- Email: [email protected]
171 Diagnosis of OSAS
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Abstracts / Sleep Medicine 7 (2006) S1–S127
The surgical options with their principle will be presented. Long term weight loss is the target and results will be reviewed. Considerations about possible protein malnutrition, glucose and lipid metabolism, Syndrome X, sleep apnea and liver morphology are going to be shown. We will also give attention to bone metabolism, pregnancy and newborn as well as quality of life and others comorbidities. Our conclusions are that morbid obesity is a physiological disease, it requires a physiological approach, a pure restrictive procedure has a limited effect but Bariatric duodenal switch (BDS) gives remarkable long term results. doi:10.1016/j.sleep.2006.07.072
169 Bariatric surgery and sleep-related breathing disorders Pierre Y. Garneau * Hoˆpital du Sacre´ Coeur, Universite´ de Montre´al, Que., Canada doi:10.1016/j.sleep.2006.07.073
170 Bariatric surgery in a community hospital Pierre Jette´ * Centre Hospitalier Pierre Boucher, Longueuil, Que., Canada Morbid obesity is a severe condition, affecting a growingly large percentage of the total population, particularly in developed countries. It is a major cause of many comorbid conditions, including premature death from cardiac events, and so called adult onset diabetes mellitus, and sleep apnoea. Most medical approaches have completely failed to obtain any persistent favorable result with that condition. It has been well documented that the only way of treating that chronic condition is by surgery if one wants to address the disease in an effective and durable way. Many techniques have evolved during the recent years, all of which show marked improvement of the weight, and resolution of almost all the associated diseases. This paper reviews two years of gastric bypass and gastric banding, in a set up of a medium sized primary hospital, and a review of the literature showing also how effective and durable those treatments are, particularly focusing on respiratory problems associated with obesity per se. In conclusion, it shows that morbid obesity is better treated by surgery, and that it is possible to build a program in a non tertiary setup, with few complications, very low mortality, and extremely effective cure of most comorbidities. doi:10.1016/j.sleep.2006.07.074
171 Diagnosis of OSAS Perleth Matthias * AOK-Bundesverband, Department of Respiratory Medicine, Berlin, Germany Background: Epidemiologic studies suggest a prevalence of obstructive sleep apnea syndrome (OSAS) of 2–4% within western populations. One of the prevailing discussions in many countries relate to the immediate referral of patients with symptoms suggesting sleep apnea syndrome to a sleep laboratory for diagnostic workup, disregarding a step-wise procedure suggested in guidelines. The lead question of this analysis is to analyse whether a step-wise diagnostic workup is justifiable and which diagnostic procedures are the most accurate. Methods: Relevant biomedical databases as well as registers of clinical studies, specialised HTA databases and grey literature were searched to identify diagnostic studies and systematic reviews. Eligible studies had to be prospective direct comparisons of the gold standard (polysomnography) with an alternative device with at least 10 patients in the study. Studies were quality rated and data were extracted in evidence tables. Where appropriate, meta-analyses according to the method of Moses and Littenberg were performed. Results: One HTA report that contained a systematic review of the literature was identified. In addition, 46 primary studies were included. The following diagnostic technologies were investigated:
Polysomnography with mobile devices Oximetry Polysomnography with reduced number of channels Part-time Polysomnography Volume-Flow-Curves Breath volume/pressure Questionnaires Prediction models Clinical impression Analysis of heart rate variability
Since only studies regarding diagnostic accuracy were identified, no conclusions concerning long-term outcomes or quality of life can be drawn. Medical history and clinical examination are not sufficient as a ‘‘screening’’ test to detect sleep apnea syndrome, although experienced physicians may be correctly identify patients with the syndrome. However, only with additional diagnostic devices the sensitivity is sufficient to accurately diagnose sleep apnea syndrome. In this analysis, portable devices that use more than one channel, including oximetry, seem to be the most sensitive of all available devices (except polysomnography). Thus, these devices are appropriate for use in case-finding of patients suspect of having sleep apnea syndrome.
Abstracts / Sleep Medicine 7 (2006) S1–S127
Oximetry alone is not a sufficient method to diagnose sleep apnea syndrome. Multi-channel portable devices are also sufficiently specific to use them in severe cases as an alternative to polysomnography for confirmation of sleep apnea syndrome. Conclusion: It can be concluded that multi-channel portable devices should be used to screen patients with symptoms suggesting sleep apnea syndrome and refer them in case of a positive test to polysomnography for differential diagnosis and initiation of therapy. However, carefully designed multicenter trials that focus on patient relevant outcomes should be conducted to validate this approach. doi:10.1016/j.sleep.2006.07.075
172 Operations, oral appliances and other treatments for obstructive sleep apnea Karl A. Franklin * Department of Respiratory Medicine, University Hospital, SE-901 85 Umea˚, Sweden Different oral appliances have been suggested in the treatment of obstructive sleep apnea including mandibular advancement devices, tongue retaining devices, mouth shields and soft palate lifters etc. Operations include uvulopalatopharyngoplasty, uvulopalatoplasty, radio frequency ablation, nasal operations, tracheostomy, inferior sagittal mandibular osteotomy, maxillo-mandibular osteotomy etc. Other treatments included different pharmacological drugs, weight reduction programs, bariatric surgery, pacemakers, nasal dilators, means to avoid the supine position, life style modifications etc. Only mandibular advancement devices, didgeridoo playing and operations in the form of laser assisted uvulopalatopharyngoplasty and radio frequency ablation was identified from a search in Medline for systematic reviews and for randomized controlled studies with at least 20 subjects treated for at least 4 weeks with placebo or conservative treatment for control subjects. Mandibular advancement devices reduce subjective sleepiness and sleep apneas but there was no evidence for an effect from operations. doi:10.1016/j.sleep.2006.07.076
173 Interventions to improve compliance with CPAP Ian Smith *, Toby Lasserson Papworth Hospital, Respiratory Support and Sleep Center, Cambridge, United Kingdom CPAP is often very effective but the benefits are short lived if it is discontinued and an important number of patients do not comply well with the treatment. Attempts have been made to improve compliance through educa-
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tional and behavioural methods aimed at increasing understanding and reducing irrational fears about the treatment. It has also been reasoned that decreasing adverse effects of treatment might increase usage. To this end humidification and altering the mode of pressure delivery have been trialled. Comparing different educational approaches is problematic but additional information and support at treatment initiation can increase compliance. Cognitive behavioural therapy and asking patients to self regulate by recording their own hours of use may also be effective. Heated humidification does reduce adverse effects in the upper airway but does not affect initial acceptance, reduce titration pressures or increase long term compliance. Auto CPAP (APAP) designed to optimise airway pressure, reducing mean overnight pressure is usually preferred by patients and may lead to a small increase in hours of use but not to improved symptoms. Current evidence suggests most benefit in patients requiring higher pressures. Compliance with conventional Bi-level ventilators is not superior to CPAP. In previously noncompliant patients a novel Bi-level device (Biflex) has been shown to be more effective than re-titrating CPAP. Expiratory pressure relief (Cflex) can increase hours of use but with no confirmed improvement in clinical status. Most studies investigating methods to increase compliance have shown high levels of CPAP usage in the control limbs. It could be concluded that with the degree of education and support afforded to trial patients compliance is not a major issue. Additional educational/psychological interventions over standard treatment can increase compliance with CPAP but cost analysis of these approaches is still required. APAP is not indicated as a routine treatment but may be beneficial in patients requiring high pressures. Further studies are required to confirm positive results in small studies using Cflex and Biflex technologies. doi:10.1016/j.sleep.2006.07.077
173A Diagnosis and treatment of obstructive sleep apnea: Evidence-based approach, CPAP treatment for OSA Najib Ayas * University of British Columbia, Department of Respiratory Medicine, Vancouver, BC, Canada Obstructive Sleep Apnea (OSA) is a common disease with myriad adverse quality of life, safety, and other health consequences. Recently, a number of randomized controlled trials, meta-analyses, and large prospective epidemiologic studies have been published that address issues related to diagnosis and treatment of disease. Using an Evidence Based Medicine approach, this lecture will review recent data concerning the diagnosis and treatment of OSA. The strengths and weaknesses of the various study designs described above will be highlighted.
Abstracts / Sleep Medicine 7 (2006) S1–S127
The surgical options with their principle will be presented. Long term weight loss is the target and results will be reviewed. Considerations about possible protein malnutrition, glucose and lipid metabolism, Syndrome X, sleep apnea and liver morphology are going to be shown. We will also give attention to bone metabolism, pregnancy and newborn as well as quality of life and others comorbidities. Our conclusions are that morbid obesity is a physiological disease, it requires a physiological approach, a pure restrictive procedure has a limited effect but Bariatric duodenal switch (BDS) gives remarkable long term results. doi:10.1016/j.sleep.2006.07.072
169 Bariatric surgery and sleep-related breathing disorders Pierre Y. Garneau * Hoˆpital du Sacre´ Coeur, Universite´ de Montre´al, Que., Canada doi:10.1016/j.sleep.2006.07.073
170 Bariatric surgery in a community hospital Pierre Jette´ * Centre Hospitalier Pierre Boucher, Longueuil, Que., Canada Morbid obesity is a severe condition, affecting a growingly large percentage of the total population, particularly in developed countries. It is a major cause of many comorbid conditions, including premature death from cardiac events, and so called adult onset diabetes mellitus, and sleep apnoea. Most medical approaches have completely failed to obtain any persistent favorable result with that condition. It has been well documented that the only way of treating that chronic condition is by surgery if one wants to address the disease in an effective and durable way. Many techniques have evolved during the recent years, all of which show marked improvement of the weight, and resolution of almost all the associated diseases. This paper reviews two years of gastric bypass and gastric banding, in a set up of a medium sized primary hospital, and a review of the literature showing also how effective and durable those treatments are, particularly focusing on respiratory problems associated with obesity per se. In conclusion, it shows that morbid obesity is better treated by surgery, and that it is possible to build a program in a non tertiary setup, with few complications, very low mortality, and extremely effective cure of most comorbidities. doi:10.1016/j.sleep.2006.07.074
171 Diagnosis of OSAS Perleth Matthias * AOK-Bundesverband, Department of Respiratory Medicine, Berlin, Germany Background: Epidemiologic studies suggest a prevalence of obstructive sleep apnea syndrome (OSAS) of 2–4% within western populations. One of the prevailing discussions in many countries relate to the immediate referral of patients with symptoms suggesting sleep apnea syndrome to a sleep laboratory for diagnostic workup, disregarding a step-wise procedure suggested in guidelines. The lead question of this analysis is to analyse whether a step-wise diagnostic workup is justifiable and which diagnostic procedures are the most accurate. Methods: Relevant biomedical databases as well as registers of clinical studies, specialised HTA databases and grey literature were searched to identify diagnostic studies and systematic reviews. Eligible studies had to be prospective direct comparisons of the gold standard (polysomnography) with an alternative device with at least 10 patients in the study. Studies were quality rated and data were extracted in evidence tables. Where appropriate, meta-analyses according to the method of Moses and Littenberg were performed. Results: One HTA report that contained a systematic review of the literature was identified. In addition, 46 primary studies were included. The following diagnostic technologies were investigated:
Polysomnography with mobile devices Oximetry Polysomnography with reduced number of channels Part-time Polysomnography Volume-Flow-Curves Breath volume/pressure Questionnaires Prediction models Clinical impression Analysis of heart rate variability
Since only studies regarding diagnostic accuracy were identified, no conclusions concerning long-term outcomes or quality of life can be drawn. Medical history and clinical examination are not sufficient as a ‘‘screening’’ test to detect sleep apnea syndrome, although experienced physicians may be correctly identify patients with the syndrome. However, only with additional diagnostic devices the sensitivity is sufficient to accurately diagnose sleep apnea syndrome. In this analysis, portable devices that use more than one channel, including oximetry, seem to be the most sensitive of all available devices (except polysomnography). Thus, these devices are appropriate for use in case-finding of patients suspect of having sleep apnea syndrome.
Abstracts / Sleep Medicine 7 (2006) S1–S127
Oximetry alone is not a sufficient method to diagnose sleep apnea syndrome. Multi-channel portable devices are also sufficiently specific to use them in severe cases as an alternative to polysomnography for confirmation of sleep apnea syndrome. Conclusion: It can be concluded that multi-channel portable devices should be used to screen patients with symptoms suggesting sleep apnea syndrome and refer them in case of a positive test to polysomnography for differential diagnosis and initiation of therapy. However, carefully designed multicenter trials that focus on patient relevant outcomes should be conducted to validate this approach. doi:10.1016/j.sleep.2006.07.075
172 Operations, oral appliances and other treatments for obstructive sleep apnea Karl A. Franklin * Department of Respiratory Medicine, University Hospital, SE-901 85 Umea˚, Sweden Different oral appliances have been suggested in the treatment of obstructive sleep apnea including mandibular advancement devices, tongue retaining devices, mouth shields and soft palate lifters etc. Operations include uvulopalatopharyngoplasty, uvulopalatoplasty, radio frequency ablation, nasal operations, tracheostomy, inferior sagittal mandibular osteotomy, maxillo-mandibular osteotomy etc. Other treatments included different pharmacological drugs, weight reduction programs, bariatric surgery, pacemakers, nasal dilators, means to avoid the supine position, life style modifications etc. Only mandibular advancement devices, didgeridoo playing and operations in the form of laser assisted uvulopalatopharyngoplasty and radio frequency ablation was identified from a search in Medline for systematic reviews and for randomized controlled studies with at least 20 subjects treated for at least 4 weeks with placebo or conservative treatment for control subjects. Mandibular advancement devices reduce subjective sleepiness and sleep apneas but there was no evidence for an effect from operations. doi:10.1016/j.sleep.2006.07.076
173 Interventions to improve compliance with CPAP Ian Smith *, Toby Lasserson Papworth Hospital, Respiratory Support and Sleep Center, Cambridge, United Kingdom CPAP is often very effective but the benefits are short lived if it is discontinued and an important number of patients do not comply well with the treatment. Attempts have been made to improve compliance through educa-
S29
tional and behavioural methods aimed at increasing understanding and reducing irrational fears about the treatment. It has also been reasoned that decreasing adverse effects of treatment might increase usage. To this end humidification and altering the mode of pressure delivery have been trialled. Comparing different educational approaches is problematic but additional information and support at treatment initiation can increase compliance. Cognitive behavioural therapy and asking patients to self regulate by recording their own hours of use may also be effective. Heated humidification does reduce adverse effects in the upper airway but does not affect initial acceptance, reduce titration pressures or increase long term compliance. Auto CPAP (APAP) designed to optimise airway pressure, reducing mean overnight pressure is usually preferred by patients and may lead to a small increase in hours of use but not to improved symptoms. Current evidence suggests most benefit in patients requiring higher pressures. Compliance with conventional Bi-level ventilators is not superior to CPAP. In previously noncompliant patients a novel Bi-level device (Biflex) has been shown to be more effective than re-titrating CPAP. Expiratory pressure relief (Cflex) can increase hours of use but with no confirmed improvement in clinical status. Most studies investigating methods to increase compliance have shown high levels of CPAP usage in the control limbs. It could be concluded that with the degree of education and support afforded to trial patients compliance is not a major issue. Additional educational/psychological interventions over standard treatment can increase compliance with CPAP but cost analysis of these approaches is still required. APAP is not indicated as a routine treatment but may be beneficial in patients requiring high pressures. Further studies are required to confirm positive results in small studies using Cflex and Biflex technologies. doi:10.1016/j.sleep.2006.07.077
173A Diagnosis and treatment of obstructive sleep apnea: Evidence-based approach, CPAP treatment for OSA Najib Ayas * University of British Columbia, Department of Respiratory Medicine, Vancouver, BC, Canada Obstructive Sleep Apnea (OSA) is a common disease with myriad adverse quality of life, safety, and other health consequences. Recently, a number of randomized controlled trials, meta-analyses, and large prospective epidemiologic studies have been published that address issues related to diagnosis and treatment of disease. Using an Evidence Based Medicine approach, this lecture will review recent data concerning the diagnosis and treatment of OSA. The strengths and weaknesses of the various study designs described above will be highlighted.