Airway surgery for obstructive sleep apnea and partial upper airway obstruction during sleep

This study analyzed the feasibility and efficacy of surgical therapies in patients with sleep-disordered breathing ranging from partial upper airway obstruction during sleep to severe obstructive sleep apnea syndrome. The surgical procedures evaluated were tracheostomy, laser-assisted uvulopalatoplasty (LUPP) and uvulopalatopharyngoplasty (UPPP) with laser or ultrasound scalpel. Obstructive sleep apnea and partial upper airway obstruction during sleep were measured with the static charge-sensitive bed (SCSB) and pulse oximeter. The patients with severe obstructive sleep apnea syndrome were treated with tracheostomy. Palatal surgery was performed only if the upper airway narrowing occurred exclusively at the soft palate level in patients with partial upper airway obstruction during sleep. The ultrasound scalpel technique was compared to laser-assisted UPPP. The efficacy of LUPP to reduce partial upper airway obstruction during sleep was assessed and histology of uvulopalatal specimen was compared to body fat distributional parameters and sleep study findings. Tracheostomy was effective therapy in severe obstructive sleep apnea. Partial upper airway obstruction and arterial oxyhemoglobin desaturation index during sleep decreased significantly after LUPP. The minimal retropalatal airway dimension increased and soft palate collapsibility decreased at the level where the velopharyngeal obstruction had occurred before the surgery. Ultrasound scalpel did not offer any significant benefits over the laser-assisted technique, except fewer postoperative haemorrhage events. The loose connective tissue as a manifestation of edema was the only histological finding showing correlation with partial upper airway obstruction parameters of SCSB. Tracheostomy remains a life-saving therapy and also long-term option when adherence to CPAP fails in patients with obstructive sleep apnea syndrome. LUPP effectively reduces partial upper airway obstruction during sleep provided that obstruction at the other levels than the soft palate and uvula were preoperatively excluded. Technically the ultrasound scalpel or laser surgeries are equal. In patients with partial upper airway obstruction the loose connective tissue is more important than fat accumulation in the soft palate. This supports the hypothesis that edema is a primary trigger for aggravation of upper airway narrowing during sleep at the soft palate level and evolution towards partial or complete upper airway obstruction during sleep.

Regulatory Mechanisms involved in Th2 Cell Differentiation. A Proteomics Approach.

Th2-solujen erilaistumista ohjaavat säätelyverkostot ja niiden tutkiminen proteomiikan avulla Astma ja allergiat ovat laajalle levinneitä ja vakavia sairauksia, joista kärsivät miljoonat ihmiset ympäri maailmaa. Koe-eläimillä tehdyt tutkimukset osoittavat, että interleukiini-4 (IL-4) on tärkeä allergisen astman ja allergioiden kehittymiselle ja kroonistumiselle. Se ohjaa T-auttajasolujen (Th-solujen) kehittymistä Th2-tyypin soluiksi, joilla on merkittävä rooli näiden tautien puhkeamisessa. Th2-solut tuottavat myös itse IL-4:ä, joka edesauttaa taudin seuraavien vaiheiden kehittymistä. Erityisesti STAT6-proteiini, joka aktivoituu IL-4-stimulaation seurauksena, on tarpeen Th2- vasteen syntymiselle ja kroonistumiselle antigeenin aiheuttamassa keuhkoputkien astmaattisessa tulehduksessa. Väitöskirjatyöni tarkoituksena oli käyttää kaksidimensionaaliseen elektroforeesiin (2- DE) perustuvaa proteomiikkaa ja massaspektrometriaa uusien Th2-solujen erilaistumista säätelevien proteiinien tunnistamiseksi. Erilaistumattomat Th-solut eristettiin vastasyntyneen napaverestä tai hiiren pernasta. Solut aktivoitiin Tsolureseptorin ja ns. ko-stimulatoristen reseptorien kautta ja erilaistettiin joko Th1- tai Th2-suuntaan vastaavasti erilaistavien IL-12- ja IL-4-sytokiinien avulla. Ensimmäisessä tutkimuksessa in vitro -erilaistettujen Th1- ja Th2-solujen proteomeja verrattiin keskenään proteiinien ilmenemisessä tai proteiinimodifikaatioissa olevien erojen tunnistamiseksi. Kaksi muuta päätutkimusta keskittyivät IL-4:n aiheuttamaan proteiinitason säätelyyn ensimmäisen vuorokauden aikana T-soluaktivaation jälkeen. Näistä ensimmäisessä IL-4:n aiheuttamia eroja tunnistettiin aktivoiduista ihmisen Thsoluista. IL-4:n todettiin säätelevän useita proteiineja kaspaasien välittämissä signalointiteissä sekä lisäävän T-solujen elävyyttä ja aktivoitumista. Toisessa tutkimuksessa STAT6-poistogeenisten hiirien lymfosyyttien proteomia verrattiin villityypin kontrollisoluihin T-soluaktivaation ja IL-4-stimulaation jälkeen. Näissä tutkimuksissa karakterisoitiin useita uusia IL-4:n ja STAT6:n kohdeproteiineja ja löydettiin uusia säätelyverkostoja. Tutkimustulokset ovat johtaneet uusiin Th2-erilaistumismekanismeja koskeviin hypoteeseihin.

Sleep-Disordered Breathing in Women

Sleep-disordered breathing (SDB) is underdiagnosed in women, probably due to the different gender-related manifestation. We investigated the differences in presentation, symptoms and co-morbidities of SDB in men and in pre- and postmenopausal women by a clinical, retrospective, cross-sectional study of 601 consecutively referred women and 233 age- and BMI-matched male-female pairs studied with the static-chargesensitive bed (SCSB) and an oximeter. Data on the use of nasal CPAP were gathered from the Paimio hospital database, and the co-morbidity information was based on reimbursed medication data from the National Agency for Medicines and the Social Insurance institution. The abnormal breathing episodes at night were more frequent in men than in women, and in postmenopausal women compared to premenopausal ones. Partial upper airway obstruction was the most common type of SDB in both genders but especially in females. BMI and the major symptoms of SDB were similar in pre- and postmenopausal women, and a menopause effect on symptoms was not found. CPAP adherence did not differ between symptomatic patients with partial upper airway obstruction and those presenting with conventional obstructive sleep apnea. Comorbidities were more frequent in SDB patients than in the general Finnish population. Compared to sleep apnea, partial upper airway obstruction was associated with a threefold prevalence of asthma and/or COPD in both genders, and with a 60% reduced prevalence of hypertension in females matched for age and BMI. Our results emphasize that partial upper airway obstruction is not a milder form of SDB but a different entity, the severity of which is underestimated when using the conventional apnea-hypopnea index. It seems clinically relevant to diagnose and treat the co-morbidities and SDB also in patients with partial upper airway obstruction, especially in elderly and symptomatic women.

Clinical and genetic markers in disease progression – a study among subjects with obstructive lung diseases

Asthma, COPD, and asthma and COPD overlap syndrome (ACOS) are chronic pulmonary diseases with an obstructive component. In COPD, the obstruction is irreversible and the disease is progressive. The aim of the study was to define and analyze factors that affected disease progression and patients’ well-being, prognosis and mortality in Chronic Airway Disease (CAD) cohort. The main focus was on COPD and ACOS patients. Retrospective data from medical records was combined with genetic and prospective follow-up data. Smoking is the biggest risk factor for COPD and even after the diagnosis of the disease, smoking plays an important role in disease development and patient’s prognosis. Sixty percent of the COPD patients had succeeded in smoking cessation. Patients who had managed to quit smoking had lower mortality rates and less psychiatric diseases and alcohol abuse although they were older and had more cardiovascular diseases than patients who continued smoking. Genetic polymorphism rs1051730 in the nicotinic acethylcholine receptor gene (CHRNA3/5) associated with heavy smoking, cancer prevalence and mortality in two Finnish independent cohorts consisting of COPD patients and male smokers. Challenges in smoking cessation and higher mortality rates may be partly due to individual patient’s genetic composition. Approximately 50% of COPD patients are physically inactive and the proportion was higher among current smokers. Physically active and inactive patients didn’t differ from each other in regard to age, gender or comorbidities. Bronchial obstruction explained inactivity only in severe disease. Subjective sensation of dyspnea, however, had very strong association to inactivity and was also associated to low health related quality of life (HRQoL). ACOS patients had a significantly lower HRQoL than either the patients with asthma or with COPD even though they were younger than COPD patients, had better lung functions and smaller tobacco exposure.