OBJECTIVE:To assess the efficacy of a mandibular advancement prosthesis for treating obstructive sleep apnea syndrome (OSAS). METHOD:Mandibular advancement appliances were prescribed for 21 patients (20 men) with OSAS diagnosed by polysomnography. Mean age was 51 (8) years, BMI was 30 (4) kg/m2, and the apnea-hypopnea index (AHI) per hour was 48 (17). If the device was well tolerated, regardless of clinical response, polysomnography was repeated between 1 to 3 months after start of treatment. The device was considered effective if the AHI decreased to < 15/h and symptoms related to OSAS disappeared. RESULTS:Seven patients withdrew from treatment after only a few days. The remaining 14 (66%) tolerated treatment well and the second polysomnogram was performed. In six of the 14 (43%), the device proved effective for correcting OSAS. In six more patients, the AHI decreased but failed to become normal. In the remaining two patients, no improvement was observed. Improvement in the AHI was unrelated to severity of OSAS. CONCLUSION:The mandibular advancement prosthesis is effective for some patients with OSAS, including those in whom the AHI is high. Larger studies are needed to allow us to define the type of patients that might benefit.

To assess the efficacy of a mandibular advancement prosthesis for treating obstructive sleep apnea syndrome (OSAS).Mandibular advancement appliances were prescribed for 21 patients (20 men) with OSAS diagnosed by polysomnography. Mean age was 51 (8) years, BMI was 30 (4) kg/m2, and the apnea-hypopnea index (AHI) per hour was 48 (17). If the device was well tolerated, regardless of clinical response, polysomnography was repeated between 1 to 3 months after start of treatment. The device was considered effective if the AHI decreased to < 15/h and symptoms related to OSAS disappeared.Seven patients withdrew from treatment after only a few days. The remaining 14 (66%) tolerated treatment well and the second polysomnogram was performed. In six of the 14 (43%), the device proved effective for correcting OSAS. In six more patients, the AHI decreased but failed to become normal. In the remaining two patients, no improvement was observed. Improvement in the AHI was unrelated to severity of OSAS.The mandibular advancement prosthesis is effective for some patients with OSAS, including those in whom the AHI is high. Larger studies are needed to allow us to define the type of patients that might benefit.

BACKGROUND:Acute respiratory insufficiency (ARI) with alveolar hypoventilation or incapacitating dyspnoea but without peripheral muscle involvement can be an early manifestation of respiratory involvement in amyotrophic lateral sclerosis (ALS). Some of these patients benefit from assisted ventilation. The object of this study was to analyse the results of long-term mechanical ventilation (LTMV) in ten patients with ALS.METHODS:A retrospective analysis of intensive care unit (ICU) or ambulant patients with ALS who underwent LTMV in a conventional hospital ward was performed. Erect and supine spirometry, blood gas analysis and pulse oximetry were performed before the start and during the course of ventilation.RESULTS:Ten patients on LTMV were included. Four from the ICU were ventilated via tracheostomy, and six ambulant patients had non-invasive (nasal) ventilation. In all cases, ventilation was performed in a conventional hospital ward. The ambulant patients improved symptomatically during ventilation, confirmed by measurement of gas exchange and of SaO2 by continuous pulse oximetry. Three of the ten patients survive in long-term care--two with nasal and one with tracheostomy ventilation.CONCLUSIONS:LTMV outside ICU was possible in ten patients, seven of whom returned home. Returning home is very difficult for patients dependent on a ventilator who lack family support.

The acceptance of transtracheal catheters (TTC) in chronic obstructive pulmonary disease (COPD) patients with severe hypoxaemia was analysed and the adverse events associated with this system of oxygenation described. Once the TTC (Oxycat) was inserted, each patient was monitored on an outpatient basis and information about the associated adverse events was collected. In a group of 70 patients that met the inclusion criteria, only 14 (20%) accepted TTC insertion. The observed adverse events were: haemorrhage through the stoma (3); ejection of the TTC in a cough reflex (2); subcutaneous emphysema (2); mucous plugging (1); and haemoptysis (1). Removal of the TTC was necessary in 29% of the cases, and was associated with the onset of an adverse event in all cases except one. Despite the proven benefits of oxygen therapy performance and the improvement in effort tolerance, transtracheal catheter has a low level of acceptance among patients with extremely disabling diseases. The adverse events observed were frequent, but could have been corrected and in no case worsened our patients' prognosis.

BACKGROUND--Tuberculous pleurisy can result in pleural fibrosis, calcification and thickening. To prevent these complications, corticosteroids are frequently used in addition to antituberculous drugs; however, new therapeutic regimens can control the disease and minimise the sequelae, and there is no convincing evidence of the benefit of the use of corticosteroids as adjuvant therapy. METHODS--Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Additionally, they were randomly assigned to a double blind treatment with either prednisone (1 mg/kg/day for 15 days and then tapering off) or placebo during the first month of treatment. Different clinical, radiological, and functional parameters were evaluated to assess the effect of corticosteroids. RESULTS--Fifty seven patients received prednisone and 60 placebo. At the end of the treatment the clinical outcome, the rate of reabsorption of the pleural fluid, the pleural sequelae, as well as lung capacity were similar in both groups. CONCLUSIONS--Corticosteroids do not influence the clinical outcome or the development of long term pleural sequelae in tuberculous pleurisy.

BACKGROUND:Tuberculous pleurisy is associated with small numbers of bacteria. Due to the low rate of primary resistance to antituberculous drugs a two-drug regimen was used to treat the condition.METHODS:Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Clinical, radiological, and haematological assessments were performed during treatment and patients were followed up for a median period of 41 (range 6-96) months.RESULTS:One hundred and thirty patients were studied with a mean age of 27 (range 11-53) years. Seven were withdrawn due to parenchymal disease and eight were lost to follow up during the treatment period. Side effects during treatment were frequent (20.7%), but only three patients required a change in medication. No treatment failures were observed. One hundred and fifteen patients completed therapy and were followed up for 41 (range 6-96) months with no evidence of a relapse.CONCLUSIONS:Tuberculous pleurisy responds well to a two-drug regimen of antituberculous therapy given for six months.

1. Comprobar si un tratamiento de seis meses con dos fármacos bactericidas es suficiente en la pleuritis tuberculosa sin lesión parenquimatosa. 2. Observar los efectos de la corticoterapia en la pleuritis tuberculosa. El objetivo es el de investigar cuáles son los efectos de la corticoterapia en la pleuritis tuberculosa (PT) junto a un tratamiento de seis meses con dos fármacos bactericidas. Se han estudiado 29 pacientes diagnosticados de PT con evidencia bacteriológica o histológica de pleuritis tuberculosa o bien mediante líquido pleural linfocitario, intradermorreacción (PPD) positiva o una cifra superior a 0,75 Kat/litro en líquido pleural. En ningún caso se observó una lesión parenquimatosa ni presencia de bacilo de Koch en las secreciones bronquiales ni en el aspirado gástrico. A todos los pacientes se les dio un tratamiento de isoniacida de 5 mg/kg/día (sin sobrepasar los 300 mg/día), rifampicina 10 mg/Kg/día (sin sobrepasar los 600 mg/ día) durante seis meses. De forma aleatorizada a doble ciego se añadía prednisolona (o placebo) a dosis de 1 mg/kg/día durante 15 días y reduciendo la dosis hasta completar un mes. Hemos controlado la temperatura, el hemograma, la función hepática, la radiografía de tórax y la espirometría al mes, a los seis meses y al año. Las diferencias entre los dos grupos han sido analizadas mediante el test de Mann-Whitney y el Fisher exact test. La edad media es de 28 (11-53) años, 24 varones y 11 mujeres, siendo 23 incluidos en el grupo con prednisona y 24 con placebo. En la tabla se resumen los resultados.Media días T.a > 37 °CEngrosamiento pleural máximo ≥: 0,5 cmFVC < 80%1 m6 m12 m1 m> 6mPred (n=23)216/239/232/173/85/23Placebo (n=24)821/2411/2410/194/73/24p = 0,002NSNSp = 0,02NSNS La media de los días con fiebre es menor en el grupo de pacientes tratados con prednisona. El engrosamiento pleural es el mismo en los dos grupos durante los 6 primeros meses aunque existen diferencias al año, que no se reflejan en la espirometría. Teniendo en cuenta que los beneficios que se esperan de los corticoides en la PT es el evitar la paquipleuritis, de acuerdo con estos resultados no está justificado su uso de forma sistemática. Únicamente en casos en que el síndrome febril provoque una situación clínica mal tolerada.

Los riesgos de la administración aguda de oxígeno se refieren a los efectos secundarios precoces, como la hipercapnia o las atelectasias por absorción y al daño tisular, como la citotoxicidad pulmonar o la retinopatía de los prematuros. No se han demostrado riesgos relacionados con la administración crónica de oxígeno en pacientes estables. La oxigenoterapia crónica no incrementa significativamente la PaC02 ni se reconocen lesiones tisulares atribuibles al tratamiento. El riesgo de explosión puede minimizarse con unas precauciones elementales. El mal funcionamiento de las fuentes de oxígeno pueden condicionar la efectividad del tratamiento, especialmente en el caso del concentrador si no se somete a revisiones periódicas. Los accesorios utilizados para recibir oxígeno pueden producir irritación local, especialmente si se administran flujos elevados. Pueden producirse fugas en los tubos acodados o con múltiples conexiones. El uso de humidificadores no está justificado en la mayoría de pacientes, siendo además otra fuente de fugas. El catéter transtraqueal (CTT) es una forma invasiva de administrar oxígeno muy eficaz pero que plantea problemas en el momento de la insercisón (enfisema subcutáneo, hematoma, broncoespasmo), o a largo plazo (tapones de moco alrededor del CTT o las infecciones locales). The risks of the acute administration of oxygen refer to early secondary effects such as hypercapnia or atelectasis by absorption and to tissue damage as in pulmonary cytotoxicity or retinopathy of premature newborns. No risks related with the chronic administration of oxygen have been demonstrated in stable patients. Chronic oxygen therapy does not significantly increase PaC02, nor have tissue lesions attibutable to this treatment been recognized. The risk of explosion may be minimized by elemental precautions. Bad functioning of the sources of oxygen may condition the efficacy of the treatment specially in the case of the concentrator if not submitted to periodic revision. The accessories used for receiving oxygen may produce local irritation, specialy if high flows are administered. Leaks may be produced in jointed tubes or in those with multiple connections. The use of humidifiers is not justified in most patients, and is rather, another source of leaks. The transtracheal catheter (TTC) is a very effective invasive form of administering oxygen but presents problems at the time of inserction (subcutaneous emphysema, hematoma, bronchospasm) or during long term administration (blockage by mucous around the TTC or local infections).

BACKGROUND: The oxygen conserving valve (OCV) permits reduction in oxygen consumption upon the release of oxigen only during inhalation thereby increasing the autonomy of portable sources.METHODS: In order to confirm its efficacy during exercise, 15 patients with chronic limitation of air flow and gasometric criteria of domiciliary oxigenotherapy were selected. The patients underwent three walking tests (WT) of 6 minutes during which the continuous form of transcutaneous hemoglobin saturation (SaO2) and the distance covered were registered. The first was carried out breathing synthetic air at a flow of 2 liters per minute; the second with continuous oxygen released by a portable source at 2 liters per minute and the third with the OCV coupled to a portable source at the same flow.RESULTS: SaO2 reached with the continuous oxygen is significantly higher to that of synthetic air while there was no difference between the SaO2 with continuous oxygen and with valve. Improvement in SaO2 upon use the valve was obtained in only 2 of the 15 patients. A significant increase was observed in the distance covered upon oxygen administration not only in the continuous form but also with OCV with respect to synthetic air.CONCLUSIONS: OCV is as effective as continuous oxygen in the correction of desaturation during exercise, however its indications must be individualized by exercise tests (WT) in each patients in order to ensure its correct functioning.

El síndrome de la apnea obstructiva del sueño se produce por la oclusión recurrente de las vías respiratorias altas durante la noche. El tratamiento inicial de elección es la aplicación de la presión continua por vía nasal, que evita el colapso de las estructuras blandas de la orofaringe. La presión la genera un flujo de aire que se aplica en la nariz a través de una mascarilla. Las complicaciones y efectos secundarios de esta forma terapéutica son mínimos pero al ser una terapia de larga duración pueden representar un inconveniente para su continuidad. Presentamos un caso en el que el flujo de aire durante una noche, produjo una conjuntivitis aguda debido en parte a la especial anatomía de los pómulos. La utilización de un sistema denominado ADAM, con dos salidas de aire aplicadas a cada uno de los orificios de la nariz, es una alternativa a la mascarilla, que en nuestro caso ha permitido continuar con el tratamiento. The obstructive apnea syndrome during sleep is produced by a recurrent occlusion of the upper respiratory ways which takes place during night. The initial elective treatment consists on the application of a continuous positive nasal-airway pressure system in order to impede collapse of soft structures of the oropharynx. Pressure is generated by an airflow that is applied to the nose by means of a mask. Complications and secondary effects of this therapeutic technique are minimal. However, due to the long duration of this treatment, these complications may represent an inconvenient for treatment continuity. We present a case in which airflow during night produced a conjunctivitis. A contributory factor was the particular cheekbone anatomy. The ADAM system which has two airflow exits applied at each nose hole is an alternative to the mask. In our patient this system allowed continuation of the treatment.