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Epworth Sleepiness Scale in obstructive sleep apnea syndrome – An underestimated subjective scale
Escala de sonolência de Epworth na síndroma de apneia obstrutiva do sono: uma subjetividade subestimada
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Significant difference (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.0001) was found between the sandblasters and stone carvers.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.J. Lopes, W. Costa, T. Thomaz Mafort, A. de Sá Ferreira, S.L. Silveira de Menezes, F. Silva Guimarães" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A.J." "apellidos" => "Lopes" ] 1 => array:2 [ "nombre" => "W." "apellidos" => "Costa" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Thomaz Mafort" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "de Sá Ferreira" ] 4 => array:2 [ "nombre" => "S.L." "apellidos" => "Silveira de Menezes" ] 5 => array:2 [ "nombre" => "F." 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Guimarães, M.V. Martins, L. Vaz Rodrigues, F. Teixeira, J. Moutinho dos Santos" "autores" => array:5 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Guimarães" "email" => array:1 [ 0 => "catarina.guimaraes@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.V." "apellidos" => "Martins" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Vaz Rodrigues" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Teixeira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Moutinho dos Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Serviço de Pneumologia, Centro Hospitalar de Coimbra, EPE, Coimbra, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Pneumologia e Centro de Medicina do Sono, Centro Hospitalar de Coimbra, EPE, Coimbra, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Medicina do Sono, Centro Hospitalar de Coimbra, EPE, Coimbra, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Escala de sonolência de Epworth na síndroma de apneia obstrutiva do sono: uma subjetividade subestimada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1236 "Ancho" => 1660 "Tamanyo" => 110878 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Correlation between ESS scores.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Excessive daytime sleepiness is a key symptom in patients with OSAS and represents a new major public health issue due to its repercussions.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Sleepiness can be evaluated using subjective and objective instruments. The Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT) belong to the latter category, and the MSLT is generally considered to be the gold standard. The MSLT is based on the principle that degrees of sleepiness can be measured by how quickly one falls asleep (sleep latency) if given the opportunity to do so.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> By contrast, the MWT measures sleep latency when the subject is asked to stay awake.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although reliable these tests are expensive, time-consuming and impractical for widespread clinical use. The pupillographic sleepiness test, based on the evaluation of spontaneous pupillary changes in darkness, is gaining widespread use and approval for the quantitative assessment of daytime sleepiness.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The ESS is a simple and validated method, first described in 1991, which measures the probability of falling asleep in a variety of situations.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> It consists of eight questions, each scored with a degree of severity ranging from 0 to 3. This yields a total score of 0 (minimum) to 24 (maximum).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> It is easy to administer and is currently the most widely used subjective test for sleepiness.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> There are many published reports about the correlation between ESS scores and MSLT scores. The agreement between objective and subjective methods of sleepiness evaluation has been found to be only moderate.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10–12</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Excessive sleepiness is an important symptom when deciding whether patients with OSAS should be treated and not all patients with OSAS complain of it. There are some studies that discuss the use of positive airway pressure in subjects without sleepiness<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>; however, the subjective character of the ESS may condition the real perception of pretreatment levels of sleepiness.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Objective</span><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to compare the severity of sleepiness reported at baseline visit with severity of baseline sleepiness measured, retrospectively, after effective treatment with APAP using the same clinical instrument (ESS). Possible mechanisms underlying this difference were also explored.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a prospective study that included consecutive patients observed in a sleep clinic and diagnosed with OSAS by in-laboratory polysomnography (Level I of ASDA), Somnostar<span class="elsevierStyleSup">®</span>, or home sleep studies (level III of ASDA),<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Embletta<span class="elsevierStyleSup">®</span> and Stardust<span class="elsevierStyleSup">®</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients had an AHI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10 and an ESS<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>10 was considered to represent abnormal daytime sleepiness.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In follow-up visits we analysed the minimal SatO<span class="elsevierStyleInf">2</span>, perception of pre-treatment disease duration (understood as the number of years of witnessed apneas), residual AHI and adherence to APAP treatment. We excluded patients with other sleep disorders associated with daytime sleepiness such as restless legs syndrome and chronic sleep deprivation and those with unresolved sleep apnea (residual AHI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>5).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients routinely answered ESS on their first interview and again during follow-up visits (3–6 months of APAP treatment). During the follow-up consultation they were given 2 questionnaires and asked to assess post-treatment, as well as baseline (retrospective evaluation) severity of sleepiness.</p><p id="par0035" class="elsevierStylePara elsevierViewall">SPSS 17.0 was used for the statistical analysis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">We included 66 patients, with a mean age of 53.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.3; 23–72 (<span class="elsevierStyleItalic">x</span><span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>sd; min–max) years, of whom 88% were men (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>58) and 12% women (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8). Their mean BMI was 31.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5; 22.4–52.9<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. The mean baseline ESS score (pretreatment) was 11.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.3; 0–23. A number of patients did not show scores comparable with abnormal daytime sleepiness (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>32, ESS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10). The majority of subjects (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>59) underwent home cardiorespiratory study and 7 laboratory polysomnography. As a group they had a AHI of 34.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.6; 11.5–85<span class="elsevierStyleHsp" style=""></span>events/h, a minimal recorded SatO<span class="elsevierStyleInf">2</span> of 77.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.6; 60–90<span class="elsevierStyleHsp" style=""></span>mmHg and a perception of the disease duration of 7.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.6; 1–30 years. There was no correlation between the ESS score and these parameters.</p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients were treated with APAP with a mean delivered pressure of 8.6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>H<span class="elsevierStyleInf">2</span>O. The mean daily use of APAP was 5.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.3; 2.5–8.5<span class="elsevierStyleHsp" style=""></span>h, and 35 patients (53%) had daily compliance ≥6<span class="elsevierStyleHsp" style=""></span>h. Residual AHI was 2.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.3; 1–5<span class="elsevierStyleHsp" style=""></span>events/h. After treatment with APAP the mean ESS score was 7.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.7; 0–21 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 <span class="elsevierStyleItalic">t</span>-test). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> represents the basic characteristics of EES scores and AHI.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The retrospective baseline ESS score was 15.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.6; 2–25, with a mean difference between the initial and retrospective score of 3.55 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 <span class="elsevierStyleItalic">t</span>-test). After receiving APAP treatment the retrospective baseline ESS score was <10 in only 12 patients. Twenty-three percent of all patients had initial ‘normal’ scores and retrospective ‘sleepy’ scores. In this subgroup of patients there was a significant difference in age, with a younger group having a higher retrospective score (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 <span class="elsevierStyleItalic">t</span>-test). The differences (statistical significance) between baseline, retrospective baseline and post-treatment ESS score are represented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">There was no significant correlation between the difference in the ESS score (baseline<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>retrospective baseline) and the average daily (hours) use of APAP (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.066, Pearson), the AHI (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.315, Pearson), the minimal recorded SatO<span class="elsevierStyleInf">2</span> (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.273, Pearson), perceived length of the disease (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.111, Pearson), age (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.103, Pearson) and BMI (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.060, Pearson). There was no difference between the retrospective and post-treatment ESS scores in compliant and non-compliant patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.201 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.069 <span class="elsevierStyleItalic">t</span>-test).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The difference in the ESS scores, baseline<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>retrospective baseline and baseline<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>post-treatment, were significantly correlated (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.667, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001, Pearson; <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) illustrating that the greater the symptom relief the higher the scores attributed retrospectively.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">As expected our population shows a predominance of middle-aged men, results that are in keeping with the prevalence of OSAS.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In accordance with other studies<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> there was no correlation between the initial ESS score and the AHI, emphasizing the subjectivity of this scale.</p><p id="par0075" class="elsevierStylePara elsevierViewall">A large number of patients had not recognized the degree of sleepiness experienced before treatment until they had received APAP treatment: 48% (32/66) of the patients scored the Epworth scale <10 before treatment, a number that reduced to 18% (12/66) when answered retrospectively. The perception of sleepiness determined before APAP treatment changed significantly after treatment. The mean ESS score was significantly increased from 11.8 to 15.4. Engleman et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> published data that suggest a high prevalence of symptom minimization before treatment in OSAS patients, in 99 patients median ESS score for pre-treatment sleepiness increased from 12 initially to 14 retrospectively. These authors did not offer an explanation for this outcome.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Howard et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and Golembiewski et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> were the first to describe the concept of response shift, defined as a change in one's internal perception or understanding over time. It is a naturally occurring process believed to be part of natural coping and adaptive mechanisms.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> When these patients experienced positive changes in health status it reinforced the significance of the initial symptoms. Chin et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> set out to evaluate the response shift in ESS scores in 31 OSAS patients before and after continuous positive airway pressure (CPAP). They tested the AHI, the severity of desaturation and the duration of CPAP use but they did not find any mechanism for the response shift in patients with OSAS.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We did not find any significant correlation between the variables tested and the difference in ESS scores, so we cannot conclude that this difference was due to age, BMI, average daily use of APAP, AHI, minimal recorded SatO<span class="elsevierStyleInf">2</span> or supposed length of disease. However, the subgroup with higher retrospective baseline ESS scores was younger than the rest of our study group. The strong positive correlation between ESS scores, baseline<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>retrospective baseline and baseline<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>post-treatment indicates that the greater the improvement in daytime sleepiness after APAP treatment, the better their retrospective perception of sleepiness. The concept of response shift applies here. Only after effective treatment are patients able to correctly assess their degree of initial sleepiness.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Daytime sleepiness in OSAS is of growing interest and significance to sleep physicians. It is accepted that the diagnosis of OSAS should not depend on a particular level of AHI alone, but also take into account the degree of functional impairment associated with sleepiness. The ESS is the best available tool for the physician to estimate the patient's perceived sleepiness and has been extensively used to group patients according to the severity of sleepiness and determine whether patients with OSAS are treated or not.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Although our sample size is small, our results indicate that patients underestimate the severity of their sleepiness and there is a risk in using such a subjective measure to validate the decision to treat. A more objective measure is needed to substantiate these decisions pertaining to sleepiness.</p><p id="par0095" class="elsevierStylePara elsevierViewall">As with any questionnaire-based instrument, the ESS is limited by the subject's ability to read and understand the questionnaire and to answer the questions honestly. Patients may also deny clinically significant sleepiness because of social stigma and potential job loss. Perhaps the scale should be completed by both the patient and their partner in order to minimize problems and underestimated sleepiness.</p><p id="par0100" class="elsevierStylePara elsevierViewall">ESS scores can also be used to predict the likelihood of long-term compliance with CPAP<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and in our study there was a significant relief of sleepiness after treatment.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Daytime sleepiness is common but often unrecognized in OSAS and the ESS is currently the most widely used subjective test for determining its severity. Our results show that the degree of subjective sleepiness recorded before treatment was frequently underestimated by patients with OSAS. Sleepiness scores determined before treatment changed significantly after treatment, as measured by baseline ESS scores before and after (retrospective baseline) APAP treatment. There is considerable individual variation not only in susceptibility but also in sleepiness perception among patients with OSAS and no cause was found to justify this variability.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres173907" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec162204" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres173906" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec162205" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Material and methods" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-11-22" "fechaAceptado" => "2012-04-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec162204" "palabras" => array:3 [ 0 => "Epworth Sleepiness Scale" 1 => "Obstructive sleep apnea syndrome" 2 => "Subjective sleepiness" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec162205" "palabras" => array:3 [ 0 => "Escala de sonolência de Epworth" 1 => "Síndrome da apneia obstrutiva do sono" 2 => "Sonolência subjetiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Excessive daytime sleepiness is a major symptom in obstructive sleep apnea syndrome (OSAS) and can be evaluated using both subjective and objective methods. The Epworth Sleepiness Scale (ESS) is a simple and validated questionnaire for assessing subjective daytime sleepiness in the context of sleep disorders. Although its subjective character may limit the accurate expression of daytime sleepiness, the clinical benefit of sequential ESS is clear and demonstrates how ESS scores evolve in individual patients and how these scores may relate to various parameters.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this context we compared the severity of daytime sleepiness reported at baseline visit with severity of baseline sleepiness assessed, retrospectively, after treatment with automatic positive airway pressure (APAP).</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We conducted a prospective study that included 66 patients evaluated in a sleep clinic diagnosed with OSAS. The diagnosis was confirmed by in-laboratory or portable sleep studies. Their mean age was 53.3 years and the majority were men (88%, <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>58). The ESS was answered during the first interview (baseline daytime sleepiness). During follow-up visits, after APAP treatment, the patient was asked to assess baseline sleepiness, retrospectively, as well as post-treatment sleepiness. The mean baseline ESS score was 11.8, mean retrospective baseline ESS 15.4, with a mean difference of 3.55 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001 <span class="elsevierStyleItalic">t</span>-test) and post-treatment ESS 7.3. There was no significant correlation between the difference in ESS score (baseline<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>retrospective baseline) with the average daily (hours) use of APAP, the apnea–hypopnea index (AHI), the minimal recorded SatO<span class="elsevierStyleInf">2</span>, disease duration, body mass index (BMI) and age.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our findings confirm that the severity of subjective sleepiness reported before treatment with positive airway pressure is often underestimated by patients with OSAS.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A hipersonolência diurna é uma das manifestações mais relevantes da síndrome da apneia obstrutiva do sono (SAOS) e pode ser avaliada quer por testes subjetivos quer por testes objetivos. A escala de sonolência de Epworth (ESE) é um instrumento simples e validado que permite avaliar a sonolência diurna no contexto clínico de distúrbios do sono. No entanto, o seu caráter subjetivo pode condicionar a exata expressão do verdadeiro grau de sonolência. O uso clínico da ESE é demonstrado neste trabalho, mostrando que, no mesmo doente em momentos diferentes o s<span class="elsevierStyleItalic">core</span> da ESE é díspar e como este <span class="elsevierStyleItalic">score</span> pode estar ou não relacionado em determinadas variáveis.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Assim, comparamos o grau de sonolência basal com o grau de sonolência na mesma situação, mas avaliado retrospetivamente após tratamento com pressão positiva contínua das vias aéreas (<span class="elsevierStyleItalic">Automatic Positive Airway Pressure</span> – APAP).</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Realizamos um estudo prospetivo que incluiu 66 doentes observados na consulta de Patologia do Sono em que, após estudo poligráfico do sono ou cardiorrespiratório domiciliário, foi feito o diagnóstico de SAOS. Os doentes apresentavam uma idade média de 53,3 <span class="elsevierStyleItalic">anos</span>, sendo a maioria do sexo masculino (<span class="elsevierStyleItalic">88%</span>, <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>58). Os doentes preencheram o questionário da ESE no dia da primeira consulta (pré APAP) e posteriormente, na consulta de seguimento, preencheram novamente a ESE referente ao período pós-tratamento com APAP e pediu-se, retrospetivamente, nova quantificação da ESE inicial. A média do <span class="elsevierStyleItalic">score</span> da ESE basal foi de 11,8, a retrospetiva de 15,4, com uma diferença média de 3,55 (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001 <span class="elsevierStyleItalic">t</span>-Test) e após terapêutica com APAP 7,4. Não houve correlação entre a diferença do <span class="elsevierStyleItalic">score</span> da ESE (basal retrospetiva) com a média de tempo de uso diário do APAP (horas), com o índice de apneia-hipopneia (IAH), com a SatO<span class="elsevierStyleInf">2</span> mínima registada no estudo do sono, com a perceção do tempo de evolução da doença, com o índice de massa corporal (IMC) nem com a idade.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estes resultados mostram que o grau de sonolência subjetiva estimado antes do tratamento é frequentemente subavaliado pelos doentes com SAOS.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Guimarães C, et al. Escala de sonolência de Epworth na síndroma de apneia obstrutiva do sono: uma subjetividade subestimada. Rev Port Pneumol. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.04.009">http://dx.doi.org/10.1016/j.rppneu.2012.04.009</span>.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1285 "Ancho" => 1632 "Tamanyo" => 58882 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Epworth score.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1236 "Ancho" => 1660 "Tamanyo" => 110878 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Correlation between ESS scores.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Baseline (pretreatment) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Retrospective baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Post-treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESS (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>st) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>10 (<span class="elsevierStyleItalic">n</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHI (mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>st) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab266845.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara"><span class="elsevierStyleItalic">t</span>-Student between 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| 2024 September | 148 | 50 | 198 |
| 2024 August | 171 | 61 | 232 |
| 2024 July | 158 | 51 | 209 |
| 2024 June | 147 | 54 | 201 |
| 2024 May | 95 | 53 | 148 |
| 2024 April | 113 | 32 | 145 |
| 2024 March | 125 | 39 | 164 |
| 2024 February | 67 | 38 | 105 |
| 2024 January | 92 | 29 | 121 |
| 2023 December | 73 | 23 | 96 |
| 2023 November | 84 | 44 | 128 |
| 2023 October | 110 | 38 | 148 |
| 2023 September | 74 | 31 | 105 |
| 2023 August | 61 | 23 | 84 |
| 2023 July | 69 | 26 | 95 |
| 2023 June | 69 | 33 | 102 |
| 2023 May | 92 | 26 | 118 |
| 2023 April | 58 | 15 | 73 |
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