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Perturbação respiratória do sono em crianças e adolescentes com fibrose quística
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Introdução:
As alterações do sono são frequentes em doentes com fibrose quística (FQ). Estudos realizados em populações adultas mostraram que existem alterações significativas na qualidade do sono, frequentemente relacionadas com a doença pulmonar desta patologia. Na idade pediátrica são escassos os trabalhos sobre o sono e os dados que existem são contraditórios: enquanto alguns estudos indicam que existem alterações da oximetría noturna associadas à deterioração da função respiratória, a maioria dos autores considera que a gravidade da doença respiratória na FQ não se correlaciona com a gravidade das alterações estruturais do sono.
A determinação da incidência de perturbação respiratória de sono nesta população e a correlação com dados clínicos e de função respiratória podem ser preditivos da sua ocorrência, contribuindo para a intervenção precoce, favorável à melhoria da qualidade de vida destes doentes.
Objetivos: Identificar a presença e o perfil de alterações respiratórias do sono em doentes com FQ em idade pediátrica. Identificar os parâmetros espirométricos (FEV1, FEF25-75, FEV1 /FVC) e de saturação de oxigénio (SpO2) que se associam a alterações respiratórias do sono e podem vir a ser potenciais indicadores de gravidade.
Métodos: Estudo observacional, descritivo e transversal. Contactaram-se as 45 crianças seguidas na consulta do Centro Especializado de FQ do Departamento de Pediatria do Hospital de Santa Maria (HSM) durante o ano de 2013, com idades entre os 6 e os 18 anos e 364 dias. Foi realizada polissonografia (PSG) noturna em laboratório, após avaliação da SpO2 basal, e espirometria no dia seguinte à mesma. Foi aplicado o questionário habitualmente utilizado no Laboratório Pediátrico de Sono. Os resultados foram avaliados por estatística descritiva, coeficientes de correlação de Pearson e os testes Mann-Whitney e K-Smirnov, conforme apropriado. Foi considerado um nível de significância de 5%.
Resultados: Foram incluídos 33 indivíduos, 16 (48,5%) do sexo masculino, com idade mediana de 12 anos (6min-18max). O z-score médio de IMC foi de -0,35 (dp0,78).
Vinte e nove doentes (87,9%) apresentavam queixas em relação à qualidade do sono e/ou alterações respiratórias do mesmo.
Na PSG a eficiência de sono estava reduzida e a latência de sono (LS) e vigília pós sono (VPS) aumentadas. N1 encontrava-se ligeiramente aumentado, N2, N3 e REM normais, tal como o
número e o índice e despertares. O índice de apneia/hipopneia (IAH) médio foi de 0,6/h (dp0,9) e índice de dificuldade respiratória (IDR) médio de 6,6 (dp5,2). O valor médio da SpO2 em vigília (97% (dp1,1)) e durante o sono (95% (dp2,7)) foram normais; o valor mínimo de SpO2 foi de 89% (dp4,1). O índice de dessaturação (ID) médio foi 2,36 (dp2,4). O valor médio da mediana de CO2transcutâneo (TcCO2) foi de 41,2 (dp8,01) e o valor máximo de 45,3 (dp 5,19). Dezassete (51,5%) doentes tiveram tosse noturna, 29 (87,9%) respiração paradoxal e 8 (24,2%) roncopatia. A estratificação para sexo, idade e FEV1 não revelou diferenças significativas. Verificou-se uma associação positiva e moderada entre a SpO2 em vigília e a SpO2 média durante o sono (r=0,326 p=0,064). O IAH relacionou-se negativa e moderadamente com a SpO2 em vigília (r=0,469 p=0,006). Os valores de FEV1 associaram-se positiva e moderadamente com SpO2 média durante o sono (r=0,528 p=0,002). Os achados da PSG associaram-se com os dados do inquérito relativamente aos despertares noturnos e à vigília pós adormecer e à dificuldade respiratória durante o sono e IDR.
Conclusão: Este estudo permitiu verificar que a maioria das crianças com o diagnóstico de FQ tem queixas relativamente à qualidade do sono e presença de perturbação respiratória do sono. A avaliação subjetiva da qualidade de sono destes doentes correlaciona-se com os achados polissonográficos. Nestas crianças, clinicamente estáveis e com doença respiratória ligeira, apesar do registo de escassos eventos de dessaturação noturna, estes associam-se à gravidade da doença respiratória avaliada por espirometria. A associação entre a SpO2 em vigília e a SpO2 média durante o sono e o IAH indica que este parâmetro pode servir de preditor de risco para dessaturação noturna e outros eventos respiratórios. Não encontrámos nesta amostra perturbação respiratória do sono significativa, o que pode refletir bom controlo clínico da doença. É importante confirmar estes resultados em amostras de maiores dimensões.
Introduction: Sleep disorders are common in cystic fibrosis (CF) patients. Studies in adult populations have shown that there are significant changes in sleep quality, often related to respiratory disturbance. Pediatrics studies are scarce and contradictory: while some studies indicate that there are changes in nocturnal oximetry associated with deterioration of pulmonary function, most authors believe that the severity of respiratory disease in CF does not correlate with the severity of the structural changes of sleep. The determination of the incidence of sleep respiratory disturbance (SRD) in this population and of clinical and respiratory function predictive factors is essential for early intervention. Objectives: To identify the presence of respiratory and sleep quality disturbances in CF children and to identify spirometric indices (FEV1, FEF25-75, FEV1/FVC) and SpO2 that are associated with SRD as potential severity predictors. Methods: An observational, descriptive and transversal study was done. Children followed in the Specialized Center for Cystic Fibrosis, Department of Pediatrics, HSM, aged between 6 and 18 years and 364 days were recruited. In-lab polysomnography (PSG) followed by spirometry was carried out. Baseline SPO2 was assessed. The sleep questionnaire (SQ) commonly used in the Pediatric Sleep Laboratory was applied. The results were analyzed with descriptive statistics, correlations by Pearson`s coefficient, Mann-Whitney Test and K - Smirnov test, as appropriate. A significance level of 5% was considered. Results: 33 subjects out of 45 were included, 16 (48,5%) were male, with a median age of 12 years (6-18). The BMI average z-score was -0,35 (sd0,78). 29 patients (87,9%) had complaints about sleep quality and/or respiratory disturbances. In PSG. sleep efficiency was reduced and sleep latency and wake after sleep increased. N1 was slightly increased; N2, N3 and REM were normal, such as the number and the index of awakenings. The apnea/hypopnea Index was 0,6/h (sd0,9) and mean RDI 6,6/h (sd5,2). The mean SpO2 during wakefulness (97% (sd1,1)) and sleep (95% (sd2,7)) were normal, the minimum SpO2 was 89% (sd4,1). The average desaturation index was 2,36/h(sd2,4). The average transcutaneous CO2 median was 41,2mmHg (sd8,01) and the maximum value was 45,3mmHg (sd5,19). Seventeen (51.5 %) patients had nocturnal cough, 29 (87,9%) had paradoxical breathing and 8 (24.2%) snored. The sex, age and FEV1 stratification showed no significant differences. There was a moderate correlation between the waking and the average SpO2 during sleep (r=0.326 p=0.064). FEV1 was positive and moderately associated with average O2 saturation during sleep (r=0.528 p=0.002). The findings of PSG significantly correlate with the SQ data for night awakenings and wake after sleep (p=0.985) and difficulty breathing during sleep and IDR (p=0.722)). Conclusion: This study showed that most children had complaints about sleep quality and the presence of SRD. The subjective assessment of sleep quality in these patients correlates with polysomnographic findings. Although slight, the nocturnal O2 desaturation occurs in these clinically stable, mild respiratory disease children, and was associated with respiratory disease severity assessed by spirometry. The association between SpO2 awake and mean SpO2 during sleep and IAH indicates that this parameter may serve as a risk predictor of nocturnal desaturation and other nocturnal respiratory events. We didn´t found significant RSD which can well reflect a good disease control. It is important to confirm these results in larger samples.
Introduction: Sleep disorders are common in cystic fibrosis (CF) patients. Studies in adult populations have shown that there are significant changes in sleep quality, often related to respiratory disturbance. Pediatrics studies are scarce and contradictory: while some studies indicate that there are changes in nocturnal oximetry associated with deterioration of pulmonary function, most authors believe that the severity of respiratory disease in CF does not correlate with the severity of the structural changes of sleep. The determination of the incidence of sleep respiratory disturbance (SRD) in this population and of clinical and respiratory function predictive factors is essential for early intervention. Objectives: To identify the presence of respiratory and sleep quality disturbances in CF children and to identify spirometric indices (FEV1, FEF25-75, FEV1/FVC) and SpO2 that are associated with SRD as potential severity predictors. Methods: An observational, descriptive and transversal study was done. Children followed in the Specialized Center for Cystic Fibrosis, Department of Pediatrics, HSM, aged between 6 and 18 years and 364 days were recruited. In-lab polysomnography (PSG) followed by spirometry was carried out. Baseline SPO2 was assessed. The sleep questionnaire (SQ) commonly used in the Pediatric Sleep Laboratory was applied. The results were analyzed with descriptive statistics, correlations by Pearson`s coefficient, Mann-Whitney Test and K - Smirnov test, as appropriate. A significance level of 5% was considered. Results: 33 subjects out of 45 were included, 16 (48,5%) were male, with a median age of 12 years (6-18). The BMI average z-score was -0,35 (sd0,78). 29 patients (87,9%) had complaints about sleep quality and/or respiratory disturbances. In PSG. sleep efficiency was reduced and sleep latency and wake after sleep increased. N1 was slightly increased; N2, N3 and REM were normal, such as the number and the index of awakenings. The apnea/hypopnea Index was 0,6/h (sd0,9) and mean RDI 6,6/h (sd5,2). The mean SpO2 during wakefulness (97% (sd1,1)) and sleep (95% (sd2,7)) were normal, the minimum SpO2 was 89% (sd4,1). The average desaturation index was 2,36/h(sd2,4). The average transcutaneous CO2 median was 41,2mmHg (sd8,01) and the maximum value was 45,3mmHg (sd5,19). Seventeen (51.5 %) patients had nocturnal cough, 29 (87,9%) had paradoxical breathing and 8 (24.2%) snored. The sex, age and FEV1 stratification showed no significant differences. There was a moderate correlation between the waking and the average SpO2 during sleep (r=0.326 p=0.064). FEV1 was positive and moderately associated with average O2 saturation during sleep (r=0.528 p=0.002). The findings of PSG significantly correlate with the SQ data for night awakenings and wake after sleep (p=0.985) and difficulty breathing during sleep and IDR (p=0.722)). Conclusion: This study showed that most children had complaints about sleep quality and the presence of SRD. The subjective assessment of sleep quality in these patients correlates with polysomnographic findings. Although slight, the nocturnal O2 desaturation occurs in these clinically stable, mild respiratory disease children, and was associated with respiratory disease severity assessed by spirometry. The association between SpO2 awake and mean SpO2 during sleep and IAH indicates that this parameter may serve as a risk predictor of nocturnal desaturation and other nocturnal respiratory events. We didn´t found significant RSD which can well reflect a good disease control. It is important to confirm these results in larger samples.
Descrição
Tese de mestrado, Ciências do Sono, Faculdade de Medicina, Universidade de Lisboa, 2014
Palavras-chave
Polissonografia Espirometria Fibrose quística Pediatria Teses de mestrado - 2014