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Parrino L, Halasz P, Szucs A, Thomas RJ, Azzi N, Rausa F, Pizzarotti S, Zilioli A, Misirocchi F, Mutti C. Sleep medicine: Practice, challenges and new frontiers. Front Neurol 2022; 13:966659. [PMID: 36313516 PMCID: PMC9616008 DOI: 10.3389/fneur.2022.966659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Sleep medicine is an ambitious cross-disciplinary challenge, requiring the mutual integration between complementary specialists in order to build a solid framework. Although knowledge in the sleep field is growing impressively thanks to technical and brain imaging support and through detailed clinic-epidemiologic observations, several topics are still dominated by outdated paradigms. In this review we explore the main novelties and gaps in the field of sleep medicine, assess the commonest sleep disturbances, provide advices for routine clinical practice and offer alternative insights and perspectives on the future of sleep research.
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Affiliation(s)
- Liborio Parrino
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- *Correspondence: Liborio Parrino
| | - Peter Halasz
- Szentagothai János School of Ph.D Studies, Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Anna Szucs
- Department of Behavioral Sciences, National Institute of Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Robert J. Thomas
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Nicoletta Azzi
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
| | - Francesco Rausa
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Silvia Pizzarotti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
| | - Alessandro Zilioli
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Francesco Misirocchi
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Carlotta Mutti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
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Oktay Arslan B, Ucar Hosgor ZZ, Ekinci S, Cetinkol I. Evaluation of the Impact of Body Position on Primary Central Sleep Apnea Syndrome. Arch Bronconeumol 2021; 57:393-398. [PMID: 34088390 DOI: 10.1016/j.arbr.2020.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/01/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of the body position on primary central sleep apnea syndrome. METHODS Fifty-five subjects diagnosed with central sleep apnea (CSA) through polysomnographic examinations were prospectively enrolled in the study. All patients underwent cardiologic and neurologic examinations. Primary positional central sleep apnea (PCSA) was determined when the supine Apnea-Hypopnea Index (AHI) was greater than two times the non-supine AHI. The primary PCSA and non-PCSA groups were compared in terms of demographic characteristics, sleep parameters, and treatment approaches. RESULTS Overall, 39 subjects diagnosed with primary CSA were included in the study; 61.5% of the subjects had primary PCSA. There were no differences between the primary PCSA and non-PCSA groups regarding age, sex, body mass index (BMI), co-morbidities, and history of septoplasty. In terms of polysomnography parameters, AHI (P=.001), oxygen desaturation index (P=.002), the time spent under 88% saturation during sleep (P=.003), number of obstructive apnea (P=.011), mixed apnea (P=.009), and central apnea (P=.007) was lower in the primary PCSA group than in the non-PCSA group. Twenty-nine percent of the patients in the primary PCSA group were recommended position treatment and 71% were recommended positive airway pressure (PAP) therapy; all patients in the non-PCSA group were recommended PAP therapy. CONCLUSIONS Our results demonstrated that the rate of primary PCSA was high (61.5%) and primary PCSA was associated with milder disease severity compared with non-PCSA. The classification of patients with primary CSA regarding positional dependency may be helpful in terms of developing clinical approaches and treatment recommendations.
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Affiliation(s)
- Burcu Oktay Arslan
- University of Health Science, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Department of Chest Medicine and Sleep Disorders Center, Izmir, Turkey.
| | - Zeynep Zeren Ucar Hosgor
- University of Health Science, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Department of Chest Medicine and Sleep Disorders Center, Izmir, Turkey
| | - Selim Ekinci
- University of Health Science, Tepecik Training and Research Hospital, Department of Cardiology, Izmir, Turkey
| | - Isil Cetinkol
- University of Health Science, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Department of Neurology, Izmir, Turkey
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Javaheri S, McKane S. Transvenous phrenic nerve stimulation to treat idiopathic central sleep apnea. J Clin Sleep Med 2021; 16:2099-2107. [PMID: 32946372 DOI: 10.5664/jcsm.8802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVES Idiopathic central sleep apnea (ICSA) is a rare disorder diagnosed when known causes of central sleep apnea are excluded. No established treatments exist for ICSA, and long-term studies are lacking. We assessed the long-term effectiveness and safety of transvenous phrenic nerve stimulation in patients with ICSA. METHODS In the remedē System Pivotal Trial, 16/151 (11%) participants with central sleep apnea were diagnosed as having ICSA. Patients were implanted and followed through 18 months of active therapy. Polysomnograms obtained at baseline and at 6, 12, and 18 months were scored by a central laboratory. Sleep metrics and patient-reported quality of life outcomes were assessed. RESULTS Patients experienced moderate-severe central sleep apnea. The baseline AHI, central apnea index, and arousal index were 40, 25, and 32 events/h of sleep, respectively. These metrics improved at 6, 12, and 18 months of therapy: the AHI decreased by 25, 25, and 23 events/h (P < .001 at each visit), the central apnea index by 22, 23, and 22 events/h (P < .001 at each visit), and the arousal index by 12 (P = .005), 11 (P = .035), and 13 events/h (P < .001). Quality of life instruments showed clinically meaningful improvements in daytime somnolence, fatigue, general and mental health, and social functioning. The only related serious adverse event was lead component failure in 1 patient. CONCLUSIONS This is the longest prospective study for the treatment of ICSA. Transvenous phrenic nerve stimulation significantly decreased sleep-disordered breathing metrics with consequent improvement in quality of life at 6 months, and all benefits were sustained through 18 months. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Respicardia, Inc. Pivotal Trial of the remedē System; URL: https://clinicaltrials.gov/ct2/show/NCT01816776; Identifier: NCT01816776.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, Ohio
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Abstract
Treatment-emergent central sleep apnea (TECSA) is a specific form of sleep-disordered breathing, characterized by the emergence or persistence of central apneas during treatment for obstructive sleep apnea. The purpose of this review was to summarize the definition, epidemiology, potential mechanisms, clinical characteristics, and treatment of TECSA. We searched for relevant articles up to January 31, 2020, in the PubMed database. The prevalence of TECSA varied widely in different studies. The potential mechanisms leading to TECSA included ventilatory control instability, low arousal threshold, activation of lung stretch receptors, and prolonged circulation time. TECSA may be a self-limited disorder in some patients and could be resolved spontaneously over time with ongoing treatment of continuous positive airway pressure (CPAP). However, central apneas persist even with the regular CPAP therapy in some patients, and new treatment approaches such as adaptive servo-ventilation may be necessary. We concluded that several questions regarding TECSA remain, despite the findings of many studies, and it is necessary to carry out large surveys with basic scientific design and clinical trials for TECSA to clarify these irregularities. Further, it will be vital to evaluate the baseline demographic and polysomnographic data of TECSA patients more carefully and comprehensively.
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Johnson KG, Sullivan SS, Nti A, Rastegar V, Gurubhagavatula I. The impact of the COVID-19 pandemic on sleep medicine practices. J Clin Sleep Med 2021; 17:79-87. [PMID: 32964828 DOI: 10.5664/jcsm.8830] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
STUDY OBJECTIVES The COVID-19 pandemic required sleep centers to consider and implement infection control strategies to mitigate viral transmission to patients and staff. Our aim was to assess measures taken by sleep centers due to the COVID-19 pandemic and plans surrounding reinstatement of sleep services. METHODS We distributed an anonymous online survey to health care providers in sleep medicine on April 29, 2020. From responders, we identified a subset of unique centers by region and demographic variables. RESULTS We obtained 379 individual responses, which represented 297 unique centers. A total of 93.6% of unique centers reported stopping all or nearly all sleep testing of at least one type, without significant differences between adult and pediatric labs, geographic region, or surrounding population density. By contrast, a greater proportion of respondents continued home sleep apnea testing services. A total of 60.3% reduced home sleep apnea testing volume by at least 90%, compared to 90.4% that reduced in-laboratory testing by at least 90%. Respondents acknowledged that they implemented a wide variety of mitigation strategies. While no respondents reported virtual visits to be ≥ 25% of clinical visits prior to the pandemic, more than half (51.9%) anticipated maintaining ≥ 25% virtual visits after the pandemic. CONCLUSIONS Among surveyed sleep centers, the vast majority reported near-cessation of in-laboratory sleep studies, while a smaller proportion reported reductions in home sleep apnea tests. A large increase in the use of telemedicine was reported, with the majority of respondents expecting the use of telehealth to endure in the future.
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Affiliation(s)
- Karin G Johnson
- Department of Neurology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.,Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Shannon S Sullivan
- Department of Pediatrics, Division of Pulmonary, Asthma & Sleep Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Afua Nti
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Vida Rastegar
- Department of Medicine, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Oktay Arslan B, Ucar Hosgor ZZ, Ekinci S, Cetinkol I. Evaluation of the Impact of Body Position on Primary Central Sleep Apnea Syndrome. Arch Bronconeumol 2020. [PMID: 32527712 DOI: 10.1016/j.arbres.2020.03.004] [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: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of the body position on primary central sleep apnea syndrome. METHODS Fifty-five subjects diagnosed with central sleep apnea (CSA) through polysomnographic examinations were prospectively enrolled in the study. All patients underwent cardiologic and neurologic examinations. Primary positional central sleep apnea (PCSA) was determined when the supine Apnea-Hypopnea Index (AHI) was greater than two times the non-supine AHI. The primary PCSA and non-PCSA groups were compared in terms of demographic characteristics, sleep parameters, and treatment approaches. RESULTS Overall, 39 subjects diagnosed with primary CSA were included in the study; 61.5% of the subjects had primary PCSA. There were no differences between the primary PCSA and non-PCSA groups regarding age, sex, body mass index (BMI), co-morbidities, and history of septoplasty. In terms of polysomnography parameters, AHI (P=.001), oxygen desaturation index (P=.002), the time spent under 88% saturation during sleep (P=.003), number of obstructive apnea (P=.011), mixed apnea (P=.009), and central apnea (P=.007) was lower in the primary PCSA group than in the non-PCSA group. Twenty-nine percent of the patients in the primary PCSA group were recommended position treatment and 71% were recommended positive airway pressure (PAP) therapy; all patients in the non-PCSA group were recommended PAP therapy. CONCLUSIONS Our results demonstrated that the rate of primary PCSA was high (61.5%) and primary PCSA was associated with milder disease severity compared with non-PCSA. The classification of patients with primary CSA regarding positional dependency may be helpful in terms of developing clinical approaches and treatment recommendations.
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Affiliation(s)
- Burcu Oktay Arslan
- University of Health Science, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Department of Chest Medicine and Sleep Disorders Center, Izmir, Turkey.
| | - Zeynep Zeren Ucar Hosgor
- University of Health Science, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Department of Chest Medicine and Sleep Disorders Center, Izmir, Turkey
| | - Selim Ekinci
- University of Health Science, Tepecik Training and Research Hospital, Department of Cardiology, Izmir, Turkey
| | - Isil Cetinkol
- University of Health Science, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, Department of Neurology, Izmir, Turkey
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The effect of acetazolamide on the improvement of central apnea caused by abusing opioid drugs in the clinical trial. Sleep Breath 2019; 24:1417-1425. [PMID: 31808012 DOI: 10.1007/s11325-019-01968-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/25/2019] [Accepted: 10/25/2019] [Indexed: 01/12/2023]
Abstract
PURPOSE Acetazolamide is utilized as a treatment which falls effective in treating some type of CSA. Hence, it might be effective as far as opium addicts who suffer from CSA are concerned. MATERIALS AND METHOD The current study was a double-blind, placebo-controlled, cross-over study ( clinicalTrials.gov ID: NCT02371473). The whole procedures were identical for both placebo and acetazolamide phases of clinical research. There were 14 CSA more than 5/h and more than 50% of apnea-hypopnea index (AHI). Out of these 14 patients, 10 volunteered to participate in the study. Fast Fourier transformation was used to separate heart rate variability (HRV) into its component VLF (very low frequency band), LF (low frequency band), and HF (high frequency band) rhythms that operate within different frequency ranges. RESULT There are significant results in terms of decreased mix apnea and central apnea together due to acetazolamide compared with placebo (P < 0.023). Time of SatO2 < 90% is decreased as well (P < 0.1). There is also decrease of SDNN and NN50 after treatment with acetazolamide respectively (P < 0.001). Regarding fast Fourier transformation, there is increase of pHF and decrease of pLF after acetazolamide treatment (P < 0.001). CONCLUSION Acetazolamide seems to be effective in improving oxygenation and a decrease of mixed and central apnea events together. In HRV analysis section, LF power has decreased significantly, which may more likely improve prognosis of the patients.
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Affiliation(s)
- Kevin Gipson
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA
| | - Mengdi Lu
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA
| | - T Bernard Kinane
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA
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Khouri C, Arbib F, Revol B, Pepin JL, Tamisier R. Severe central sleep apnoea associated with nalmefene: a case report. Br J Clin Pharmacol 2018; 84:1075-1076. [DOI: 10.1111/bcp.13547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/10/2018] [Accepted: 01/28/2018] [Indexed: 12/01/2022] Open
Affiliation(s)
- Charles Khouri
- Pharmacovigilance Unit; Grenoble Alps University Hospital; Grenoble France
- Clinical Pharmacology Department, INSERM CIC1406; Grenoble Alps University Hospital; Grenoble France
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
| | - François Arbib
- Thorax and Vessel Division; Grenoble Alps University Hospital; Grenoble France
| | - Bruno Revol
- Pharmacovigilance Unit; Grenoble Alps University Hospital; Grenoble France
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
| | - Jean-Louis Pepin
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
- Thorax and Vessel Division; Grenoble Alps University Hospital; Grenoble France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
- Thorax and Vessel Division; Grenoble Alps University Hospital; Grenoble France
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Koo DL, Nam H, Thomas RJ, Yun CH. Sleep Disturbances as a Risk Factor for Stroke. J Stroke 2018; 20:12-32. [PMID: 29402071 PMCID: PMC5836576 DOI: 10.5853/jos.2017.02887] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 12/30/2022] Open
Abstract
Sleep, a vital process of human being, is carefully orchestrated by the brain and consists of cyclic transitions between rapid eye movement (REM) and non-REM (NREM) sleep. Autonomic tranquility during NREM sleep is characterized by vagal dominance and stable breathing, providing an opportunity for the cardiovascular-neural axis to restore homeostasis, in response to use, distress or fatigue inflicted during wakefulness. Abrupt irregular swings in sympathovagal balance during REM sleep act as phasic loads on the resting cardiovascular system. Any causes of sleep curtailment or fragmentation such as sleep restriction, sleep apnea, insomnia, periodic limb movements during sleep, and shift work, not only impair cardiovascular restoration but also impose a stress on the cardiovascular system. Sleep disturbances have been reported to play a role in the development of stroke and other cardiovascular disorders. This review aims to provide updated information on the role of abnormal sleep in the development of stroke, to discuss the implications of recent research findings, and to help both stroke clinicians and researchers understand the importance of identification and management of sleep pathology for stroke prevention and care.
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Affiliation(s)
- Dae Lim Koo
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunwoo Nam
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Robert J Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Chang-Ho Yun
- Department of Neurology, Bundang Clinical Neuroscience Institute, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Severe obstructive sleep apnea treatment with oral appliance: the impact on obstructive, central and mixed events. Sleep Breath 2017; 22:91-98. [PMID: 28702829 DOI: 10.1007/s11325-017-1535-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 06/22/2017] [Accepted: 07/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study is to evaluate the effectiveness of two types of oral appliance (OA) in the treatment of severe obstructive sleep apnea syndrome (OSAS) and their impact on the reduction of obstructive, central and mixed apneas. METHODS Forty-eight patients suffering from severe OSAS with a history of non-adherence to positive airway pressure therapy were treated with OA (lingual orthosis and combined orthosis). Polysomnography exams were performed before and after treatment. Computed tomography and cephalometric radiography were requested for all patients to evaluate the titrated position of the OA and the airspace obtained. Statistical tests used the Minitab, version 17, program. The level of statistical significance was 5%. RESULTS Before treatment, the mean AHI was 56.3 ± 19.1 events/h. It decreased to 8.1 ± 5.2 after the OA titration (p ≤ 0.001). There was a significant reduction in obstructive events from 43.0 ± 20.2 to 7.1 ± 4.6 events/h (p ≤ 0.001). The reduction in central events after OA treatment was also significant (from 5.1 ± 9.3 to 0.8 ± 1.9 events/h; p ≤ 0.001), whereas that in mixed events decreased from 6.4 ± 9.5 to 0.1 ± 0.3 events/h (p ≤ 0.001). The minimum oxygen saturation also showed significant improvement after treatment (p ≤ 0.001). There was no statistically significant difference between both OA with respect to central events (p = 0.22) or mixed events (p = 0.98). CONCLUSION The treatment was effective in reducing obstructive events which were evaluated through the AHI and minimum oxygen saturation. The oral appliances also normalized central and mixed events among patients with severe OSAS.
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Thomas RJ, Shin C, Bianchi MT, Kushida C, Yun CH. Distinct polysomnographic and ECG-spectrographic phenotypes embedded within obstructive sleep apnea. SLEEP SCIENCE AND PRACTICE 2017. [DOI: 10.1186/s41606-017-0012-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. Chest 2017; 152:880-892. [PMID: 28372949 DOI: 10.1016/j.chest.2017.03.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Normal sleep-related rapid eye movement sleep atonia, reduced lung volumes, reduced chemosensitivity, and impaired airway dilator activity become significant vulnerabilities in the setting of neuromuscular disease. In that context, the compounding effects of respiratory muscle weakness and disease-specific features that promote upper airway collapse or cause dilated cardiomyopathy contribute to various sleep-disordered breathing events. The reduction in lung volumes with neuromuscular disease is further compromised by sleep and the supine position, exaggerating the tendency for upper airway collapse and desaturation with sleep-disordered breathing events. The most commonly identified events are diaphragmatic/pseudo-central, due to a decrease in the rib cage contribution to the tidal volume during phasic rapid eye movement sleep. Obstructive and central sleep apneas are also common. Noninvasive ventilation can improve survival and quality of sleep but should be used with caution in the context of dilated cardiomyopathy or significant bulbar symptoms. Noninvasive ventilation can also trigger sleep-disordered breathing events, including ineffective triggering, autotriggering, central sleep apnea, and glottic closure, which compromise the potential benefits of the intervention by increasing arousals, reducing adherence, and impairing sleep architecture. Polysomnography plays an important diagnostic and therapeutic role by correctly categorizing sleep-disordered events, identifying sleep-disordered breathing triggered by noninvasive ventilation, and improving noninvasive ventilation settings. Optimal management may require dedicated hypoventilation protocols and a technical staff well versed in the identification and troubleshooting of respiratory events.
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