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Doctoral Thesis
DOI
https://doi.org/10.11606/T.5.2017.tde-23082017-122123
Document
Author
Full name
Bruno Caldin da Silva
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2017
Supervisor
Committee
Elias, Rosilene Motta (President)
Canziani, Maria Eugenia Fernandes
Drager, Luciano Ferreira
Lorenzi Filho, Geraldo
Title in Portuguese
Meias elásticas compressivas versus CPAP na apneia do sono em pacientes em hemodiálise: um estudo prospectivo e randomizado 
Keywords in Portuguese
Apneia obstrutiva do sono
Faringe/histologia
Fibras musculares
Músculo constritor superior da faringe
Músculo esquelético
Músculo palatofaríngeo
Abstract in Portuguese

Introdução: Apneia Obstrutiva do Sono (AOS) é prevalente em estados edematosos, especialmente em pacientes em hemodiálise (HD). Uma vez que o deslocamento noturno de fluidos (DNF) acarreta piora da AOS, nós elaboramos a hipótese de que a interferência na redistribuição de fluidos pelo uso de meias elásticas compressivas (MEC) atenuaria a gravidade da AOS, por mecanismos diferentes em comparação à terapia padrão para AOS, a pressão positiva em vias aéreas (CPAP).

Métodos: este é um estudo randomizado e cross-over, que incluiu 14 pacientes dialíticos com AOS (índice de apneia/hipopneia - IAH > 5 eventos/hora) em exame de polissonografia (PSG), que era realizada em três momentos: basal, titulação de CPAP e após uma semana de uso diário de MEC. Circunferência cervical (CC), bioimpedância elétrica segmentar e variabilidade de frequência cardíaca (VFC) foram avaliadas antes e após cada exame de PSG.

Resultados: A idade média foi 53±9 anos (57% de homens) e o índice de massa corporal foi 29,7±6,8 Kg/m². O IAH foi reduzido de 20,8 (14,2; 39,6) no exame basal para 7,9 (2,8; 25,4) durante titulação de CPAP e para 16,7 (3,5; 28,9) eventos/hora após uso de MEC (CPAP vs. basal, p=0,004; MEC vs. basal, p=0,017; e CPAP vs. MEC, p=0.017). Comparando basal, CPAP e MEC, o conteúdo de água noturna em membros inferiores foi menor com MEC (p=0,04), enquanto a água intracelular noturna em tronco foi maior (p=0,03). DNF basal, com CPAP e MEC foi de -183±72, -343±220, e -290±213ml, respectivamente (p=0,006). Houve aumento da circunferência cervical durante a noite durante o exame basal (0,7±0,4 cm), mas houve redução dessa circunferência após titulação com CPAP (-1,0±0,4 cm) e após uso de MEC (-0,4±0,8 cm) (CPAP vs. basal, p<0.0001; MEC vs. basal, p=0.001; CPAP vs. MEC, p=0.01). VFC, avaliada pelos componentes de alta e baixa frequência, demonstrou menor ativação simpática durante o exame de titulação de CPAP: OR: 11 (95% CI: 1,06 - 114,2), p=0,025, mas não com MEC: OR: 7,8 (95% CI: 0,75 - 82,2), p=0,059.

Conclusões: tanto o CPAP quanto MEC melhoraram AOS em pacientes em HD, mas por mecanismos distintos: enquanto o CPAP reduziu o edema de vias aéreas superiores, ao exercer pressão local, o uso de MEC reduziu o DNF, ao evitar retenção de fluidos em membros inferiores, acumulando água no componente intracelular do tronco. Ativação simpática foi somente reduzida com uso de CPAP.

Title in English
Histological comparison between fibers of the palatopharyngeal and superior pharyngeal constrictor muscles in individuals with and without obstructive sleep apnea
Keywords in English
Obstructive sleep apnea
Palatopharyngeal muscle
Pharinx/etiopathogenesis
Pharynx/histology
Skeletal muscle
Superior pharyngeal constrictor muscle
Abstract in English

Background: Obstructive Sleep Apnea (OSA) is prevalent in edematous states, notably in hemodialysis (HD) patients. Once overnight fluid shift (OFS) augments OSA, we hypothesized that interfering in fluid redistribution by wearing compression stockings (CS) would attenuate OSA severity by different mechanisms in comparison to the standard treatment to OSA, the positive airway pressure (CPAP).

Methods: This is a randomized crossover study that included 14 dialytic patients with OSA (apnea/hypopnea index - AHI >5 events/hour) by polysomnography (PSG), which was performed in three moments: at baseline, for CPAP titration, and one week after daily wearing of CS. Neck circumference (NC), segmental bioelectrical impedance and heart rate variability (HRV) were assessed before and after each PSG.

Results: Mean age was 53±9 years (57% men) and body mass index was 29.7±6.8 kg/m2. AHI decreased from 20.8 (14.2; 39.6) at baseline to 7.9 (2.8; 25.4) during CPAP titration and to 16.7 (3.5; 28.9) events/hour after wearing CS (CPAP vs. baseline, p=0.004; CS vs. baseline, p=0.017; and CPAP vs. CS, p=0.017). Comparing baseline, CPAP and CS, nocturnal lower limbs water content was lower with CS (p=0.04), while nocturnal intracellular trunk water was higher (p=0.03). OFS at baseline, CPAP and CS was -183±72, -343±220, and -290±213ml, respectively (p=0.006). Overnight NC variation increased at baseline (0.7±0.4 cm), but decreased after CPAP titration (-1.0±0.4 cm) and while wearing CS (-0.4±0.8 cm) (CPAP vs. baseline, p<0.0001; CS vs. baseline, p=0.001; CPAP vs. CS, p=0.01). HRV, assessed by both high and low frequency components, showed a lower sympathetic activation during CPAP titration: OR: 11 (95% CI: 1.06 - 114.2), p=0.025, but not with CS: OR: 7,8 (95% CI: 0.75 - 82.2), p=0.059

Conclusions: Both CPAP and CS improved OSA in HD patients by different mechanisms: while CPAP reduced edema in upper airways by exerting local pressure, wearing CS reduced OFS by avoiding fluid retention in the legs, accumulating water in the intracellular component of the trunk. Sympathetic activation was decreased only with CPAP.

 
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Publishing Date
2017-08-23
 
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