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Pinna GD, Maestri R. Computer-Assisted Assessment of the Interaction Between Arousals, Breath-by-Breath Ventilation, and Chemical Drive During Cheyne-Stokes Respiration in Heart Failure Patients. Front Physiol 2022; 13:815352. [PMID: 35222084 PMCID: PMC8867072 DOI: 10.3389/fphys.2022.815352] [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: 11/15/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Transient increases in ventilation induced by arousal from sleep during Cheyne-Stokes respiration in heart failure patients are thought to contribute to sustaining and exacerbating the ventilatory oscillation. The only possibility to investigate the validity of this notion is to use observational data. This entails some significant challenges: (i) accurate identification of both arousal onset and offset; (ii) detection of short arousals (<3 s); (iii) breath-by-breath analysis of the interaction between arousals and ventilation; (iv) careful control for important confounding factors. In this paper we report how we have tackled these challenges by developing innovative computer-assisted methodologies. The identification of arousal onset and offset is performed by a hybrid approach that integrates visual scoring with computer-based automated analysis. We use a statistical detector to automatically discriminate between dominant theta–delta and dominant alpha activity at each instant of time. Moreover, a statistical detector is used to validate visual scoring of K complexes, delta waves or artifacts associated with an EEG frequency shift, as well as frequency shifts to beta activity. A high-resolution (250 ms) state-transition diagram providing continuous information on the sleep-wake state of the subject is finally obtained. Based on this information, arousals are automatically identified as any state change from sleep to wakefulness lasting ≥2 s. The assessment of the interaction between arousals and ventilation is performed using a breath-by-breath, case-control approach. The arousal-associated change in ventilation is measured as the normalized difference between minute ventilation in the case breath (i.e., with arousal) and that in the control breath (i.e., without arousal), controlling for sleep stage and chemical drive. The latter is estimated by using information from pulse oximetry at the finger. In the last part of the paper, we discuss main potential sources of error inherent in the described methodologies.
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Pinna GD, Robbi E, Bruschi C, La Rovere MT, Maestri R. Interaction Between Arousals and Ventilation During Cheyne-Stokes Respiration in Heart Failure Patients: Insights From Breath-by-Breath Analysis. Front Med (Lausanne) 2022; 8:742458. [PMID: 34977056 PMCID: PMC8717813 DOI: 10.3389/fmed.2021.742458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Study Objectives: Arousals from sleep during the hyperpneic phases of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA) in patients with heart failure are thought to cause ventilatory overshoot and a consequent longer apnea, thereby sustaining and exacerbating ventilatory instability. However, data supporting this model are lacking. We investigated the relationship between arousals, hyperpnea and post-hyperpnea apnea length during CSR-CSA. Methods: Breath-by-breath changes in ventilation associated with the occurrence of arousal were evaluated in 18 heart failure patients with CSR-CSA, apnea-hypopnea index ≥15/h and central apnea index ≥5/h. The change in apnea length associated with the presence of arousal during the previous hyperpnea was also evaluated. Potential confounding variables (chemical drive, sleep stage) were controlled for. Results: Arousals were associated with a large increase in ventilation at the beginning of the hyperpnea (+76 ± 35%, p < 0.0001), that rapidly declined during its crescendo phase. Around peak hyperpnea, the change in ventilation was -8 ± 26% (p = 0.14). The presence of arousal during the hyperpnea was associated with a median increase in the length of the subsequent apnea of +4.6% (Q1, Q2: -0.7%, 20.5%; range: -8.5%, 36.2%) (p = 0.021). The incidence of arousals occurring at the beginning of hyperpnea and mean ventilation in the region around its peak were independent predictors of the change in apnea length (p = 0.004 and p = 0.015, respectively; R2 = 0.78). Conclusions: Arousals from sleep during CSR-CSA in heart failure patients are associated with a rapidly decreasing ventilatory overshoot at the beginning of the hyperpnea, followed by a tendency toward a slight ventilatory undershoot around its peak. On average, arousals are also associated with a modest increase in post-hyperpnea apnea length; however, large increases in apnea length (>20%) occur in about a quarter of the patients.
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Affiliation(s)
- Gian Domenico Pinna
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Elena Robbi
- Sleep and Respiratory Function Unit, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy.,Laboratory for the Study of the Autonomic Nervous System, Department of Cardiology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Claudio Bruschi
- Department of Pneumology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Maria Teresa La Rovere
- Laboratory for the Study of the Autonomic Nervous System, Department of Cardiology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Roberto Maestri
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
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Callara AL, Morelli MS, Hartwig V, Landini L, Giannoni A, Passino C, Emdin M, Vanello N. Ld-EEG Effective Brain Connectivity in Patients With Cheyne-Stokes Respiration. IEEE Trans Neural Syst Rehabil Eng 2020; 28:1216-1225. [PMID: 32191895 DOI: 10.1109/tnsre.2020.2981991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The characterization of brain cortical activity in heart-failure patients affected by Cheyne-Stokes Respiration might provide relevant information about the mechanism underlying this pathology. Central autonomic network is gaining increasing attention for its role in the regulation of breathing and cardiac functions. In this scenario, evaluating changes in cortical connectivity associated with Cheyne-Stokes Respiration may be of interest in the study of specific brain-activity related to such disease. Nonetheless, the inter subject variability, the temporal dynamics of Central-Apnea/Hyperpnea cycles and the limitations of clinical setups lead to different methodological challenges. To this aim, we present a framework for the assessment of cortico-cortical interactions from Electroencephalographic signals acquired using low-density caps and block-design paradigms, arising from endogenous triggers. The framework combines ICA-decomposition, unsupervised clustering, MVAR modelling and a permutation-bootstrap strategy for evaluating significant connectivity differences between conditions. A common network, lateralized towards the left hemisphere, was depicted across 8 patients exhibiting Cheyne-Stokes Respiration patterns during acquisitions. Significant differences in connectivity at the group level were observed based on patients' ventilatory condition. Interactions were significantly higher during hyperpnea periods with respect to central apneas and occurred mainly in the delta band. Opposite-sign differences were observed for higher frequencies (i.e. beta, low-gamma).
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Sands SA, Mebrate Y, Edwards BA, Nemati S, Manisty CH, Desai AS, Wellman A, Willson K, Francis DP, Butler JP, Malhotra A. Resonance as the Mechanism of Daytime Periodic Breathing in Patients with Heart Failure. Am J Respir Crit Care Med 2017; 195:237-246. [PMID: 27559818 DOI: 10.1164/rccm.201604-0761oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE In patients with chronic heart failure, daytime oscillatory breathing at rest is associated with a high risk of mortality. Experimental evidence, including exaggerated ventilatory responses to CO2 and prolonged circulation time, implicates the ventilatory control system and suggests feedback instability (loop gain > 1) is responsible. However, daytime oscillatory patterns often appear remarkably irregular versus classic instability (Cheyne-Stokes respiration), suggesting our mechanistic understanding is limited. OBJECTIVES We propose that daytime ventilatory oscillations generally result from a chemoreflex resonance, in which spontaneous biological variations in ventilatory drive repeatedly induce temporary and irregular ringing effects. Importantly, the ease with which spontaneous biological variations induce irregular oscillations (resonance "strength") rises profoundly as loop gain rises toward 1. We tested this hypothesis through a comparison of mathematical predictions against actual measurements in patients with heart failure and healthy control subjects. METHODS In 25 patients with chronic heart failure and 25 control subjects, we examined spontaneous oscillations in ventilation and separately quantified loop gain using dynamic inspired CO2 stimulation. MEASUREMENTS AND MAIN RESULTS Resonance was detected in 24 of 25 patients with heart failure and 18 of 25 control subjects. With increased loop gain-consequent to increased chemosensitivity and delay-the strength of spontaneous oscillations increased precipitously as predicted (r = 0.88), yielding larger (r = 0.78) and more regular (interpeak interval SD, r = -0.68) oscillations (P < 0.001 for all, both groups combined). CONCLUSIONS Our study elucidates the mechanism underlying daytime ventilatory oscillations in heart failure and provides a means to measure and interpret these oscillations to reveal the underlying chemoreflex hypersensitivity and reduced stability that foretells mortality in this population.
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Affiliation(s)
- Scott A Sands
- 1 Division of Sleep and Circadian Disorders and.,2 Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Yoseph Mebrate
- 3 International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,4 Department of Clinical Engineering, Royal Brompton Hospital, London, United Kingdom
| | - Bradley A Edwards
- 1 Division of Sleep and Circadian Disorders and.,5 Sleep and Circadian Medicine Laboratory, Department of Physiology, and.,6 School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | | | - Charlotte H Manisty
- 7 Institute of Cardiovascular Sciences, University College London, London, United Kingdom; and
| | - Akshay S Desai
- 8 Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Keith Willson
- 3 International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P Francis
- 3 International Center for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Atul Malhotra
- 1 Division of Sleep and Circadian Disorders and.,9 Division of Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, California
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Abstract
Congestive heart failure (CHF) is among the most common causes of admission to hospitals in the United States, especially in those over age 65. Few data exist regarding the prevalence CHF of Cheyne-Stokes respiration (CSR) owing to congestive heart failure in the intensive care unit (ICU). Nevertheless, CSR is expected to be highly prevalent among those with CHF. Treatment should focus on the underlying mechanisms by which CHF increases loop gain and promotes unstable breathing. Few data are available to determine prevalence of CSR in the ICU, or how CSR might affect clinical management and weaning from mechanical ventilation.
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Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, Alfred Hospital and Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037, USA.
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Flinta I, Ponikowski P. Relationship between central sleep apnea and Cheyne-Stokes Respiration. Int J Cardiol 2016; 206 Suppl:S8-12. [PMID: 26961739 DOI: 10.1016/j.ijcard.2016.02.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/21/2016] [Indexed: 10/22/2022]
Abstract
Central sleep apnea (CSA) in patients with heart failure (HF) occurs frequently and shows a serious influence on prognosis in this population. The key elements in the pathophysiology of CSA are respiratory instability with chronic hyperventilation, changes of arterial carbon dioxide pressure (pCO2) and elongated circulation time. The main manifestation of CSA in patients with HF is Cheyne-Stokes Respiration (CSR). The initial treatment is the optimization of HF therapy. However, many other options of the therapeutic management have been studied, particularly those based on positive airway pressure methods. In patients with heart failure we often can observe the overlap of CSA and CSR; we will discuss the differences between these forms of breathing disorders during sleep. We will also discuss when CSA and CSR occur independently of each other and the importance of CSR occurring during the daytime in context of CSA during the nighttime.
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Affiliation(s)
- Irena Flinta
- Department of Cardiology, 4th Military Hospital, Wrocław, Poland; Department of Physiology, Medical University, Wrocław, Poland.
| | - Piotr Ponikowski
- Department of Cardiology, 4th Military Hospital, Wrocław, Poland; Clinic of Cardiac Diseases, Department of Heart Diseases, Medical University, Wrocław, Poland
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Acute improvement of pulmonary hemodynamics does not alleviate Cheyne-Stokes respiration in chronic heart failure-a randomized, controlled, double-blind, crossover trial. Sleep Breath 2016; 20:795-804. [PMID: 26782102 DOI: 10.1007/s11325-015-1300-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/23/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This randomized, controlled trial aimed to investigate whether acute improvement of pulmonary congestion would reduce the severity of Cheyne-Stokes respiration (CSR) in patients with chronic heart failure (CHF). METHODS Twenty-one consecutive patients with CHF and CSR (apnea-hypopnea index [AHI] ≥15/h) underwent right heart catheterization with titration of intravenous (IV) glyceryltrinitrate (GTN) to a maximum tolerable dosage and inhalation of iloprost 10 μg/mL after a washout phase. Maximum tolerable dosages of GTN and iloprost were randomly applied during full cardiorespiratory polysomnography within two split-night procedures and compared with IV or inhaled sodium chloride (NaCl) 0.9 %, respectively. RESULTS GTN (6.2 ± 1.5 mg/h) and iloprost significantly lowered \mean pulmonary artery pressure (20.1 ± 9.0 to 11.6 ± 4.2 mmHg, p < 0.001 and 16.9 ± 7.9 to 14.2 ± 6.4 mmHg, p < 0.01, respectively). Pulmonary capillary wedge pressure was only reduced by GTN (14.0 ± 5.6 to 7.2 ± 3.9 mmHg, p < 0.001), and there was no significant change in the cardiac index. Sleep studies revealed no significant improvement in markers of CSR severity, including AHI, central apnea index, and CSR cycle length following GTN or iloprost treatment. Significant decreases in blood pressure, mean oxygen saturation, and S3 sleep were documented during GTN infusion. CONCLUSIONS Acute improvement of pulmonary congestion by GTN had no immediate impact on CSR severity. Future investigations must therefore include longer treatment periods and treatment regimens that have positive, rather than negative, additional effects on peripheral and central chemoreceptors and sleep structure. TRIAL REGISTRATION German Clinical Trial Registry-ID:DRKS00000467 ( www.germanctr.de ).
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Wang Y, Cao J, Feng J, Chen BY. Cheyne-Stokes respiration during sleep: mechanisms and potential interventions. Br J Hosp Med (Lond) 2015; 76:390-6. [PMID: 26140557 DOI: 10.12968/hmed.2015.76.7.390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cheyne-Stokes respiration is characterized by a typical waxing and waning pattern in breathing amplitude, interspersed with central apnoeas or hypopnoeas. This article reviews current knowledge regarding Cheyne-Stokes respiration with a particular emphasis on the mechanisms and latest methods of intervention.
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Affiliation(s)
| | | | | | - Bao-Yuan Chen
- Chief Physician in the Department of Respiratory Diseases, Tianjin Medical University General Hospital, Tianjin, 300052, China
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Abstract
Congestive heart failure (CHF) is among the most common causes of admission to hospitals in the United States, especially in those over age 65. Few data exist regarding the prevalence CHF of Cheyne-Stokes respiration (CSR) owing to congestive heart failure in the intensive care unit (ICU). Nevertheless, CSR is expected to be highly prevalent among those with CHF. Treatment should focus on the underlying mechanisms by which CHF increases loop gain and promotes unstable breathing. Few data are available to determine prevalence of CSR in the ICU, or how CSR might affect clinical management and weaning from mechanical ventilation.
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Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, Alfred Hospital and Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037, USA.
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