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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.
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Sleep apnea syndrome in children is usually caused by adenoidal and tonsillar hypertrophy. Here, we report on a typical case of obstructive sleep apnea syndrome, and also discuss recent indications for tonsillectomy in children. A 6-year-old boy came to our hospital suffering from serious obesity and somnolescence. He could not sleep lying down and thus started to sleep in a sitting position. Even during daytime he slept while standing, and exhibited hypersomnolescence. He was 133 cm tall and weighed 80 kg, and tonsillar hypertrophy was recognised. Consequently, tonsillectomy and a weight reducing program were undertaken. The lowest SaO(2) improved from 50% to 70%, and sleep apnea also decreased from 141 to 71 episodes. Moreover, the hypersomnolescence improved.
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We measured inspiratory resistance (R1), inspiratory occlusion pressure (P0.1), and the ventilatory responses to hypercapnia and isocapnic hypoxia during waking and during stage 2 non-rapid eye movement sleep in nine young men who were habitual snorers. They were studied on 2 nights during the 3 hours after receiving a bedtime drink containing either a placebo or 100-proof vodka (1.5 ml/kg) in orange juice. We compared the results with those we reported previously in 10 nonsnoring but otherwise similar men. Waking R1 was the same in nonsnorers and snorers, and it was not affected by ethanol. During sleep on the control night, R1 increased by 70% in nonsnorers and by 280% in snorers. On the ethanol night, the increase from waking to sleeping was more than doubled in both nonsnorers and snorers. P0.1 and the responses to hypercapnia and hypoxia showed no differences between nonsnorers and snorers, therefore the results from the two groups were pooled. Minute ventilation and the hypercapnic response decreased from waking to sleeping and P0.1 was more negative during sleep, but there was no significant effect of ethanol. There was a significant correlation between the changes from waking to sleeping in R1 and P0.1 on the ethanol night suggesting that inspiratory effort increased in response to the increased resistance. The response to isocapnic hypoxia showed no effect of either sleep state or drink. Inspiratory time did not change but mean inspiratory flow (VT/T1) was significantly reduced during sleep on both control and ethanol nights. The duty cycle ratio (T1/Ttot) was significantly increased during sleep on the ethanol night. Despite its great effect on inspiratory resistance, especially in snorers, ethanol, in the dose used in our study, does not augment the depression of minute ventilation or of the hypercapnic response that occur normally in stage 2 non-rapid eye movement sleep. After ethanol, our subjects showed the decreased VT/T1 and the increased T1/Ttot that occur normally during sleep in response to an inspiratory resistive load. However, they also showed increased inspiratory effort. The combination of increased inspiratory resistance and greater inspiratory effort would increase the tendency of an unstable upper airway to collapse and could account for the aggravation of obstructive sleep apnea by ethanol.
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Nasal CPAP is a well documented successful therapy for obstructive sleep apnoea syndrome (OSAS), but adverse effects are common and the compliance is 80 percent or less. We investigated the value of an oral device called "Snor Ex"). Eleven obese patients with severe OSAS were examined. Complete polysomnographic studies were performed while sleeping one night without therapy, with nCPAP and after an adaptation period with Snor Ex, respectively. The apopnoeahypopnoea index and the minimal SaO2 could be normalised for all patients using CPAP but only for three patients with Snor Ex. Nine patients tolerated nCPAP and Snor-Ex, respectively. We conclude that this oral device is a successful therapy for only few patients with OSAS.
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The paper concerns surgical treatment of rhonchus. 41 patients with rhonchus and sleep apnea were examined and treated. The patients were characterized by obesity, short fat neck, diseases of the upper respiratory tracts (chronic tonsillitis, adenoids, distortion of the nasal septum, deformity of the external nose, weakness of the palatine curtain). After cleansing of the upper respiratory tracts and recovery of nasal breathing all the patients underwent CO2 laser surgery on the soft palate with good effect.