Brazilian Journal of Pulmonology

ISSN (on-line): 1806-3756 | ISSN (printed): 1806-3713


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Obstructive sleep apnea: a contagious disease?

Apnéia obstrutiva do sono: uma doença contagiosa?

Denis Martinez

J Bras Pneumol.2006;32(2):9-10

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Sleep disordered breathing concomitant with fibromyalgia syndrome

Coexistência de transtornos respiratórios do sono e síndrome fibromiálgica

Dienaro Germanowicz, Magali Santos Lumertz, Denis Martinez, Ane Freitas Margaretes

J Bras Pneumol.2006;32(4):333-338

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Objective: To identify fibromyalgia syndrome in patients with sleep disordered breathing. Method: We studied 50 patients seeking treatment at a sleep disorder clinic for snoring, apnea and excessive daytime sleepiness. Sleep disordered breathing was diagnosed through the use of polysomnography. To diagnose fibromyalgia syndrome, patients were evaluated in accordance with the criteria established by the American College of Rheumatology. Results: Of the 50 patients, 32 were male. The mean (± standard deviation) age of the group was 50 ± 12 years. The mean body mass index was 29.7 ± 5.6 kg/m2. The mean apnea-hypopnea index was 36 ± 29 attacks of apnea or hypopnea per hour of sleep. Of the 18 women and 32 men evaluated, 9 and 2, respectively, met the American College of Rheumatology criteria for fibromyalgia syndrome. Conclusion: Considering the fact that the prevalence of fibromyalgia syndrome in the general population is 0.5% for men and 3.4% for women, the more than ten-fold higher proportion of fibromyalgia cases seen in this sample supports the hypothesis that there is an association between sleep disordered breathing and fibromyalgia syndrome.


Keywords: Respiration disorders/complications; Fibromyalgia/complications; Sleep apnea, obstructive; Polysomnography


Diagnosis of circadian rhythm sleep disorders

Diagnóstico dos transtornos do sono relacionados ao ritmo circadiano

Denis Martinez, Maria do Carmo Sfreddo Lenz, Luiz Menna-Barreto

J Bras Pneumol.2008;34(3):173-180

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Insomnia and excessive sleepiness are common in the investigation of sleep-disordered breathing. Circadian rhythm sleep disorders are perhaps the most often overlooked conditions in the differential diagnosis of these symptoms. Circadian rhythm sleep disorders manifest as misalignment between the sleep period and the physical/social 24-h environmental cycle. The two most prevalent circadian rhythm sleep disorders are delayed sleep phase (common in adolescents) and advanced sleep phase (common in the elderly), situations in which the sleep period is displaced to a later or earlier time, respectively. It is important to keep these two disorders in mind, since they can be confused with insomnia and excessive sleepiness. However, there are nine possible diagnoses, and all nine are of clinical interest. Since light is the principal cue used in synchronizing the biological clock, blind individuals and night-shift/swing-shift workers are more prone to develop circadian rhythm sleep disorders. In this article, the new international classification of circadian rhythm sleep disorders is reviewed.


Keywords: Circadian rhythm; Sleep disorders; Sleep initiation and maintenance disorders; Sleep stages; Sleep apnea syndromes.


Dimensions of sleepiness and their correlations with sleep-disordered breathing in mild sleep apnea

Dimensões da sonolência e suas correlações com os transtornos respiratórios do sono na apneia do sono leve

Denis Martinez, Magali Santos Lumertz, Maria do Carmo Sfreddo Lenz

J Bras Pneumol.2009;35(6):507-514

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Objective: There are many ways of assessing sleepiness, which has many dimensions. In patients presenting a borderline apnea-hypopnea index (AHI, expressed as events/hour of sleep), the mechanisms of excessive daytime sleepiness (EDS) remain only partially understood. In the initial stages of sleep-disordered breathing, the AHI might be related to as-yet-unexplored EDS dimensions. Methods: We reviewed the polysomnography results of 331 patients (52% males). The mean age was 40 ± 13 years, and the mean AHI was 4 ± 2 (range, 0-9). We assessed ten potential dimensions of sleepiness based on polysomnography results and medical histories. Results: The AHI in non-rapid eye movement (NREM) stage 1 sleep (AHI-N1), in NREM stage 2 sleep (AHI-N2), and in REM sleep (AHI-REM) were, respectively, 6 ± 7, 3 ± 3 and 10 ± 4. The AHI-N2 correlated significantly with the greatest number of EDS dimensions (5/10), including the Epworth sleepiness scale score (r = 0.216, p < 0.001). Factor analysis, using Cronbach's alpha, reduced the variables to three relevant factors: QUESTIONNAIRE (α = 0.7); POLYSOMNOGRAPHY (α = 0.68); and COMPLAINTS (α = 0.55). We used these factors as dependent variables in a stepwise multiple regression analysis, adjusting for age, gender, and body mass index. The AHI-N1 correlated significantly with POLYSOMNOGRAPHY (β = −0.173, p = 0.003), and the AHI-N2 correlated significantly with COMPLAINTS (β = −0.152, p = 0.017). The AHI-REM did not correlate with any factor. Conclusions: Our results underscore the multidimensionality of EDS in mild sleep apnea.


Keywords: Disorders of excessive somnolence; Sleep apnea syndromes; Sleep, REM; Polysomnography.


Sleep-disordered breathing in patients with cystic fibrosis

Distúrbios respiratórios do sono em pacientes com fibrose cística

Jefferson Veronezi1,2, Ana Paula Carvalho3, Claudio Ricachinewsky4, Anneliese Hoffmann4, Danielle Yuka Kobayashi5, Otavio Bejzman Piltcher6, Fernando Antonio Abreu e Silva7, Denis Martinez1,2,8

J Bras Pneumol.2015;41(4):351-357

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Objective: To test the hypothesis that disease severity in patients with cystic fibrosis (CF) is correlated with an increased risk of sleep apnea. Methods: A total of 34 CF patients underwent clinical and functional evaluation, as well as portable polysomnography, spirometry, and determination of IL-1β levels. Results: Mean apnea-hypopnea index (AHI), SpO2 on room air, and Epworth Sleepiness Scale score were 4.8 ± 2.6, 95.9 ± 1.9%, and 7.6 ± 3.8 points, respectively. Of the 34 patients, 19 were well-nourished, 6 were at nutritional risk, and 9 were malnourished. In the multivariate model to predict the AHI, the following variables remained significant: nutritional status (β = −0.386; p = 0.014); SpO2 (β = −0.453; p = 0.005), and the Epworth Sleepiness Scale score (β = 0.429; p = 0.006). The model explained 51% of the variation in the AHI. Conclusions: The major determinants of sleep apnea were nutritional status, SpO2, and daytime sleepiness. This knowledge not only provides an opportunity to define the clinical risk of having sleep apnea but also creates an avenue for the treatment and prevention of the disease.


Keywords: Cystic fibrosis; Oxygenation; Sleep apnea, obstructive.


Effects of exercise on sleep symptoms in patients with severe obstructive sleep apnea

Efeitos do exercício nos sintomas do sono em pacientes com apneia obstrutiva do sono

Roberto Pacheco da Silva1,a, Denis Martinez1,2,3,b, Kelly Silveira da Silva Bueno1,c, Jhoana Mercedes Uribe-Ramos2,d

J Bras Pneumol.2019;45(3):e20180085-e20180085

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Objective: To investigate the extent to which exercise is associated with symptoms in patients with severe obstructive sleep apnea (OSA). Methods: We included subjects with an apnea-hypopnea index (AHI) > 30 events/h who completed validated sleep and exercise questionnaires. We compared symptom frequency/scores between exercisers and nonexercisers, adjusting for the usual confounders. Results: The sample included 907 nonexercisers and 488 exercisers (mean age, 49 ± 14 years; mean AHI, 53 ± 20 events/h; 81% men). Nonexercisers and exercisers differed significantly in terms of obesity (72% vs. 54%), the mean proportion of sleep in non-rapid eye movement stage 3 sleep (9 ± 8% vs. 11 ± 6%), and tiredness (78% vs. 68%). Nonexercisers had a higher symptom frequency/scores and poorer sleep quality. Adjustment for exercise weakened the associations between individual symptoms and the AHI, indicating that exercise has a mitigating effect. In binary logistic models, exercise was associated with approximately 30% lower adjusted questionnaire1 score > 2, tiredness; poor-quality sleep, unrefreshing sleep, and negative mood on awakening. Although the odds of an Epworth Sleepiness Scale score > 10 were lower in exercisers, that association did not withstand adjustment for confounders. Conclusions: Exercise is associated with lower frequency/intensity of symptoms in patients with severe OSA. Because up to one third of patients with severe OSA might exercise regularly and therefore be mildly symptomatic, it is important not to rule out a diagnosis of OSA in such patients.


Keywords: Sleep apnea syndromes; Exercise; Sleepiness; Polysomnography.


Uncoupling protein-2 mRNA expression in mice subjected to intermittent hypoxia

Expressão do mRNA da uncoupling protein-2 em camundongos submetidos à hipóxia intermitente

Luciana Rodrigues Vieira, Denis Martinez, Luiz Felipe Forgiarini, Darlan Pase da Rosa, Gustavo Alfredo Ochs de Muñoz, Micheli Fagundes, Emerson Ferreira Martins, Carolina Caruccio Montanari, Cintia Zappe Fiori

J Bras Pneumol.2015;41(2):167-174

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Objective: To investigate the effect of intermittent hypoxia-a model of obstructive sleep apnea (OSA)-on pancreatic expression of uncoupling protein-2 (UCP2), as well as on glycemic and lipid profiles, in C57BL mice. Methods: For 8 h/day over a 35-day period, male C57BL mice were exposed to intermittent hypoxia (hypoxia group) or to a sham procedure (normoxia group). The intermittent hypoxia condition involved exposing mice to an atmosphere of 92% N and 8% CO2 for 30 s, progressively reducing the fraction of inspired oxygen to 8 ± 1%, after which they were exposed to room air for 30 s and the cycle was repeated (480 cycles over the 8-h experimental period). Pancreases were dissected to isolate the islets. Real-time PCR was performed with TaqMan assays. Results: Expression of UCP2 mRNA in pancreatic islets was 20% higher in the normoxia group than in the hypoxia group (p = 0.11). Fasting serum insulin was higher in the hypoxia group than in the normoxia group (p = 0.01). The homeostasis model assessment of insulin resistance indicated that, in comparison with the control mice, the mice exposed to intermittent hypoxia showed 15% lower insulin resistance (p = 0.09) and 21% higher pancreatic β-cell function (p = 0.01). Immunohistochemical staining of the islets showed no significant differences between the two groups in terms of the area or intensity of α- and β-cell staining for insulin and glucagon. Conclusions: To our knowledge, this is the first report of the effect of intermittent hypoxia on UCP2 expression. Our findings suggest that UCP2 regulates insulin production in OSA. Further study of the role that UCP2 plays in the glycemic control of OSA patients is warranted.


Keywords: Blood glucose; Sleep apnea syndromes; Pancreas; Glucagon-secreting cells.


Obstructive sleep apnea-hypopnea syndrome: association with gender, obesity and sleepiness-related factors

Síndrome das apnéias-hipopnéias obstrutivas do sono: associação com gênero e obesidade e fatores relacionados à sonolência

Marli Maria Knorst, Fábio José Fabrício de Barros Souza, Denis Martinez

J Bras Pneumol.2008;34(7):490-496

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Objective: To study the effects that gender and obesity have on excessive daytime sleepiness (EDS) in individuals with obstructive sleep apnea-hypopnea syndrome (OSAHS), as well as to identify factors associated with EDS in such individuals. Methods: A total of 300 consecutive patients who completed the clinical evaluation satisfactorily and whose polysomnography showed an apnea-hypopnea index (AHI) > 10 events/hour of sleep were selected from a sleep clinic population for inclusion in the study. Results: Mean age was 47 ± 11 years, and mean AHI was 52.1 ± 29.2 events/hour of sleep. Females presented higher mean age, lower EDS scores and less time in apnea . Mean EDS score was 14.7 ± 7.2. The EDS score correlated best with body movements (r = 0.43; p < 0.01), respiratory events during sleep (r = 0.40; p < 0.01), duration of apnea (r = 0.40; p < 0.01), peripheral oxygen saturation (SpO2; r = -0.38; p < 0.01) and AHI (r = 0.37; p < 0.01). Mean body mass index (BMI) was 30.2 ± 5.3 kg/m2. Overweight, obesity and morbid obesity were observed in 41, 44 and 5.3% of cases, respectively. Disease severity correlated most strongly with BMI (r = 0.51; p < 0.01). Conclusions: Higher mean age, lower EDS scores and less time spent in sleep apnea time in apnea were associated with being female. Fragmented sleep, number/duration of respiratory events during sleep, SpO2 levels and obesity were associated with sleepiness. The BMI had a significant effect on OSAHS severity.


Keywords: Sleep apnea, obstructive; Sleep apnea syndromes; Polysomnography; Sleep stages; Obesity.




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