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Background and Purpose— Sleep apnea has been associated with a poor outcome in acute stroke patients. Polysomnography is the gold standard diagnostic method for sleep apnea, but it is not feasible as a routine in the acute stroke setting. The current generation of positive airway pressure (PAP) devices can detect the different types of respiratory events. This study aimed to compare the algorithms used in PAP device to manually scored events on polysomnography in patients with acute stroke. Methods— A sleep study was performed with standard polysomnography and PAP device, simultaneously, within the first 48 hours after acute stroke onset. Results— We prospectively evaluated 29 patients with acute stroke (59.5±12.1 years). The area under the receiver operating characteristic curve for each apnea-hypopnea index value was above 0.90 by PAP device. There was a good correlation of apnea-hypopnea index ( r s =0.92; P r s =0.89; P r s =0.70; P Conclusions— Given the high frequency of sleep apnea during the acute phase of stroke and the complexity of a full polysomnography study in this setting, PAP device on diagnostic mode can be used as an alternative tool for sleep apnea detection in acute stroke patients.

Objectives Sleep-disordered breathing (SDB) is very common in acute stroke patients and has been related to poor outcome. However, there is a lack of data about the association between SDB and stroke in developing countries. The study aims to characterize the frequency and severity of SDB in Brazilian patients during the acute phase of ischemic stroke; to identify clinical and laboratorial data related to SDB in those patients; and to assess the relationship between sleep apnea and functional outcome after six months of stroke. Methods Clinical data and laboratorial tests were collected at hospital admission. The polysomnography was performed on the first night after stroke symptoms onset. Functional outcome was assessed by the modified Rankin Scale (mRS). Results We prospectively evaluated 69 patients with their first-ever acute ischemic stroke. The mean apnea–hypopnea index (AHI) was 37.7 ± 30.2. Fifty-three patients (76.8%) exhibited an AHI ≥ 10 with predominantly obstructive respiratory events (90.6%), and thirty-three (47.8%) had severe sleep apnea. Age (OR: 1.09; 95% CI: 1.03–1.15; p = 0.004) and hematocrit (OR: 1.18; 95% CI: 1.03–1.34; p = 0.01) were independent predictors of sleep apnea. Age (OR: 1.13; 95% CI: 1.03–1.24; p = 0.01), body mass index (OR: 1.54; 95% CI: 1.54–2.18; p = 0.01), and hematocrit (OR: 1.19; 95% CI: 1.01–1.40; p = 0.04) were independent predictors of severe sleep apnea. The National Institutes of Health Stroke Scale (NIHSS; OR: 1.30; 95% CI: 1.1–1.5; p = 0.001) and severe sleep apnea (OR: 9.7; 95% CI: 1.3–73.8; p = 0.03) were independently associated to mRS >2 at six months, after adjusting for confounders. Conclusion Patients with acute ischemic stroke in Brazil have a high frequency of SDB. Severe sleep apnea is associated with a poor long-term functional outcome following stroke in that population.

Introduction The clinical and polysomnographic meaning of the Alternating Leg Muscle Activation (ALMA) and Hypnagogic Foot Tremor (HFT) patterns in children is not known. Methods A descriptive study was carried out to identify the prevalence and polysomnographic characteristics of ALMA and HFT sequences in a sample of 122 children sequentially admitted in the sleep laboratory, with the analysis of clinical and demographic characteristics of the ALMA/HFT group in relation to a comparison group without this condition, paired by age and gender. Results Sample prevalence was 14.8% for any HFT/ALMA event, 13.1% for ALMA and 10.7% for HFT. In the HFT/ALMA group, the mean age was 8 years old (2-12 years old), 66.7% of males. Obstructive Sleep Apnea was observed in 75% of children, but HFT / ALMA sequences only occasionally occurred in association with respiratory events. The use of medications with monoaminergic activity was associated with the occurrence of HFT/ALMA, p=0,019. There was higher N1 sleep content in the HFT / ALMA group, p=0,0301. There was no significant difference between both groups regarding the other clinical-demographic or polysomnographic parameters analyzed. Autonomic activation represented by heart rate fluctuations often occurred in association with the HFT / ALMA sequences, irrespective of the occurrence of arousals, awakenings, other motor or respiratory events. Conclusion HFT / ALMA is a frequent condition in children that are referred to the sleep lab.The stereotypy of the HFT / ALMA series suggests that their origin might be motor central pattern generators, which are potentially influenced by substances with monoaminergic effect. The finding of higher superficial sleep content in children with HFT / ALMA may indicate greater susceptibility to alteration of pediatric sleep architecture by such subtle motor events. The possibility of clinical consequences and cardiovascular diseases should be considered in relation to the association of HFT / ALMA with observed autonomic activation. Support None.

Obstructive Sleep Apnoea Syndrome (OSAS) is believed to be associated with craniofacial and neuromuscular changes, although the interplay among these variables still is poorly recognised. The objective of this study was to identify hyoid, muscular and swallowing changes associated with OSAS, and to correlate these alterations with OSAS severity. Cross-sectional study, in a tertiary referral centre. Seventy-two adult individuals participated in this study: 12 controls (without apnoea) and 60 patients with apnoea (mild, moderate and severe OSAS-20 individuals in each group). All participants were initially evaluated by otorhinolaryngologist and neurologist and underwent polysomnography for OSAS stratification. Cephalometric data, clinical myofunctional status and swallow videofluoroscopy exam were assessed. A hybrid effect model was used to analyse swallowing parameters; dependent variables were age, body mass index (BMI) and cephalometric measures. Individuals with OSAS presented lower hyoid position and narrower posterior airway distance when compared to controls. These parameters correlated to OSAS severity. Additionally, OSAS patients exhibited significantly lower myofunctional scores. Both velum and hyoid contraction times were significantly lower in the OSAS group at videofluoroscopy, regardless of its severity. Premature leakage into pharynx was more common in OSAS groups. Laryngeal penetration phenomenon occurred only in two patients (both from OSAS group). Our results suggest that hyoid bone position is associated with OSAS severity. Muscular pattern and swallowing are impaired in OSAS patients, irrespective of OSAS severity and facial profile. These findings indicate a higher predisposition of OSAS patients to present an inferior hyoid positioning, accompanied by myofunctional and swallowing disorders.

Background: Obstructive sleep apnea (OSA) is very common in acute stroke patients and has been associated with a poor short-term and long-term outcome. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is not feasible as a routine for all acute stroke patients. Therefore, it is essential to validade alternative methods to accurately diagnose OSA in acute stroke patients. The newest generation of automatic continuous positive airway pressure (auto-CPAP) devices innovates by the possibility of detecting the different types of respiratory events. However, the accuracy of auto-CPAP devices for OSA diagnosis has never been tested in comparison to PSG in the acute stroke setting. The main objective of this study was to evaluate the accuracy of an auto-CPAP device to diagnose OSA and to validate its algorithm of respiratory events detection to diagnose OSA in patients during the acute phase of stroke. Methods: A sleep study was performed with PSG and auto-CPAP device, simultaneously, within the first 48 hours after the acute stroke onset. The Receiver Operating Characteristic Curve (ROC), C-statistics, Spearman correlation coefficient, and intraclass correlation coefficient were analyzed. Results: We prospectively evaluated 31 adult patients with acute stroke. The mean age was 59.7 ± 12 years and 60% were males. All patients used auto-CPAP for longer than 4 hours. The PSG revealed an apnea-hypopnea index (AHI) mean of 34 ± 41 events/h, and the auto-CPAP showed an AHI of 18 ± 16 events/h. The area under the ROC curve for OSA diagnosis by the auto-CPAP was above 0.90, with sensitivity and specificity above 80% for each AHI value. The Spearman correlation coefficients (rs) of the AHI, of the hypopnea index, of the obstructive apnea index and of the central apnea index were 0.92; 0.89; 0.63 and 0.62, respectively. The intraclass correlation coefficients between device-detected and PSG manually scored events were 0.60 for AHI, 0.64 for hypopnea index, and 0.45 for apnea index. Conclusion: The auto-CPAP showed an excellent accuracy for the diagnosis of OSA and it was well tolerated by acute stroke patients. Our results suggest that auto-CPAP should be considered as the preferred diagnostic tool for OSA diagnosis during the acute phase of stroke.

IntroductionThe standard therapy for obstructive sleep apnea syndrome (OSAS) is continuous positive airway pressure (CPAP), but its correct and frequent use is essential to control the disease.PurposeTo analyze adherence to CPAP among patients with OSAS treated in a multidisciplinary outpatient clinic of a public tertiary hospital.MethodsThis was a retrospective study evaluating 156 patients with OSAS who underwent polysomnography for CPAP titration from 2008 to 2011. The patients were divided into two groups, those with good adherence to CPAP (a mean use of four or more hours per night) and those with poor adherence. The groups were compared regarding the following data: gender, age, body mass index, associated diseases, AHI at diagnostic polysomnography, and pressure (cmH2O) suggested by titration polysomnography.Results125 patients were analyzed, and it was observed that 82 of the patients (65%) had good adherence, whereas 43 (35%) showed poor adherence. Comparison between groups revealed that patients with a higher apnea-hypopnea index (AHI) were those who better adhered to treatment with CPAP.Conclusionsthe rate of adherence to CPAP among OSAS patients undergoing clinical monitoring at a public service was 65%. Patients with a higher AHI were those who adhered better to treatment with CPAP.© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

The aim of the study was to evaluate facial features and hyoid bone position in children with obstructive sleep apnea syndrome (OSAS) by cephalometric radiography. A prospective cross-sectional study was conducted in a tertiary referral hospital. Twenty-nine children in the 3-6 year age bracket were evaluated: 14 children with OSAS and 15 nasal-breathing children. All children underwent otorhinolaryngologic examination, and those with OSAS also underwent in-laboratory polysomnography for diagnostic confirmation. The children were then submitted to orthodontic evaluation and cephalometry. Lateral cephalometric radiographs from children with OSAS were compared to those of nasal-breathing children. We found no differences between the two groups regarding the linear and angular measurements of the face. However, the children with OSAS presented, already at the preschool age, with an inferiorly positioned hyoid bone, thus increasing the pharyngeal area. In children with OSAS, the hyoid bone appears to be in a significantly inferior position at an early age. Our findings provide evidence that there is a relationship between the position of the hyoid bone and OSAS in children, which could contribute to the persistence of OSAS into adulthood.

Objectives/Hypothesis The treatment for obstructive sleep apnea syndrome (OSAS) depends on correct localization of upper airway obstruction, exception made for continuous positive airway pressure (CPAP). Drug-induced sleep endoscopy (DISE) with propofol allows this evaluation, but the drug effects on sleep parameters are not yet well established. Our objective was to study by polysomnography (PSG) whether propofol would change sleep parameters by means of a prospective cross-sectional clinical study in a tertiary hospital. Study Design Thirty non-obese subjects (6 controls and 24 OSAS patients) underwent two daytime PSGs, one with DISE and the other without DISE. Methods During DISE exam, propofol was administered intravenously in continuous infusion using a target-controlled infusion pump. The parameters evaluated were: presence of snoring, apnea-hypopnea index (AHI), oxyhemoglobin saturation (SaO2), and sleep macroarchitecture. Results Snoring was absent in all healthy subjects during DISE sleep with propofol, and present in all OSAS patients (100%). AHI and mean SaO2 showed no statistical difference between the two tests, with and without propofol. However, minimum SaO2 was significantly lower during propofol infusion (88.64 for without vs. 85.04 for with propofol; P < 0.01). Regarding sleep macroarchitecture, the tests with propofol significantly increased N3 sleep and totally extinguished REM sleep (P < 0.005). Conclusions The results demonstrate that propofol significantly changes sleep macroarchitecture. However, the main respiratory parameters, AHI and mean SaO2, remained unaffected. Thus, in order to determine the sites of obstruction, propofol DISE used with target-controlled infusion proved to be an effective drug for endoscopic evaluation of patients with OSAS. Level of Evidence 4. Laryngoscope, 123:2300–2305, 2013

Background: Obstructive sleep apnea (OSA) is frequent in acute stroke patients and is associated with increased mortality and poor functional outcome. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is impracticable as a routine for all acute stroke patients. We evaluated how OSA screening tools such as the Berlin Questionnaire (BQ) and the Epworth Sleepiness Scale (ESS) would perform when administered to relatives of stroke patients in the acute setting, and compared these individual tools against a combined screening score (SOS score). Methods: Ischemic stroke patients were submitted to a full PSG at the first night after symptoms onset. OSA severity was measured by apnea-hypopnea index (AHI). BQ and ESS were administered to relatives of stroke patients before the PSG. We combined elements of the BQ and ESS to create a new screening tool for OSA named Sleep Obstructive apnea score optimized for Stroke (SOS score). Results: Thirty-nine consecutives ischemic stroke patients were enrolled in our study. The mean age was 62.3 ±12.2 years. Age was significantly different between those with and without OSA (p=0.02). The mean body mass index and neck circumference were 26.7 ± 4.7 and 38.9 ± 4.0cm, respectively. OSA (AHI ≥ 10) was present in 76.9%. The area under the curve for SOS score (AUC:0.812; p=0.005) was superior to BQ (AUC:0.567; p=0.549) and also to ESS (AUC:0.646; p=0.119 vs. AUC:0.686; p=0.048) for severe OSA (IAH ≥ 30). The threshold of SOS ≤ 10 (present in 20.5% of patients) showed high sensitivity (90%) and negative predictive value (96.2%) for OSA; SOS ≥20 (17.9% of patients) showed high specificity (100%) and positive predictive value (92.5%) for severe OSA. Using SOS as a screening approach would decrease by around 40% the demand for PSG during the acute stroke setting. Conclusions: The SOS score when administered to relatives of stroke patients appears to be an appropriate tool to screen acute stroke patients for OSA, while decreasing the need for a formal sleep study during the acute stroke setting. The new derived SOS score is superior to BQ and ESS for identifying patients with OSA and Severe OSA during the acute phase of stroke.

Background Obstructive sleep apnea (OSA) is frequent in acute stroke patients, and has been associated with higher mortality and worse prognosis. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is impracticable as a routine for all acute stroke patients. We evaluated the accuracy of two OSA screening tools, the Berlin Questionnaire (BQ), and the Epworth Sleepiness Scale (ESS) when administered to relatives of acute stroke patients; we also compared these tools against a combined screening score (SOS score). Methods Ischemic stroke patients were submitted to a full PSG at the first night after onset of symptoms. OSA severity was measured by apnea-hypopnea index (AHI). BQ and ESS were administered to relatives of stroke patients before the PSG and compared to SOS score for accuracy and C-statistics. Results We prospectively studied 39 patients. OSA (AHI ≥10/h) was present in 76.9%. The SOS score [area under the curve (AUC): 0.812; P = 0.005] and ESS (AUC: 0.789; P = 0.009) had good predictive value for OSA. The SOS score was the only tool with significant predictive value (AUC: 0.686; P = 0.048) for severe OSA (AHI ≥30/h), when compared to ESS (P = 0.119) and BQ (P = 0.191). The threshold of SOS ≤10 showed high sensitivity (90%) and negative predictive value (96.2%) for OSA; SOS ≥20 showed high specificity (100%) and positive predictive value (92.5%) for severe OSA. Conclusions The SOS score administered to relatives of stroke patients is a useful tool to screen for OSA and may decrease the need for PSG in acute stroke setting.

The treatment for obstructive sleep apnea syndrome (OSAS) depends on correct localization of upper airway obstruction, exception made for continuous positive airway pressure (CPAP). Drug-induced sleep endoscopy (DISE) with propofol allows this evaluation, but the drug effects on sleep parameters are not yet well established. Our objective was to study by polysomnography (PSG) whether propofol would change sleep parameters by means of a prospective cross-sectional clinical study in a tertiary hospital.Thirty non-obese subjects (6 controls and 24 OSAS patients) underwent two daytime PSGs, one with DISE and the other without DISE.During DISE exam, propofol was administered intravenously in continuous infusion using a target-controlled infusion pump. The parameters evaluated were: presence of snoring, apnea-hypopnea index (AHI), oxyhemoglobin saturation (SaO2), and sleep macroarchitecture.Snoring was absent in all healthy subjects during DISE sleep with propofol, and present in all OSAS patients (100%). AHI and mean SaO2 showed no statistical difference between the two tests, with and without propofol. However, minimum SaO2 was significantly lower during propofol infusion (88.64 for without vs. 85.04 for with propofol; P0.01). Regarding sleep macroarchitecture, the tests with propofol significantly increased N3 sleep and totally extinguished REM sleep (P0.005).The results demonstrate that propofol significantly changes sleep macroarchitecture. However, the main respiratory parameters, AHI and mean SaO2 , remained unaffected. Thus, in order to determine the sites of obstruction, propofol DISE used with target-controlled infusion proved to be an effective drug for endoscopic evaluation of patients with OSAS.

Este artigo relata as conclusões da reunião de consenso com médicos especialistas sobre diagnóstico de narcolepsia baseada na revisão dos artigos sobre narcolepsia listados no Medline entre 1980 e 2010. A narcolepsia é uma doença crônica de início entre a primeira e segunda décadas de vida do indivíduo. Os sintomas essenciais são cataplexia e sonolência excessiva. A cataplexia é definida como episódios súbitos, recorrentes e reversíveis de fraqueza da musculatura esquelética desencadeados por situações de conteúdo emocional. Os sintomas acessórios são alucinações hipnagógicas, paralisia do sono e sono fragmentado. Critérios de diagnóstico clínico de acordo com a Classificação Internacional dos Transtornos do Sono são de sonolência excessiva e cataplexia. Recomenda-se a realização de polissonografia seguida do teste de latência múltipla do sono em um laboratório de sono para confirmação e diagnóstico de comorbidades. Quando não houver cataplexia, deve haver duas ou mais sonecas com sono REM no teste de latência múltipla do sono. Tipagem HLA-DQB1*0602 positiva com níveis de hipocretina-1 abaixo de 110pg/mL devem estar presentes para o diagnóstico de narcolepsia sem cataplexia e sem sonecas com sono REM. This manuscript contains the conclusion of the consensus meeting on the diagnosis of narcolepsy based on the review of Medline publications between 1980-2010. Narcolepsy is a chronic disorder with age at onset between the first and second decade of life. Essential narcolepsy symptoms are cataplexy and excessive sleepiness. Cataplexy is defined as sudden, recurrent and reversible attacks of muscle weakness triggered by emotions. Accessory narcolepsy symptoms are hypnagogic hallucinations, sleep paralysis and nocturnal fragmented sleep. The clinical diagnosis according to the International Classification of Sleep Disorders is the presence of excessive sleepiness and cataplexy. A full in-lab polysomnography followed by a multiple sleep latency test is recommended for the confirmation of the diagnosis and co-morbidities. The presence of two sleep-onset REM period naps in the multiple sleep latency test is diagnostic for cataplexy-free narcolepsy. A positive HLA-DQB1*0602 with lower than 110pg/mL level of hypocretin-1 in the cerebrospinal fluid is required for the final diagnosis of cataplexy- and sleep-onset REM period -free narcolepsy.

Background: Obstructive sleep apnea (OSA) is related to increased systemic inflammation and arterial hypertension. We hypothesize that OSA is frequent in patients with acute hypertensive intracerebral hemorrhage (ICH) and is related to the perihematoma edema. Methods: Thirty-two non-comatose patients with a hypertensive ICH underwent polysomnography in the acute phase. Perihematoma edema volume was measured on CT scans at admission, after 24 h (early control) and after 4–5 days (late control). The Spearman coefficient (rs) was used for correlations. Results: OSA occurred in 19 (59.4%) patients. The apnea-hypopnea index was correlated with relative edema at admission CT (rs = 0.40; p = 0.031), early CT (rs = 0.46; p = 0.011) and at late CT (rs = 0.59; p = 0.006). Conclusions: OSA is highly frequent during the acute phase of hypertensive ICH and is related to perihematoma edema.

The localization of upper airway obstruction in patients with obstructive sleep apnea (OSA) may optimize treatment. Nasoendoscopy during propofol sedation allows such an evaluation, but the effect of this drug on respiratory patterns and muscle relaxation is unknown. The objective of the present study was to determine through polysomnography whether propofol would change sleep parameters.Prospective study of subjects submitted to polysomnography under sedation with propofol.Tertiary referral center.Fifteen non-obese subjects (4 controls/11 OSA patients) were submitted to two diurnal polysomnograms (90-120 minutes of sleep), with and without the use of propofol. The parameters presence of snoring, apnea-hypopnea index (AHI), oxygen desaturation, and sleep architecture were compared.The use of propofol did not induce snoring in the control subjects, whereas 100 percent of the OSA patients snored. AHI and mean oxygen saturation (SaO(2)) did not differ significantly between examinations with and without sedation. However, minimum SaO(2) differed significantly (P0.05) with sedation, being lower during propofol sedation. Propofol also significantly changed the sleep architecture, with a significant increase in N3 sleep (P0.005) and total abolishment of rapid eye movement sleep (P0.0005) during propofol sedation.These preliminary results allow us to infer that sedation with propofol changes sleep architecture but permits respiratory evaluation, because the main respiratory parameters evaluated in OSA are maintained. These preliminary results support the view that nasoendoscopy under propofol sedation is a promising examination for management of this disease.

Objective: To evaluate the clinical and polysomnographic evolution of patients with severe laryngomalacia who underwent supraglottoplasty. Design: Retrospective study. Setting: University hospital. Patients: Seven children with severe laryngomalacia. Main Outcome Measures: The patients were evaluated with a questionnaire given to their parents and with polysomnographic examination before and 3 months after surgery. The clinical data of respiratory and swallowing symptoms as well as the parameters of minimum oxygen saturation and respiratory disturbance index were evaluated after bilateral supraglottoplasty and compared with the preoperative data. Results: Two patients had pharyngolaryngomalacia and required tracheotomy. Four patients had a marked improvement of respiratory and deglutition symptoms. Polysomnographic data showed a significant improvement in the respiratory disturbance index after surgery (P