Apnee Si Boli Asociate

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Apnee Si Boli Asociate

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Spitalul Clinic de Pneumologie Iasi D.Boisteanu

SINDROMUL DE APNEE IN SOMN (SAS)

AFECTIUNI ASOCIATEAPNEEA DE SOMN - DEFINITIIApneea de somn este oprirea repetata a fluxului aerian naso-bucal > 10sec insotita de sforait, hipoxie si somnolenta diurna excesiva (treziri frecvente).

Aceasta terminologie implica 2 probleme distincte apneea obstructiva (colapsul CRS la nivelul faringelui); cea mai frecventa forma de apnee de somn; persista efortul respirator - apneea centrala este determinata de alterarea controlului respiratiei oprirea efortului ventilator si a fluxului aerian se asociaza cu insuficienta cardiaca si respiratia periodica Cheyne-Stokes - apneea mixta incepe ca fenomen central si se termina obstructiv APNEEA DE SOMN - DEFINITIIHipopneea = scaderea fluxului aerian cu 30-50% din valoarea initiala, asociata cu desaturare de min. 3%Indexul de apnei-hipopnei (IAH sau RDI)SAS = IAH > 5 /ora de somnAprecierea severitii SAS uor: IAH = 5- 15/or moderat: IAH = 15 30/or sever > 30/or de somnRERA (respiratory event related arousal) = scaderea fluxului aerian la nivelul nasului si gurii mai mult de 10 sec. insotita intotdeauna de o microtrezire.

OBEZITATEA Ample studii populaionale au evideniat corelarea SAS cu obezitatea, dovedind o relaie direct ntre severitatea SAS (apreciat prin indexul de apneehipopnee) i indicele de mas corporal (BMI).

Asocierea ntre obezitate i apneea obstructiv de somn este mai frecvent la pacienii care prezint creteri ale circumferinei taliei i gtului, nsoite de sforit.

Obezitatea este principalul predictor al apneei de somn.

OBEZITATEAObezitate majoritate cazuriCircumferinta gatului > 44cmAnomalii cranio-faciale (micro/retrognatie, acromegalie, bolta palatina ogivala)Malocluzie maxilo-mandibulara

APNEEA DE SOMN (SAS) SI SDR. PICKWICK (SOH)Majoritatea dar nu toti pacientii cu SOH au SASPerez de Llano (Chest, 2005): 87% cu ambele afectiuni.Prevalenta Sdr.Pickwck la pacientii cu apnee - 8 10% cand IMC = 30-34 kg/m- 18 25% cand IMC = 40 kg/m

Mokhlesi B, Kryger M, Grunstein R. Assessment and management of patients with Obesity Hypoventilation Syndrome. Proc Am Thorac.Soc 2008;5:218-225.

Mark Anthony Powers.The Obesity Hypoventilation Syndrome. Respir Care 2008;53(12):17231730.

ROLUL LEPTINEILeptina = proteina endogena derivata din adipociteParticipa la reglarea metabolica a greutatii corporaleFeed-back negativ care activeaza receptorii ce suprima apetitul.Stimuleaza centrii respiratori si pare sa aiba un rol protector impotriva complicatiilor respiratorii la obezi;La obezi, nivelul leptinei este mult , ceea ce implica o posibila rezistenta la leptina.Nivelul seric al leptinei este un predictor mai bun al SOH decat IMC, independent de IAH.VNI reduce nivelul leptinei in SOH.ROLUL LEPTINEI

Claudio Rabec. Leptin, obesity and control of breathing : the new aventures of mr pickwick Rev Electron Biomed / Electron J Biomed 2006;1:3-7

TRATAMENT

Mark Anthony Powers.The Obesity Hypoventilation Syndrome. Respir Care 2008;53(12):17231730.

COMORBIDITATI HTA (risc x 2) Boala coronariana (risc x 3) Tulburari de ritm cardiac Insuficienta cardiaca Accidente ischemice cerebrale (risc x 4) Trombembolism pulmonar Sdr. metabolic (diabet, dislipidemie, hiperuricemie) Hipotiroidie, acromegalie Afectiuni in sfera ORL

APNEEA DE SOMN POATE DETERMINA APARITIA URMATOARELOR AFECTIUNI Hipertensiune arteriala Boala coronariana Tulburari de ritm cardiac Accidente ischemice cerebrale Embolie pulmonaraSpitalul Clinic de Pneumologie Iasi D.BoisteanuSe poate asocia cu sindromul metabolic: diabet zaharat, dislipidemie, hiperuricemie, obezitate, HTAAPNEEA DE SOMN SI HTASAS factor de risc independent pt. HTA

la pacientii cu SAOS, TA nocturna profil non-dipper

la bolnavii cu HTA rezistenta la trat. se recomanda screening pt. apnee de somn

la aceasta categorie de pacienti (cu HTA rezistenta la trat. si SAS), folosirea nCPAP min. 5 ore/noapte duce la imbunatatirea controlului TAAPNEEA DE SOMN SI HTAWisconsin Sleep Cohort Study: SAOS factor de risc independent pt. HTA TA nocturna profil non-dipper TA diurna, sistolica si diastolica, > la cei cu SAOS

Efectul tratamentului nCPAP (Becker, 2003)

nCPAP timp de 9 sapt. scade TA (sist.+diast.) la pacienti cu HTA rezistenta la trat. si SAOS, folosirea nCPAP min. 5 ore/noapte duce la TA

CONSECINTELE CARDIOVASCULARE ALE APNEEI DE SOMN

PREVALENTA TULBURARILOR RESPIRATORII DE SOMN LA PACIENTII CU BOLI CARDIOVASCULARE30% din pacientii cu boli cardiovasculareSchafer, et al. Cardiology 199950% din bolnavii cu insuficienta cardiaca cronicaJavaheri, Circulation 199860% dintre supravietuitorii unui AVCBassetti, et al. Sleep 199983% din pacientii cu HTA rezistenta la tratamentLogan, et al. J Hypertension, 2001

SAS SI MORBIDITATEA CARDIOVASCULARA MECANISME BIOLOGICEAlterarea endoteliului vascular, aterogeneza

Cresterea activarii plachetareActivarea factorilor proinflamatori Stres oxidativ

Legatura intre aceste modificari biologice si datele clinico-experimentale nu este complet stabilita

Boala coronarianaApneea de somnHipoxieHipertensiune (nocturna)TreziriObezitateHipercolesterolemieHiperuricemieDiabet zaharatHipertensiune (diurna)PROFILUL FACTORILOR DE RISC+Spitalul Clinic de Pneumologie Iasi D.BoisteanuAPNEEA DE SOMN SI BOALA CORONARIANAMODIFICARI CARDIACE IN TIMPUL APNEEI DE SOMN

Spitalul Clinic de Pneumologie Iasi D.Boisteanu

EFECTELE MECANICE ALE APNEEIHipoventilatia(CO2) determina efortului inspirator impotriva cailor aeriene inchise (manevra Mueller) => activare vagala => bradiaritmie.

Dupa 10-60 sec respiratia se reia, manevra Mueller inceteaza, scade tonusul vagal si creste activitatea simpatica => potentand efectul aritmic.

compliantei VS = disfunctie diastolica,

dimensiunea ADJournal of Cardiovascular Electrophysiology Vol. 18, No. 9, September 2007Sleep Medicine Reviews, Vol, 2, No. 1, pp 45-60, 1998(7)26RESPIRAIA CHEYNE-STOKES ASOCIATA IC

DIAGNOSTIC SAS : SINTEZAApneea de somn este subdiagnosticataSuspiciunea de diagnostic poate fi emisa de pacient, familie sau medic.Confirmarea SAS se poate face in etapa actuala numai de catre pneumolog prin polisomnografie sau poligrafie.Screeningul preliminar poate fi realizat prin chestionar Epworth si o anamneza orientata pe tulburarile somnului.La pacientii obezi cu afectiuni cardiovasculare, poligrafia de somn pentru depistarea SAS ar trebui sa devina un test de rutina.TRATAMENTUL CU PRESIUNE POZITIVA NAZALA (CPAP)

Cea mai eficienta metoda terapeutica pentru apneea desomn moderata si severa

Titrarea polisomnografica a presiunii CPAP

Spitalul Clinic de Pneumologie Iai nCPAP elimina OA & CA si reduce postsarcina ventricolului stang prin scaderea presiunii arteriale.INFLUENTA CPAP ASUPRA APNEILOR (OBSTRUCTIVE SI CENTRALE)

(Yan AT. Et al. Chest 2001;120:1675-1685)32Congestive heart failure (CHF) is a serious medical condition frequently associated with sleep-related breathing disorders, which remain underdiagnosed and undertreated. Recent studies have provided important insight into the pathophysiology of sleep apnea syndrome in patients with CHF, with potential therapeutic implications. In addition to abolition of sleep apnea, continuous positive airway pressure (CPAP) treatment can improve cardiac function and relieve symptoms of CHF. Postulated mechanisms include beneficial hemodynamic effects on ventricular remodeling, unloading of fatigued respiratory muscles, and neurohormonal modulation. Although medium-term studies using CPAP to treat sleep-related breathing disorders associated with CHF have been encouraging, more definitive data from ongoing large clinical trials are necessary to clarify its therapeutic role AUTO-CPAP ESTE FOLOSIT ATAT PENTRU TRATAMENT CAT SI PENTRU TITRAREA PRESIUNII EFICIENTEAvantajele auto-CPAP fata de CPAP cu presiune fixa:Evita titrarea.Poate face titrarea automat.Simplifica modul de aplicare a tratamentului, economisind o noapte de polisomnografie astfel incat pot fi tratati mai multi pacienti.4. Detecteaza deficientele de complianta, defectele mastii si apneile reziduale.Ca eficienta, auto-CPAP nu este mai bun decat CPAP cu presiune fixa. 33INFLUENTA AUTO-CPAP ASUPRA RESPIRATIEI PERIODICE CHEYNE-STOKES DIN INSUFICIENTA CARDIACA

(Teschler H. et al. AJRCCM 2001;164:614-619)34Ref 45

Figure 1. (A) Typical 5-min polygraph recording on the diagnostic night. EMG =submental electromyogram; Thorax =rib cage movement strain gauge (uncalibrated). Abdomen =abdominal movement strain gauge (uncalibrated); Thermistor =oronasal airflow (uncalibrated); SaO2 =pulse oximetry. The subject is in stage 1sleep. Note five central apneas and associated desaturations and arousals. (B) Typical 5-min polygraph recording on the adaptive servo-ventilation night. Same subject as (A). Pressure =mask pressure. Other abbreviations as for (A). Note the transient increase in pressure modulation amplitude within 1to 2breaths of the onset of a central hypopnea early in the trace, and the absence of desaturation or arousal. [Thermistor, rib cage, and abdominal movement signal gains were chosen for visual clarity, are uncalibrated, and therefore differ from (A).]

Figure 1. (A) Typical 5-min polygraph recording on the diagnostic night. EMG =submental electromyogram; Thorax =rib cage movement strain gauge (uncalibrated). Abdomen =abdominal movement strain gauge (uncalibrated); Thermistor =oronasal airflow (uncalibrated); SaO2 =pulse oximetry. The subject is in stage 1sleep. Note five central apneas and associated desaturations and arousals. (B) Typical 5-min polygraph recording on the adaptive servo-ventilation night. Same subject as (A). Pressure =mask pressure. Other abbreviations as for (A). Note the transient increase in pressure modulation amplitude within 1to 2breaths of the onset of a central hypopnea early in the trace, and the absence of desaturation or arousal. [Thermistor, rib cage, and abdominal movement signal gains were chosen for visual clarity, are uncalibrated, and therefore differ from (A).]

Figure 1. (A) Typical 5-min polygraph recording on the diagnostic night. EMG =submental electromyogram; Thorax =rib cage movement strain gauge (uncalibrated). Abdomen =abdominal movement strain gauge (uncalibrated); Thermistor =oronasal airflow (uncalibrated); SaO2 =pulse oximetry. The subject is in stage 1sleep. Note five central apneas and associated desaturations and arousals. (B) Typical 5-min polygraph recording on the adaptive servo-ventilation night. Same subject as (A). Pressure =mask pressure. Other abbreviations as for (A). Note the transient increase in pressure modulation amplitude within 1to 2breaths of the onset of a central hypopnea early in the trace, and the absence of desaturation or arousal. [Thermistor, rib cage, and abdominal movement signal gains were chosen for visual clarity, are uncalibrated, and therefore differ from (A).]

Adaptive servo-ventilation (ASV) is a novel method of ventilatory support designed for Cheyne-Stokes respiration (CSR) in heart failure. The aim of our study was to compare the effect of one night of ASV on sleep and breathing with the effect of other treatments. Fourteen subjects with stable cardiac failure and receiving optimal medical treatment were tested untreated and on four treatment nights in random order: nasal oxygen (2 L/min), continuous positive airway pressure (CPAP) (mean 9.25 cm H(2)O), bilevel (mean 13.5/5.2 cm H(2)O), or ASV largely at the default settings (mean pressure 7 to 9 cm H(2)O) during polysomnography. Thermistor apnea + hypopnea index (AHI) declined from 44.5 +/- 3.4/h (SEM) untreated to 28.2 +/- 3.4/h oxygen and 26.8 +/- 4.6/h CPAP (both p < 0.001 versus control), 14.8 +/- 2.3/h bilevel, and 6.3 +/- 0.9/h ASV (p < 0.001 versus bilevel). Effort band AHI behaved similarly. Arousal index decreased from 65.1 +/- 3.9/h untreated to 29.8 +/- 2.8/h oxygen and 29.9 +/- 3.2/h CPAP, to 16.0 +/- 1.3/h bilevel and 14.7 +/- 1.8/h ASV (p < 0.01 versus all except bilevel). There were large increases in slow-wave and rapid eye movement (REM) sleep with ASV but not with oxygen or CPAP. All subjects preferred ASV to CPAP. One night ASV suppresses central sleep apnea and/or CSR (CSA/CSR) in heart failure and improves sleep quality better than CPAP or 2 L/min oxygen

CPAP ASOCIAT CU OXIGENAdaugarea oxigenului la CPAP sau BiPAP la pacienti cu SAS care sunt hipoxemici in stare de veghe (ex. sdr.Pickwick) - boli coronariene-accidente vasculare cerebrale- trombembolism pulmonarVPAP : ADAPT SERVO-VENTILATIA

Trateaza toate formele de apnee centrala, mixta si respiratie periodica.Este dotat cu un sistem inteligent de calcul care determina continuu suportul de presiune necesar pentru a aduce ventilatia pacientului la un nivel-target.In ansamblu, realizeaza sincronizarea intre presiunea furnizata de aparat si respiratia pacientului.CORECTIA CHIRURGICALA A FARINGELUIUvulo-palato-faringoplastie (UPPP)

Laser-UPPP

Rigidizarea valului palatin cu radiofrecventa

AVANSAREA MAXILO-MANDIBULARA Obiective Cresterea diametrului caii aeriene superioare

Diminuarea tendintei la colaps al faringelui

PROTEZELE MANDIBULARE Dispozitivele pot fi:neajustabilepartial ajustabile total ajustabile mandibula este avansata progresiv pana ajunge in pozitia utila terapeutic.

KLEARWAYOVERLAP SYNDROMEConcomitena BPOC i SAS

Frecvena apneilor la bolnavii cu BPOC ~ 4%

Frecvena BPOC la bolnavii cu apnee n somn ~ 11% Prezena celor dou afeciuni la acelai bolnav duce la: Agravarea desaturrilor nocturne Permanentizarea hipoxemiei Instalarea HTAP PAP se coreleaz cu PaO2 i nu cu severitatea SASPATOGENIA OVERLAP SYNDROMERolul hipoxemiei diurne prin obstrucie bronic este primordial n determinismul HTAP permanente.

Hipoxemia nocturn datorat apneilor are un rol secundar n instalarea HTAP permanente i apariia cordului pulmonar cronic.

HTAP este corelat cu severitatea obezitii i consecinele ei asupra ventilaiei.PATOGENIA OVERLAP SYNDROME Factori predictivi pentru hipercapnie n overlap sdr. PaO2 (38%) - VEMS (15%) - BMI (12%)

Hipercapnia din overlap sdr. are etiologie plurifactorial, fiind numai parial explicat de asocierea obezitii cu apneea de somn i cu deteriorarea funciei respiratorii.TESTE PRELIMINARE DE DEPISTARE A APNEILOR NOCTURNE LA BOLNAVII CU BPOC Asociaz simptomele/semnele BPOC i ale SAS nregistrarea nocturn continu a saturaiei arteriale a O2 nregistrarea zgomotelor respiratorii traheale Chestionare (evaluarea somnolenei diurne: scala Stanford sau Epworth)TRATAMENTUL OVERLAP SYNDROMEOxigenoterapia la domiciliu SpO2 < 88%Crete durata de viaAmelioreaz calitatea somnuluiPrevine creterea PAP n somnul paradoxal

Ventilaia nocturna pe masc nazal:- cu auto-titrare sau- cu doua nivele de presiune (bi-PAP) asociata la nevoie cu oxigenEfect de atel pneumatic meninndpermeabilitatea CRSSe aplic pe toat durata nopiiPrevine instalarea HTAP permanentePrevine complicaiile cardiovasculareSpitalul Clinic de Pneumologie Iasi D.Boisteanu

APNEEA DE SOMN SI TULBURARILE DE RITM alternanta bradicardie (in apnee) tahicardie (la reluarea respiratiei) hipoxia prelungita poate declansa aritmii supraventriculare sau ventriculare cu risc de moarte subita in somn

Bradicardizarea indus de hipopnee cu tahicardizare la trezire Variaia ciclic a frecvenei cardiace predictor dgn. SASOPrevalenta Estimata a Apneei Obstructive de Somn la pacientii cu afectiuni cardiovasculareHipertensiune arteriala 50%

Boala coronariana 33%

Insuficienta cardiaca cu disfunctie sistolica 30-40%

Atac cerebral 50%

Fibrilatie atriale ce necesita cardioversie 50% Circulation2004;110:364

Fibrilatie atriala izolata 33%chest2004;125:879 Braunwalds heart disease 8th ed474747OSA IS highly prevalent in patient with CV disease:is present in half of patient with HTN,HALF OF ACUTE STROKEHALF OF PATIENTS WITH AFIB requiring cardioversion and 1/3 of patients with lone Afib1/3 of CAD patients,1/3 of H failure.Many of these Cardiovascular disease occur association because of comorbidity of OSA.(obesity and metabolic syndrome).

Aritmii supraventriculare;Aritmii ventriculare;Moartea subit cardiac;Bradicardia i tulburrile de conducere;Pacing cardiac .

Mehra R, Am J Respir Crit Care Med. 2006,15Aritmiile cardiace din SASO (Sdr. Apnee in Somn Obstructiv)

48Sindromul de apnee obstructiva de somnHipoxie intermitenta/ ReoxigenareInflamatieDisfunctie endotelialaAterosclerozaObezitate Stres oxidativActivare simpaticaSomn fragmentatActivarea factorilor de transcriptie (HIF-1, NFkB)Citockine proinflamatorii: IL-1, IL-6, IL-8, TNF-Activarea Ly, monocitelorCelulelor endotelialeAdaptare Eur Respir J 2009; 33: 11951205 VOLUME 33 NUMBER 5, Obstructive sleep apnea and cardiac arrhythmias Ahmad Salah Hersi, King Fahad Cardiac Centre, Saudi Arabia Ann Thorac Med. 2010; 5(1)Aritmiile sunt mai frecvente la pacientii cu SASO care au hipoxemie severa in timpul somnului REM (Shepard et al,Chest. 1985)

La pacientii cu SASO netratat si cardioversie reusita pentru fibrilatie atriala, s-a constatat o recurenta a aritmiei de 82% dupa primul an, comparativ cu 42% la cei cu SASO tratati cu CPAP.(Kanagala et al., Circulation. 2003)In concluzie, se poate afirma ca pacientii cu apnee severa au un risc de 2-4 ori mai mare pentru aritmii complexe decat cei fara apnee.

Low efficacy of atrial fibrillation ablation in severe obstructive sleep apnoea patientsMatiello M, Nadal M, Tamborero D, Berruezo A, Montserrat J, Embid C, Rios J, Villacastn J, Brugada J, Mont LOxford Journals, Europace (2010) Scopul a fost urmarirea efectului SASO asupra rezultatului pe termen lung al ablatiei ca tratament pt. fibrilatia atriala174 pacienti monitorizati timp de 1 an dupa ablatie, 42 au prezentat apnee de somnDintre cei cu apnee usoara si moderata, 30,4% nu au prezentat recurenta fibrilatiei dupa un an, fata de numai 14% dintre cei cu apnee severa.Concluzie: apneea severa este un predictor al recurentei fibrilatiei atriale dupa ablatie.

Obstructive Sleep Apnea Is Common and Independently Associated With Atrial Fibrillation in Patients With Hypertrophic CardiomyopathyR.P. Pedrosa, L.F. Drager, P.R. Genta, A.Amaro, M.O.Antunes, A.Y. Matsumoto, E.ArteagaChest 2010;137;1078-1084Ipoteza de studiu: apneea de somn se asociaza frecvent cu fibrilatie atriala si remodelare miocardica la pacientii cu cardiomiopatie hipertrofica80 pacienti diagnosticati cu CMH au fost investigati poligrafic pentru apnee nocturna (AHI>15/ora)32 au fost diagnosticati cu SASO (40%); varsta lor (56 vs 38.5, P=001) si BMI au fost semnificativ mai mari decat in lotul fara SASO (28,2 vs 25,2).Diametrul atriului stang (45 vs 41 mm) si diametrul aortei (34 vs 29 mm) au fost semnificativ crescute la pacientii cu apnee.

Obstructive Sleep Apnea Is Common and Independently Associated With Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy Chest 2010;137;1078-1084AHI si BMI au fost asociate cu diametrul atriului stg. AHI a fost singura variabila asociata cu diametrul aortei.

fibrilatia atriala a fost prezenta in 31% cazuri la pacientii cu SASO vs 6% la cei fara SASO

Apneea si diametrul atriului stg. au fost singurii factori asociati independent cu fibrilatia atriala.

CONCLUZII: apneea sde somn are o prevalenta crescuta la pacientii cu CMH si se asociaza cu hipertrofie atriala stg.si cresterea diametrului aortei.

Obstructive Sleep Apnea in PatientsAdmitted for Acute Myocardial Infarction*Prevalence, Predictors, and Effect on Microvascular PerfusionChi-Hang Lee, See-Meng Khoo, Choo Tai, Eric Y. Chong, Cindy Lau, Yemon Than (CHEST 2009; 135:14881495)105 pacienti cu varsta medie 53+/-10 ani, 103 barbatiSpitalizati pt. IMA necomplicatNediagnosticati anterior cu SASOAHI>15 a fost pragul de diagnostic pt SASO (s-a exclus apneea usoara)Diabetul zaharat a fost asociat semnificativ si independent cu SASO, fiind considerat factor de risc pentru apnee (OR 2,86, 95% CI, p=0,033)

Obstructive Sleep Apnea in PatientsAdmitted for Acute Myocardial Infarction*ConcluziiApneea de somn de tip obstructiv (moderata si severa) are o prevalenta crescuta la pacientii cu IMADZ se asociaza independent cu SASO, pentru care este considerat un important predictor.Nu s-au constatat modificari ale perfuziei microvasculare dupa interventia coronariana percutana la pacientii cu apnee fata de cei fara SASO.Autorii recomanda investigarea somnului la toti pacientii cu IMA si DZ asociat.Grup I 151 pac. FA vs. Grup II 373 pac fr FA SASO : 49% (grup I) vs. 32% (grup II);

SASO unic predictor de FAIndependent vrst, sex, HTA, IMC;

Prevalena FA la pac cu SASO sever X 4;

Incidena recurenelor FA dup EE scade la cei cu CPAP.

Gami A. et al. Association of atrial fibrillation and obstructive sleep apneea. Circulation 2004;110:364-367.

Fibrilaia atrial565656Presence of OSA predispose to the developpment of Afib

Apoor S et al, J Am Coll Cardiol, 2007

Obezitatea SASOFactori de risc independeni !Probabilitatea incidenei FA la pac.< 65 ani

TERAPIA CU CPAPDeschide CRS si previne colapsul acestora.Ischemia nocturna este ameliorata si activitatea simpatica este .Imbunatateste controlul HTA nocturne si diurne.Ameliorand ischemia, imbunatateste FE & statusul functional in SASO asociata cu insuf. cardiaca.Scade postsarcinaStudiile observationale au aratat evenimentelor cv

PAP therapy is effective in relieving symptoms in some OSA patients with nocturnal myocardial ischemia or angina. In patients with heart failure and OSA, PAP causes direct improvements in left ventricular systolic function and, over several months of therapy, leads to increased left ventricular ejection fraction and improved functional status.[15] Long-term observational studies have suggested that OSA patients who use PAP are at decreased risk of major adverse cardiovascular events, such as myocardial infarction, coronary revascularization, stroke, and death Mayo clinic cardiology 3rd edBraunwalds heart disease 8th ed..585858Preventing ypper airways from collapsing when muscular tone drop during sleep.CPAP SOLUIE N ARITMII CARDIACE BENIGNE I MALIGNEPrin eliminarea pauzelor respiratorii, CPAP reduce activitatea simpatica si s-a demonstrat ca astfel creste fractia de ejectie a VS cu 8%.

CPAP: poate determina reversia opririi sinusale si a blocului AV

Reduce recurenta fibrilatiei atriale postcardioversie

dilatarea si disfunctia VD in concordanta cu severitatea apneei s-au ameliorat cu CPAP

FA poate persista datorita unei compliante inadecvate la CPAP.

JACC Vol. 47, No. 7, 2006(1)

Sleep Medicine Reviews, Vol, 2, No. 1, pp 45-60, 1998(7)NEJM 2003;348:123359High prevalence of cardiovascular events in patients with OSArisk of a cardiovascular events higher in patients with untreated OSA

Treatment can lower risk of cardiovascular events in sleep apnea patientsCONCLUSIONIn ansamblu, studiile recente demonstreaza utilitatea tratamentului cu presiune pozitiva si rolul compliantei la CPAP in imbunatatirea controlului medicamentos si ameliorarea prognosticului pacientilor cu apnee de somn si afectiuni cardiovasculare.APNEEA DE SOMN SI DIABETUL

ASOCIERE BIDIRECTIONALA

1. Apneea de somn poate contribui la aparitia DZ 2 Sleep Heart Health Study relatie independenta intre SAS si DZ 2

2. Pacientii cu diabet si neuropatie autonoma (vegetativa) au mai frecvent apnee de somn care poate fi consecinta neuropatiei locale. Diabeticii cu neuropatie au sensibilitate modificata la CO2, fiind predispusi la respiratie periodica.

Downloaded from: Principles and Practice of Sleep Medicine (on 30 September 2006 01:37 PM) 2005 Elsevier SAOS poate contribui la aparitia DZ 264

III. APNEEA DE SOMN SI BRGESAOS = obstructia repetata a caii aeriene superioare in timpul somnului, soldata cu scaderea saturatiei oxigenului arterial si numeroase treziri.Pacientii cu apnee de somn prezinta o incidenta crescuta a BRGE.Factori de risc comuni : obezitatea, consumul de alcool si benzodiazepine, hernia hiatala.

Apneea favorizeaza refluxul prin contractiile repetate si ample ale diafragmului si prin oscilatiile presiunii intratoracice.Graf KI, Karaus M, Heinemann S, et al: Gastroesophageal reflux in patients with sleep apnea syndrome. Gastroenterol 1995; 33:689-693

APNEEA DE SOMN SI BRGETratamentul apneei cu presiune pozitiva pe masca nazala aduce un beneficiu terapeutic suplimentar, ameliorand semnificativ refluxul nocturn.

In sens invers, refluxul poate favoriza producerea apneei prin iritatia si inflamatia produsa la nivelul mucoasei cailor respiratorii superioare.

S-a demonstrat ca trat. cu esomeprazol timp de o luna a dus la reducerea semnificativa a numarului de apnei pe ora de somn.

Green BT, Broughton WA, O'Connor JB: Marked improvement in nocturnal gastroesophageal reflux in a large cohort of patients with obstructive sleep apnea treated with continuous positive airway pressure. Arch Intern Med 2003;163:41-45