- Email: [email protected]
Response: Continuous positive airway pressure ventilation does correct nasal inflammation in patients with obstructive sleep apnea syndrome
Sleep Medicine 14 (2013) 581–583
Contents lists available at SciVerse ScienceDirect
Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Letters to the Editor Continuous positive airway pressure and nasal inflammation patterns in obstructive sleep apnea: Anti-inflammatory or proinflammatory?
To the editor: There are several data implicating a role of inflammation in the pathogenesis of obstructive sleep apnea (OSA) [1,2]. Gelardi et al. [3] have observed a form of rhinopathy in all subjects with OSA. Interestingly, rhinopathy did not affect continuous positive airway pressure (CPAP) compliance, but OSA treatment with regular CPAP could significantly change cell infiltration. The main pitfall of this manuscript is that all patients treated with CPAP used a humidifier. Therefore, we are not able to attribute reduction of nasal inflammation to CPAP itself because humidification itself could have played an important role. This observation is strengthened by data already present in the literature [4]. In the present study, many variables have been investigated; however, inflammatory changes observed in the group of OSA without CPAP may have other potential factors that are not addressed in the discussion. We consider it important to take into account some additional pathways to distinguish nasal inflammation and CPAP relations. First, factors could be separated into physical factors (i.e., nasal airflows, tidal breathing patterns) and environmental factors (i.e., temperature, humidity, intensity of the regional expiratory rewarming) that differ between normal subjects, snorers, and patients with OSA [5]. Second, factors related to the noninvasive ventilation equipment itself, the interface nasal, or the facial mask, as well as the mechanical ventilator and inspiratory oxygenation fraction should be considered. The use of positive pressure by CPAP may have either adverse effects or favorable effects on inflammation. Finally, obesity causes a proinflammatory state, which is common in OSA patients. We consider that the factors mentioned above could affect the interpretation of the results of the study by Gelardi et al. [3], according to previous studies [1,4,5]. Further studies are needed to extend nasal inflammation pathogenesis in OSA during CPAP therapy. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.01.010. References [1] Sabato R, Guido P, Salerno FG, Resta O, Spanevello A, Barbaro MP. Airway inflammation in patients affected by obstructive sleep apnea. Monaldi Arch Chest Dis 2006;65:102–5. [2] Hatipog˘lu U, Rubinstein I. Inflammation and obstructive sleep apnea syndrome pathogenesis: a working hypothesis. Respiration 2003;70:665–71.
[3] Gelardi M, Carbonara G, Maffezzoni E, Marvisi M, Quaranta N, Ferri R. Regular CPAP utilization reduces nasal inflammation assessed by nasal cytology in obstructive sleep apnea syndrome. Sleep Med 2012;13:859–63. [4] Koutsourelakis I, Vagiakis E, Perraki E, Karatza M, Magkou C, Kopaka M, et al. Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification. Eur Respir J 2011;37:587–94. [5] Sériès F, Marc I. Upper airway mucosa temperature in obstructive sleepapnoea/ hypopnoea syndrome, nonapnoeic snorers and nonsnorers. Eur Respir J 1998;12:193–7.
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A.M. Esquinas International Fellow AARC, Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain ⇑ Corresponding author. Address: International Fellow AARC, Intensive Care Unit, Hospital Morales Meseguer, Avenida Marques de Los Velez s/n, Murcia 30008, Spain. Tel.: +39 34 6 09 62 19 66; fax: +39 34 9 68 23 24 84. E-mail address: [email protected] G. Ferrari Department of Emergency Medicine, Ospedale S. Giovanni Bosco, Torino, Italy
1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. doi:http://dx.doi.org/10.1016/j.sleep.2013.01.010
Response: Continuous positive airway pressure ventilation does correct nasal inflammation in patients with obstructive sleep apnea syndrome To the Editor: We thank Drs. Esquinas and Ferrari for their interest in our recent paper on the effects of continuous positive airway pressure (CPAP) ventilation on nasal inflammation in patients with obstructive sleep apnea syndrome (OSAS) [1]. In our paper we have reported that all of our patients with OSAS were affected by some form of rhinopathy, mostly subclinical, which was not found to influence compliance to CPAP. Regular CPAP treatment induced a considerable reduction of cell infiltration (neutrophils, eosinophils, lymphocytes, and muciparous cells), which was not seen in nontreated patients. In their letter, Esquinas and Ferrari [2] point out some factors that might exert a role in determining nasal inflammation in OSAS and/or contribute to the beneficial effects of CPAP, but the possible underlying mechanisms are not explained. We have already mentioned [1] that with our study we cannot rule out a role for the humidification of the air used in our patients; however, this ruling does not detract from the significance of our results demonstrating the effectiveness of CPAP with air humidification in correcting nasal inflammation. We agree with Esquinas and Ferrari [2] that other factors might be involved and that additional studies might clarify at least some
582
Letters to the Editor / Sleep Medicine 14 (2013) 581–583
of these mechanisms. However, we can exclude environmental factors playing a crucial role because nasal inflammation was found in all patients from different socioeconomic statuses and was found in those who used to sleep in different environmental conditions. Finally although it is reasonable to believe that other factors related to ventilation therapy might be beneficial, the claim that CPAP (correctly performed) might be exerting a proinflammatory action is an unsupported speculation that cannot be accepted with the current knowledge. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.01.003. References [1] Gelardi M, Carbonara G, Maffezzoni E, Marvisi M, Quaranta N, Ferri R. Regular CPAP utilization reduces nasal inflammation assessed by nasal cytology in obstructive sleep apnea syndrome. Sleep Med 2012;13:859–63. [2] Esquinas AM, Ferrari G. Continuous positive airway pressure (CPAP) and nasal inflammation patterns in OSA: antinflammatory or proinflamatory. Sleep Med 2013;14:581.
Matteo Gelardi Nicola Quaranta Otolaryngology Unit, Department of Neuroscience and Sensory Organs, University of Bari, Bari, Italy Giuseppe Carbonara Unit of Otolaryngology, ‘‘San Giacomo’’ Hospital, Monopoli, Italy Enrico Maffezzoni Unit of Otolaryngology, Istituto Figlie di S. Camillo, Cremona, Italy Maurizio Marvisi Unit of Internal Medicine, Ospedale di Fiorenzuola d’Arda, Piacenza, Italy
⇑
Raffaele Ferri Sleep Research Centre, Department of Neurology I.C., Oasi Institute (IRCCS), Troina, Italy ⇑ Corresponding author. Address: Sleep Research Centre, Department of Neurology I.C., Oasi Institute (IRCCS), Via Conte Ruggero 73, 94018 Troina, Italy. Tel.: +39 0935 936111; fax: +39 0935 936694. E-mail address: [email protected]
1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. doi:http://dx.doi.org/10.1016/j.sleep.2013.01.003
[3] and the change in the lifestyle in the modern society are becoming important factors in the investigation of the relationship between these factors. Di Milia et al [4] analyzed several demographic, social, work, and health variables associated with duration of sleep. This study was markedly relevant, as it showed the association between short sleep and obesity after controlling for age, gender, smoking, alcohol consumption, education level, physical activity, diabetes mellitus, hypertension, and working hours. Taking into account the great sample and controlled variables numbers, the authors deserve congratulations. We would like to suggest that some other points should be considered. The classification of sleep duration in 66 or >6 hours can represent an ambiguous interpretation, as a long duration of sleep does not necessarily indicate a good quality sleep. Therefore, a better investigation of sleep disorders such as obstructive sleep apnea should be included in this analysis. This inclusion is important mainly because the risk factors related to short sleep and obesity including diabetes mellitus and hypertension are frequent conditions in patients with obstructive sleep apnea [5]. Thus, the application of questionnaires and polysomnography could better characterize this population. Furthermore, the authors suggest a robust association between short sleep and weight gain. This conclusion should be more thoroughly examined, as the overweight individuals did not demonstrate a significant correlation with shorter time of sleep, corroborating our proposition that sleep disorders seem to be subsequent factors leading to obesity and not just sleep duration. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.03.006. References [1] Jackson ML, Gunzelmann G, Whitney P, Hinson JM, Belenky G, Rabat A, et al. Deconstructing and reconstructing cognitive performance in sleep deprivation. Sleep Med Rev. 2013;17:215–25. [2] Valent F, Di Bartolomeo S, Marchetti R, Sbrojavacca R, Barbone F. A casecrossover study of sleep and work hours and the risk of road traffic accidents. Sleep 2010;33:349–54. [3] Centers for Disease Control and Prevention. Halting the epidemic by making health easier: at a glance 2010. Atlanta: Centers for Disease Control and Prevention; 2010. [4] Di Milia L, Vandelannote C, Duncan MJ. The association between short sleep and obesity after controlling for demographic, lifestyle, work and health related factors. Sleep Med. 2013;14:319–323. [5] Fusetti M, Fioretti AB, Valenti M, Masedu F, Lauriello M, Pagliarella M. Cardiovascular and metabolic comorbidities in patients with obstructive sleep apnoea syndrome. Acta Otorhinolaryngol Ital 2012;32:320–5.
Luísa Mendes Amando de Barros Lenise Jihe Kim Sergio Tufik ⇑ Monica Levy Andersen Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil ⇑ Corresponding author. Tel./fax: +55 11 21490155. E-mail address: [email protected] (A. Andersen)
Short sleep and obesity: other factors to be considered To the Editor: Sleep loss has been suggested to cause many comorbidities, including traffic accidents, cognitive impairments, and decreased quality of life [1,2]. One of the most reported associations between sleep restriction and metabolic alterations is weight gain. Collectively, the high and increasing prevalence of obesity in the world
1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. doi:http://dx.doi.org/10.1016/j.sleep.2013.03.006
Contents lists available at SciVerse ScienceDirect
Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Letters to the Editor Continuous positive airway pressure and nasal inflammation patterns in obstructive sleep apnea: Anti-inflammatory or proinflammatory?
To the editor: There are several data implicating a role of inflammation in the pathogenesis of obstructive sleep apnea (OSA) [1,2]. Gelardi et al. [3] have observed a form of rhinopathy in all subjects with OSA. Interestingly, rhinopathy did not affect continuous positive airway pressure (CPAP) compliance, but OSA treatment with regular CPAP could significantly change cell infiltration. The main pitfall of this manuscript is that all patients treated with CPAP used a humidifier. Therefore, we are not able to attribute reduction of nasal inflammation to CPAP itself because humidification itself could have played an important role. This observation is strengthened by data already present in the literature [4]. In the present study, many variables have been investigated; however, inflammatory changes observed in the group of OSA without CPAP may have other potential factors that are not addressed in the discussion. We consider it important to take into account some additional pathways to distinguish nasal inflammation and CPAP relations. First, factors could be separated into physical factors (i.e., nasal airflows, tidal breathing patterns) and environmental factors (i.e., temperature, humidity, intensity of the regional expiratory rewarming) that differ between normal subjects, snorers, and patients with OSA [5]. Second, factors related to the noninvasive ventilation equipment itself, the interface nasal, or the facial mask, as well as the mechanical ventilator and inspiratory oxygenation fraction should be considered. The use of positive pressure by CPAP may have either adverse effects or favorable effects on inflammation. Finally, obesity causes a proinflammatory state, which is common in OSA patients. We consider that the factors mentioned above could affect the interpretation of the results of the study by Gelardi et al. [3], according to previous studies [1,4,5]. Further studies are needed to extend nasal inflammation pathogenesis in OSA during CPAP therapy. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.01.010. References [1] Sabato R, Guido P, Salerno FG, Resta O, Spanevello A, Barbaro MP. Airway inflammation in patients affected by obstructive sleep apnea. Monaldi Arch Chest Dis 2006;65:102–5. [2] Hatipog˘lu U, Rubinstein I. Inflammation and obstructive sleep apnea syndrome pathogenesis: a working hypothesis. Respiration 2003;70:665–71.
[3] Gelardi M, Carbonara G, Maffezzoni E, Marvisi M, Quaranta N, Ferri R. Regular CPAP utilization reduces nasal inflammation assessed by nasal cytology in obstructive sleep apnea syndrome. Sleep Med 2012;13:859–63. [4] Koutsourelakis I, Vagiakis E, Perraki E, Karatza M, Magkou C, Kopaka M, et al. Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification. Eur Respir J 2011;37:587–94. [5] Sériès F, Marc I. Upper airway mucosa temperature in obstructive sleepapnoea/ hypopnoea syndrome, nonapnoeic snorers and nonsnorers. Eur Respir J 1998;12:193–7.
⇑
A.M. Esquinas International Fellow AARC, Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain ⇑ Corresponding author. Address: International Fellow AARC, Intensive Care Unit, Hospital Morales Meseguer, Avenida Marques de Los Velez s/n, Murcia 30008, Spain. Tel.: +39 34 6 09 62 19 66; fax: +39 34 9 68 23 24 84. E-mail address: [email protected] G. Ferrari Department of Emergency Medicine, Ospedale S. Giovanni Bosco, Torino, Italy
1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. doi:http://dx.doi.org/10.1016/j.sleep.2013.01.010
Response: Continuous positive airway pressure ventilation does correct nasal inflammation in patients with obstructive sleep apnea syndrome To the Editor: We thank Drs. Esquinas and Ferrari for their interest in our recent paper on the effects of continuous positive airway pressure (CPAP) ventilation on nasal inflammation in patients with obstructive sleep apnea syndrome (OSAS) [1]. In our paper we have reported that all of our patients with OSAS were affected by some form of rhinopathy, mostly subclinical, which was not found to influence compliance to CPAP. Regular CPAP treatment induced a considerable reduction of cell infiltration (neutrophils, eosinophils, lymphocytes, and muciparous cells), which was not seen in nontreated patients. In their letter, Esquinas and Ferrari [2] point out some factors that might exert a role in determining nasal inflammation in OSAS and/or contribute to the beneficial effects of CPAP, but the possible underlying mechanisms are not explained. We have already mentioned [1] that with our study we cannot rule out a role for the humidification of the air used in our patients; however, this ruling does not detract from the significance of our results demonstrating the effectiveness of CPAP with air humidification in correcting nasal inflammation. We agree with Esquinas and Ferrari [2] that other factors might be involved and that additional studies might clarify at least some
582
Letters to the Editor / Sleep Medicine 14 (2013) 581–583
of these mechanisms. However, we can exclude environmental factors playing a crucial role because nasal inflammation was found in all patients from different socioeconomic statuses and was found in those who used to sleep in different environmental conditions. Finally although it is reasonable to believe that other factors related to ventilation therapy might be beneficial, the claim that CPAP (correctly performed) might be exerting a proinflammatory action is an unsupported speculation that cannot be accepted with the current knowledge. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.01.003. References [1] Gelardi M, Carbonara G, Maffezzoni E, Marvisi M, Quaranta N, Ferri R. Regular CPAP utilization reduces nasal inflammation assessed by nasal cytology in obstructive sleep apnea syndrome. Sleep Med 2012;13:859–63. [2] Esquinas AM, Ferrari G. Continuous positive airway pressure (CPAP) and nasal inflammation patterns in OSA: antinflammatory or proinflamatory. Sleep Med 2013;14:581.
Matteo Gelardi Nicola Quaranta Otolaryngology Unit, Department of Neuroscience and Sensory Organs, University of Bari, Bari, Italy Giuseppe Carbonara Unit of Otolaryngology, ‘‘San Giacomo’’ Hospital, Monopoli, Italy Enrico Maffezzoni Unit of Otolaryngology, Istituto Figlie di S. Camillo, Cremona, Italy Maurizio Marvisi Unit of Internal Medicine, Ospedale di Fiorenzuola d’Arda, Piacenza, Italy
⇑
Raffaele Ferri Sleep Research Centre, Department of Neurology I.C., Oasi Institute (IRCCS), Troina, Italy ⇑ Corresponding author. Address: Sleep Research Centre, Department of Neurology I.C., Oasi Institute (IRCCS), Via Conte Ruggero 73, 94018 Troina, Italy. Tel.: +39 0935 936111; fax: +39 0935 936694. E-mail address: [email protected]
1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. doi:http://dx.doi.org/10.1016/j.sleep.2013.01.003
[3] and the change in the lifestyle in the modern society are becoming important factors in the investigation of the relationship between these factors. Di Milia et al [4] analyzed several demographic, social, work, and health variables associated with duration of sleep. This study was markedly relevant, as it showed the association between short sleep and obesity after controlling for age, gender, smoking, alcohol consumption, education level, physical activity, diabetes mellitus, hypertension, and working hours. Taking into account the great sample and controlled variables numbers, the authors deserve congratulations. We would like to suggest that some other points should be considered. The classification of sleep duration in 66 or >6 hours can represent an ambiguous interpretation, as a long duration of sleep does not necessarily indicate a good quality sleep. Therefore, a better investigation of sleep disorders such as obstructive sleep apnea should be included in this analysis. This inclusion is important mainly because the risk factors related to short sleep and obesity including diabetes mellitus and hypertension are frequent conditions in patients with obstructive sleep apnea [5]. Thus, the application of questionnaires and polysomnography could better characterize this population. Furthermore, the authors suggest a robust association between short sleep and weight gain. This conclusion should be more thoroughly examined, as the overweight individuals did not demonstrate a significant correlation with shorter time of sleep, corroborating our proposition that sleep disorders seem to be subsequent factors leading to obesity and not just sleep duration. Conflict of interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.03.006. References [1] Jackson ML, Gunzelmann G, Whitney P, Hinson JM, Belenky G, Rabat A, et al. Deconstructing and reconstructing cognitive performance in sleep deprivation. Sleep Med Rev. 2013;17:215–25. [2] Valent F, Di Bartolomeo S, Marchetti R, Sbrojavacca R, Barbone F. A casecrossover study of sleep and work hours and the risk of road traffic accidents. Sleep 2010;33:349–54. [3] Centers for Disease Control and Prevention. Halting the epidemic by making health easier: at a glance 2010. Atlanta: Centers for Disease Control and Prevention; 2010. [4] Di Milia L, Vandelannote C, Duncan MJ. The association between short sleep and obesity after controlling for demographic, lifestyle, work and health related factors. Sleep Med. 2013;14:319–323. [5] Fusetti M, Fioretti AB, Valenti M, Masedu F, Lauriello M, Pagliarella M. Cardiovascular and metabolic comorbidities in patients with obstructive sleep apnoea syndrome. Acta Otorhinolaryngol Ital 2012;32:320–5.
Luísa Mendes Amando de Barros Lenise Jihe Kim Sergio Tufik ⇑ Monica Levy Andersen Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil ⇑ Corresponding author. Tel./fax: +55 11 21490155. E-mail address: [email protected] (A. Andersen)
Short sleep and obesity: other factors to be considered To the Editor: Sleep loss has been suggested to cause many comorbidities, including traffic accidents, cognitive impairments, and decreased quality of life [1,2]. One of the most reported associations between sleep restriction and metabolic alterations is weight gain. Collectively, the high and increasing prevalence of obesity in the world
1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved. doi:http://dx.doi.org/10.1016/j.sleep.2013.03.006