important role in the diagnosis and surgical treatment of tuberculosis (recurrent pleural effusion, resection of peripheral pulmonary nodules turning out to be tuberculoma).
AIDS-Related Opportunistic Infections↗
[Breathing disorders during sleep: current developments].
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Airway Obstruction↗
Patterns of muscle activity in legs in sleep apnea patients before and during nCPAP therapy.
Nocturnal muscle activity in legs (MAL) was studied in 19 patients with sleep apnea syndrome before and during nCPAP. We distinguished periodic (P-MAL) and nonperiodic (N-MAL) as well as apnea-associated and independent MALs. N-MALs were strongly associated with apneas and disappeared during nasal continuous positive airway pressure (nCPAP). P-MALs showed a rather long intermovement interval (IMI) of about 54 s when associated with respiratory disturbances and a shorter one of about 38 s when occurring independently. In 5 patients with predominantly independent P-MALs and a short IMI before and during nCPAP an incidental coexistence of sleep apnea with periodic leg movements in sleep syndrome (PLMS) was postulated. Five patients with an equal number of apnea-associated and independent MALs before nCPAP had a long IMI which shortened under nCPAP, while the majority of MALs become independent. This could indicate a facilitating or an unmasking effect of nCPAP on PLMS. Four patients with predominantly apnea-associated MALs with a long IMI before nCPAP showed an unchanged MAL pattern under nCPAP, despite the disappearance of apneas. Since some arousals persisted in these patients, insufficient nCPAP pressure with an upper airway resistance syndrome was suspected. We conclude that when P-MALs persist under nCPAP therapy a long IMI may indicate an upper airway resistance syndrome, whereas a short IMI may indicate a coexisting or even induced PLMS.
Adult↗
Comparison of ResMed AutoSet (version 3.03) with polysomnography in the diagnosis of the sleep apnoea/hypopnoea syndrome.
In patients with the sleep apnoea/hypopnoea syndrome (SAHS), accurate and timely diagnostic evaluation and initiation of effective treatment is important. Therefore, an increasing number of limited sleep studies are now performed nowadays diagnosing the SAHS in typical patients. It was the aim of the present study to evaluate the diagnostic accuracy of one such system, the updated ResMed Sullivan AutoSet, against polysomnography. Sixty seven patients underwent full overnight polysomnography and simultaneous data acquisition with the AutoSet. Up to now, the AutoSet was designed for apnoea detection only. The new AutoSet, with software version 3.03, detects apnoeas if ventilation drops to <25%, and apnoeas+hypopnoeas if ventilation drops to <50%, compared with the recent average (100 s), using two independent detectors. A two page report with graphically displayed information on oximetry, snoring and breathing parameters, and an apnoea+hypopnoea index (AHI) and an apnoea index (AI) are provided at the end of each study night. There was a correlation between the AHI assessed by the AutoSet (AHI-AutoSet) and by polysomnography (AHI-PSG; r=0.95). The mean difference between the AHI-AutoSet minus the AHI-PSG was 4.2 (SD 7.2) respiratory events x h(-1) (p<0.001). The AutoSet identified patients with an AHI-PSG >20 events x h(-1) (a level of respiratory disturbance that would warrant consideration for treatment in most centres for sleep disorders), with a sensitivity of 97% and a specificity of 77%. The AutoSet was superior to oximetry alone. As event counting was similar between the two methods, the AHI-AutoSet may provide a reasonable indicator of the respiratory disturbance at night, especially when taking the patients graphic study report into consideration. In conjunction with full clinical information on the patients under investigation, the AutoSet might become a useful device in diagnosing the sleep apnoea/hypopnoea syndrome.
Body Mass Index↗
[Iatrogenic respiratory and sleep disorders and snoring].
Four different examples from the field of pulmonary and in particular sleep medicine are quoted to demonstrate how iatrogenic damage can be avoided or reduced. Teamwork and sound professional know-how are key elements in achieving this goal in this field.
Aged↗
Hypersomnia following paramedian thalamic stroke: a report of 12 patients.
Paramedian thalamic stroke (PTS) is a cause of organic hypersomnia, which in the absence of systematic sleep-wake studies has been attributed to disruption of ascending activating impulses and considered a "dearoused" state. However, an increasing mount of data suggests a role of the thalamus in sleep regulation and raises the possibility that a sleep disturbance contributes to hypersomnia in PTS. We evaluated 12 patients with magnetic resonance imaging-proven isolated PTS and hypersomnia with 10 to >20 hours of sleep behavior per day. Nocturnal polysomnographic findings paralleled the severity of hypersomnia. All subjects had increased stage 1 NREM sleep, reduced stage 2 NREM sleep, and reduced numbers of sleep spindles. In patients with severe hypersomnia, slow-wave (stages 3-4) NREM sleep was often reduced, but there were no major REM sleep alterations. Daytime sleep behavior was associated mostly with stage 1 sleep by electroencephalogram; there was no correlation between hypersomnia and results of nap tests. We conclude that hypersomnia following PTS is accompanied by deficient arousal during the day and insufficient spindling and slow-wave sleep production at night. These observations support the hypothesis of a dual role of the paramedian thalamus as "final common pathway' for both maintenance of wakefulness and promotion of NREM sleep.
Adolescent↗
[Screening for sleep apnea: clinical use of Mesam IV and Apnoe-Check].
With the introduction of nasal continuous positive airway pressure as an effective treatment of the sleep apnea syndrome, the demand for costly polysomnographic investigations has markedly increased. Hence a reliable screening method would be desirable. Patients undergoing overnight oxymetry were simultaneously examined by MESAM (n = 54) and by Apnoe-Check (n = 23) in a prospective manner. The results were compared among themselves and with the complete overnight polysomnography (MESAM n = 38, Apnoe-Check n = 20). Simple overnight oxymetry, automatically assessed oxymetry by MESAM and apnea identification by Apnoe-Check correlated well with the polysomnographic findings. On the other hand, variation of heart rate, snoring events and changes of body position as identified by MESAM did not add relevant information. Only the detection of moderate to severe sleep apnea syndrome was satisfactory, though not infallible. Thus, there is still no screening method available to identify or exclude sleep apnea syndrome, particularly the milder form, which is nevertheless a significant disease.
Adult↗
[Should patients with asymptomatic sleep apnea syndrome be treated with CPAP?].
Treatment of sleep apnea patients may be justified even when symptoms are absent. On the one hand, hypersomnia or daytime sleepiness are subjective symptoms and only reflect one aspect of the clinical syndrome of sleep apnea. On the other hand, an apnea index in excess of 5, e.g. the "laboratory diagnosis" of sleep apnea, has been reported as an independent risk factor for myocardial infarction. The main problem is scientific definition of cut-off points for treatment. There is no controversy about whether patients with symptoms should be treated or not. A CPAP trial seems to be justified in asymptomatic patients with an apnea/hypopnea index in excess of 20-30 and in patients with cardiovascular risk factors when the apnea/hypopnea index is in excess of 5. These laboratory cut-off values are not absolute values but represent flexible guidelines for initiating a CPAP trial in asymptomatic patients with apnea. The reasons for uncertainty whether or not to treat patients with asymptomatic sleep apnea are discussed.
Adult↗
Accuracy of an intelligent CPAP machine with in-built diagnostic abilities in detecting apnoeas: a comparison with polysomnography.
BACKGROUND: In patients with sleep apnoea early diagnostic evaluation and treatment may be delayed due to limited access to full polysomnography (PSG). For "typical" patients, simplified strategies are needed. A study was performed to evaluate the accuracy of a new continuous positive airway pressure (CPAP) device with in-built diagnostic abilities (Autoset) in detecting apnoeas. METHODS: Twenty seven patients underwent full overnight polysomnography. Data with the Autoset were acquired simultaneously. Standard nasal prongs were used. Apnoeas were detected by special analysis of the flow signal. As the Autoset derives all its data from one signal, careful examination of the raw data is important to assess the quality of the flow signal. RESULTS: There was a correlation between the apnoea index (AI) assessed by the Autoset (AI-Autoset) and by polysomnography AI-PSG (r = 0.85) and between the AI-Autoset and the apnoea/hypopnoea index (AHI) during polysomnography (r = 0.87). The Autoset identified patients with an AHI-PSG of > 20 (a level of respiratory disturbance that would warrant consideration for treatment in most centres for sleep disorders) with a sensitivity of 82% and a specificity of 90%. CONCLUSIONS: The good correlation between the apnoea index measured by the Autoset and by polysomnography, and the high sensitivity in detecting patients with an AHI of > 20, may make the Autoset a valuable tool for the management of typical patients with sleep apnoea. However, very low values for nasal ventilation on the printout raises the suspicion of poor signal quality and misleading results.
Adult↗
Bronchial reactivity to isocapnic hyperventilation: results in an unselected population of outpatients with known or suspected asthma.
Isocapnic hyperventilation with dry air is nearly as effective as with dry cold air, and appears to be a valuable screening test for bronchial hyperresponsiveness. However some incidental factors such as prechallenge bronchoconstriction, level of hyperventilation, age and smoking habits have barely been examined or were investigated in small samples of either normals or well-characterised asthmatics. In an inhomogeneous population of 186 outpatients with known asthma, 286 with suspected asthma and 32 normals, a single isocapnic hyperventilation challenge of 6-min duration was performed. There was a weak, but significant correlation between the degree of prechallenge airway function and the bronchial response, assessed by the change in forced expiratory volume in 1 s (r = 0.27, p = 0.000) in known asthmatics, but not in patients with suspected asthma and in normals. No significant relation was found between the level of hyperventilation and the bronchial response when comparing the bronchial response to the single-dose hyperventilation test between the subjects (NS). Increasing age appears to be associated with an attenuation of the response in known asthmatics (r = 0.21, p = 0.004), but not in patients with suspected asthma. Smoking habits did not affect the bronchial response in this study. In conclusion, the main finding is that there is a weak correlation between baseline airway obstruction and the subsequent response to isocapnic hyperventilation, a slow decline in response with age and no increase in responsiveness in smokers. Hence, isocapnic hyperventilation is a relatively robust test for assessing bronchial reactivity in an inhomogeneous population of outpatients like ours.
Adolescent↗