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Kothare SV, Singh K. Cardiorespiratory abnormalities during epileptic seizures. Sleep Med 2014; 15:1433-9. [PMID: 25311834 DOI: 10.1016/j.sleep.2014.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 07/17/2014] [Accepted: 08/22/2014] [Indexed: 01/01/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a leading cause of death in young and otherwise healthy patients with epilepsy, and sudden death is at least 20 times more common in epilepsy patients as compared to patients without epilepsy. A significant proportion of patients with epilepsy experience cardiac and respiratory complications during seizures. These cardiorespiratory complications are suspected to be a significant risk factor for SUDEP. Sleep physicians are increasingly involved in the care of epilepsy patients and a recognition of these changes in relation to seizures while a patient is under their care may improve their awareness of these potentially life-threatening complications that may occur during sleep studies. This paper details these cardiopulmonary changes that take place in relation to epileptic seizures and how these changes may relate to the occurrence of SUDEP.
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Affiliation(s)
- Sanjeev V Kothare
- Comprehensive Epilepsy Center, Department of Neurology, New York University Langone Medical Center, New York, NY, USA.
| | - Kanwaljit Singh
- Comprehensive Epilepsy Center, Department of Neurology, New York University Langone Medical Center, New York, NY, USA; Department of Pediatrics (Neurology), University of Massachusetts Medical School, Worcester, MA, USA
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Pavlova M, Singh K, Abdennadher M, Katz ES, Dworetzky BA, White DP, Llewellyn N, Kothare SV. Comparison of cardiorespiratory and EEG abnormalities with seizures in adults and children. Epilepsy Behav 2013; 29:537-41. [PMID: 24140516 DOI: 10.1016/j.yebeh.2013.09.026] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/13/2013] [Accepted: 09/16/2013] [Indexed: 11/17/2022]
Abstract
Cardiopulmonary dysfunction and postictal generalized EEG suppression (PGES) are proposed as possible risk factors for the occurrence of SUDEP. The evolution of cardiorespiratory abnormalities with seizures has not been systematically studied for any age-related findings. Additionally, not many studies have looked into the possible effect of age-related brain maturation on PGES. The purpose of this study was to compare these SUDEP risk factors in adults versus children. We prospectively recorded cardiopulmonary abnormalities during seizures using pulse oximetry, EKG, and respiratory inductance plethysmography. Linear and logistic regression models adjusting for multiple seizures in a single patient were used to compare the cardiorespiratory and EEG findings between adults and children. We recorded 101 seizures in 26 children and 55 seizures in 22 adults. Ictal central apnea and bradycardia occurred more often in children than in adults (p=0.02 and p=0.008, respectively), while ictal tachycardia occurred more often in adults (p=0.001) than in children. Postictal generalized EEG suppression of longer duration occurred more often in adults (p=0.003) than in children. Minimum O2 saturation and seizure duration/generalization/lateralization did not significantly differ between adults and children (p>0.1). Children had more frontal lobe seizures, and adults had more temporal lobe seizures recorded (p=0.01). There may be an age-related effect on cardiorespiratory and EEG abnormalities associated with seizures, with higher rates of apnea and bradycardia in children and a much higher prevalence of PGES of longer duration in adults. This may indicate why, despite lower rates of cardiopulmonary dysfunction, adults die more frequently from SUDEP than children.
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Affiliation(s)
- Milena Pavlova
- Division of Epilepsy, Neurophysiology, and Sleep, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Singh K, Katz ES, Zarowski M, Loddenkemper T, Llewellyn N, Manganaro S, Gregas M, Pavlova M, Kothare SV. Cardiopulmonary complications during pediatric seizures: a prelude to understanding SUDEP. Epilepsia 2013; 54:1083-91. [PMID: 23731396 DOI: 10.1111/epi.12153] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Sudden unexpected death in epilepsy (SUDEP) is an important, unexplained cause of death in epilepsy. Role of cardiopulmonary abnormalities in the pathophysiology of SUDEP is unclear in the pediatric population. Our objective was to assess cardiopulmonary abnormalities during epileptic seizures in children, with the long-term goal of identifying potential mechanisms of SUDEP. METHODS We prospectively recorded cardiopulmonary functions using pulse-oximetry, electrocardiography (ECG), and respiratory inductance plethysmography (RIP). Logistic regression was used to evaluate association of cardiorespiratory findings with seizure characteristics and demographics. KEY FINDINGS We recorded 101 seizures in 26 children (average age 3.9 years). RIP provided analyzable data in 78% and pulse-oximetry in 63% seizures. Ictal central apnea was more prevalent in patients with younger age (p = 0.01), temporal lobe (p < 0.001), left-sided (p < 0.01), symptomatic generalized (p = 0.01), longer duration seizures (p < 0.0002), desaturation (p < 0.0001), ictal bradycardia (p < 0.05), and more antiepileptic drugs (AEDs; p < 0.01), and was less prevalent in frontal lobe seizures (p < 0.01). Ictal bradypnea was more prevalent in left-sided (p < 0.05), symptomatic generalized seizures (p < 0.01), and in brain magnetic resonance imaging (MRI) lesions (p < 0.1). Ictal tachypnea was more prevalent in older-age (p = 0.01), female gender (p = 0.05), frontal lobe (p < 0.05), right-sided seizures (p < 0.001), fewer AEDs (p < 0.01), and less prevalent in lesional (p < 0.05) and symptomatic generalized seizures (p < 0.05). Ictal bradycardia was more prevalent in male patients (p < 0.05) longer duration seizures (p < 0.05), desaturation (p = 0.001), and more AEDs (p < 0.05), and was less prevalent in frontal lobe seizures (p = 0.01). Ictal and postictal bradycardia were directly associated (p < 0.05). Desaturation was more prevalent in longer-duration seizures (p < 0.0001), ictal apnea (p < 0.0001), ictal bradycardia (p = 0.001), and more AEDs (p = 0.001). SIGNIFICANCE Potentially life-threatening cardiopulmonary abnormalities such as bradycardia, apnea, and hypoxemia in pediatric epileptic seizures are associated with predictable patient and seizure characteristics, including seizure subtype and duration.
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Affiliation(s)
- Kanwaljit Singh
- Division of Clinical Neurophysiology, Department of Neurology, Harvard Medical School, Children's Hospital, Boston, Massachusetts 02115, USA
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Fujisawa H, Yoshida Y, Niida Y, Hasegawa M, Yamashita J. Cyanotic breath-holding spell: a life-threatening complication after radical resection of a cervicomedullary ganglioglioma. Pediatr Neurosurg 2005; 41:93-7. [PMID: 15942280 DOI: 10.1159/000085163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2004] [Accepted: 11/17/2004] [Indexed: 11/19/2022]
Abstract
Cyanotic breath-holding spell is a benign and self-limiting disease of young children but occasionally associated with sudden, unexpected death. The authors report a rare case in a 2-year-old girl with a severe form that started after radical resection of a cervicomedullary ganglioglioma. She was admitted to our hospital because of delayed and unstable gait. Since magnetic resonance imaging showed a cervicomedullary tumor, she underwent a radical resection and histology showed the tumor to be a ganglioglioma. Postoperatively, the function of the lower cranial nerves and cerebellum deteriorated and hemiparesis on the left became apparent, but she returned to the preoperative state in a few months. In addition, mild sleep apnea (Ondine curse) and severe cyanotic breath-holding spells occurred. The former responded to medication but the latter failed and continued several times per day with a rapid onset and progression of hypoxemia, loss of consciousness, sweating and opisthotonos. Five months after the operation, the patient returned home with a portable oxygen saturation monitor equipped with an alarm. This case indicates that cyanotic breath-holding spell, as well as sleep apnea, is critical during the early postoperative period. This is the first report observing that such spells may occur as a complication of radical resection of a cervicomedullary tumor.
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Affiliation(s)
- Hironori Fujisawa
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
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Ramelli GP, Donati F, Bianchetti M, Vassella F. Apnoeic attacks as an isolated manifestation of epileptic seizures in infants. Eur J Paediatr Neurol 1998; 2:187-91. [PMID: 10726590 DOI: 10.1016/s1090-3798(98)80018-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Apnoea as an isolated manifestation of seizures is well described in neonates but is only occasionally observed in infants. We present data from four infants, with apnoea as the sole manifestation of seizures, documented by polygraphic ictal electroencephalogram (EEGC) and video recording. The four infants, after normal pregnancy and delivery at term, showed the first apnoea at the age of 2-11 months. The interictal EEG was normal. The ictal EEG and video recording showed in all infants a focal rhythmic alpha or theta activity with or without generalization, which lasted 40-120 seconds. The apnoea appeared a few seconds after the beginning of rhythmic activity and the heart rate remained unchanged during the apnoea. At 2 years' follow-up, three children are seizure-free under anti-epileptic therapy with normal psychomotor development in two, and a slight delay in the third infant. The fourth child has partial seizures and is severely retarded.
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Affiliation(s)
- G P Ramelli
- Department of Pediatrics, University of Berne, Switzerland
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North KN, Laing NG, Wallgren-Pettersson C. Nemaline myopathy: current concepts. The ENMC International Consortium and Nemaline Myopathy. J Med Genet 1997; 34:705-13. [PMID: 9321754 PMCID: PMC1051052 DOI: 10.1136/jmg.34.9.705] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- K N North
- Neurogenetics Research Unit, Royal Alexandra Hospital for Children, Sydney, Australia
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Paydarfar D, Buerkel DM. Sporadic apnea: paradoxical transformation to eupnea by perturbations that inhibit inspiration. Med Hypotheses 1997; 49:19-26. [PMID: 9247902 DOI: 10.1016/s0306-9877(97)90246-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We speculate that sporadic apneas may be initiated and terminated by stochastic neural perturbations arising within or impinging upon the respiratory oscillator. A curious situation can then arise in which tiny perturbations that inhibit inspiration, paradoxically stimulate breathing. The plausibility of the hypothesis is supported by numerical analysis of a noisy attractor-cycle oscillator, and in studies of a preterm sleeping infant with sporadic apnea; low-level vibratory stimulation transformed the irregular apneic rhythm to eupnea.
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Affiliation(s)
- D Paydarfar
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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8
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Abstract
Of 46 infants who were investigated for apparent life-threatening events, central nervous system disorders were diagnosed in seven (15%). Convulsive disorders, intraventricular hemorrhage and hydrocephalus, absent corpus callosum, and development deficits were found. In four of the seven, no neurologic deficit was suspected before the event. Electroencephalographic studies (overnight in two) would have identified the disorder in all four. Electroencephalography is therefore a recommended routine procedure in investigation of apparent life-threatening events. Central nervous system disorders should be routinely ruled out in cases of apparent life-threatening event, even in the absence of clinical clues.
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Affiliation(s)
- E Tirosh
- Jacobo Lichtmann Apnea Investigation Unit, Department of Pediatrics, Bnai Zion Medical Center, Haifa, Israel
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9
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Paydarfar D, Buerkel DM. Dysrhythmias of the respiratory oscillator. CHAOS (WOODBURY, N.Y.) 1995; 5:18-29. [PMID: 12780150 DOI: 10.1063/1.166067] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Breathing is regulated by a central neural oscillator that produces rhythmic output to the respiratory muscles. Pathological disturbances in rhythm (dysrhythmias) are observed in the breathing pattern of children and adults with neurological and cardiopulmonary diseases. The mechanisms responsible for genesis of respiratory dysrhythmias are poorly understood. The present studies take a novel approach to this problem. The basic postulate is that the rhythm of the respiratory oscillator can be altered by a variety of stimuli. When the oscillator recovers its rhythm after such perturbations, its phase may be reset relative to the original rhythm. The amount of phase resetting is dependent upon stimulus parameters and the level of respiratory drive. The long-range hypothesis is that respiratory dysrhythmias can be induced by stimuli that impinge upon or arise within the respiratory oscillator with certain combinations of strength and timing relative to the respiratory cycle. Animal studies were performed in anesthetized or decerebrate preparations. Neural respiratory rhythmicity is represented by phrenic nerve activity, allowing use of open-loop experimental conditions which avoid negative chemical feedback associated with changes in ventilation.In animal experiments, respiratory dysrhythmias can be induced by stimuli having specific combinations of strength and timing. Newborn animals readily exhibit spontaneous dysrhythmias which become more prominent at lower respiratory drives. In human subjects, swallowing was studied as a physiological perturbation of respiratory rhythm, causing a pattern of phase resetting that is characterized topologically as type 0. Computational studies of the Bonhoeffer-van der Pol (BvP) equations, whose qualitative behavior is representative of many excitable systems, supports a unified interpretation of these experimental findings. Rhythmicity is observed when the BvP model exhibits recurrent periods of excitation alternating with refractory periods. The same system can be perturbed to a state in which amplitude of oscillation is attenuated or abolished. We have characterized critical perturbations which induce transitions between these two states, giving rise to patterns of dysrhythmic activity that are similar to those seen in the experiments. We illustrate the importance of noise in initiation and termination of rhythm, comparable to normal respiratory rhythm intermixed with spontaneous dysrhythmias. In the BvP system the incidence and duration of dysrhythmia is shown to be strongly influenced by the level of noise. These studies should lead to greater understanding of rhythmicity and integrative responses of the respiratory control system, and provide insight into disturbances in control mechanisms that cause apnea and aspiration in clinical disease states. (c) 1995 American Institute of Physics.
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Affiliation(s)
- David Paydarfar
- Departments of Medicine and Biomedical Research, St. Elizabeth's Medical Center of Boston and Tufts University School of Medicine, Boston Massachusetts 02135
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Abstract
Apneic episodes, quite common in newborns, are considered rare after age 1 month, when gastroesophageal reflux, cardiac arrhythmias, idiopathic central apnea, and seizures become included in differential diagnosis. Determining the cause of apnea is important as treatment differs significantly and can be harmful; Caffeine given for presumed idiopathic central apnea is reported to have precipitated seizures in 2 patients with apneic seizures. Two cases of partial seizures presenting as apnea in infants were studied. Interictal EEG was normal in 1 and showed focal spikes in the other. Video EEG monitoring (16 channel) showed focal ictal discharge originating from temporal areas clearly preceding onset of apnea in both patients. Because therapeutic options are sometimes diametrically opposite and interictal EEGs are particularly unreliable for diagnosis, we recommend video-EEG monitoring if there is any doubt about the diagnosis before starting treatment in patients with apneic episodes.
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Affiliation(s)
- B Singh
- Department of Paediatric Neurology, Riyadh Armed Forces Hospital, Saudi Arabia
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Southall DP, Noyes JP, Poets CF, Samuels MP. Mechanisms for hypoxaemic episodes in infancy and early childhood. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1993; 82 Suppl 389:60-2. [PMID: 8374196 DOI: 10.1111/j.1651-2227.1993.tb12879.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- D P Southall
- Department of Paediatric Clinical Physiology, National Heart and Lung Institute, London, UK
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Samuels MP, Poets CF, Noyes JP, Hartmann H, Hewertson J, Southall DP. Diagnosis and management after life threatening events in infants and young children who received cardiopulmonary resuscitation. BMJ (CLINICAL RESEARCH ED.) 1993; 306:489-92. [PMID: 8448459 PMCID: PMC1676783 DOI: 10.1136/bmj.306.6876.489] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine the mechanisms and thereby appropriate management for apparent life threatening events treated with cardiopulmonary resuscitation in infants and young children. DESIGN Prospective clinical and physiological study. SETTING Royal Brompton Hospital or in patients' homes, or both. SUBJECTS 157 Patients referred at median age 2.8 months (range 1 week to 96 months), 111 (71%) had recurrent events, 44 were born preterm, 19 were siblings of infants who had died suddenly and unexpectedly, and 18 were over 12 months old. INTERVENTIONS Multichannel physiological recordings, including oxygenation, in hospital (n = 150) and at home (n = 61). Additional recordings with electroencephalogram, video, or other respiratory measures were used to confirm diagnoses. Management involved monitoring of oxygen at home, additional inspired oxygen, anticonvulsant treatment, or child protection procedures. MAIN OUTCOME MEASURES Abnormalities on recordings compared to published normal data and their correlation with clinical events; sudden death. RESULTS 53 of 150 patients had abnormalities of oxygenation on hospital recordings, 28 of whom had an accompanying clinical event. Home recordings produced physiological data from 34 of 61 patients during subsequent clinical events. Final diagnoses were reached in 77 patients: deliberate suffocation by a parent (18), hypoxaemia induced by epileptic seizure (10), fabricated history and data (Munchausen syndrome by proxy; seven), acute hypoxaemia of probable respiratory origin (40), and changes in peripheral perfusion and skin colour without hypoxaemia (two). Four patients died: three suddenly and unexpectedly (none on home oxygen monitors) and one from pneumonia. CONCLUSIONS Identification of mechanisms is essential to the appropriate management of infants with apparent life threatening events.
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Affiliation(s)
- M P Samuels
- Academic Department of Paediatrics, University of Keele, North Staffordshire Hospital Centre, Stoke-on-Trent
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Poets CF, Samuels MP, Southall DP. On sudden severe bradycardia secondary to hypoxemia. Pediatr Pulmonol 1992; 12:59-60. [PMID: 1579378 DOI: 10.1002/ppul.1950120115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Affiliation(s)
- R W Byard
- Department of Histopathology, Adelaide Children's Hospital, South Australia
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Affiliation(s)
- O F D'Cruz
- Department of Neurology, Medical College of Wisconsin, Milwaukee 53226
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Abstract
Eighteen patients with various mucopolysaccharidoses or mucolipidosis III were studied electrophysiologically to determine the presence or absence of carpal tunnel syndrome. In 17 patients this was clearly demonstrated, the only exception being a boy with mucopolysaccharidosis II, age 6 months at testing. All patients had a remarkable lack of symptoms. Carpal tunnel syndrome is a very common complication of the mucopolysaccharidoses and mucolipidosis III and should be actively looked for in affected patients. Early diagnosis and treatment offer the best chance of a good response to surgery.
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Affiliation(s)
- J E Wraith
- Royal Manchester Children's Hospital, Willink Biochemical Genetics Unit
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Abraham NG, Stebbens VA, Samuels MP, Southall DP. Investigation of cyanotic/apneic episodes and sleep-related upper airway obstruction by long-term non-invasive bedside recordings. Pediatr Pulmonol 1990; 8:259-62. [PMID: 2371074 DOI: 10.1002/ppul.1950080409] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over a 4 year period, investigations were performed on 226 infants and children suffering cyanotic episodes and 160 suspected to be the victims of sleep-related upper airway obstruction. These investigations have been considerably aided by long-term tape recordings of multiple cardiorespiratory and neurophysiological variables from non-invasive sensors. In addition to identifying the underlying mechanisms responsible for cyanotic episodes, recordings have identified the presence or absence of airway obstruction, documented its severity by its effects on oxygenation and on sleep-state organization, and evaluated objectively the effects of treatment. The recording system, which is transportable, has been especially developed for use outside of the specialized sleep laboratory and was used on patients in hospital wards and at home.
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Affiliation(s)
- N G Abraham
- Department of Clinical Engineering, Charing Cross Hospital, London, England
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Southall DP, Kerr AM, Tirosh E, Amos P, Lang MH, Stephenson JB. Hyperventilation in the awake state: potentially treatable component of Rett syndrome. Arch Dis Child 1988; 63:1039-48. [PMID: 3140736 PMCID: PMC1779110 DOI: 10.1136/adc.63.9.1039] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hyperventilation, which occurs in some patients with severe mental handicap, is a prominent feature in the histories of most girls with Rett syndrome but its mechanism and effects have not been established. Respiratory function was therefore studied in 18 patients with Rett syndrome and 23 healthy controls. Ten of the patients (56%), but none of the controls, hyperventilated only when awake, and began doing so after a period of normal breathing without hypoxaemia. After hyperventilation was established it was interspersed with prolonged periods of apnoea (over 19 seconds) accompanied by Valsalva manoeuvres. Hypoxaemia (less than 90%) occurred in 47% of these periods of apnoea and five (50%) of the patients had oxygen saturation values of under 50%. During hyperventilation severe hypocapnia developed in every patient, and recorded arterial pH measurements ranged from 7.47 to 7.60. A further four patients (22%) did not hyperventilate, but had clear histories of hyperventilation when younger. All had frequent apnoeic pauses accompanied by Valsalva manoeuvres. The remaining four girls (22%) neither hyperventilated nor gave a clear history of doing so. Three had occasional apnoeic pauses associated with the Valsalva manoeuvres. All but one of the 18 patients had increased quantities of periodic apnoea compared with the control subjects. The hypocapnic alkalaemia and hypoxaemia resulting from hyperventilation may contribute to the cerebral impairment in Rett syndrome. Since the hyperventilation is 'primary', and not secondary to preceding apnoea, it is potentially treatable. Further studies will determine if treatment is practical and of benefit.
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Affiliation(s)
- D P Southall
- Cardiothoracic Institute, Brompton Hospital, London
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Southall DP, Talbert DG. Mechanisms for abnormal apnea of possible relevance to the sudden infant death syndrome. Ann N Y Acad Sci 1988; 533:329-49. [PMID: 3048174 DOI: 10.1111/j.1749-6632.1988.tb37262.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- D P Southall
- Cardiothoracic Institute, Brompton Hospital, London, United Kingdom
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Affiliation(s)
- N Gordon
- Booth Hall Children's Hospital, Blackley, Manchester
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