101
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Response. Chest 2021; 159:2118-2119. [PMID: 33965145 DOI: 10.1016/j.chest.2020.12.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 11/23/2022] Open
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102
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Gurges P, Liu H, Horner RL. Modulation of TASK-1/3 channels at the hypoglossal motoneuron pool and effects on tongue motor output and responses to excitatory inputs in vivo: implications for strategies for obstructive sleep apnea pharmacotherapy. Sleep 2021; 44:5880005. [PMID: 32745213 PMCID: PMC7819847 DOI: 10.1093/sleep/zsaa144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/29/2020] [Indexed: 12/25/2022] Open
Abstract
Obstructive sleep apnea (OSA) occurs exclusively during sleep due to reduced tongue motor activity. Withdrawal of excitatory inputs to the hypoglossal motor nucleus (HMN) from wake to sleep contributes to this reduced activity. Several awake-active neurotransmitters with inputs to the HMN (e.g. serotonin [5-HT]) inhibit K+ leak mediated by TASK-1/3 channels on hypoglossal motoneurons, leading to increased neuronal activity in vitro. We hypothesize that TASK channel inhibition at the HMN will increase tongue muscle activity in vivo and modulate responses to 5-HT. We first microperfused the HMN of anesthetized rats with TASK channel inhibitors: doxapram (75 μM, n = 9), A1899 (25 μM, n = 9), ML365 (25 μM, n = 9), acidified artificial cerebrospinal fluid (ACSF, pH = 6.25, n = 9); and a TASK channel activator terbinafine (50 μM, n = 9); all with and without co-applied 5-HT (10 mM). 5-HT alone at the HMN increased tongue motor activity (202.8% ± 45.9%, p < 0.001). However, neither the TASK channel inhibitors, nor activator, at the HMN changed baseline tongue activity (p > 0.716) or responses to 5-HT (p > 0.127). Tonic tongue motor responses to 5-HT at the HMN were also not different (p > 0.05) between ChAT-Cre:TASKf/f mice (n = 8) lacking TASK-1/3 channels on cholinergic neurons versus controls (n = 10). In freely behaving rats (n = 9), microperfusion of A1899 into the HMN increased within-breath phasic tongue motor activity in wakefulness only (p = 0.005) but not sleep, with no effects on tonic activity across all sleep-wake states. Together, the findings suggest robust maintenance of tongue motor activity despite various strategies for TASK channel manipulation targeting the HMN in vivo, and thus currently do not support this target and direction for potential OSA pharmacotherapy.
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Affiliation(s)
- Patrick Gurges
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Hattie Liu
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Richard L Horner
- Department of Medicine, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Canada
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103
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Finnsson E, Ólafsdóttir GH, Loftsdóttir DL, Jónsson SÆ, Helgadóttir H, Ágústsson JS, Sands SA, Wellman A. A scalable method of determining physiological endotypes of sleep apnea from a polysomnographic sleep study. Sleep 2021; 44:5905594. [PMID: 32929467 PMCID: PMC7819840 DOI: 10.1093/sleep/zsaa168] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
Sleep apnea is caused by several endophenotypic traits, namely pharyngeal collapsibility, poor muscle compensation, ventilatory instability (high loop gain), and arousability from sleep (low arousal threshold). Measures of these traits have shown promise for predicting outcomes of therapies (e.g. oral appliances, surgery, hypoglossal nerve stimulation, CPAP, and pharmaceuticals), which may become an integral part of precision sleep medicine. Currently, the methods Sands et al. developed for endotyping sleep apnea from polysomnography (PSG) are embedded in the original authors' code, which is computationally expensive and requires technological expertise to run. We present a reimplementation and validation of the integrity of the original authors' code by reproducing the endo-Phenotyping Using Polysomnography (PUP) method of Sands et al. The original MATLAB methods were reprogrammed in Python; efficient algorithms were developed to detect breaths, calculate normalized ventilation (moving time-average), and model ventilatory drive (intended ventilation). The new implementation (PUPpy) was validated by comparing the endotypes from PUPpy with the original PUP results. Both endotyping methods were applied to 38 manually scored polysomnographic studies. Results of the new implementation were strongly correlated with the original (p < 10-6 for all): ventilation at eupnea V̇ passive (ICC = 0.97), ventilation at arousal onset V̇ active (ICC = 0.97), loop gain (ICC = 0.96), and arousal threshold (ICC = 0.90). We successfully implemented the original PUP method by Sands et al. providing further evidence of its integrity. Additionally, we created a cloud-based version for scaling up sleep apnea endotyping that can be used more easily by a wider audience of researchers and clinicians.
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Affiliation(s)
| | | | | | | | | | | | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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104
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Carter SG, Eckert DJ. Effects of hypnotics on obstructive sleep apnea endotypes and severity: Novel insights into pathophysiology and treatment. Sleep Med Rev 2021; 58:101492. [PMID: 33965721 DOI: 10.1016/j.smrv.2021.101492] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023]
Abstract
Impaired upper airway anatomy is the main cause of obstructive sleep apnea (OSA). However, there are other important non-anatomical contributors or "endotypes" including ventilatory control instability, poor pharyngeal dilator muscle responsiveness and waking up too easily to minor respiratory events (low arousal threshold). Recent studies have focused on the potential to target specific OSA causes with novel treatments to reduce OSA severity and improve efficacy with existing non-CPAP therapies which are often suboptimal (e.g., mandibular advancement splints). One novel target is pharmacotherapy with hypnotics to increase the threshold for arousal and reduce OSA severity in the approximately 30% of patients who have a low arousal threshold endotype. This increasing body of work has produced varied and at times unexpected findings which have challenged previous knowledge on the effects of hypnotics on upper airway physiology and breathing during sleep in people with OSA. This review provides a concise overview of the latest research that has investigated the effects of common hypnotics/sedative agents on upper airway physiology and OSA severity and potential implications for OSA pathophysiology, treatment and safety. This includes a summary of the latest knowledge on the effects of hypnotics on OSA endotypes. Priorities for future research are also highlighted.
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Affiliation(s)
- Sophie G Carter
- Neuroscience Research Australia (NeuRA) Barker Street and the University of New South Wales, Sydney, NSW, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute, Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia.
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105
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Bokov P, Mauvais FX, Madani A, Matrot B, Lecendreux M, Delanoë C, Konofal E, Gallego J, Delclaux C. Cross-sectional case-control study of the relationships between pharyngeal compliance and heart rate variability indices in childhood obstructive sleep apnoea. J Sleep Res 2021; 30:e13337. [PMID: 33880823 DOI: 10.1111/jsr.13337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 12/20/2022]
Abstract
A combination of noradrenergic and antimuscarinic agents reduces the apnea-hypopnea index (AHI) in adult patients with obstructive sleep apnoea (OSA) via reduced upper airway collapsibility, suggesting that a shift in the sympathovagal balance improves OSA. The objectives of our present case-control study were to assess heart rate variability (HRV) indices in the stages of sleep in children with and without OSA to evaluate OSA-induced sleep HRV modifications and to assess whether increased collapsibility measured during wakefulness is associated with reduced sympathetic activity during non-rapid eye movement (NREM) sleep. Three groups of 15 children were matched by sex, age, z-score of body mass index and ethnicity: non-OSA (obstructive AHI [OAHI] <2 events/hr), mild (OAHI ≥2 to <5 events/hr) or moderate-severe (OAHI ≥5 events/hr) OSA. Pharyngeal compliance was measured during wakefulness using acoustic pharyngometry. HRV indices (time and frequency domain variables) were calculated on 5-min electrocardiography recordings from polysomnography during wakefulness, NREM and REM sleep in periods free of any event. As compared to children without OSA, those with OSA (n = 30) were characterised by increased compliance and no physiological parasympathetic tone increase in REM sleep. Children with increased pharyngeal compliance (n = 21) had a higher OAHI due to higher AHI in NREM sleep, whereas their sympathetic tone was lower than that of those with normal compliance (n = 24). In conclusion, children with increased pharyngeal compliance exhibit decreased sympathetic tone associated with increased AHI in NREM sleep. Therapeutics directed at sympathovagal balance modifications should be tested in childhood OSA.
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Affiliation(s)
- Plamen Bokov
- Service de Physiologie Pédiatrique-Centre du Sommeil, Université de Paris, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, Paris, France
| | - François-Xavier Mauvais
- Service de Physiologie Pédiatrique-Centre du Sommeil, Université de Paris, UMR1151, AP-HP, Hôpital Robert Debré, CNRS UMR8253, Paris, France
| | - Amélia Madani
- Service de Physiologie Pédiatrique-Centre du Sommeil, AP-HP, Hôpital Robert Debré, Paris, France
| | - Boris Matrot
- INSERM NeuroDiderot, Equipe NeoPhen, Paris, France
| | - Michel Lecendreux
- Service de Physiologie Pédiatrique-Centre du Sommeil, AP-HP, Hôpital Robert Debré, Paris, France
| | - Catherine Delanoë
- Service de Physiologie Pédiatrique-Centre du Sommeil, AP-HP, Hôpital Robert Debré, Paris, France
| | - Eric Konofal
- Service de Physiologie Pédiatrique-Centre du Sommeil, AP-HP, Hôpital Robert Debré, Paris, France
| | | | - Christophe Delclaux
- Service de Physiologie Pédiatrique-Centre du Sommeil, Université de Paris, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, Paris, France
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106
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Koka V, De Vito A, Roisman G, Petitjean M, Filograna Pignatelli GR, Padovani D, Randerath W. Orofacial Myofunctional Therapy in Obstructive Sleep Apnea Syndrome: A Pathophysiological Perspective. ACTA ACUST UNITED AC 2021; 57:medicina57040323. [PMID: 33915707 PMCID: PMC8066493 DOI: 10.3390/medicina57040323] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 01/02/2023]
Abstract
Obstructive sleep apnea (OSA) syndrome is a multi-factorial disorder. Recently identified pathophysiological contributing factors include airway collapsibility, poor pharyngeal muscle responsiveness, a low arousal threshold, and a high loop gain. Understanding the pathophysiology is of pivotal importance to select the most effective treatment option. It is well documented that conventional treatments (continuous positive airway pressure (CPAP), upper airway surgery, and dental appliance) may not always be successful in the presence of non-anatomical traits, especially in mild to moderate OSA. Orofacial myofunctional therapy (OMT) consists of isotonic and isometric exercises targeted to oral and oropharyngeal structures, with the aim of increasing muscle tone, endurance, and coordinated movements of pharyngeal and peripharyngeal muscles. Recent studies have demonstrated the efficacy of OMT in reducing snoring, apnea-hypopnea index, and daytime sleepiness, and improving oxygen saturations and sleep quality. Myofunctional therapy helps to reposition the tongue, improve nasal breathing, and increase muscle tone in pediatric and adult OSA patients. Studies have shown that OMT prevents residual OSA in children after adenotonsillectomy and helps adherence in CPAP-treated OSA patients. Randomized multi-institutional studies will be necessary in the future to determine the effectiveness of OMT in a single or combined modality targeted approach in the treatment of OSA. In this narrative review, we present up-to-date literature data, focusing on the role of OSA pathophysiology concepts concerning pharyngeal anatomical collapsibility and muscle responsiveness, underlying the response to OMT in OSA patients.
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Affiliation(s)
- Venkata Koka
- Department of Sleep Medicine, Hospital Antoine Beclere, 92140 Clamart, France; (G.R.); (M.P.)
- Correspondence: (V.K.); (A.D.V.)
| | - Andrea De Vito
- Ear Nose Throat (ENT) Unit, Head & Neck Department, Santa Maria delle Croci Hospital, Romagna Health Service, 48121 Ravenna, Italy; (G.R.F.P.); (D.P.)
- Correspondence: (V.K.); (A.D.V.)
| | - Gabriel Roisman
- Department of Sleep Medicine, Hospital Antoine Beclere, 92140 Clamart, France; (G.R.); (M.P.)
| | - Michel Petitjean
- Department of Sleep Medicine, Hospital Antoine Beclere, 92140 Clamart, France; (G.R.); (M.P.)
| | - Giulio Romano Filograna Pignatelli
- Ear Nose Throat (ENT) Unit, Head & Neck Department, Santa Maria delle Croci Hospital, Romagna Health Service, 48121 Ravenna, Italy; (G.R.F.P.); (D.P.)
| | - Davide Padovani
- Ear Nose Throat (ENT) Unit, Head & Neck Department, Santa Maria delle Croci Hospital, Romagna Health Service, 48121 Ravenna, Italy; (G.R.F.P.); (D.P.)
| | - Winfried Randerath
- Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute for Pneumology at the University Witten/Herdecke, 42699 Solingen, Germany;
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107
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Leung TN, Cheng JW, Chan AK. Paediatrics: how to manage obstructive sleep apnoea syndrome. Drugs Context 2021; 10:dic-2020-12-5. [PMID: 33828609 PMCID: PMC8007210 DOI: 10.7573/dic.2020-12-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 02/02/2023] Open
Abstract
Obstructive sleep apnoea syndrome (OSAS) is defined as the intermittent reduction or cessation of airflow due to partial or complete obstruction of the upper airway during sleep. Paediatric OSAS has specific contributing factors, presenting symptoms and management strategies in various age groups. Untreated OSAS can lead to detrimental effects on neurocognitive development and cardiovascular and metabolic functions of a growing child. In the past decade, practice guidelines have been developed to guide the evaluation and management of OSAS. This article provides a narrative review on the current diagnostic and treatment options for paediatric OSAS. Alternative diagnostic tools other than the standard polysomnography are discussed. Adenotonsillectomy is considered the first-line therapy yet it is not suitable for treatment of all OSAS cases. Nocturnal non-invasive positive airway pressure ventilation is effective and could be the priority treatment for patients with complex comorbidities, residual OSAS post-adenotonsillectomy or obesity. However, intolerance and non-adherence are major challenges of positive airway pressure therapy especially in young children. There is increasing evidence for watchful waiting and other gentler alternative treatment options in mild OSAS. The role of anti-inflammatory drugs as the primary or adjunctive treatment is discussed. Other treatment options, including weight reduction, orthodontic procedures and myofunctional therapy, are indicated for selected patients. Nevertheless, the successful management of paediatric OSAS often requires a multidisciplinary team approach.
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Affiliation(s)
- Theresa Nh Leung
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong SAR, China
| | - James Wch Cheng
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong SAR, China
| | - Anthony Kc Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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108
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Landry SA, Edwards BA. Pharmacotherapy for sleep apnoea: A search for the right therapeutic key. Respirology 2021; 26:411-412. [PMID: 33730763 DOI: 10.1111/resp.14038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
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109
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Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome. Lung 2021; 199:87-101. [PMID: 33713177 DOI: 10.1007/s00408-021-00426-w] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/09/2021] [Indexed: 02/08/2023]
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.
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110
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Schütz SG, Dunn A, Braley TJ, Pitt B, Shelgikar AV. New frontiers in pharmacologic obstructive sleep apnea treatment: A narrative review. Sleep Med Rev 2021; 57:101473. [PMID: 33853035 DOI: 10.1016/j.smrv.2021.101473] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 12/22/2022]
Abstract
Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing characterized by intermittent partial or complete closure of the upper airway during sleep. If left untreated, OSA is associated with adverse cardiovascular outcomes such as hypertension, coronary heart disease, heart failure, cardiac arrhythmia, stroke, and death. Positive airway pressure (PAP) is often considered the first-line treatment for OSA. While PAP can be very effective in reducing the number of obstructive apneas and hypopneas, its impact on prevention of adverse cardiovascular consequences remains controversial, and treatment adherence is often poor. Hence, the necessity for novel treatment options to help those who cannot adhere to positive airway pressure treatment. Different classes of medications have been tested with regards to their effect on OSA severity. This review 1) provides an update on the epidemiology and pathophysiology of OSA, 2) outlines the mechanistic rationale for medication classes tested as OSA treatment and 3) discusses the effects of these medications on OSA. Several wake-promoting medications are approved for management of persistent sleepiness despite OSA treatment; discussion of these symptomatic treatments is outside the scope of this review. Herein, the authors review the current evidence for pharmacological management of OSA and provide future directions.
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Affiliation(s)
- Sonja G Schütz
- Department of Neurology Sleep Disorders Center, University of Michigan Ann Arbor, MI, USA.
| | - Abbey Dunn
- Department of Neurology Sleep Disorders Center, University of Michigan Ann Arbor, MI, USA
| | - Tiffany J Braley
- Department of Neurology Multiple Sclerosis and Sleep Disorders Center, University of Michigan, Ann Arbor, MI, USA
| | - Bertram Pitt
- Department of Internal Medicine Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Anita V Shelgikar
- Department of Neurology Sleep Disorders Center, University of Michigan Ann Arbor, MI, USA
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111
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Schulz R. Schlafbezogene Atmungsstörungen. SOMNOLOGIE 2021. [DOI: 10.1007/s11818-021-00302-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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112
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Doyle BM, Singer ML, Fleury-Curado T, Rana S, Benevides ES, Byrne BJ, Polotsky VY, Fuller DD. Gene delivery to the hypoglossal motor system: preclinical studies and translational potential. Gene Ther 2021; 28:402-412. [PMID: 33574581 PMCID: PMC8355248 DOI: 10.1038/s41434-021-00225-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/16/2020] [Accepted: 01/15/2021] [Indexed: 12/15/2022]
Abstract
Dysfunction and/or reduced activity in the tongue muscles contributes to conditions such as dysphagia, dysarthria, and sleep disordered breathing. Current treatments are often inadequate, and the tongue is a readily accessible target for therapeutic gene delivery. In this regard, gene therapy specifically targeting the tongue motor system offers two general strategies for treating lingual disorders. First, correcting tongue myofiber and/or hypoglossal (XII) motoneuron pathology in genetic neuromuscular disorders may be readily achieved by intralingual delivery of viral vectors. The retrograde movement of viral vectors such as adeno-associated virus (AAV) enables targeted distribution to XII motoneurons via intralingual viral delivery. Second, conditions with impaired or reduced tongue muscle activation can potentially be treated using viral-driven chemo- or optogenetic approaches to activate or inhibit XII motoneurons and/or tongue myofibers. Further considerations that are highly relevant to lingual gene therapy include (1) the diversity of the motoneurons which control the tongue, (2) the patterns of XII nerve branching, and (3) the complexity of tongue muscle anatomy and biomechanics. Preclinical studies show considerable promise for lingual directed gene therapy in neuromuscular disease, but the potential of such approaches is largely untapped.
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Affiliation(s)
- Brendan M Doyle
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Rehabilitation Science PhD Program, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Michele L Singer
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Rehabilitation Science PhD Program, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Thomaz Fleury-Curado
- Department of Pediatrics and Powell Gene Therapy Center, University of Florida, Gainesville, FL, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sabhya Rana
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Ethan S Benevides
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA.,McKnight Brain Institute, University of Florida, Gainesville, FL, USA.,Rehabilitation Science PhD Program, University of Florida, Gainesville, FL, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
| | - Barry J Byrne
- Department of Pediatrics and Powell Gene Therapy Center, University of Florida, Gainesville, FL, USA
| | - Vsevolod Y Polotsky
- Department of Pediatrics and Powell Gene Therapy Center, University of Florida, Gainesville, FL, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA. .,McKnight Brain Institute, University of Florida, Gainesville, FL, USA. .,Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA.
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113
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Joosten SA, Landry SA, Wong AM, Edwards BA. Considering the Role of Adherence in New and Emerging Sleep Treatments. Sleep Med Clin 2021; 16:203-211. [PMID: 33485528 DOI: 10.1016/j.jsmc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There are several novel and emerging treatments for obstructive sleep apnea (OSA), including new devices and pharmacotherapies. Long-term efficacy and adherence data for these interventions in the sleep context are lacking. Future studies exploring the long-term adherence and efficacy in novel and emerging treatments of OSA are required to fully understand the place of these treatments in treatment hierarchies. Such research also should aim to evaluate the use of these novel therapies in real-world clinical settings, because many of the studies performed to date have been done under closely monitored research populations and relatively small sample sizes.
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Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton 3168, Victoria, Australia; School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia; Monash Partners - Epworth, Clayton, Victoria, Australia.
| | - Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedicine Discovery Institute, Monash University, 264 Ferntreegully Road, Notting Hill 3168, Melbourne, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Ai-Ming Wong
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton 3168, Victoria, Australia; School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedicine Discovery Institute, Monash University, 264 Ferntreegully Road, Notting Hill 3168, Melbourne, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
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114
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Fleury Curado T, Pho H, Freire C, Amorim MR, Bonaventura J, Kim LJ, Lee R, Cabassa ME, Streeter SR, Branco LG, Sennes LU, Fishbein K, Spencer RG, Schwartz AR, Brennick MJ, Michaelides M, Fuller DD, Polotsky VY. Designer Receptors Exclusively Activated by Designer Drugs Approach to Treatment of Sleep-disordered Breathing. Am J Respir Crit Care Med 2021; 203:102-110. [PMID: 32673075 DOI: 10.1164/rccm.202002-0321oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale: Obstructive sleep apnea is recurrent upper airway obstruction caused by a loss of upper airway muscle tone during sleep. The main goal of our study was to determine if designer receptors exclusively activated by designer drugs (DREADD) could be used to activate the genioglossus muscle as a potential novel treatment strategy for sleep apnea. We have previously shown that the prototypical DREADD ligand clozapine-N-oxide increased pharyngeal diameter in mice expressing DREADD in the hypoglossal nucleus. However, the need for direct brainstem viral injections and clozapine-N-oxide toxicity diminished translational potential of this approach, and breathing during sleep was not examined.Objectives: Here, we took advantage of our model of sleep-disordered breathing in diet-induced obese mice, retrograde properties of the adeno-associated virus serotype 9 (AAV9) viral vector, and the novel DREADD ligand J60.Methods: We administered AAV9-hSyn-hM3(Gq)-mCherry or control AAV9 into the genioglossus muscle of diet-induced obese mice and examined the effect of J60 on genioglossus activity, pharyngeal patency, and breathing during sleep.Measurements and Main Results: Compared with control, J60 increased genioglossus tonic activity by greater than sixfold and tongue uptake of 2-deoxy-2-[18F]fluoro-d-glucose by 1.5-fold. J60 increased pharyngeal patency and relieved upper airway obstruction during non-REM sleep.Conclusions: We conclude that following intralingual administration of AAV9-DREADD, J60 can activate the genioglossus muscle and improve pharyngeal patency and breathing during sleep.
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Affiliation(s)
- Thomaz Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, University of São Paulo, São Paulo, Brazil
| | - Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carla Freire
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, University of São Paulo, São Paulo, Brazil
| | - Mateus R Amorim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Dental School of Ribeirao Preto, University of São Paulo, Ribeirao Preto, Brazil
| | - Jordi Bonaventura
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse, and
| | - Lenise J Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Laboratory of Clinical Investigation, National Institute on Aging, NIH, Baltimore, Maryland
| | - Rachel Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Meaghan E Cabassa
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stone R Streeter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luiz G Branco
- Dental School of Ribeirao Preto, University of São Paulo, Ribeirao Preto, Brazil
| | - Luiz U Sennes
- Department of Otolaryngology, University of São Paulo, São Paulo, Brazil
| | - Kenneth Fishbein
- Departament of Psychobiology, Federal University of São Paulo, São Paulo, Brazil
| | - Richard G Spencer
- Departament of Psychobiology, Federal University of São Paulo, São Paulo, Brazil
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Michael J Brennick
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Michaelides
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse, and
| | - David D Fuller
- Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Taranto-Montemurro L, Sands S, Azarbarzin A, Calianese N, Vena D, Hess L, Kim SW, White DP, Wellman A. Impact of cold and flu medication on obstructive sleep apnoea and its underlying traits: A pilot randomized controlled trial. Respirology 2021; 26:485-492. [PMID: 33491327 DOI: 10.1111/resp.14009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/17/2020] [Accepted: 01/04/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Animal studies indicate that alpha-1 adrenergic receptor agonists and antimuscarinic agents improve genioglossus muscle activity during sleep and may be candidates for the pharmacological treatment of OSA. On the other hand, noradrenergic stimulants may be wake-promoting or cause insomnia symptoms if taken before bedtime, and the addition of a medication with sedative properties, such as an antihistaminic, may reduce these side effects. In this study, we aimed to determine the effects of the combination of an alpha-1 adrenergic agonist (pseudoephedrine) and an antihistaminic-antimuscarinic (diphenhydramine) on OSA severity (AHI), genioglossus responsiveness and other endotypic traits (Vpassive , muscle compensation, LG and arousal threshold). METHODS Ten OSA patients performed a randomized, placebo-controlled, double-blind, crossover trial comparing one night of pseudoephedrine 120 mg plus diphenhydramine 50 mg (DAW1033D) to placebo administered prior to sleep. The AHI, genioglossus muscle responsiveness to negative oesophageal pressure and the endotypic traits were measured via PSG. RESULTS The participants' median (interquartile range) age was 50 (46-53) years and body mass index (BMI) was 34.3 (30.6-39.2) kg/m2 . The drug combination had no effect on AHI (21.6 (9.1-49.8) on placebo vs 37.9 (5.1-55.4) events/h on DAW1033D, P > 0.5) or genioglossus responsiveness (6.0 (2.6-9.2) on placebo vs 4.0 (3.5-7.3) %/cm H2 O). Amongst the phenotypic traits, only Vpassive was improved by 29 (3-55) % eupnoea, P = 0.03 (mean (95% CI)). CONCLUSION The combination of pseudoephedrine and diphenhydramine did not improve OSA severity or genioglossus responsiveness but induced a small improvement in upper airway collapsibility, possibly due to the decongestant effect of the medications. The results of this study do not support the use of these medications for OSA treatment.
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Affiliation(s)
- Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lauren Hess
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sang-Wook Kim
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Otorhinolaryngology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - David P White
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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116
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Raphelson JR, Kreitinger KY, Malhotra A. Positive Airway Pressure Therapy in Sleep-Disordered Breathing. Neurotherapeutics 2021; 18:75-80. [PMID: 33230691 PMCID: PMC8116368 DOI: 10.1007/s13311-020-00971-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition with major neurocognitive and cardiovascular health effects. Positive airway pressure (PAP) therapy prevents the collapse of the pharyngeal airway to improve hypoxemia, hypercapnia, and sleep fragmentation caused by OSA. While adherence to PAP therapy has been thought to be a barrier to use, consistent usage is likely much higher than commonly thought. In addition, many strategies have been developed to assist providers in improving their patients' PAP adherence.
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Affiliation(s)
| | | | - Atul Malhotra
- Department of Medicine, UC San Diego, San Diego, CA, USA
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117
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Boulos MI, Dharmakulaseelan L, Brown DL, Swartz RH. Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches. Stroke 2020; 52:366-372. [PMID: 33349009 DOI: 10.1161/strokeaha.120.031709] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.
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Affiliation(s)
- Mark I Boulos
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laavanya Dharmakulaseelan
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Devin L Brown
- Department of Neurology, University of Michigan, Ann Arbor (D.L.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
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118
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Journey towards a personalised medicine approach for OSA: Can a similar approach to adult OSA be applied to paediatric OSA? Paediatr Respir Rev 2020; 36:128-135. [PMID: 32217050 DOI: 10.1016/j.prrv.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/31/2020] [Indexed: 11/21/2022]
Abstract
The concept of personalised medicine is likely to revolutionise the treatment of adult obstructive sleep apnoea as a result of recent advances in the understanding of disease heterogeneity by identifying clinical phenotypes, pathophysiological endotypes, biomarkers and treatable traits. Children with the condition show a similar level of heterogeneity and paediatric obstructive sleep apnoea would also benefit from a more targeted approach to diagnosis and management. This review aims to summarise the adult literature on the phenotypes and endotypes of obstructive sleep apnoea and assess whether a similar approach may also be suitable to guide the development of new diagnostic and management approaches for paediatric obstructive sleep apnoea.
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119
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Leary EB, Zinchuk A, Stone KL, Mehra R. Update in Sleep 2019. Am J Respir Crit Care Med 2020; 201:1473-1479. [PMID: 32293912 DOI: 10.1164/rccm.202003-0586up] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Eileen B Leary
- Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, California
| | - Andrey Zinchuk
- Section of Pulmonary, Critical Care and Sleep Medicine, Internal Medicine Department, School of Medicine, Yale University, New Haven, Connecticut
| | - Katie L Stone
- California Pacific Medical Center Research Institute, San Francisco, California
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute.,Respiratory Institute.,Heart, Vascular and Thoracic Institute, and.,Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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120
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Messineo L, Eckert DJ, Lim R, Chiang A, Azarbarzin A, Carter SG, Carberry JC. Zolpidem increases sleep efficiency and the respiratory arousal threshold without changing sleep apnoea severity and pharyngeal muscle activity. J Physiol 2020; 598:4681-4692. [PMID: 32864734 DOI: 10.1113/jp280173] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/20/2020] [Indexed: 12/23/2022] Open
Abstract
KEY POINTS A decreased respiratory arousal threshold is one of the main contributors to obstructive sleep apnoea (OSA) pathogenesis. Several recent studies have sought to find a drug capable of increasing the respiratory arousal threshold without impairing pharyngeal muscle activity to reduce OSA severity, with variable success. Here we show that zolpidem increases the respiratory arousal threshold by ∼15%, an effect size which was insufficient to systematically decrease OSA severity as measured by the apnoea-hypopnoea index. Unlike recent physiological findings that showed paradoxical increases in pharyngeal muscle responsiveness during transient manipulations of airway pressure, zolpidem did not alter pharyngeal muscle responsiveness during natural sleep. It did, however, increase sleep efficiency without changing apnoea length, oxygen desaturation, next-day perceived sleepiness and alertness. These novel findings indicate that zolpidem was well tolerated and effective in promoting sleep in people with OSA, which may be therapeutically useful for people with OSA and comorbid insomnia. ABSTRACT A recent physiology study performed using continuous positive airway pressure (CPAP) manipulations indicated that the hypnotic zolpidem increases the arousal threshold and genioglossus responsiveness in people with and without obstructive sleep apnoea (OSA). Thus, zolpidem may stabilise breathing and reduce OSA severity without CPAP. Accordingly, we sought to determine the effects of zolpidem on OSA severity, upper airway physiology and next-day sleepiness and alertness. Nineteen people with OSA with low-to-moderate arousal threshold received 10 mg zolpidem or placebo according to a double-blind, randomised, cross-over design. Participants completed two overnight in-laboratory polysomnographies (1-week washout), with an epiglottic catheter, intramuscular genioglossus electromyography, nasal mask and pneumotachograph to measure OSA severity, arousal threshold and upper airway muscle responsiveness. Next-morning sleepiness and alertness were also assessed. Zolpidem did not change the apnoea-hypopnoea index versus placebo (40.6 ± 12.3 vs. 40.3 ± 16.4 events/h (means ± SD), p = 0.938) or nadir oxyhaemoglobin saturation (79.6 ± 6.6 vs. 79.7 ± 7.4%, p = 0.932), but was well tolerated. Zolpidem increased sleep efficiency by 9 ± 14% (83 ± 11 vs. 73 ± 17%, p = 0.010). Arousal threshold increased by 15 ± 5% with zolpidem throughout all sleep stages (p = 0.010), whereas genioglossus muscle responsiveness did not change. Next-morning sleepiness and alertness were not different between nights. In summary, a single night of 10 mg zolpidem is well tolerated and does not cause next-day impairment in alertness or sleepiness, or overnight hypoxaemia in OSA. However, despite increases in arousal threshold without any change in pharyngeal muscle responsiveness, zolpidem does not alter OSA severity. It does, however, increase sleep efficiency by ∼10%, which may be beneficial in people with OSA and insomnia.
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Affiliation(s)
- Ludovico Messineo
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia.,Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia.,Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Richard Lim
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia.,Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Alan Chiang
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Sophie G Carter
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | - Jayne C Carberry
- Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
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122
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Sunwoo BY, Schmickl CN, Malhotra A. Contemporary Concise Review 2019: Sleep and ventilation. Respirology 2020; 25:552-558. [PMID: 32048407 PMCID: PMC7162714 DOI: 10.1111/resp.13781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Bernie Y Sunwoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), La Jolla, CA, USA
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Abstract
IMPORTANCE Obstructive sleep apnea (OSA) affects 17% of women and 34% of men in the US and has a similar prevalence in other countries. This review provides an update on the diagnosis and treatment of OSA. OBSERVATIONS The most common presenting symptom of OSA is excessive sleepiness, although this symptom is reported by as few as 15% to 50% of people with OSA in the general population. OSA is associated with a 2- to 3-fold increased risk of cardiovascular and metabolic disease. In many patients, OSA can be diagnosed with home sleep apnea testing, which has a sensitivity of approximately 80%. Effective treatments include weight loss and exercise, positive airway pressure, oral appliances that hold the jaw forward during sleep, and surgical modification of the pharyngeal soft tissues or facial skeleton to enlarge the upper airway. Hypoglossal nerve stimulation is effective in select patients with a body mass index less than 32. There are currently no effective pharmacological therapies. Treatment with positive airway pressure lowers blood pressure, especially in patients with resistant hypertension; however, randomized clinical trials of OSA treatment have not demonstrated significant benefit on rates of cardiovascular or cerebrovascular events. CONCLUSIONS AND RELEVANCE OSA is common and the prevalence is increasing with the increased prevalence of obesity. Daytime sleepiness is among the most common symptoms, but many patients with OSA are asymptomatic. Patients with OSA who are asymptomatic, or whose symptoms are minimally bothersome and pose no apparent risk to driving safety, can be treated with behavioral measures, such as weight loss and exercise. Interventions such as positive airway pressure are recommended for those with excessive sleepiness and resistant hypertension. Managing asymptomatic OSA to reduce cardiovascular and cerebrovascular events is not currently supported by high-quality evidence.
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Affiliation(s)
- Daniel J Gottlieb
- Medical Service, VA Boston Healthcare System, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Naresh M Punjabi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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Effect of Venlafaxine on Apnea-Hypopnea Index in Patients With Sleep Apnea: A Randomized, Double-Blind Crossover Study. Chest 2020; 158:765-775. [PMID: 32278781 DOI: 10.1016/j.chest.2020.02.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/11/2020] [Accepted: 02/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND One of the key mechanisms underlying OSA is reduced pharyngeal muscle tone during sleep. Data suggest that pharmacologic augmentation of central serotonergic/adrenergic tone increases pharyngeal muscle tone. RESEARCH QUESTION We hypothesized that venlafaxine, a serotonin-norepinephrine reuptake inhibitor, would improve OSA severity. STUDY DESIGN AND METHODS In this mechanistic, randomized, double-blind, placebo-controlled crossover trial, 20 patients with OSA underwent two overnight polysomnograms ≥ 4 days apart, receiving either 50 mg of immediate-release venlafaxine or placebo before bedtime. Primary outcomes were the apnea-hypopnea index (AHI) and peripheral oxygen saturation (Spo2) nadir, and secondary outcomes included sleep parameters and pathophysiologic traits with a view toward understanding the impact of venlafaxine on mechanisms underlying OSA. RESULTS Overall, there was no significant difference between venlafaxine and placebo regarding AHI (mean reduction, -5.6 events/h [95% CI, -12.0 to 0.9]; P = .09) or Spo2 nadir (median increase, +1.0% [-0.5 to 5]; P = .11). Venlafaxine reduced total sleep time, sleep efficiency, and rapid eye movement (REM) sleep, while increasing non-REM stage 1 sleep (Pall < .05). On the basis of exploratory post hoc analyses venlafaxine decreased ("improved") the ventilatory response to arousal (-30%; P = .049) and lowered ("worsened") the predicted arousal threshold (-13%; [P = .02]; ie, more arousable), with no effects on other pathophysiologic traits (Pall ≥ .3). Post hoc analyses further suggested effect modification by arousal threshold (P = .002): AHI improved by 19% in patients with a high arousal threshold (-10.9 events/h [-3.9 to -17.9]) but tended to increase in patients with a low arousal threshold (+7 events/h [-2.0 to 16]). Other predictors of response were elevated AHI and less collapsible upper airway anatomy at baseline (|r| > 0.5, P ≤ .02). INTERPRETATION In unselected patients, venlafaxine simultaneously worsened and improved various pathophysiologic traits, resulting in a zero net effect. Careful patient selection based on pathophysiologic traits, or combination therapy with drugs countering its alerting effects, may produce a more robust response. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02714400; URL: www.clinicaltrials.gov.
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125
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González Mangado N, Egea-Santaolalla CJ, Chiner Vives E, Mediano O. Apnea obstructiva del sueño. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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126
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Several new treatment strategies have become available for patients with sleep disordered breathing. Sleep Biol Rhythms 2020. [DOI: 10.1007/s41105-020-00265-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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128
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Tsai MS, Li HY, Huang CG, Wang RYL, Chuang LP, Chen NH, Liu CH, Yang YH, Liu CY, Hsu CM, Cheng WN, Lee LA. Risk of Alzheimer's Disease in Obstructive Sleep Apnea Patients With or Without Treatment: Real-World Evidence. Laryngoscope 2020; 130:2292-2298. [PMID: 32045010 DOI: 10.1002/lary.28558] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/30/2019] [Accepted: 01/12/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the risk of Alzheimer's disease (AD) in patients with obstructive sleep apnea (OSA) with or without treatment based on real-world evidence. STUDY DESIGN Retrospective cohort study. METHODS Patients newly diagnosed with OSA during 1997-2012 were identified using the National Health Insurance Research Database of Taiwan. Patients without OSA were randomly selected and matched in a 1:4 ratio by age, sex, urbanization level, and income. All patients were followed up until death or the end of 2013. The primary outcome was AD occurrence. RESULTS This study included 3,978 OSA patients and 15,912 non-OSA patients. OSA was independently and significantly associated with a higher incidence of AD in an adjusted Cox proportional hazard model (adjusted hazard ratio: 2.12; 95% confidence interval [CI], 1.27-3.56). The average period of AD detection from the time of OSA occurrence was 5.44 years (standard deviation: 2.96). Subgroup analyses revealed that the effect of OSA remained significant in patients aged ≥60 years, male subgroups, patients without CPAP or surgical treatment, and patients without pharmacological therapies. Patients with OSA who received treatment (continuous positive airway pressure or surgery) exhibited a significantly reduced risk of AD compared with those without treatment (incidence rate ratio 0.23, 95% CI, 0.06-0.98). CONCLUSION OSA is independently associated with an increased risk of AD. Treatment for OSA reduces the AD risk in OSA patients. AD irreversibility renders OSA as a potential modifiable target for slowing or preventing the process of AD development. LEVEL OF EVIDENCE IV Laryngoscope, 130:2292-2298, 2020.
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Affiliation(s)
- Ming-Shao Tsai
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsueh-Yu Li
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology - Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chung-Guei Huang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Biomedical Sciences, Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Robert Y L Wang
- Research Center for Emerging Viral Infections, Chang Gung University, Taoyuan, Taiwan
| | - Li-Pang Chuang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pulmonary and Critical Care Medicine, Taoyuan Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ning-Hung Chen
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pulmonary and Critical Care Medicine, Taoyuan Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Hung Liu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Yen Liu
- Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Cheng-Ming Hsu
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Nuan Cheng
- Department of Sports Sciences, University of Taipei, Taipei, Taiwan
| | - Li-Ang Lee
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology - Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Taranto-Montemurro L, Messineo L, Azarbarzin A, Vena D, Hess LB, Calianese NA, White DP, Wellman A, Sands SA. Effects of the Combination of Atomoxetine and Oxybutynin on OSA Endotypic Traits. Chest 2020; 157:1626-1636. [PMID: 32006590 DOI: 10.1016/j.chest.2020.01.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/12/2019] [Accepted: 01/12/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We recently showed that administration of the combination of the noradrenergic drug atomoxetine plus the antimuscarinic oxybutynin (ato-oxy) prior to sleep greatly reduced OSA severity, likely by increasing upper airway dilator muscle activity during sleep. In patients with OSA who performed the ato-oxy trial with an esophageal pressure catheter to estimate ventilatory drive, the effect of the drug combination (n = 17) and of the single drugs (n = 6) was measured on the endotypic traits over a 1-night administration and compared vs placebo. This study also tested if specific traits were predictors of complete response to treatment (reduction in apnea-hypopnea index [AHI] > 50% and < 10 events/h). METHODS The study was a double-blind, randomized, placebo-controlled trial. The arousal threshold, collapsibility (ventilation at eupneic drive [Vpassive]), ventilation at arousal threshold, and loop gain (stability of ventilatory control, LG1), were calculated during spontaneous breathing during sleep. Muscle compensation (upper airway response) was calculated as a function of ventilation at arousal threshold adjusted for Vpassive. Ventilation was expressed as a percentage of the eupneic level of ventilation (%eupnea). Data are presented as mean [95% CI]. RESULTS Compared with placebo, ato-oxy increased Vpassive by 73 [54 to 91]%eupnea (P < .001) and muscle compensation by 29 [8 to 51]%eupnea (P = .012), reduced the arousal threshold by -9 [-14 to -3]% (P = .022) and LG1 by -11 [-22 to 2]% (P = .022). Atomoxetine alone significantly reduced arousal threshold and LG1. Both agents alone improved collapsibility (Vpassive) but not muscle compensation. Patients with lower AHI, higher Vpassive, and higher fraction of hypopneas over total events had a complete response with ato-oxy. FINDINGS Ato-oxy markedly improved the measures of upper airway collapsibility, increased breathing stability, and slightly reduced the arousal threshold. Patients with relatively lower AHI and less severe upper airway collapsibility had the best chance for OSA resolution with ato-oxy.
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Affiliation(s)
- Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA.
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA; Respiratory Medicine and Sleep Laboratory, Department of Internal Medicine, Spedali Civili di Brescia, University of Brescia, Brescia, Italy; Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Nicole A Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
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130
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Cao W, Luo J, Xiao Y. A Review of Current Tools Used for Evaluating the Severity of Obstructive Sleep Apnea. Nat Sci Sleep 2020; 12:1023-1031. [PMID: 33239929 PMCID: PMC7680675 DOI: 10.2147/nss.s275252] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/08/2020] [Indexed: 12/21/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common and heterogeneous disease characterized by episodic collapse within the upper airways, which leads to reduced ventilation and adverse consequences, including hypoxia, hypercapnia, sleep fragmentation, and long-term effects such as cardiovascular comorbidities. The clinical diagnosis of OSA and its severity classification are often determined based on the apnea-hypopnea index (AHI), defining the number of apneic and hypopnea events per hour of sleep. However, the limitations of the AHI to assess disease severity have necessitated the exploration of other metrics for additional information to reflect the complexity of OSA. Novel parameters such as the hypoxic burden have the potential to better capture the main features of OSA by maximizing the information available from the polysomnogram. These emerging measures have described multidimensional qualities of sleep-disordered breathing events and breathing irregularity and will ultimately result in better management of OSA.
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Affiliation(s)
- Wenhao Cao
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Jinmei Luo
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yi Xiao
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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131
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Heffernan A, Malik U, Cheng R, Yo S, Narang I, Ryan CM. Transition to Adult Care for Obstructive Sleep Apnea. J Clin Med 2019; 8:jcm8122120. [PMID: 31810317 PMCID: PMC6947540 DOI: 10.3390/jcm8122120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/26/2019] [Accepted: 11/26/2019] [Indexed: 01/10/2023] Open
Abstract
Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include risk factors, such as obesity, male sex, and aging. More recently, there has been a precipitous increase in the prevalence of obstructive sleep apnea in youth. Drivers of this phenomenon include both increasing obesity and the survival of children with complex medical conditions into adulthood. Appropriate treatment and long-term management of obstructive sleep apnea is critical to ensure that these youth maintain well-being unfettered by secondary comorbidities. To this end, patient engagement and seamless transition of care from pediatric to adult health care systems is of paramount importance. To date, this is an unacknowledged and unmet need in most sleep programs. This article highlights the need for guideline-driven sleep disorder transition processes and illustrates the authors’ experience with the development of a program for sleep apnea.
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Affiliation(s)
- Austin Heffernan
- Sleep Research Laboratory, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G2A2, Canada; (A.H.); (U.M.); (R.C.)
| | - Uzair Malik
- Sleep Research Laboratory, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G2A2, Canada; (A.H.); (U.M.); (R.C.)
| | - Russell Cheng
- Sleep Research Laboratory, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G2A2, Canada; (A.H.); (U.M.); (R.C.)
| | - Shaun Yo
- Sleep Research Laboratory, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G2A2, Canada; (A.H.); (U.M.); (R.C.)
| | - Indra Narang
- Department of Pediatrics, Division of Respirology, University of Toronto, Toronto, ON M5G1X8, Canada;
- Sleep Laboratory, Hospital for Sick Children, Toronto, ON M5G1X8, Canada
| | - Clodagh M. Ryan
- Sleep Research Laboratory, Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G2A2, Canada; (A.H.); (U.M.); (R.C.)
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, ON M5G2N2, Canada
- Correspondence:
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132
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Amat P, Tran Lu Y É. [The contribution of orofacial myofunctional reeducation to the treatment of obstructive sleep apnoea syndrome (OSA): a systematic review of the literature]. Orthod Fr 2019; 90:343-370. [PMID: 34643521 DOI: 10.1051/orthodfr/2019035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem. Orofacial myofunctional reeducation (OMR) has been shown to be effective in the multidisciplinary treatment of OSA in children, adolescents and adults and is prescribed at several stages of OSA management. The main objective of this systematic literature review was to evaluate the effectiveness of active or passive orofacial myofunctional reeducation (OMR) in the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. The systematic literature review was undertaken from the three electronic databases: Medline (via PubMed), Cochrane Library, Web of Science Core Collection, and supplemented by a limited grey literature search (Google Scholar) in order to identify the studies evaluating the effectiveness of the OMR on OSA. The primary outcome of interest was a decrease in the Apnea-Hypopnea Index (AHI) of at least five episodes per hour compared to the baseline state. Secondary outcomes were an improvement in subjective sleep quality, sleep quality measured by night polysomnography and subjectively measured quality of life. Only ten studies met all the inclusion criteria. Eight were randomized controlled clinical trials, one was a prospective cohort study and another was a retrospective cohort study. Six studies were devoted to adult OSA and four to pediatric OSA. All included studies were assessed as "low risk of bias" based on the 12 bias risk criteria of the Cochrane Back Review Group. Based on the available evidence, RMO allows a significant reduction in AHI, up to 90.6% in children and up to 92.06% in adults. It significantly reduces the intensity and frequency of snoring, helps reduce daytime sleepiness, limits the recurrence of OSA symptoms after adenoamygdalectomy in children and improves adherence to PPC therapy. Passive RMO, with the assistance provided to the patient by wearing a custom orthosis, increases adherence to reeducation, significantly improves snoring intensity, AHI and significantly increases the upper airway. Published data show that orofacial myofunctional rééducation is effective in the multidisciplinary treatment of OSA in children, adolescents and adults and should be widely prescribed at several stages of OSA management. Passive RMO, with the pearl mandibular advancement orthosis designed by Michèle Hervy-Auboiron, helps to compensate for the frequent non-compliance observed during active RMO treatments.
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133
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Philippe C. [Non-surgical treatment of the sleep related breathing disorders in adults]. Orthod Fr 2019; 90:379-387. [PMID: 34643523 DOI: 10.1051/orthodfr/2019032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The treatment of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) must allow for the suppression of symptoms and also prevent its immediate and long-term consequences. The evaluation of the effectiveness of treatments is now based on a normal apnea/hypopnea index, a normal oxygen saturation and the disappearance of sleep fragmentation. Clinical and biological follow-up of co-morbidities must be ensured. Compliance with treatment, a major element of success, must be monitored. Continuous Positive Airway Pressure (CPAP) is still the most effective and widely used treatment. However, mandibular advancement orthosis is now recommended as a first-line treatment in moderate forms in the absence of severe cardiovascular comorbidities (CV) and remains a therapeutic alternative in the event of refusal or intolerance to CPAP. Nutritional management in cases of obesity and a physical activity program must be systematically offered. A reduction in nocturnal breathing disorders can also be achieved by using a device in the event of positional OSAHS, or by limiting fluid movements. The contribution of myofunctional therapy is currently being evaluated. Very recently, a study testing the efficiency of pharmacological treatment on the severity of OSAHS and the reactivity of geniogloss appears to be promising. The evaluation of these different treatments and their combination should make it possible to evolve towards a personalised management adapted to each patient.
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Affiliation(s)
- Carole Philippe
- Unité des Pathologies du Sommeil, Service du Pr Arnulf, Groupe Hospitalier Pitié Salpêtrière, 47-83 boulevard de l'hôpital, 75651 Paris Cedex 13, France
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Kim LJ, Freire C, Fleury Curado T, Jun JC, Polotsky VY. The Role of Animal Models in Developing Pharmacotherapy for Obstructive Sleep Apnea. J Clin Med 2019; 8:jcm8122049. [PMID: 31766589 PMCID: PMC6947279 DOI: 10.3390/jcm8122049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/12/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent disease characterized by recurrent closure of the upper airway during sleep. It has a complex pathophysiology involving four main phenotypes. An abnormal upper airway anatomy is the key factor that predisposes to sleep-related collapse of the pharynx, but it may not be sufficient for OSA development. Non-anatomical traits, including (1) a compromised neuromuscular response of the upper airway to obstruction, (2) an unstable respiratory control (high loop gain), and (3) a low arousal threshold, predict the development of OSA in association with anatomical abnormalities. Current therapies for OSA, such as continuous positive airway pressure (CPAP) and oral appliances, have poor adherence or variable efficacy among patients. The search for novel therapeutic approaches for OSA, including pharmacological agents, has been pursued over the past years. New insights into OSA pharmacotherapy have been provided by preclinical studies, which highlight the importance of appropriate use of animal models of OSA, their applicability, and limitations. In the present review, we discuss potential pharmacological targets for OSA discovered using animal models.
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135
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Lavigne G, Herrero Babiloni A, Beetz G, Dal Fabbro C, Sutherland K, Huynh N, Cistulli P. Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea. J Dent Res 2019; 99:26-35. [DOI: 10.1177/0022034519885644] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.
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Affiliation(s)
- G.J. Lavigne
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
- Division of Experimental Medicine, McGill University, Montréal, Canada
| | - A. Herrero Babiloni
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
- Division of Experimental Medicine, McGill University, Montréal, Canada
| | - G. Beetz
- Research Center, CIUSSS du Nord-de-l’Île-de-Montréal, Montréal, Canada
| | | | - K. Sutherland
- Charles Perkins Centre and Sydney Medical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
| | - N. Huynh
- Faculté de médicine dentaire, Université de Montréal, Montréal, Canada
| | - P.A. Cistulli
- Charles Perkins Centre and Sydney Medical School, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
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136
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Targeting Endotypic Traits with Medications for the Pharmacological Treatment of Obstructive Sleep Apnea. A Review of the Current Literature. J Clin Med 2019; 8:jcm8111846. [PMID: 31684047 PMCID: PMC6912255 DOI: 10.3390/jcm8111846] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition with few therapeutic options. To date there is no approved pharmacotherapy for this disorder, but several attempts have been made in the past and are currently ongoing to find one. The recent identification of multiple endotypes underlying this disorder has oriented the pharmacological research towards tailored therapies targeting specific pathophysiological traits that contribute differently to cause OSA in each patient. In this review we retrospectively analyze the literature on OSA pharmacotherapy dividing the medications tested on the basis of the four main endotypes: anatomy, upper airway muscle activity, arousal threshold and ventilatory instability (loop gain). We show how recently introduced drugs for weight loss that modify upper airway anatomy may play an important role in the management of OSA in the near future, and promising results have been obtained with drugs that increase upper airway muscle activity during sleep and reduce loop gain. The lack of a medication that can effectively increase the arousal threshold makes this strategy less encouraging, although recent studies have shown that the use of certain sedatives do not worsen OSA severity and could actually improve patients' sleep quality.
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137
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Phenotypic approach to pharmacotherapy in the management of obstructive sleep apnoea. Curr Opin Pulm Med 2019; 25:594-601. [DOI: 10.1097/mcp.0000000000000628] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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138
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Obstructive Sleep Apnea: Emerging Treatments Targeting the Genioglossus Muscle. J Clin Med 2019; 8:jcm8101754. [PMID: 31652594 PMCID: PMC6832267 DOI: 10.3390/jcm8101754] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
Obstructive sleep apnea (OSA) is characterized by repetitive episodes of upper airway obstruction caused by a loss of upper airway dilator muscle tone during sleep and an inadequate compensatory response by these muscles in the context of an anatomically compromised airway. The genioglossus (GG) is the main upper airway dilator muscle. Currently, continuous positive airway pressure is the first-line treatment for OSA. Nevertheless, problems related to poor adherence have been described in some groups of patients. In recent years, new OSA treatment strategies have been developed to improve GG function. (A) Hypoglossal nerve electrical stimulation leads to significant improvements in objective (apnea-hypopnea index, or AHI) and subjective measurements of OSA severity, but its invasive nature limits its application. (B) A recently introduced combination of drugs administered orally before bedtime reduces AHI and improves the responsiveness of the GG. (C) Finally, myofunctional therapy also decreases AHI, and it might be considered in combination with other treatments. Our objective is to review these therapies in order to advance current understanding of the prospects for alternative OSA treatments.
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139
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Sleep Pharmacotherapy for Common Sleep Disorders in Pregnancy and Lactation. Chest 2019; 157:184-197. [PMID: 31622589 DOI: 10.1016/j.chest.2019.09.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/03/2019] [Accepted: 09/21/2019] [Indexed: 12/18/2022] Open
Abstract
Sleep disturbances are common in pregnancy, and sleep disorders may worsen or present de novo in the course of gestation. Managing a pregnant patient is complicated by the risk of teratogenicity, pharmacokinetic changes, and the dynamic nature of pregnancy. Although nonpharmacologic interventions are likely safest, they are often ineffective, and a patient is left dealing with frustrations of the sleep disturbance, as well as the negative outcomes of poor sleep in pregnancy. As with any other condition in pregnancy, management requires an understanding of pregnancy physiology, knowledge of the impact of a given condition on pregnancy or fetal and neonatal outcomes, and an ability to weigh the risk of the exposure to an untreated, or poorly treated condition, against the risk of a given drug. In partnership with the pregnant patient or couple, options for therapy should be reviewed in the context of the impact of the condition on pregnancy and offspring outcomes, while understanding that data (positive or negative) on the impact of therapy on perinatal outcomes are lacking. This article reviews the epidemiology of sleep disorders in pregnancy, general principles of prescribing in pregnancy and lactation, and safety surrounding therapeutic options in pregnancy.
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140
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Marra S, Arnaldi D, Nobili L. The pharmacotherapeutic management of obstructive sleep apnea. Expert Opin Pharmacother 2019; 20:1981-1991. [DOI: 10.1080/14656566.2019.1652271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Stefano Marra
- Department of Neuroscience, IRCCS, G. Gaslini Institute, Genoa, Italy
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Dario Arnaldi
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
- Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Lino Nobili
- Department of Neuroscience, IRCCS, G. Gaslini Institute, Genoa, Italy
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
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141
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142
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143
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Muscarinic Inhibition of Hypoglossal Motoneurons: Possible Implications for Upper Airway Muscle Hypotonia during REM Sleep. J Neurosci 2019; 39:7910-7919. [PMID: 31420456 DOI: 10.1523/jneurosci.0461-19.2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/08/2019] [Accepted: 08/13/2019] [Indexed: 01/02/2023] Open
Abstract
Proper function of pharyngeal dilator muscles, including the genioglossus muscle of the tongue, is required to maintain upper airway patency. During sleep, the activity of these muscles is suppressed, and as a result individuals with obstructive sleep apnea experience repeated episodes of upper airway closure when they are asleep, in particular during rapid-eye-movement (REM) sleep. Blocking cholinergic transmission in the hypoglossal motor nucleus (MoXII) restores REM sleep genioglossus activity, highlighting the importance of cholinergic transmission in the inhibition of hypoglossal motor neurons (HMNs) during REM sleep. Glutamatergic afferent input from neurons in the parahypoglossal (PH) region to the HMNs is critical for MoXII respiratory motor output. We hypothesized that state-dependent cholinergic regulation may be mediated by this pathway. Here we studied the effects of cholinergic transmission in HMNs in adult male and female mice using patch-clamp recordings in brain slices. Using channelrhodopsin-2-assisted circuit mapping, we first demonstrated that PH glutamatergic neurons directly and robustly activate HMNs (PHGlut → HMNs). We then show that carbachol consistently depresses this input and that this effect is presynaptic. Additionally, carbachol directly affects HMNs by a variable combination of muscarinic-mediated excitatory and inhibitory responses. Altogether, our results suggest that cholinergic signaling impairs upper airway dilator muscle activity by suppressing glutamatergic input from PH premotoneurons to HMNs and by directly inhibiting HMNs. Our findings highlight the complexity of cholinergic control of HMNs at both the presynaptic and postsynaptic levels and provide a possible mechanism for REM sleep suppression of upper airway muscle activity.SIGNIFICANCE STATEMENT Individuals with obstructive sleep apnea can breathe adequately when awake but experience repeated episodes of upper airway closure when asleep, in particular during REM sleep. Similar to skeletal postural muscles, pharyngeal dilator muscles responsible for maintaining an open upper airway become hypotonic during REM sleep. Unlike spinal motoneurons controlling postural muscles that are inhibited by glycinergic transmission during REM sleep, hypoglossal motoneurons that control the upper airway muscles are inhibited in REM sleep by the combination of monoaminergic disfacilitation and cholinergic inhibition. In this study, we demonstrated how cholinergic signaling inhibits hypoglossal motoneurons through presynaptic and postsynaptic muscarinic receptors. Our results provide a potential mechanism for upper airway hypotonia during REM sleep.
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144
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Cistulli PA, Hedner J. Drug therapy for obstructive sleep apnea: From pump to pill? Sleep Med Rev 2019; 46:A1-A3. [DOI: 10.1016/j.smrv.2019.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 12/22/2022]
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145
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Cistulli PA, Sutherland K. Phenotyping obstructive sleep apnoea—Bringing precision to oral appliance therapy. J Oral Rehabil 2019; 46:1185-1191. [DOI: 10.1111/joor.12857] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney New South Wales Australia
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine Royal North Shore Hospital Sydney New South Wales Australia
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146
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Fenik VB, Penzel T, Malhotra A. Editorial: Anatomy of Upper Airway and Neuronal Control of Pharyngeal Muscles in Obstructive Sleep Apnea. Front Neurol 2019; 10:733. [PMID: 31338060 PMCID: PMC6626907 DOI: 10.3389/fneur.2019.00733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/20/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Victor B Fenik
- Department of Medical Research, VA Greater Los Angeles Healthcare System (VHA), Los Angeles, CA, United States.,Websciences International, Los Angeles, CA, United States
| | - Thomas Penzel
- Center of Sleep Medicine, Charité University Hospital, Berlin, Germany
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, CA, United States
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147
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Fleury Curado T, Berger S, Polotsky VY. Pharmacotherapy of Obstructive Sleep Apnea: Is Salvation Just Around a Corner? Am J Respir Crit Care Med 2019; 199:1186-1187. [PMID: 30521761 PMCID: PMC6519854 DOI: 10.1164/rccm.201811-2135ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Slava Berger
- 1 Johns Hopkins University School of Medicine Baltimore, Maryland
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148
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Affiliation(s)
- Sigrid C Veasey
- From the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ilene M Rosen
- From the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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