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Cousin C, Di Maria J, Hartley S, Vaugier I, Delord V, Bensmail D, Prigent H, Léotard A. Predictive factors and screening strategy for obstructive sleep apnea in patients with advanced multiple sclerosis. Mult Scler Relat Disord 2024; 86:105608. [PMID: 38614056 DOI: 10.1016/j.msard.2024.105608] [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: 01/23/2023] [Revised: 03/22/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) screening questionnaires have been evaluated in Multiple Sclerosis (MS) but not yet validated in patients with advanced disease. The aim of this study is to identify OSA predictive factors in advanced MS and to discuss screening strategies. METHODS Oximetry data from 125 patients were retrospectively derived from polysomnographic reports. Univariate and multivariate analysis were used to determine predictive factors for OSA. A two-level screening model was assessed combining the oxygen desaturation index (ODI) and a method of visual analysis. RESULTS multivariate analysis showed that among the clinical factors only age and snoring were associated with OSA. Usual predictive factors such as sleepiness, Body mass index (BMI) or sex were not significantly associated with increased Apnea Hypopnea Index (AHI). The ODI was highly predictive (p < 0.0001) and correctly identified 84.1 % of patients with moderate OSA and 93.8 % with severe OSA. The visual analysis model combined with the ODI did not outperform the properties of ODI used alone. CONCLUSION As the usual clinical predictors are not associated with OSA in patients with advanced MS, questionnaires developed for the general population are not appropriate in these patients. Nocturnal oximetry seems a pertinent, ambulatory and accessible method for OSA screening in this population.
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Affiliation(s)
- C Cousin
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, Hôpital Raymond Poincaré, Garches, France; Unité de recherche clinique Paris Saclay Ouest, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - J Di Maria
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, Hôpital Raymond Poincaré, Garches, France; « End:icap » U1179 Inserm, UVSQ-Université Paris-Saclay, 78000, Versailles, France
| | - S Hartley
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - I Vaugier
- Centre d'investigation clinique 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | | | - D Bensmail
- « End:icap » U1179 Inserm, UVSQ-Université Paris-Saclay, 78000, Versailles, France; Service de médecine physique et de réadaptation, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - H Prigent
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, Hôpital Raymond Poincaré, Garches, France; « End:icap » U1179 Inserm, UVSQ-Université Paris-Saclay, 78000, Versailles, France
| | - A Léotard
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, Hôpital Raymond Poincaré, Garches, France; « End:icap » U1179 Inserm, UVSQ-Université Paris-Saclay, 78000, Versailles, France; Sleep Lab Initiative In PMR group (SLIIP), France.
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Yang L, Ding Z, Zhou J, Zhang S, Wang Q, Zheng K, Wang X, Chen L. Algorithmic detection of sleep-disordered breathing using respiratory signals: a systematic review. Physiol Meas 2024; 45:03TR02. [PMID: 38387048 DOI: 10.1088/1361-6579/ad2c13] [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: 09/10/2023] [Accepted: 02/22/2024] [Indexed: 02/24/2024]
Abstract
Background and Objective. Sleep-disordered breathing (SDB) poses health risks linked to hypertension, cardiovascular disease, and diabetes. However, the time-consuming and costly standard diagnostic method, polysomnography (PSG), limits its wide adoption and leads to underdiagnosis. To tackle this, cost-effective algorithms using single-lead signals (like respiratory, blood oxygen, and electrocardiogram) have emerged. Despite respiratory signals being preferred for SDB assessment, a lack of comprehensive reviews addressing their algorithmic scope and performance persists. This paper systematically reviews 2012-2022 literature, covering signal sources, processing, feature extraction, classification, and application, aiming to bridge this gap and provide future research references.Methods. This systematic review followed the registered PROSPERO protocol (CRD42022385130), initially screening 342 papers, with 32 studies meeting data extraction criteria.Results. Respiratory signal sources include nasal airflow (NAF), oronasal airflow (OAF), and respiratory movement-related signals such as thoracic respiratory effort (TRE) and abdominal respiratory effort (ARE). Classification techniques include threshold rule-based methods (8), machine learning models (13), and deep learning models (11). The NAF-based algorithm achieved the highest average accuracy at 94.11%, surpassing 78.19% for other signals. Hypopnea detection sensitivity with single-source respiratory signals remained modest, peaking at 73.34%. The TRE and ARE signals proved to be reliable in identifying different types of SDB because distinct respiratory disorders exhibited different patterns of chest and abdominal motion.Conclusions. Multiple detection algorithms have been widely applied for SDB detection, and their accuracy is closely related to factors such as signal source, signal processing, feature selection, and model selection.
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Affiliation(s)
- Liqing Yang
- Key Laboratory of Biorheological Science and Technology of Ministry of Education, Chongqing University, Chongqing, People's Republic of China
- Chongqing Medical Electronics Engineering Technology Research Center, Chongqing University, Chongqing, People's Republic of China
| | - Zhimei Ding
- Key Laboratory of Biorheological Science and Technology of Ministry of Education, Chongqing University, Chongqing, People's Republic of China
- Chongqing Medical Electronics Engineering Technology Research Center, Chongqing University, Chongqing, People's Republic of China
| | - Jiangjie Zhou
- Chongqing Medical Electronics Engineering Technology Research Center, Chongqing University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Artificial Intelligence and Service Robot Control Technology, Chongqing, People's Republic of China
| | - Siyuan Zhang
- Key Laboratory of Biorheological Science and Technology of Ministry of Education, Chongqing University, Chongqing, People's Republic of China
- Chongqing Medical Electronics Engineering Technology Research Center, Chongqing University, Chongqing, People's Republic of China
| | - Qi Wang
- Chongqing Medical Electronics Engineering Technology Research Center, Chongqing University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Artificial Intelligence and Service Robot Control Technology, Chongqing, People's Republic of China
| | - Kaige Zheng
- Chongqing Medical Electronics Engineering Technology Research Center, Chongqing University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Artificial Intelligence and Service Robot Control Technology, Chongqing, People's Republic of China
| | - Xing Wang
- Key Laboratory of Biorheological Science and Technology of Ministry of Education, Chongqing University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Artificial Intelligence and Service Robot Control Technology, Chongqing, People's Republic of China
| | - Lin Chen
- Key Laboratory of Biorheological Science and Technology of Ministry of Education, Chongqing University, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Artificial Intelligence and Service Robot Control Technology, Chongqing, People's Republic of China
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Yang H, Lu S, Yang L. Clinical prediction models for the early diagnosis of obstructive sleep apnea in stroke patients: a systematic review. Syst Rev 2024; 13:38. [PMID: 38268059 PMCID: PMC10807185 DOI: 10.1186/s13643-024-02449-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/29/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common sleep disorder characterized by repetitive cessation or reduction in airflow during sleep. Stroke patients have a higher risk of OSA, which can worsen their cognitive and functional disabilities, prolong their hospitalization, and increase their mortality rates. METHODS We conducted a comprehensive literature search in the databases of PubMed, CINAHL, Embase, PsycINFO, Cochrane Library, and CNKI, using a combination of keywords and MeSH words in both English and Chinese. Studies published up to March 1, 2022, which reported the development and/or validation of clinical prediction models for OSA diagnosis in stroke patients. RESULTS We identified 11 studies that met our inclusion criteria. Most of the studies used logistic regression models and machine learning approaches to predict the incidence of OSA in stroke patients. The most frequently selected predictors included body mass index, sex, neck circumference, snoring, and blood pressure. However, the predictive performance of these models ranged from poor to moderate, with the area under the receiver operating characteristic curve varying from 0.55 to 0.82. All the studies have a high overall risk of bias, mainly due to the small sample size and lack of external validation. CONCLUSION Although clinical prediction models have shown the potential for diagnosing OSA in stroke patients, their limited accuracy and high risk of bias restrict their implications. Future studies should focus on developing advanced algorithms that incorporate more predictors from larger and representative samples and externally validating their performance to enhance their clinical applicability and accuracy.
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Affiliation(s)
- Hualu Yang
- Department of Rehabilitation, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 581052, China
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, 999077, China
| | - Shuya Lu
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, 999077, China
| | - Lin Yang
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, 999077, China.
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Graco M, Ruehland WR, Schembri R, Churchward TJ, Saravanan K, Sheers NL, Berlowitz DJ. Prevalence of central sleep apnea in people with tetraplegic spinal cord injury: a retrospective analysis of research and clinical data. Sleep 2023; 46:zsad235. [PMID: 37691432 DOI: 10.1093/sleep/zsad235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
STUDY OBJECTIVES Over 80% of people with tetraplegia have sleep-disordered breathing (SDB), but whether this is predominantly obstructive or central is unclear. This study aimed to estimate the prevalence of central sleep apnea (CSA) in tetraplegia and the contributions of central, obstructive, and hypopnea respiratory events to SDB summary indices in tetraplegia. METHODS Research and clinical data from 606 individuals with tetraplegia and full overnight polysomnography were collated. The proportions of different respiratory event types were calculated; overall and for mild, moderate, and severe disease. The prevalence of Predominant CSA (Central Apnea Index [CAI] ≥ 5 and more central than obstructive apneas) and Any CSA (CAI ≥ 5) was estimated. Prevalence of sleep-related hypoventilation (SRH) was estimated in a clinical sub-cohort. RESULTS Respiratory events were primarily hypopneas (71%), followed by obstructive (23%), central (4%), and mixed apneas (2%). As severity increased, the relative contribution of hypopneas and central apneas decreased, while that of obstructive apneas increased. The prevalence of Predominant CSA and Any CSA were 4.3% (26/606) and 8.4% (51/606) respectively. Being male, on opiates and having a high tetraplegic spinal cord injury were associated with CSA. SRH was identified in 26% (26/113) of the clinical sub-cohort. CONCLUSIONS This is the largest study to characterize SDB in tetraplegia. It provides strong evidence that obstructive sleep apnea is the predominant SDB type; 9-18 times more prevalent than CSA. The prevalence of CSA was estimated to be 4%-8%, significantly lower than previously reported.
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Affiliation(s)
- Marnie Graco
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Department of Physiotherapy, University of Melbourne, Parkville, VIC, Australia
| | - Warren R Ruehland
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
| | - Rachel Schembri
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Thomas J Churchward
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
| | - Krisha Saravanan
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
| | - Nicole L Sheers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Department of Physiotherapy, University of Melbourne, Parkville, VIC, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Department of Physiotherapy, University of Melbourne, Parkville, VIC, Australia
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Chen J, Shen M, Ma W, Zheng W. A spatio-temporal learning-based model for sleep apnea detection using single-lead ECG signals. Front Neurosci 2022; 16:972581. [PMID: 35992920 PMCID: PMC9389170 DOI: 10.3389/fnins.2022.972581] [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: 06/18/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Sleep apnea (SA) is a common chronic sleep breathing disorder, which would cause stroke, cognitive decline, cardiovascular disease, or even death. The SA symptoms often manifest as frequent breathing interruptions during sleep and most individuals with sleeping disorders are not aware of the SA events. Using a portable device with single-lead ECG signal is an effective way to help an individual to monitor their sleep conditions at home. However, the SA detection performance of ECG-based methods is still difficult to meet the clinical practice requirement. In this study, we propose an end-to-end spatio-temporal learning-based SA detection method, which consists of multiple spatio-temporal blocks. Each block has the identical architecture with a convolutional neural network (CNN) layer, a max-pooling layer, and a bi-gated recurrent unit (BiGRU) layer. This architecture with repeated spatio-temporal blocks can well capture the morphological spatial feature information as well as the temporal feature information from ECG signals. The proposed SA detection model was evaluated on the publicly available datasets of PhysioNet Apnea-ECG dataset (Apnea-ECG) and University College Dublin Sleep Apnea Database (UCDDB). Extensive experimental results show that our proposed SA model on both Apnea-ECG and UCDDB datasets achieves state-of-the-art results, which are obviously superior to existing ECG-based SA detection methods. It means that our proposed method has the potential to be deployed into a healthcare system to provide a sleep monitoring service, which can screen out SA population with high risk and help to take timely interventions to prevent serious consequences.
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Affiliation(s)
- Junyang Chen
- School of Computer Science, South China Normal University, Guangzhou, China
| | - Mengqi Shen
- Grado Department of Industrial and Systems Engineering, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States
| | - Wenjun Ma
- School of Computer Science, South China Normal University, Guangzhou, China
| | - Weiping Zheng
- School of Computer Science, South China Normal University, Guangzhou, China
- *Correspondence: Weiping Zheng
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Graco M, Gobets DF, M O'Connell C, E Baumberger M, Mueller G, Daniëls B, L Knowles B, Lustenberger H, J Berlowitz D. Management of sleep-disordered breathing in three spinal cord injury rehabilitation centres around the world: a mixed-methods study. Spinal Cord 2022; 60:414-421. [PMID: 35241799 DOI: 10.1038/s41393-022-00780-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Mixed-methods observational study. OBJECTIVE To describe the sleep-disordered breathing (SDB) management models of three spinal cord injury (SCI) rehabilitation centres that are screening, diagnosing and treating uncomplicated SDB, and to determine their common elements. SETTING Three specialist SCI rehabilitation centres. METHODS Data collection at each site included direct observations and interviews with lead clinical staff and an audit of SDB-related clinical practice in 2019. Detailed descriptions of the models of care, including process maps, were developed. A theory-based analysis of the common elements of the three care models was undertaken. RESULTS At each centre a multidisciplinary team, consisting of medical, allied health and/or nursing staff, provided a comprehensive SDB management service that included screening, diagnosis and treatment. Inpatients with SCI were assessed for SDB with overnight oximetry and/or polygraphy. Further assessment of patient symptoms, respiratory function, and hypercapnia supported the diagnostic process. Treatment with positive airway pressure was initiated on the ward. Having a collaborative, skilled team with strong leadership and adequate resources were the key, common enablers to providing the service. CONCLUSION It is feasible for multi-disciplinary SCI rehabilitation teams to independently diagnose and treat uncomplicated SDB without referral to specialist sleep services provided they are adequately resourced with equipment and skilled staff. Similar models of care could substantially improve access to SDB treatment for people with SCI. Further research is required to determine the non-inferiority of these alternatives to specialist care.
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Affiliation(s)
- Marnie Graco
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia. .,Department of Allied Health, Alfred Health, Melbourne, VIC, Australia. .,Department of Physiotherapy, University of Melbourne, Melbourne, VIC, Australia.
| | - David F Gobets
- Heliomare Rehabilitation Center, Wijk aan Zee, Noord Holland, The Netherlands
| | - Colleen M O'Connell
- Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada.,Faculty of Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | | | - Gabi Mueller
- Swiss Paraplegic Center, Nottwil, Lucerne, Switzerland
| | - Brita Daniëls
- Heliomare Rehabilitation Center, Wijk aan Zee, Noord Holland, The Netherlands
| | - Beth L Knowles
- Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada
| | | | - David J Berlowitz
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia.,Department of Physiotherapy, University of Melbourne, Melbourne, VIC, Australia
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Panza GS, Sutor T, Gee CM, Graco M, McCully KK, Chiodo A, Badr MS, Nash MS. Is Sleep Disordered Breathing Confounding Rehabilitation Outcomes in Spinal Cord Injury Research? Arch Phys Med Rehabil 2021; 103:1034-1045. [PMID: 34537222 DOI: 10.1016/j.apmr.2021.08.015] [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: 08/15/2021] [Accepted: 08/24/2021] [Indexed: 11/02/2022]
Abstract
The purpose of this article is to highlight the importance of considering sleep-disordered breathing (SDB) as a potential confounder to rehabilitation research interventions in spinal cord injury (SCI). SDB is highly prevalent in SCI, with increased prevalence in individuals with higher and more severe lesions, and the criterion standard treatment with continuous positive airway pressure remains problematic. Despite its high prevalence, SDB is often untested and untreated in individuals with SCI. In individuals without SCI, SDB is known to negatively affect physical function and many of the physiological systems that negatively affect physical rehabilitation in SCI. Thus, owing to the high prevalence, under testing, low treatment adherence, and known negative effect on the physical function, it is contended that underdiagnosed SDB in SCI may be confounding physical rehabilitation research studies in individuals with SCI. Studies investigating the effect of treating SDB and its effect on physical rehabilitation in SCI were unable to be located. Thus, studies investigating the likely integrated relationship among physical rehabilitation, SDB, and proper treatment of SDB in SCI are needed. Owing to rapid growth in both sleep medicine and physical rehabilitation intervention research in SCI, the authors contend it is the appropriate time to begin the conversations and collaborations between these fields. We discuss a general overview of SDB and physical training modalities, as well as how SDB could be affecting these studies.
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Affiliation(s)
- Gino S Panza
- John D. Dingell Veterans Affairs Medical Center, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI.
| | - Tommy Sutor
- Research Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA
| | - Cameron M Gee
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Marnie Graco
- Institute for Breathing and Sleep, Austin Health; and School of Physiotherapy, University of Melbourne, Melbourne, Australia
| | | | - Anthony Chiodo
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
| | - M Safwan Badr
- John D. Dingell Veterans Affairs Medical Center, Detroit, MI; Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Mark S Nash
- Department of Neurological Surgery, Physical Medicine & Rehabiliation, and Physical Therapy, Miami, FL; The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL
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Don't Forget About the Sleep Disorders: Letter to the Editor Responding to Cognitive Profiles Among Individuals with Spinal Cord Injuries. Arch Phys Med Rehabil 2021; 102:1860-1861. [PMID: 34019884 DOI: 10.1016/j.apmr.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/20/2022]
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Sutor T, Cavka K, Vose AK, Welch JF, Davenport P, Fuller DD, Mitchell GS, Fox EJ. Single-session effects of acute intermittent hypoxia on breathing function after human spinal cord injury. Exp Neurol 2021; 342:113735. [PMID: 33951477 DOI: 10.1016/j.expneurol.2021.113735] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/14/2021] [Accepted: 04/29/2021] [Indexed: 12/13/2022]
Abstract
After spinal cord injury (SCI) respiratory complications are a leading cause of morbidity and mortality. Acute intermittent hypoxia (AIH) triggers spinal respiratory motor plasticity in rodent models, and repetitive AIH may have the potential to restore breathing capacity in those with SCI. As an initial approach to provide proof of principle for such effects, we tested single-session AIH effects on breathing function in adults with chronic SCI. 17 adults (13 males; 34.1 ± 14.5 years old; 13 motor complete SCI; >6 months post injury) completed two randomly ordered sessions, AIH versus sham. AIH consisted of 15, 1-min episodes (hypoxia: 10.3% O2; sham: 21% O2) interspersed with room air breathing (1.5 min, 21% oxygen); no attempt was made to regulate arterial CO2 levels. Blood oxygen saturation (SpO2), maximal inspiratory and expiratory pressures (MIP; MEP), forced vital capacity (FVC), and mouth occlusion pressure within 0.1 s (P0.1) were assessed. Outcomes were compared using nonparametric Wilcoxon's tests, or a 2 × 2 ANOVA. Baseline SpO2 was 97.2 ± 1.3% and was unchanged during sham experiments. During hypoxic episodes, SpO2 decreased to 84.7 ± 0.9%, and returned to baseline levels during normoxic intervals. Outcomes were unchanged from baseline post-sham. Greater increases in MIP were evident post AIH vs. sham (median values; +10.8 cmH2O vs. -2.6 cmH2O respectively, 95% confidence interval (-18.7) - (-4.3), p = .006) with a moderate Cohen's effect size (0.68). P0.1, MEP and FVC did not change post-AIH. A single AIH session increased maximal inspiratory pressure generation, but not other breathing functions in adults with SCI. Reasons may include greater spared innervation to inspiratory versus expiratory muscles or differences in the capacity for AIH-induced plasticity in inspiratory motor neuron pools. Based on our findings, the therapeutic potential of AIH on breathing capacity in people with SCI warrants further investigation.
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Affiliation(s)
- Tommy Sutor
- Hunter Holmes McGuire VA Medical Center, United States.
| | - Kathryn Cavka
- Brooks Rehabilitation, Jacksonville, FL, United States.
| | - Alicia K Vose
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
| | - Joseph F Welch
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
| | - Paul Davenport
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States; Department of Physiological Sciences, University of Florida, Gainesville, FL, United States.
| | - David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
| | - Gordon S Mitchell
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
| | - Emily J Fox
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States; Brooks Rehabilitation, Jacksonville, FL, United States; Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, United States.
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10
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Prevalence of sleep-disordered breathing in people with tetraplegia-a systematic review and meta-analysis. Spinal Cord 2021; 59:474-484. [PMID: 33446931 DOI: 10.1038/s41393-020-00595-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN Systematic review with meta-analysis. OBJECTIVES To determine the prevalence of sleep-disordered breathing (SDB) in people with tetraplegia and to identify the characteristics associated with SDB. METHODS A systematic literature search using Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and grey literature sources was conducted using a combination of spinal cord injury (SCI) and SDB related terms. Articles were restricted to publication dates between 1/1/2000 and 4/9/2020 and with objectively measured SDB with an overnight sleep study. The frequency of SDB stratified by the apnoea hypopnea index (AHI) was extracted and weighted averages, using a random effects model, were calculated with 95% confidence intervals. Sub-group analyses were performed where possible. RESULTS Twelve articles were included in the review; of these nine were included in meta-analysis (combined sample = 630). Sample sizes and case detection methods varied. Reported SDB prevalence rates ranged from 46 to 97%. The prevalence of at least mild (AHI ≥ 5), moderate (AHI ≥ 15) and severe (AHI ≥ 30) SDB were 83% (95% CI = 73-91), 59% (46-71) and 36% (26-46), respectively. Sub-group analyses found that prevalence increased with age (p < 0.001). There were no statistically significant differences in SDB prevalence by sex (p = 0.06), complete/incomplete SCI (p = 0.06), body mass index (p = 0.07), acute/chronic SCI (p = 0.73) or high/low level of cervical SCI (p = 0.90). CONCLUSION Our results confirm that SDB is highly prevalent in people with tetraplegia, and prevalence increases with age. The high prevalence suggests that routine screening and subsequent treatment should be considered in both acute and community care.
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11
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Graco M, Berlowitz DJ, Green SE. Understanding the clinical management of obstructive sleep apnoea in tetraplegia: a qualitative study using the theoretical domains framework. BMC Health Serv Res 2019; 19:405. [PMID: 31226999 PMCID: PMC6588842 DOI: 10.1186/s12913-019-4197-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 05/28/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend further testing for people with tetraplegia and signs and symptoms of obstructive sleep apnoea (OSA), followed by treatment with positive airway pressure therapy. Little is known about how clinicians manage OSA in tetraplegia. The theoretical domains framework (TDF) is commonly used to identify determinants of clinical behaviours. This study aimed to describe OSA management practices in tetraplegia, and to explore factors influencing clinical practice. METHODS Semi-structured interviews were conducted with 20 specialist doctors managing people with tetraplegia from spinal units in Europe, UK, Canada, USA, Australia and New Zealand. Interviews were audiotaped for verbatim transcription. OSA management was divided into screening, diagnosis and treatment components for inpatient and outpatient services, allowing common practices to be categorised. Data were thematically coded to the 12 constructs of the TDF. Common beliefs were identified and comparisons were made between participants reporting different practices. RESULTS Routine screening for OSA signs and symptoms was reported by 10 (50%) doctors in inpatient settings and eight (40%) in outpatient clinics. Doctors commonly referred to sleep specialists for OSA diagnosis (9/20 in inpatients; 16/20 in outpatients), and treatment (12/20, 17/20). Three doctors reported their three spinal units were managing non-complicated OSA internally, without referral to sleep specialists. Ten belief statements representing six domains of the TDF were generated about screening. Lack of time and support staff (Environmental context and resources) and no prompts to screen for OSA (Memory, attention and decision processes) were commonly identified barriers to routine screening. Ten belief statements representing six TDF domains were generated for diagnosis and treatment behaviours. Common barriers to independent management practices were lack of skills (Skills), low confidence (Beliefs about capabilities), and the belief that OSA management was outside their scope of practice (Social/Professional role and identity). The three units independently managing OSA were well resourced with multidisciplinary involvement (Environmental context and resources), had 'clinical champions' to lead the program (Social influences). CONCLUSION Clinical management of OSA in tetraplegia is highly varied. Several influences on OSA management within spinal units have been identified, facilitating the development of future interventions aiming to improve clinical practice.
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Affiliation(s)
- Marnie Graco
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria Australia
| | - David J. Berlowitz
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria Australia
| | - Sally E. Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
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12
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Berlowitz DJ, Schembri R, Graco M, Ross JM, Ayas N, Gordon I, Lee B, Graham A, Cross SV, McClelland M, Kennedy P, Thumbikat P, Bennett C, Townson A, Geraghty TJ, Pieri-Davies S, Singhal R, Marshall K, Short D, Nunn A, Mortimer D, Brown D, Pierce RJ, Cistulli PA. Positive airway pressure for sleep-disordered breathing in acute quadriplegia: a randomised controlled trial. Thorax 2019; 74:282-290. [PMID: 30538163 PMCID: PMC6467247 DOI: 10.1136/thoraxjnl-2018-212319] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 12/03/2022]
Abstract
RATIONALE Highly prevalent and severe sleep-disordered breathing caused by acute cervical spinal cord injury (quadriplegia) is associated with neurocognitive dysfunction and sleepiness and is likely to impair rehabilitation. OBJECTIVE To determine whether 3 months of autotitrating CPAP would improve neurocognitive function, sleepiness, quality of life, anxiety and depression more than usual care in acute quadriplegia. METHODS AND MEASUREMENTS Multinational, randomised controlled trial (11 centres) from July 2009 to October 2015. The primary outcome was neurocognitive (attention and information processing as measure with the Paced Auditory Serial Addition Task). Daytime sleepiness (Karolinska Sleepiness Scale) was a priori identified as the most important secondary outcome. MAIN RESULTS 1810 incident cases were screened. 332 underwent full, portable polysomnography, 273 of whom had an apnoea hypopnoea index greater than 10. 160 tolerated at least 4 hours of CPAP during a 3-day run-in and were randomised. 149 participants (134 men, age 46±34 years, 81±57 days postinjury) completed the trial. CPAP use averaged 2.9±2.3 hours per night with 21% fully 'adherent' (at least 4 hours use on 5 days per week). Intention-to-treat analyses revealed no significant differences between groups in the Paced Auditory Serial Addition Task (mean improvement of 2.28, 95% CI -7.09 to 11.6; p=0.63). Controlling for premorbid intelligence, age and obstructive sleep apnoea severity (group effect -1.15, 95% CI -10 to 7.7) did not alter this finding. Sleepiness was significantly improved by CPAP on intention-to-treat analysis (mean difference -1.26, 95% CI -2.2 to -0.32; p=0.01). CONCLUSION CPAP did not improve Paced Auditory Serial Addition Task scores but significantly reduced sleepiness after acute quadriplegia. TRIAL REGISTRATION NUMBER ACTRN12605000799651.
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Affiliation(s)
- David J Berlowitz
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Schembri
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Marnie Graco
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Jacqueline M Ross
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Victorian Spinal Cord Service, Austin Hospital, Heidelberg, Victoria, Australia
| | - Najib Ayas
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ian Gordon
- Statistical Consulting Centre, School of Mathematics and Statistics, University of Melbourne, Melbourne, Victoria, Australia
| | - Bonne Lee
- Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Allison Graham
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
| | - Susan V Cross
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
| | - Martin McClelland
- Princess Royal Spinal Cord Injuries Centre, Northern General Hospital, Sheffield, UK
| | - Paul Kennedy
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
| | - Pradeep Thumbikat
- Princess Royal Spinal Cord Injuries Centre, Northern General Hospital, Sheffield, UK
| | | | - Andrea Townson
- Department of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Timothy J Geraghty
- Queensland Spinal Cord Injuries Service and The Hopkins Centre, Research for Rehabilitation and Resilience, Metro South Health and Griffith University, Woolloongabba, Queensland, Australia
| | - Sue Pieri-Davies
- North West Regional Spinal Injuries Centre, Southport and Ormskirk Hospital NHS Trust, Southport, UK
| | - Raj Singhal
- Burwood Spinal Unit, Burwood Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Karen Marshall
- Burwood Spinal Unit, Burwood Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Deborah Short
- The Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Andrew Nunn
- Victorian Spinal Cord Service, Austin Hospital, Heidelberg, Victoria, Australia
| | - Duncan Mortimer
- Centre for Health Economics, Monash Business School, Monash University, Clayton, Victoria, Australia
| | - Doug Brown
- Spinal Research Institute, Austin Hospital, Melbourne, Victoria, Australia
| | - Robert J Pierce
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Peter A Cistulli
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Sydney Medical School, University of Sydney, Melbourne, New South Wales, Australia
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13
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Apnoea and hypopnoea scoring for people with spinal cord injury: new thresholds for sleep disordered breathing diagnosis and severity classification. Spinal Cord 2019; 57:372-379. [PMID: 30626976 DOI: 10.1038/s41393-018-0229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/22/2018] [Accepted: 11/27/2018] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Descriptive study. OBJECTIVES To determine the effect of respiratory event rule-set changes on the apnoea hypopnoea index, and diagnostic and severity thresholds in people with acute and chronic spinal cord injury. SETTING Eleven acute spinal cord injury inpatient hospitals across Australia, New Zealand, Canada and England; community dwelling chronic spinal cord injury patients in their own homes. METHODS Polysomnography of people with acute (n = 24) and chronic (n = 78) tetraplegia were reanalysed from 1999 American Academy of Sleep Medicine (AASM) respiratory scoring, to 2007 AASM 'alternative' and 2012 AASM respectively. Equivalent cut points for published 1999 AASM sleep disordered breathing severity ranges were calculated using receiver operator curves, and results presented alongside analyses from the able-bodied. RESULTS In people with tetraplegia, shift from 1999 AASM to 2007 AASM 'alternative' resulted in a 22% lower apnoea hypopnoea index, and to 2012 AASM a 17% lower index. In people with tetraplegia, equivalent cut-points for 1999 AASM severities of 5,15 and 30 were calculated at 2.4, 8.1 and 16.3 for 2007 AASM 'alternative' and 3.2, 10.0 and 21.2 for 2012 AASM. CONCLUSION Interpreting research, prevalence and clinical polysomnography results conducted over different periods requires knowledge of the relationship between different rule-sets, and appropriate thresholds for diagnosis of disease. SPONSORSHIP This project was proudly supported by the Traffic Accident Commission (Program grant) and the National Health and Medical Research Council (PhD stipend 616605).
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Sankari A, Badr MS, Martin JL, Ayas NT, Berlowitz DJ. Impact Of Spinal Cord Injury On Sleep: Current Perspectives. Nat Sci Sleep 2019; 11:219-229. [PMID: 31686935 PMCID: PMC6800545 DOI: 10.2147/nss.s197375] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022] Open
Abstract
Sleep disorders are commonly encountered in people living with spinal cord injury (SCI). Primary sleep disorders such as sleep-disordered breathing (SDB), sleep-related movement disorders, circadian rhythm sleep-wake disorders, and insomnia disorder are common conditions after SCI but remain under-recognized, underdiagnosed and therefore remain untreated for a majority of patients. Sleep disturbances in people living with SCI are associated with significant impairments of daytime function and quality of life. Previous reviews have described findings related mainly to SDB but have not examined the relationship between other sleep disorders and SCI. This narrative review examines various sleep abnormalities and related functional and physical impairments in people living with SCI. It discusses new evidence pertaining to management, highlights existing limitations in the literature and recommends future directions for research.
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Affiliation(s)
- Abdulghani Sankari
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA.,Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - M Safwan Badr
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA.,Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA.,Geriatric Research, Education and Clinical Center, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Najib T Ayas
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - David J Berlowitz
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia.,Department of Physiotherapy, Austin Health, Melbourne, Australia.,Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
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15
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Graco M, Green SE, Tolson J, Stevens B, Barnes M, Rigoni A, Henderson S, Nicholls C, Berlowitz DJ. Worth the effort? Weighing up the benefit and burden of continuous positive airway pressure therapy for the treatment of obstructive sleep apnoea in chronic tetraplegia. Spinal Cord 2018; 57:247-254. [PMID: 30356181 DOI: 10.1038/s41393-018-0210-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/22/2018] [Accepted: 10/04/2018] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Mixed methods OBJECTIVES: Continuous positive airway pressure (CPAP) therapy is the recommended treatment for obstructive sleep apnoea (OSA). The aim of this study was to estimate CPAP adherence in people with tetraplegia and OSA, and to explore the barriers and facilitators to CPAP use. SETTING Hospital outpatient department in Melbourne, Australia METHODS: People with chronic tetraplegia and OSA were commenced with auto-titrating CPAP and supported for 1 month. Semi-structured interviews were conducted with participants at one month and analysed thematically. CPAP usage was measured at 1, 6 and 12 months, with "adherent" defined as achieving more than 4 h average per night. RESULTS Sixteen participants completed the study (80% male; mean age 56 (SD = 15)). Mean nightly CPAP use at one month was 3.1 h (SD = 2.5; 38% adherent), and at 6 months and 12 months were 2.6 h (SD = 2.8; 25% adherent) and 2.1 h (SD = 3.2; 25% adherent). The perceived benefit/burden balance strongly influenced ongoing use. Burden attributed to CPAP use was common, and included mask discomfort, and physical and emotional problems. Adherent participants were motivated by the immediate daytime benefits to mood, alertness and sleepiness. There was a tendency to not recognise symptoms of OSA until after they were treated. CONCLUSION CPAP use is challenging for people with tetraplegia, who experience substantial burden from using the device. When tolerated, the proximate benefits are substantial. People with tetraplegia need more intensive support for longer to help them overcome the burdens of CPAP and benefit from the treatment.
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Affiliation(s)
- Marnie Graco
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia. .,The University of Melbourne, Department of Medicine, Melbourne, Victoria, Australia.
| | - Sally E Green
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Julie Tolson
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - Bronwyn Stevens
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Department of Medicine, Melbourne, Victoria, Australia
| | - Alyssa Rigoni
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - Sandra Henderson
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - Carmel Nicholls
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Department of Physiotherapy, Melbourne, Victoria, Australia
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16
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Adler D, Janssens JP. Estimating the probability of OSA in the spinal cord injury population: specific tools are still needed. Thorax 2018; 73:803-805. [PMID: 29921701 DOI: 10.1136/thoraxjnl-2018-211954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Dan Adler
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
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