. Intensive Care Unit. Hospital Fundación de Alcorcón. Madrid. Spain
Sleep apnea is a common disease, and interest about it keeps growing as strong evidence of high incidence and important associated morbidity.
In this comprehensive review from one of the leading groups of Sleep Apnea researchers in Spain, they present current state of the art on Continuous Positive Airway Pressure (CPAP) applied to obstructive Sleep Apnea (OSA).
CPAP is used in a wide variety of situations nowadays, mainly as treatment for acute and cronic respiratory insuficiency, either in the Intensive Care environment or outside it (with a widespread use in pneumologic wards in
some centers). Ambulatory ventilation therapy is also a progresively accepted therapy in severely impaired patients, to avoid prolonged hospitalization, and CPAP is one of a wide spectrum of ventilatory strategies which can be used.
Rationale, practice, complications and scientific evidence of efficacy are reviewed thoroughly in this paper, where interested readers can find practical information to apply in common clinical situations, such as the management of patients with a disturbed sleep architecture but with no
cardiovascular or neurophysiological symptoms.
Comment Reviewer Prof. Marta Sofía López Rodríguez Profesor Principal de Anestesia. Hospital Joaquín Albarrán. Ciudad de La Habana, Cuba.
Sleep apnea is a common disease of the middle age population, consists of absent nasal and oral airflow during sleep despite continuing respiratory effort. This is generally due to backward tongue movement and pharyngeal
wall collapse (glossoptosis) secondary to interference with the normal coordinated contraction of pharyngeal and hypopharyngeal muscles. Enlargement of the tongue, tonsils and/or adenoids is often contributory.
It is diagnosed by finding at least 30 episodes of apnea (of duration at least 10 seconds) in a 7 hour study period. Many, but not all, patients are obese .During apneic episodes, bradycardia, atrioventricular block, premature ventricular contractions , and ventricular tachycardia may
develop,possibly explaining the increased incidence of sudden death seen in patients with sleep apnea. Night time nasal continuous positive airway pressure (CPAP), 10-15 cm H2O is sometimes helpful.
This attractive rewiew demostrate the improvement in sleepiness and health status with CPAP treatment in patient with OSA.Other studies is requeried for available scientific evidence of this treatment.
Comment Reviewer Prof. H Foyaca-Sibat and Dr.LdeF Ibañez-Valdés Department of Neurology, and Department of Family Medicine University of Transkei. Umtata. South Africa.
We read very carefully this manuscript and found it suitable for publication.
We could not find something written from the author's experiences on this matter, and we realize that it is not an updated and complete revision of the medical literature about this topic, nevertheless we consider that its context going to be useful for our readers. We also wish to make some comments about this issue.
Sleep apnea is an interruption of airflow for 10 seconds or more during the sleep, which can cause significantly lower oxygen levels in the bloodstream. Patients with sever apnea have 30 or more of these episodes per hour, while those with mild apnea stop breathing at least 15 times. In OSA the chest and the abdomen move normally, but a blocked airway prevents the patient from breathing. Central sleep apnea differs in that the patient's airway is not obstructed, but he body's breathing reflex is periodically interrupted so there is no chest and abdomen movement. Currently is clear-cut that sleep-breathing disorder may be a cause of heart failure (Circulation 2003:107:727-732) being another powerful reason for a proper treatment.
There are several mental impairments associated with OSA secondary to reduced oxygen to the brain and nighttime arousal. CPAP improves these problems, but may not restore them to normal (Sleep Medicine 1999;3(1):59-78).
Nasal obstruction as a risk factor for sleep apnea syndrome should be considered, and presence of OSA should be defined by the conservative criteria of 15 or more episodes of apnea or hypopnea per hour of sleep. (European Respiratory Journal, 2000;16:639-643).
We agree that traditional therapy for OSA includes nightly use of CPAP and as far we know it is the best treatment for severe OSA being safe and effective, even in children. However many problems should be solved because many patients still find the mask uncomfortable, claustrophobic, noisy or embarrassing, and they also complain of sensation of suffocation, nasal congestion, sore eyes, abdominal bloating, "dizziness", headache, sore or dry throat, chest muscle discomfort, epistaxis, and other side effects leading to poor compliant and stop the treatment causing a full return of OSA and related symptoms. In this group of patients (elderly ones) the mortally rates is higher because they also have a more extensive history of heart arrhythmias, heart attack, strokes, peripheral vascular disease, heart failure, respiratory illnesses, and neurological and psychiatric problems. Noncompliance is a significant predictor of death. Everyone with sleep apnea, but especially those with these indicators of high mortality risk, should do their utmost to get treatment and continue treatment. Fortunately better equipments for diagnosis of OSA (Sleepscreen) will be marketed worldwide very soon (Biotech Equipment Update, Apr2003, p1, 1p) because a high number of peoples remain undiagnosed until the present moment.
Obesity is another associated problem that deserve a better attention by our research community.
We cannot claim enough expertise to comment on the author's criteria to select the papers for review, but we accept their contention that it has advantages over different managements used in previous studies. The essential conclusion of this review seems quite believable