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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kim J, An S, Kim Y, Yoon DW, Son SA, Park JW, Jhe W, Park CS, Shin HW. Surface Active Salivary Metabolites Indicate Oxidative Stress and Inflammation in Obstructive Sleep Apnea. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:316-335. [PMID: 37075797 DOI: 10.4168/aair.2023.15.3.316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/25/2022] [Accepted: 12/13/2022] [Indexed: 05/17/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA), a highly prevalent and potentially serious sleep disorder, requires effective screening tools. Saliva is a useful biological fluid with various metabolites that might also influence upper airway patency by affecting surface tension in the upper airway. However, little is known about the composition and role of salivary metabolites in OSA. Therefore, we investigated the metabolomics signature in saliva from the OSA patients and evaluated the associations between identified metabolites and salivary surface tension. METHODS We studied 68 subjects who visited sleep clinic due to the symptoms of OSA. All underwent full-night in-lab polysomnography. Patients with apnea-hypopnea index (AHI) < 10 were classified to the control, and those with AHI ≥ 10 were the OSA groups. Saliva samples were collected before and after sleep. The centrifuged saliva samples were analyzed by liquid chromatography with high-resolution mass spectrometry (ultra-performance liquid chromatography-tandem mass spectrometry; UPLC-MS/MS). Differentially expressed salivary metabolites were identified using open source software (XCMS) and Compound Discoverer 2.1. Metabolite set enrichment analysis (MSEA) was performed using MetaboAnalyst 5.0. The surface tension of the saliva samples was determined by the pendant drop method. RESULTS Three human-derived metabolites (1-palmitoyl-2-[5-hydroxyl-8-oxo-6-octenoyl]-sn-glycerol-3-phosphatidylcholine [PHOOA-PC], 1-palmitoyl-2-[5-keto-8-oxo-6-octenoyl]-sn-glycerol-3-phosphatidylcholine [KPOO-PC], and 9-nitrooleate) were significantly upregulated in the after-sleep salivary samples from the OSA patients compared to the control group samples. Among the candidate metabolites, only PHOOA-PC was correlated with the AHI. In OSA samples, salivary surface tension decreased after sleep. The differences in surface tension were negatively correlated with PHOOA-PC and 9-nitrooleate concentrations. Furthermore, MSEA revealed that arachidonic acid-related metabolism pathways were upregulated in the after-sleep samples from the OSA group. CONCLUSIONS This study revealed that salivary PHOOA-PC was correlated positively with the AHI and negatively with salivary surface tension in the OSA group. Salivary metabolomic analysis may improve our understanding of upper airway dynamics and provide new insights into novel biomarkers and therapeutic targets in OSA.
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Affiliation(s)
- Jiyoung Kim
- Obstructive Upper Airway Research (OUaR) Laboratory, Department of Pharmacology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Metabolomics Medical Research Center (MMRC), Seoul National University College of Medicine, Seoul, Korea
- Ischemic/Hypoxic Disease Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sangmin An
- Department of Physics and Astronomy, Institute of Applied Physics, Seoul National University, Seoul, Korea
- Department of Physics, Research institute of Physics and Chemistry, Jeonbuk National University, Jeonju, Korea
| | - Yisook Kim
- Obstructive Upper Airway Research (OUaR) Laboratory, Department of Pharmacology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Metabolomics Medical Research Center (MMRC), Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Wui Yoon
- Obstructive Upper Airway Research (OUaR) Laboratory, Department of Pharmacology, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Ah Son
- Department of Otorhinolaryngology-Head and Neck Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Wan Park
- Obstructive Upper Airway Research (OUaR) Laboratory, Department of Pharmacology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Metabolomics Medical Research Center (MMRC), Seoul National University College of Medicine, Seoul, Korea
- Ischemic/Hypoxic Disease Institute, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wonho Jhe
- Department of Physics and Astronomy, Institute of Applied Physics, Seoul National University, Seoul, Korea.
| | - Chan-Soon Park
- Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea.
| | - Hyun-Woo Shin
- Obstructive Upper Airway Research (OUaR) Laboratory, Department of Pharmacology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Metabolomics Medical Research Center (MMRC), Seoul National University College of Medicine, Seoul, Korea
- Ischemic/Hypoxic Disease Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea.
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Abstract
Despite extensive research, there is currently no approved drug for obstructive sleep apnea (OSA) treatment. OSA is a heterogeneous condition that involves multiple dominating pathophysiological traits. Drug development in this field needs to address both pathophysiological mechanisms and associated comorbid conditions in order to meet requirements for long-term therapy in OSA. Several drug candidates have been proposed and ongoing phase II trials that target various forms of sleep-disordered breathing have been initiated. The field is moving toward tailored therapeutic approaches in patients with OSA.
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Si L, Zhang J, Wang Y, Cao J, Chen BY, Guo HJ. Obstructive sleep apnea and respiratory center regulation abnormality. Sleep Breath 2020; 25:563-570. [PMID: 32870421 DOI: 10.1007/s11325-020-02175-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 08/14/2020] [Accepted: 08/19/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is a complex disease in which phenotypic analysis and understanding pathological mechanisms facilitate personalized treatment and outcomes. However, the pathophysiology responsible for this robust observation is incompletely understood. The objective of the present work was to review how respiratory center regulation varies during sleep and wakeness in patients with OSA. DATA SOURCES We searched for relevant articles up to December 31, 2019 in PubMed database. METHODS This review examines the current literature on the characteristics of respiratory center regulation during wakefulness and sleep in OSA, detection method, and phenotypic treatment for respiratory center regulation. RESULTS Mechanisms for ventilatory control system instability leading to OSA include different sleep stages in chemoresponsiveness to hypoxia and hypercapnia and different chemosensitivity at different time. One can potentially stabilize the breathing center in sleep-related breathing disorders by identifying one or more of these pathophysiological mechanisms. CONCLUSIONS Advancing mechanism research in OSA will guide symptom research and provide alternate and novel opportunities for effective treatment for patients with OSA.
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Affiliation(s)
- Liang Si
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Jing Zhang
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Yan Wang
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Jie Cao
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China.
| | - Bao-Yuan Chen
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China.
| | - Heng-Juan Guo
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
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Abstract
The prevalence of obstructive sleep apnea (OSA) is considered to be very high in western industrialized countries. There are conservative and surgical forms of treatment for OSA; however, the pathophysiology is largely unexplained and cannot be explained by anatomical abnormalities alone. In recent years, a number of non-anatomical factors have been found that favor the development of OSA. These include the respiratory excitation threshold (arousals), the respiratory drive (loop gain), as well as the control and function of the muscular upper airway dilators. The understanding of the individual pathophysiological processes may be helpful in the future to develop individual treatment approaches for patients.
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Schenck D, Goettler S, Fiegel J. Surfactant-induced spreading of nanoparticles is inhibited on mucus mimetic surfaces that model native lung conditions. Phys Biol 2019; 16:065001. [PMID: 31292288 DOI: 10.1088/1478-3975/ab3109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We investigated the ability of surfactant-induced spreading to promote nanoparticle distribution on model mucus hydrogels. The hydrogels were formulated with viscoelastic properties and surface tensions that match those of native lung mucus. Nanoparticle-containing droplets with or without surfactant were deposited on the mucus surface and spreading patterns were monitored by time-course fluorescence imaging. Overall, surfactant-induced spreading of nanoparticles required an appropriate balance between Marangoni forces and viscoelastic subphase resistance. Spreading was enhanced on bare gels by increasing the concentration of surfactant in the droplets or reducing the viscoelastic properties of the subphase. However, with a pre-existing film of pulmonary surfactant on the mucus surface, spreading was dramatically inhibited as the surface tension gradient between the droplets and the surrounding subphase decreased. A complete lack of spreading was observed at surface tensions that matched those in the tracheobronchial region of the lungs, even with full-concentration Infasurf. These studies demonstrate that the magnitude of spreading on lung mucus-like surfaces is limited by native mucosal properties.
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Affiliation(s)
- D Schenck
- Department of Pharmaceutical Sciences and Experimental Therapeutics, The University of Iowa, Iowa City, IA, United States of America
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Nascimento JA, Genta PR, Fernandes PHS, Barroso LP, Carvalho TS, Moriya HT, Madeiro F, Lorenzi-Filho G, Nakagawa NK. Predictors of oronasal breathing among obstructive sleep apnea patients and controls. J Appl Physiol (1985) 2019; 127:1579-1585. [PMID: 31465714 DOI: 10.1152/japplphysiol.00964.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Oronasal breathing may adversely impact obstructive sleep apnea (OSA) patients either by increasing upper airway collapsibility or by influencing continuous positive airway pressure (CPAP) treatment outcomes. Predicting a preferential breathing route would be helpful to guide CPAP interface prescription. We hypothesized that anthropometric measurements but not self-reported oronasal breathing are predictors of objectively measured oronasal breathing. Seventeen OSA patients and nine healthy subjects underwent overnight polysomnography with an oronasal mask with two sealed compartments attached to independent pneumotacographs. Subjects answered questionnaires about nasal symptoms and perceived breathing route. Oronasal breathing was more common (P = <0.001) among OSA patients than controls while awake (62 ± 44 vs. 5 ± 6%) and during sleep (59 ± 39 vs. 25 ± 21%, respectively). Oronasal breathing was associated with OSA severity (P = 0.009), age (P = 0.005), body mass index (P = 0.044), and neck circumference (P = 0.004). There was no agreement between objective measurement and self-reported breathing route among OSA patients while awake (κ = -0.12) and asleep (κ = -0.02). The breathing route remained unchanged after 92% of obstructive apneas. These results suggest that oronasal breathing is more common among OSA patients than controls during both wakefulness and sleep and is associated with OSA severity and anthropometric measures. Self-reporting is not a reliable predictor of oronasal breathing and should not be considered an indication for oronasal CPAP.NEW & NOTEWORTHY Continuous positive airway pressure (CPAP) interface choice for obstructive sleep apnea (OSA) patients is often guided by nasal symptoms and self-reported breathing route. We showed that oronasal breathing can be predicted by anthropometric measurements and OSA severity but not by self-reported oronasal breathing. Self-reported breathing and nasal symptoms should not be considered for CPAP interface choice.
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Affiliation(s)
- Juliana A Nascimento
- Department of Physiotherapy, LIM-54, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Pedro R Genta
- Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paulo H S Fernandes
- Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucia P Barroso
- Departament of Statistics, Instituto de Matemática e Estatística da Universidade de São Paulo, São Paulo, Brazil
| | - Tômas S Carvalho
- Department of Physiotherapy, LIM-54, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Telecommunication and Control Engineering Department, Escola Politécnica da Universidade de São Paulo, São Paulo, Brazil
| | - Fernanda Madeiro
- Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Naomi Kondo Nakagawa
- Department of Physiotherapy, LIM-54, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Sleep Laboratory, Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Liu H, Prot VE, Skallerud BH. 3D patient-specific numerical modeling of the soft palate considering adhesion from the tongue. J Biomech 2018; 77:107-114. [PMID: 29960734 DOI: 10.1016/j.jbiomech.2018.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/12/2018] [Accepted: 06/19/2018] [Indexed: 12/29/2022]
Abstract
Collapse of the soft palate in the upper airway contributes to obstructive sleeping apnea (OSA). In this study, we investigate the influence of the adhesion from the tongue on the soft palate global response. This is achieved using a cohesive zone finite element approach. A traction-separation law is determined to describe the adhesion effect from the surface tension of the lining liquid between the soft palate and the tongue. According to pull-off experimental tests of human lining liquid from the oral surface of the soft palate, the corresponding cohesive properties, including the critical normal traction stress and the failure separation displacement, are obtained. The 3D patient-specific soft palate geometry is accounted for, based on one specific patient's computed tomography (CT) images. The calculation results show that influence of the adhesion from the tongue surface on the global response of the soft palate depends on the length ratio between the cohesive length and the soft palate length. When the length of the cohesive zone is smaller than half of the soft palate length, the adhesion's influence is negligible. When the adhesion length is larger than 70 percent of soft palate length, the adhesion force contributes to preventing the soft palate from collapsing towards to the pharynx wall, i.e. the closing pressure is more negative than in the no adhesion case. These results may provide useful information to the clinical treatment of OSA patients.
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Affiliation(s)
- Hongliang Liu
- Biomechanics Division, Department of Structural Engineering, Norwegian University of Science and Technology (NTNU), NO-7491 Trondheim, Norway
| | - Victorien Emile Prot
- Biomechanics Division, Department of Structural Engineering, Norwegian University of Science and Technology (NTNU), NO-7491 Trondheim, Norway
| | - Bjørn Helge Skallerud
- Biomechanics Division, Department of Structural Engineering, Norwegian University of Science and Technology (NTNU), NO-7491 Trondheim, Norway.
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Schmickl CN, Owens RL, Edwards BA, Malhotra A. OSA Endotypes: What Are They and What Are Their Potential Clinical Implications? CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0121-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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12
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Phenotypic approaches to obstructive sleep apnoea – New pathways for targeted therapy. Sleep Med Rev 2018; 37:45-59. [DOI: 10.1016/j.smrv.2016.12.003] [Citation(s) in RCA: 225] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/30/2016] [Accepted: 12/08/2016] [Indexed: 02/01/2023]
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Siber-Hoogeboom R, Schicht M, Hoogeboom S, Paulsen F, Traxdorf M. Obstructive sleep apnea and rhonchopathy are associated with downregulation of trefoil factor family peptide 3 (TFF3)-Implications of changes in oral mucus composition. PLoS One 2017; 12:e0185200. [PMID: 29028798 PMCID: PMC5640215 DOI: 10.1371/journal.pone.0185200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 09/07/2017] [Indexed: 11/19/2022] Open
Abstract
Study objectives Trefoil factor family (TFF) peptides belong to the family of mucin-associated peptides and are expressed in most mucosal surfaces. TFF peptides carry out functions such as proliferation and migration enhancement, anti-apoptosis, and wound healing. Moreover, TFFs are associated with mucins and interact with them as “linker peptides”, thereby influencing mucus viscosity. To test the hypothesis that in rhonchopathy and obstructive sleep apnea (OSA) changes occur in the expression of TFF3 and -2 that could contribute to changes in mucus viscosity, leading to an increase in upper airway resistance during breathing. Methods RT-PCR, Western-blot, immunohistochemistry and ELISA were performed to detect and quantify TFF3 and -2 in uvula samples. In addition, 99 saliva samples from patients with mild, moderate or severe OSA, as well as samples from rhonchopathy patients and from healthy volunteers, were analyzed by ELISA. Results TFF3 was detected in all uvula samples. Immunohistochemistry revealed a subjectively decreasing antibody reactivity of the uvula epithelia with increasing disease severity. ELISA demonstrated significantly higher TFF3 saliva protein concentrations in the healthy control group compared to cases with rhonchopathy and OSA. Predisposing factors of OSA such as BMI or age showed no correlation with TFF3. No significant changes were observed with regard to TFF2. Conclusions The results suggest the involvement of TFF3 in the pathogenesis of rhonchopathy and OSA and lead to the hypothesis that reduction of TFF3 production by the epithelium and subepithelial mucous glands of the uvula contribute to an increase in breathing resistance due to a change in mucus organization.
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Affiliation(s)
- Regina Siber-Hoogeboom
- Department of Anatomy II, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Martin Schicht
- Department of Anatomy II, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sebastian Hoogeboom
- Department of Anatomy II, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Friedrich Paulsen
- Department of Anatomy II, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
- * E-mail:
| | - Maximilian Traxdorf
- Department of Otorhinolaryngology, Head & Neck Surgery, Friedrich Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Pirnar J, Širok B, Bombač A. Effect of airway surface liquid on the forces on the pharyngeal wall: Experimental fluid-structure interaction study. J Biomech 2017; 63:117-124. [PMID: 28865707 DOI: 10.1016/j.jbiomech.2017.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 07/17/2017] [Accepted: 08/11/2017] [Indexed: 02/07/2023]
Abstract
Obstructive sleep apnoea syndrome (OSAS) is a breathing disorder with a multifactorial etiology. The respiratory epithelium is lined with a thin layer of airway surface liquid preventing interactions between the airflow and epithelium. The effect of the liquid lining in OSAS pathogenesis remains poorly understood despite clinical research. Previous studies have shown that the physical properties of the airway surface liquid or altered stimulation of the airway mechanoreceptors could alleviate or intensify OSAS; however, these studies do not provide a clear physical interpretation. To study the forces transmitted from the airflow to the liquid-lined compliant wall and to discuss the effects of the airway surface liquid properties on the stimulation of the mechanoreceptors, a novel and simplified experimental system mimicking the upper airway fundamental characteristics (i.e., liquid-lined compliant wall and complex unsteady airflow features) was constructed. The fluctuating force on the compliant wall was reduced through a damping mechanism when the liquid film thickness and/or the viscosity were increased. Conversely, the liquid film damping was reduced when the surface tension decreased. Based on the experimental data, empirical correlations were developed to predict the damping potential of the liquid film. In the future, this will enable us to extend the existing computational fluid-structure interaction simulations of airflow in the human upper airway by incorporating the airway surface liquid effect without adopting two-phase flow interface tracking methods. Furthermore, the experimental system developed in this study could be used to investigate the fundamental principles of the complex once/twice-coupled physical phenomena.
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Affiliation(s)
- Jernej Pirnar
- Laboratory for Fluid Dynamics and Thermodynamics, Faculty of Mechanical Engineering, University of Ljubljana, Aškerčeva 6, 1000 Ljubljana, Slovenia.
| | - Brane Širok
- Laboratory for Water and Turbine Machines, Faculty of Mechanical Engineering, University of Ljubljana, Aškerčeva 6, 1000 Ljubljana, Slovenia
| | - Andrej Bombač
- Laboratory for Fluid Dynamics and Thermodynamics, Faculty of Mechanical Engineering, University of Ljubljana, Aškerčeva 6, 1000 Ljubljana, Slovenia
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15
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Pulmonary surfactant-associated proteins and inflammatory factors in obstructive sleep apnea. Sleep Breath 2017; 22:99-107. [DOI: 10.1007/s11325-017-1536-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/16/2017] [Accepted: 07/03/2017] [Indexed: 12/15/2022]
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16
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Understanding Phenotypes of Obstructive Sleep Apnea: Applications in Anesthesia, Surgery, and Perioperative Medicine. Anesth Analg 2017; 124:179-191. [PMID: 27861433 DOI: 10.1213/ane.0000000000001546] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Obstructive sleep apnea (OSA) is a prevalent sleep-disordered breathing with potential long-term major neurocognitive and cardiovascular sequelae. The pathophysiology of OSA varies between individuals and is composed of different underlying mechanisms. Several components including the upper airway anatomy, effectiveness of the upper airway dilator muscles such as the genioglossus, arousal threshold of the individual, and inherent stability of the respiratory control system determine the pathogenesis of OSA. Their recognition may have implications for the perioperative health care team. For example, OSA patients with a high arousal threshold are likely to be sensitive to sedatives and narcotics with a higher risk of respiratory arrest in the perioperative period. Supplemental oxygen therapy can help to stabilize breathing in OSA patients with inherent respiratory instability. Avoidance of supine position can minimize airway obstruction in patients with a predisposition to upper airway collapse in this posture. In this review, the clinically relevant endotypes and phenotypes of OSA are described. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for most patients with OSA but tolerance and adherence can be a problem. Patient-centered individualized approaches to OSA management will be the focus of future research into developing potential treatment options that will help decrease the disease burden and improve treatment effectiveness.
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17
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Abstract
Purpose The purpose of this study is to test the effects of a mild degree of head-of-bed elevation (HOBE) (7.5°) on obstructive sleep apnea (OSA) severity and sleep quality. Methods OSA patients were recruited from a single sleep clinic (Criciúma, Santa Catarina, Brazil). Following a baseline polysomnography (PSG), all patients underwent a PSG with HOBE (within 2 weeks). In addition, a subset of patients performed a third PSG without HOBE. Results Fifty-two patients were included in the study (age 53.2 ± 9.1 years; BMI 29.6 ± 4.8 kg/m2, neck circumference 38.9 ± 3.8 cm, and Epworth Sleepiness Scale 15 ± 7). Compared to baseline, HOBE significantly decreased the apnea-hypopnea index (AHI) from 15.7 [11.3–22.5] to 10.7 [6.6–16.5] events/h; p < 0.001 and increased minimum oxygen saturation from 83.5 [77.5–87] to 87 [81–90]%; p = 0.003. The sleep architecture at baseline and HOBE were similar. However, sleep efficiency increased slightly but significantly with HOBE (87.2 [76.7–90.7] vs 88.8 [81.6–93.3]; p = 0.005). The AHI obtained at the third PSG without HOBE (n = 7) returned to baseline values. Conclusions Mild HOBE significantly improves OSA severity without interfering in sleep architecture and therefore is a simple alternative treatment to ameliorate OSA.
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18
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Gainche L, Berlowitz DJ, LeGuen M, Ruehland WR, O'Donoghue FJ, Trinder J, Graco M, Schembri R, Eckert DJ, Rochford PD, Jordan AS. Nasal Resistance Is Elevated in People with Tetraplegia and Is Reduced by Topical Sympathomimetic Administration. J Clin Sleep Med 2016; 12:1487-1492. [PMID: 27568894 DOI: 10.5664/jcsm.6272] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/27/2016] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is common in individuals with tetraplegia and associated with adverse health outcomes. The causes of the high prevalence of OSA in this population are unknown, but it is important to understand as standard treatments are poorly tolerated in tetraplegia. Nasal congestion is common in tetraplegia, possibly because of unopposed parasympathetic activity. Further, nasal obstruction can induce OSA in healthy individuals. We therefore aimed to compare nasal resistance before and after topical administration of a sympathomimetic between 10 individuals with tetraplegia (T) and 9 able-bodied (AB) controls matched for OSA severity, gender, and age. METHODS Nasal, pharyngeal, and total upper airway resistance were calculated before and every 2 minutes following delivery of ≈0.05 mL of 0.5% atomized phenylephrine to the nostrils and pharyngeal airway. The surface tension of the upper airway lining liquid was also assessed. RESULTS At baseline, individuals with tetraplegia had elevated nasal resistance (T = 7.0 ± 1.9, AB = 3.0 ± 0.6 cm H2O/L/s), that rapidly fell after phenylephrine (T = 2.3 ± 0.4, p = 0.03 at 2 min) whereas the able-bodied did not change (AB = 2.5 ± 0.5 cm H2O/L/s, p = 0.06 at 2 min). Pharyngeal resistance was non-significantly higher in individuals with tetraplegia than controls at baseline (T = 2.6 ± 0.9, AB = 1.2 ± 0.4 cm H2O/L/s) and was not altered by phenylephrine in either group. The surface tension of the upper airway lining liquid did not differ between groups (T = 64.3 ± 1.0, AB = 62.7 ± 0.6 mN/m). CONCLUSIONS These data suggest that the unopposed parasympathetic activity in tetraplegia increases nasal resistance, potentially contributing to the high occurrence of OSA in this population.
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Affiliation(s)
- Laura Gainche
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia.,The University of Melbourne, Parkville, VIC, Australia
| | - David J Berlowitz
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia.,The University of Melbourne, Parkville, VIC, Australia
| | - Mariannick LeGuen
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
| | - Warren R Ruehland
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia.,The University of Melbourne, Parkville, VIC, Australia
| | - Fergal J O'Donoghue
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia.,The University of Melbourne, Parkville, VIC, Australia
| | - John Trinder
- The University of Melbourne, Parkville, VIC, Australia
| | - Marnie Graco
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
| | - Rachel Schembri
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
| | - Danny J Eckert
- Neuroscience Research Australia and the University of New South Wales, Randwick, NSW, Australia
| | - Peter D Rochford
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia
| | - Amy S Jordan
- The Institute for Breathing and Sleep, Austin Health, Heidelberg, VIC, Australia.,The University of Melbourne, Parkville, VIC, Australia
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19
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Edwards BA, Eckert DJ, Jordan AS. Obstructive sleep apnoea pathogenesis from mild to severe: Is it all the same? Respirology 2016; 22:33-42. [PMID: 27699919 DOI: 10.1111/resp.12913] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/31/2016] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnoea (OSA) is a common disorder caused by not only an impaired upper airway anatomy (i.e. anatomically narrow/collapsible airway), but also by several non-anatomical factors. In this review, we summarise what is known about how each of the pathological factors that cause OSA vary according to disease severity as measured by the apnoea-hypopnoea index. Our synthesis of the available literature indicates that most of the key factors that cause OSA vary with disease severity. However, there is substantial heterogeneity such that the relative contribution of each of these traits varies both between patients and within different severities of disease. These differences likely contribute to variable efficacy of many non-continuous positive airway pressure treatments and inconsistencies in responses with regard to different OSA severities at baseline.
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Affiliation(s)
- Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Victoria, Australia.,School of Psychological Sciences, Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Amy S Jordan
- Department of Psychology, University of Melbourne, Melbourne, Victoria, Australia
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20
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Bosi M, De Vito A, Gobbi R, Poletti V, Vicini C. The importance of obstructive sleep apnoea and hypopnea pathophysiology for customized therapy. Eur Arch Otorhinolaryngol 2016; 274:1251-1261. [PMID: 27470114 DOI: 10.1007/s00405-016-4223-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 07/19/2016] [Indexed: 01/20/2023]
Abstract
The objective of this study is to highlight the importance of anatomical and not-anatomical factors' identification for customized therapy in OSAHS patients. The data sources are: MEDLINE, The Cochrane Library and EMBASE. A systematic review was performed to identify studies that analyze the role of multiple interacting factors involved in the OSAHS pathophysiology. 85 out of 1242 abstracts were selected for full-text review. A variable combinations pathophysiological factors contribute to realize differentiated OSAHS phenotypes: a small pharyngeal airway with a low resistance to collapse (increased critical closing pressure), an inadequate responses of pharyngeal dilator muscles (wakefulness drive to breathe), an unstable ventilator responsiveness to hypercapnia (high loop gain), and an increased propensity to wake related to upper airway obstruction (low arousal threshold). Identifying if the anatomical or not-anatomical factors are predominant in each OSAHS patient represents the current challenge in clinical practice, moreover for the treatment decision-making. In the future, if a reliable and accurate pathophysiological pattern for each OSAHS patient can be identified, a customized therapy will be feasible, with a significant improvement of surgical success in sleep surgery and a better understanding of surgical failure.
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Affiliation(s)
- Marcello Bosi
- Pneumology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Andrea De Vito
- Head & Neck Department, Ear-Nose-Throat Unit, Morgagni-Pierantoni Hospital, 47121, Forlì, Italy.
| | - Riccardo Gobbi
- Head and Neck Department, ENT Unit, Sant'Orsola University Hospital, Bologna, Italy
| | | | - Claudio Vicini
- Head & Neck Department, Ear-Nose-Throat Unit, Morgagni-Pierantoni Hospital, 47121, Forlì, Italy
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21
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Amatoury J, Cheng S, Kairaitis K, Wheatley JR, Amis TC, Bilston LE. Development and validation of a computational finite element model of the rabbit upper airway: simulations of mandibular advancement and tracheal displacement. J Appl Physiol (1985) 2016; 120:743-57. [DOI: 10.1152/japplphysiol.00820.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/12/2016] [Indexed: 11/22/2022] Open
Abstract
The mechanisms leading to upper airway (UA) collapse during sleep are complex and poorly understood. We previously developed an anesthetized rabbit model for studying UA physiology. On the basis of this body of physiological data, we aimed to develop and validate a two-dimensional (2D) computational finite element model (FEM) of the passive rabbit UA and peripharyngeal tissues. Model geometry was reconstructed from a midsagittal computed tomographic image of a representative New Zealand White rabbit, which included major soft (tongue, soft palate, constrictor muscles), cartilaginous (epiglottis, thyroid cartilage), and bony pharyngeal tissues (mandible, hard palate, hyoid bone). Other UA muscles were modeled as linear elastic connections. Initial boundary and contact definitions were defined from anatomy and material properties derived from the literature. Model parameters were optimized to physiological data sets associated with mandibular advancement (MA) and caudal tracheal displacement (TD), including hyoid displacement, which featured with both applied loads. The model was then validated against independent data sets involving combined MA and TD. Model outputs included UA lumen geometry, peripharyngeal tissue displacement, and stress and strain distributions. Simulated MA and TD resulted in UA enlargement and nonuniform increases in tissue displacement, and stress and strain. Model predictions closely agreed with experimental data for individually applied MA, TD, and their combination. We have developed and validated an FEM of the rabbit UA that predicts UA geometry and peripharyngeal tissue mechanical changes associated with interventions known to improve UA patency. The model has the potential to advance our understanding of UA physiology and peripharyngeal tissue mechanics.
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Affiliation(s)
- Jason Amatoury
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - Shaokoon Cheng
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- Department of Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - John R. Wheatley
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - Terence C. Amis
- Ludwig Engel Centre for Respiratory Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia; and
| | - Lynne E. Bilston
- Neuroscience Research Australia (NeuRA), Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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22
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Genta PR, Edwards BA, Sands SA, Owens RL, Butler JP, Loring SH, White DP, Wellman A. Tube Law of the Pharyngeal Airway in Sleeping Patients with Obstructive Sleep Apnea. Sleep 2016; 39:337-43. [PMID: 26446124 DOI: 10.5665/sleep.5440] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 09/05/2015] [Indexed: 12/22/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is characterized by repetitive pharyngeal collapse during sleep. However, the dynamics of pharyngeal narrowing and re-expansion during flow-limited breathing are not well described. The static pharyngeal tube law (end-expiratory area versus luminal pressure) has demonstrated increasing pharyngeal compliance as luminal pressure decreases, indicating that the airway would be sucked closed with sufficient inspiratory effort. On the contrary, the airway is rarely sucked closed during inspiratory flow limitation, suggesting that the airway is getting stiffer. Therefore, we hypothesized that during inspiratory flow limitation, as opposed to static conditions, the pharynx becomes stiffer as luminal pressure decreases. METHODS Upper airway endoscopy and simultaneous measurements of airflow and epiglottic pressure were performed during natural nonrapid eye movement sleep. Continuous positive (or negative) airway pressure was used to induce flow limitation. Flow-limited breaths were selected for airway cross-sectional area measurements. Relative airway area was quantified as a percentage of end-expiratory area. Inspiratory airway radial compliance was calculated at each quintile of epiglottic pressure versus airway area plot (tube law). RESULTS Eighteen subjects (14 males) with OSA (apnea-hypopnea index = 57 ± 27 events/h), aged 49 ± 8 y, with a body mass index of 35 ± 6 kg/m(2) were studied. A total of 163 flow limited breaths were analyzed (9 ± 3 breaths per subject). Compliances at the fourth (2.0 ± 4.7 % area/cmH2O) and fifth (0.0 ± 1.7 % area/cmH2O) quintiles were significantly lower than the first (12.2 ± 5.5 % area/cmH2O) pressure quintile (P < 0.05). CONCLUSIONS The pharyngeal tube law is concave (airway gets stiffer as luminal pressure decreases) during respiratory cycles under inspiratory flow limitation.
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Affiliation(s)
- Pedro R Genta
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA.,Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Bradley A Edwards
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA.,Department of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
| | - Robert L Owens
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA
| | - James P Butler
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA
| | - Stephen H Loring
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA
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23
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Kairaitis K, Foster S, Amatoury J, Verma M, Wheatley JR, Amis TC. Pharyngeal mucosal wall folds in subjects with obstructive sleep apnea. J Appl Physiol (1985) 2015; 118:707-15. [PMID: 25635002 DOI: 10.1152/japplphysiol.00691.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Mechanical processes underlying pharyngeal closure have not been examined. We hypothesized that the pharyngeal mucosal surface would fold during closure, and lowering the upper airway lining liquid surface tension would unfold areas of mucosal apposition, i.e., folds. We compared baseline pharyngeal fold numbers and response to reduction in upper airway liquid surface tension in healthy and obstructive sleep apnea (OSA) subjects. Awake, gated magnetic resonance pharyngeal airway images of 10 healthy and 11 OSA subjects were acquired before and after exogenous surfactant administration (beractant). Upper airway liquid surface tension was measured at the beginning and end of image acquisition and averaged. Velopharyngeal and oropharyngeal images were segmented and analyzed separately for average cross-sectional area, circumference, and fold number. Compared with healthy subjects, at baseline, velopharynx for OSA subjects had a smaller cross-sectional area (98.3 ± 32.5 mm(2) healthy, 52.3 ± 23.6 mm(2) OSA) and circumference (46.5 ± 8.1 mm healthy, 30.8 ± 6.1 mm OSA; both P < 0.05, unpaired t-test), and fewer folds (4.9 ± 1.6 healthy, 3.1 ± 1.8 OSA, P < 0.03). There were no differences in oropharynx for cross-sectional area, circumference, or folds. Reduction in upper airway liquid surface tension from 61.3 ± 1.2 to 55.3 ± 1.5 mN/m (P < 0.0001) did not change cross-sectional area or circumference for velopharynx or oropharynx in either group; however, in OSA subjects, oropharyngeal folds fell from 6.8 ± 3.1 to 4.7 ± 1.2 (n = 8, P < 0.05), and velopharyngeal folds from 3.3 ± 1.9 to 2.3 ± 1.2 (P = 0.08), and were unchanged in healthy subjects. Subjects with OSA have fewer velopharyngeal wall folds, which decrease further when surface tension falls. We speculate that reduced pharyngeal wall folds contribute to an increase in pharyngeal collapsibility.
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Affiliation(s)
- Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Sheryl Foster
- Department of Radiology, Westmead Hospital, Westmead, New South Wales, Australia; and University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Jason Amatoury
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Manisha Verma
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia
| | - John R Wheatley
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Terence C Amis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
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24
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Sutherland K, Cistulli PA. Recent advances in obstructive sleep apnea pathophysiology and treatment. Sleep Biol Rhythms 2014. [DOI: 10.1111/sbr.12098] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Kate Sutherland
- Department of Respiratory and Sleep Medicine; Center for Sleep Health and Research; Royal North Shore Hospital; University of Sydney; Sydney New South Wales Australia
- Discipline of Sleep Medicine; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
- Woolcock Institute of Medical Research; University of Sydney; Sydney New South Wales Australia
| | - Peter A Cistulli
- Department of Respiratory and Sleep Medicine; Center for Sleep Health and Research; Royal North Shore Hospital; University of Sydney; Sydney New South Wales Australia
- Discipline of Sleep Medicine; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
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25
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Nakahara H, Shibata O. Interfacial behavior of pulmonary surfactant preparations containing egg yolk lecithin. J Oleo Sci 2014; 63:1159-68. [PMID: 25296574 DOI: 10.5650/jos.ess14105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mammalian lungs are covered with lipid-protein complexes or pulmonary surfactants. In this work, which aimed towards the less expensive production of artificial pulmonary surfactants, we produced surfactants composed of egg yolk lecithin (eggPC), palmitic acid, and hexadecanol (= 0.30/0.35/0.35, mol/mol/mol ) containing different amounts of Hel 13-5 (NH2-KLLKLLLKLWLKLLKLLL-COOH) as a substitute for the proteins in native pulmonary surfactants. Surface pressure (π)-molecular area (A) and surface potential (DV)-A isotherms of the mixtures were measured via the Wilhelmy and ionizing (241)Am electrode methods, respectively. The interactions between the lipid components and Hel 13-5 led to variations in the surface pressure caused by the expulsion of fluid components from the surface. Furthermore, the π-A and DV-A isotherms featured large hysteresis loops for the surfactant that contained a small amount of Hel 13-5 during compression and successive expansion cycling. To elucidate the morphology, the phase behavior was visualized in situ at the air-water interface by means of fluorescence microscopy; the images suggested less effective interactions between Hel 13-5 and the unsaturated PC in eggPC despite the similarity of their monolayer properties.
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Affiliation(s)
- Hiromichi Nakahara
- Department of Biophysical Chemistry, Graduate School of Pharmaceutical Sciences, Nagasaki International University
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26
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Characterizing the phenotypes of obstructive sleep apnea: Clinical, sleep, and autonomic features of obstructive sleep apnea with and without hypoxia. Clin Neurophysiol 2014; 125:1783-91. [DOI: 10.1016/j.clinph.2014.01.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 12/26/2013] [Accepted: 01/03/2014] [Indexed: 11/19/2022]
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27
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Abstract
Respiration during sleep is determined by metabolic demand; respiratory drive is determined by a central respiratory generator. Changes in pharyngeal dilator muscle tone resulting in increased upper airway resistance and collapsibility contribute to hypoventilation. Relative hypotonia of respiratory muscles, body posture changes, and altered ventilatory control result in additional physiologic changes contributing to hypoventilation. This article reviews mechanisms of central control of respiration and normal upper and lower airway physiology. Understanding sleep-related changes in respiratory physiology will help in developing new therapies to prevent hypoventilation in susceptible populations.
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Affiliation(s)
- Mudiaga Sowho
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Johns Hopkins University, 5501 Hopkins Bayview Circle, Baltimore, MD 21224, USA
| | - Jason Amatoury
- Neuroscience Research Australia, Barker Street, Randwick, New South Wales 2031, Australia; Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, and Sydney Medical School, University of Sydney at Westmead Hospital, Hawkesbury Road, Westmead, New South Wales 2145, Australia
| | - Jason P Kirkness
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Johns Hopkins University, 5501 Hopkins Bayview Circle, Baltimore, MD 21224, USA
| | - Susheel P Patil
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Johns Hopkins University, 5501 Hopkins Bayview Circle, Baltimore, MD 21224, USA.
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28
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Edwards BA, Wellman A, Sands SA, Owens RL, Eckert DJ, White DP, Malhotra A. Obstructive sleep apnea in older adults is a distinctly different physiological phenotype. Sleep 2014; 37:1227-36. [PMID: 25061251 DOI: 10.5665/sleep.3844] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
STUDY OBJECTIVES Current evidence suggests that the pathological mechanisms underlying obstructive sleep apnea (OSA) are altered with age. However, previous studies examining individual physiological traits known to contribute to OSA pathogenesis have been assessed in isolation, primarily in healthy individuals. DESIGN We assessed the four physiological traits responsible for OSA in a group of young and old patients with OSA. SETTING Sleep research laboratory. PARTICIPANTS Ten young (20-40 y) and old (60 y and older) patients with OSA matched by body mass index and sex. MEASUREMENTS AND RESULTS Pharyngeal anatomy/collapsibility, loop gain (LG), upper airway muscle responsiveness/gain (UAG) and the respiratory arousal threshold were determined using multiple 2- to 3-min decreases or drops in continuous positive airway pressure (CPAP). Passive pharyngeal anatomy/collapsibility was quantified as the ventilation at CPAP = 0 cmH2O immediately after the CPAP drop. LG was defined as the ratio of the ventilatory overshoot to the preceding reduction in ventilation. UAG was taken as the ratio of the increase in ventilation to the increase in ventilatory drive across the pressure drop. Arousal threshold was estimated as the ventilatory drive that caused arousal. Veupnea was quantified as the mean ventilation prior to the pressure drop. In comparison with younger patients with OSA, older patients had a more collapsible airway (ventilation at 0 cmH2O = 3.4 ± 0.9 versus 1.5 ± 0.7 L/min; P = 0.05) but lower Veupnea (8.2 ± 0.5 versus 6.1 ± 0.4 L/min; P < 0.01) and a lower LG (5.0 ± 0.7 versus 2.9 ± 0.5; P < 0.05). The remaining traits were similar between groups. CONCLUSIONS Our data suggest that airway anatomy/collapsibility plays a relatively greater pathogenic role in older adults, whereas a sensitive ventilatory control system is a more prominent trait in younger adults with obstructive sleep apnea. CITATION Edwards BA, Wellman A, Sands SA, Owens RL, Eckert DJ, White DP, Malhotra A. Obstructive sleep apnea in older adults is a distinctly different physiological phenotype.
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Affiliation(s)
- Bradley A Edwards
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Robert L Owens
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Danny J Eckert
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA ; Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | - David P White
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Atul Malhotra
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA ; Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA
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Strohl KP, Butler JP, Malhotra A. Mechanical properties of the upper airway. Compr Physiol 2013; 2:1853-72. [PMID: 23723026 DOI: 10.1002/cphy.c110053] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The importance of the upper airway (nose, pharynx, and larynx) in health and in the pathogenesis of sleep apnea, asthma, and other airway diseases, discussed elsewhere in the Comprehensive Physiology series, prompts this review of the biomechanical properties and functional aspects of the upper airway. There is a literature based on anatomic or structural descriptions in static circumstances, albeit studied in limited numbers of individuals in both health and disease. As for dynamic features, the literature is limited to studies of pressure and flow through all or parts of the upper airway and to the effects of muscle activation on such features; however, the links between structure and function through airway size, shape, and compliance remain a topic that is completely open for investigation, particularly through analyses using concepts of fluid and structural mechanics. Throughout are included both historically seminal references, as well as those serving as signposts or updated reviews. This article should be considered a resource for concepts needed for the application of biomechanical models of upper airway physiology, applicable to understanding the pathophysiology of disease and anticipated results of treatment interventions.
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Affiliation(s)
- Kingman P Strohl
- Center for Sleep Disorders Research, Division of Pulmonary, Critical Care, and Sleep Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
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Abstract
Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive collapse of the pharyngeal airway during sleep. Control of pharyngeal patency is a complex process relating primarily to basic anatomy and the activity of many pharyngeal dilator muscles. The control of these muscles is regulated by a number of processes including respiratory drive, negative pressure reflexes, and state (sleep) effects. In general, patients with OSA have an anatomically small airway the patency of which is maintained during wakefulness by reflex-driven augmented dilator muscle activation. At sleep onset, muscle activity falls, thereby compromising the upper airway. However, recent data suggest that the mechanism of OSA differs substantially among patients, with variable contributions from several physiologic characteristics including, among others: level of upper airway dilator muscle activation required to open the airway, increase in chemical drive required to recruit the pharyngeal muscles, chemical control loop gain, and arousal threshold. Thus, the cause of sleep apnea likely varies substantially between patients. Other physiologic mechanisms likely contributing to OSA pathogenesis include falling lung volume during sleep, shifts in blood volume from peripheral tissues to the neck, and airway edema. Apnea severity may progress over time, likely due to weight gain, muscle/nerve injury, aging effects on airway anatomy/collapsibility, and changes in ventilatory control stability.
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Affiliation(s)
- David P White
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med 2013; 188:996-1004. [PMID: 23721582 PMCID: PMC3826282 DOI: 10.1164/rccm.201303-0448oc] [Citation(s) in RCA: 700] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 05/21/2013] [Indexed: 12/30/2022] Open
Abstract
RATIONALE The pathophysiologic causes of obstructive sleep apnea (OSA) likely vary among patients but have not been well characterized. OBJECTIVES To define carefully the proportion of key anatomic and nonanatomic contributions in a relatively large cohort of patients with OSA and control subjects to identify pathophysiologic targets for future novel therapies for OSA. METHODS Seventy-five men and women with and without OSA aged 20-65 years were studied on three separate nights. Initially, the apnea-hypopnea index was determined by polysomnography followed by determination of anatomic (passive critical closing pressure of the upper airway [Pcrit]) and nonanatomic (genioglossus muscle responsiveness, arousal threshold, and respiratory control stability; loop gain) contributions to OSA. MEASUREMENTS AND MAIN RESULTS Pathophysiologic traits varied substantially among participants. A total of 36% of patients with OSA had minimal genioglossus muscle responsiveness during sleep, 37% had a low arousal threshold, and 36% had high loop gain. A total of 28% had multiple nonanatomic features. Although overall the upper airway was more collapsible in patients with OSA (Pcrit, 0.3 [-1.5 to 1.9] vs. -6.2 [-12.4 to -3.6] cm H2O; P <0.01), 19% had a relatively noncollapsible upper airway similar to many of the control subjects (Pcrit, -2 to -5 cm H2O). In these patients, loop gain was almost twice as high as patients with a Pcrit greater than -2 cm H2O (-5.9 [-8.8 to -4.5] vs. -3.2 [-4.8 to -2.4] dimensionless; P = 0.01). A three-point scale for weighting the relative contribution of the traits is proposed. It suggests that nonanatomic features play an important role in 56% of patients with OSA. CONCLUSIONS This study confirms that OSA is a heterogeneous disorder. Although Pcrit-anatomy is an important determinant, abnormalities in nonanatomic traits are also present in most patients with OSA.
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Affiliation(s)
- Danny J. Eckert
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Neuroscience Research Australia and the School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia; and
| | - David P. White
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amy S. Jordan
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Atul Malhotra
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Kawai M, Kirkness JP, Yamamura S, Imaizumi K, Yoshimine H, Oi K, Ayuse T. Increased phosphatidylcholine concentration in saliva reduces surface tension and improves airway patency in obstructive sleep apnoea. J Oral Rehabil 2013; 40:758-66. [DOI: 10.1111/joor.12094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2013] [Indexed: 11/27/2022]
Affiliation(s)
- M. Kawai
- Department of Clinical Physiology; Nagasaki University Graduate School of Biomedical Science; Nagasaki Japan
| | - J. P. Kirkness
- Division of Pulmonary and Critical Care Medicine; The Johns Hopkins School of Medicine; Johns Hopkins Sleep Disorders Center; Baltimore MD USA
| | | | | | - H. Yoshimine
- Department of Internal Medicine; Inoue Hospital; Nagasaki Japan
| | - K. Oi
- Department of Clinical Physiology; Nagasaki University Graduate School of Biomedical Science; Nagasaki Japan
| | - T. Ayuse
- Department of Clinical Physiology; Nagasaki University Graduate School of Biomedical Science; Nagasaki Japan
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Usmani ZA, Hlavac M, Rischmueller M, Heraganahally SS, Hilditch CJ, Lester S, Catcheside PG, Antic NA, Chai-Coetzer CL, Doug McEvoy R. Sleep disordered breathing in patients with primary Sjögren’s syndrome: A group controlled study. Sleep Med 2012; 13:1066-70. [DOI: 10.1016/j.sleep.2012.06.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 06/06/2012] [Accepted: 06/15/2012] [Indexed: 10/28/2022]
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Hoshino Y, Ayuse T, Kobayashi M, Kurata S, Kawai M, Schneider H, Patil SP, Schwartz AR, Kirkness JP, Oi K. The effects of hormonal status on upper airway patency in normal female subjects during propofol anesthesia. J Clin Anesth 2012; 23:527-33. [PMID: 22050795 DOI: 10.1016/j.jclinane.2011.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 02/07/2011] [Accepted: 02/15/2011] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To determine the mechanical upper airway properties and compensatory neuromuscular responses to obstruction during propofol anesthesia in the follicular and luteal phases of the menstrual cycle. DESIGN Prospective, randomized study. SETTING University-affiliated hospital. SUBJECTS 12 premenopausal female volunteers for studies of upper airway collapse throughout their menstrual cycle during the follicular phase (6 -10 days) and mid-late luteal phase (20 - 24 days). MEASUREMENTS The level of propofol anesthesia (1.5 - 2.0 μg/mL) required to suppress arousal responses was determined by Observer's Assessment of Alertness/Sedation scoring (level 2) and confirmed by bispectral index monitoring. Pressure-flow relationships were constructed to evaluate collapsibility (P(CRIT)) and up-stream resistance (R(US)) during acute [Passive; hypotonic electromyography (EMG)] and sustained (Active; elevated EMG) changes in nasal mask pressure. The difference between passive P(CRIT) and active P(CRIT) (ΔP(CRIT A-P)) represented the magnitude of the compensatory response to obstruction. MAIN RESULTS Passive P(CRIT) was significantly higher in the mid-late luteal phase (-4.7 cm H(2)O) than in the follicular phase (-6.2 cmH(2)O; P < 0.05). Active P(CRIT) significantly decreased compared with passive P(CRIT) in the follicular phase (-10.1 cm H(2)O) and in the mid-late luteal phase (-7.7 cm H(2)O) and (P < 0.05). No significant difference was noted in ΔP(CRIT) between the follicular (3.9 ± 2.9 cm H(2)O) and mid-late luteal phases (3.0 ± 2.6 cm H(2)O). No differences were seen in R(US) between the menstrual phases for either the passive (P = 0.8) or active (P = 0.75) states. CONCLUSIONS Menstrual phase has an effect on anatomical alterations (mechanical properties) in the hypotonic upper airway during propofol anesthesia.
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Affiliation(s)
- Yuko Hoshino
- Department of Clinical Physiology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, 852-8588, Japan
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Younes M, Loewen AHS, Ostrowski M, Laprairie J, Maturino F, Hanly PJ. Genioglossus activity available via non-arousal mechanisms vs. that required for opening the airway in obstructive apnea patients. J Appl Physiol (1985) 2011; 112:249-58. [PMID: 21921245 DOI: 10.1152/japplphysiol.00312.2011] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
It is generally believed that reflex recruitment of pharyngeal dilator muscles is insufficient to open the airway of obstructive apnea (OSA) patients once it is closed and, therefore, that arousal is required. Yet arousal promotes recurrence of obstruction. There is no information about how much dilator [genioglossus (GG)] activation is required to open the airway (GG Opening Threshold) or about the capacity of reflex mechanisms to increase dilator activity before/without arousal (Non-Arousal Activation). The relationship between these two variables is important for ventilatory stability. We measured both variables in 32 OSA patients (apnea-hypopnea index 74 ± 42 events/h). GG activity was monitored while patients were on optimal continuous positive airway pressure (CPAP). Zopiclone was administered to delay arousal. Maximum GG activity (GG(MAX)) and airway closing pressure (P(CRIT)) were measured. During stable sleep CPAP was decreased to 1 cmH(2)O to induce obstructive events and the dial-downs were maintained until the airway opened with or without arousal. GG activity at the instant of opening (GG Opening Threshold) was measured. GG Opening Threshold averaged only 10.4 ± 9.5% GG(Max) and did not correlate with P(CRIT) (r = 0.04). Twenty-six patients had >3 openings without arousal, indicating that Non-Arousal Activation can exceed GG Opening Threshold in the majority of patients. GG activity reached before arousal in Arousal-Associated Openings was only 5.4 ± 4.6% GG(MAX) below GG Opening Threshold. We conclude that in most patients GG activity required to open the airway is modest and can be reached by non-arousal mechanisms. Arousals occur in most cases just before non-arousal mechanisms manage to increase activity above GG Opening Threshold. Measures to reduce GG Opening Threshold even slightly may help stabilize breathing in many patients.
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Affiliation(s)
- Magdy Younes
- Sleep Center, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.
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Li Y, Ye J, Li T, Lin N, Wang Z, Liang C, Sperry A, Han D. Anatomic predictors of retropalatal mechanical loads in patients with obstructive sleep apnea. ACTA ACUST UNITED AC 2011; 82:246-53. [PMID: 21701139 DOI: 10.1159/000327176] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 03/02/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND The retropalatal airway is one of the most collapsible sites during sleep in patients with obstructive sleep apnea (OSA). The primary anatomical contributors to increased collapsibility in the retropalatal segment remain unclear. OBJECTIVES This study seeks to investigate how the balance between pharyngeal soft tissues and the bony enclosure influences retropalatal mechanical loads in patients with OSA. METHODS The segmental mechanical load of the retropalatal pharynx was determined by the region's critical closing pressure in 30 anesthetized, paralyzed and intubated subjects with OSA. The volumetric anatomical parameters of the retropalatal airway were evaluated using magnetic resonance imaging, and their associations with retropalatal closing pressures were analyzed. RESULTS Increased retropalatal closing pressure was associated with the increased proportion of volumetric pharyngeal soft tissues to the surrounding cervicomandibular bony frame (r = 0.791, p < 0.001), enlarged soft tissues of the lateral wall (r = 0.752, p < 0.001) and soft palate (r = 0.726, p < 0.001). The decreased volume of the nasopharynx (r = -0.650, p < 0.001) and pharyngeal cavity (r = -0.653, p < 0.001) indicated a relatively higher retropalatal closing pressure. The multivariate linear regression model demonstrated that the proportion of retropalatal soft tissues to the bony frame and volume of the soft palate predicted 69.4% of the variability in closing pressure (F = 30.674, p < 0.001). CONCLUSIONS The increased volumetric proportion of pharyngeal soft tissue to the bone enclosure may be an important contributor to increased retropalatal mechanical loads.
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Affiliation(s)
- Yanru Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, China
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Ong JSL, Touyz G, Tanner S, Hillman DR, Eastwood PR, Walsh JH. Variability of human upper airway collapsibility during sleep and the influence of body posture and sleep stage. J Sleep Res 2011; 20:533-7. [PMID: 21554464 DOI: 10.1111/j.1365-2869.2011.00925.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The critical pressure at which the pharynx collapses (Pcrit) is an objective measurement of upper airway collapsibility, an important pathogenetic factor in obstructive sleep apnoea. This study examined the inherent variability of passive Pcrit measurement during sleep and evaluated the effects of sleep stage and body posture on Pcrit. Repeated measurements of Pcrit were assessed in 23 individuals (15 male) with diagnosed obstructive sleep apnoea throughout a single overnight sleep study. Body posture and sleep stage were unrestricted. Applied upper airway pressure was repetitively reduced to obtain multiple measurements of Pcrit. In 20 subjects multiple measurements of Pcrit were obtained. The overall coefficient of repeatability for Pcrit measurement was 4.1 cm H₂O. Considering only the lateral posture, the coefficient was 4.8 cm H₂O. It was 3.3 cm H₂O in the supine posture. Pcrit decreased from the supine to lateral posture [supine mean 2.5 cm H₂O, 95% confidence interval (CI) 1.4-3.6; lateral mean 0.3 cm H₂O, 95% CI -0.8-1.4, P = 0.007] but did not vary with sleep stage (P = 0.91). This study has shown that the overall coefficient of repeatability was 4.1 cm H₂O, implying that the minimum detectable difference, with 95% probability, between two repeated Pcrit measurements in an individual is 4.1 cm H₂O. Such variability in overnight measures of Pcrit indicates that a single unqualified value of Pcrit cannot be used to characterize an individual's overall collapsibility during sleep. When within-subject variability is accounted for, change in body posture from supine to lateral significantly decreases passive pharyngeal collapsibility.
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Affiliation(s)
- Jeremy S L Ong
- Centre for Sleep Science, School of Anatomy and Human Biology, University of Western Australia, Australia
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Kim SW. Possibilities for Increasing the Success Rate in Sleep Surgery. SLEEP MEDICINE RESEARCH 2011. [DOI: 10.17241/smr.2011.2.1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sahin-Yilmaz A, Naclerio RM. Anatomy and physiology of the upper airway. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2011; 8:31-39. [PMID: 21364219 DOI: 10.1016/b978-1-4160-6645-3.00101-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The nose is the major portal of air exchange between the internal and external environment. The nose participates in the vital functions of conditioning inspired air toward a temperature of 37°C and 100% relative humidity, providing local defense and filtering inhaled particulate matter and gases. It also functions in olfaction, which provides both a defense and pleasure for the individual. Understanding normal physiology provides the basis for recognizing abnormalities.
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Affiliation(s)
- Asli Sahin-Yilmaz
- Umraniye Education and Research Hospital, Department of Otolaryngology, Istanbul, Turkey
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Fleetham JA. Medical and surgical treatment of obstructive sleep apnea syndrome, including dental appliances. HANDBOOK OF CLINICAL NEUROLOGY 2011; 98:441-57. [DOI: 10.1016/b978-0-444-52006-7.00029-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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SASAI T, INOUE Y, MATSUO A, MATSUURA M, MATSUSHIMA E. Changes in respiratory disorder parameters during the night in patients with obstructive sleep apnoea. Respirology 2010; 16:116-23. [DOI: 10.1111/j.1440-1843.2010.01873.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
Anesthesia and sleep both predispose to upper airway obstruction through state-induced reductions in pharyngeal dilator muscle activation and lung volume. The tendencies are related in patients with obstructive sleep apnea commonly presenting with difficulties in airway management in the perioperative period. This is a period of great potential vulnerability for such patients because of compromise of the arousal responses that protect against asphyxiation during natural sleep. Careful preoperative evaluation and insightful perioperative observation are likely to identify patients at risk. A significant proportion of patients will have previously undiagnosed obstructive sleep apnea and anesthesiologists are well placed to identify this potential. Patients with known or suspected obstructive sleep apnea need careful postoperative management, particularly while consciousness and arousal responses are impaired. Specific follow-up of suspected cases is needed to ensure that the sleep-related component of the problem receives appropriate care.
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Affiliation(s)
- David R Hillman
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology, Sir Charles Gairdner Hospital, Nedlands, Perth, Australia.
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Madani M, Madani F. Epidemiology, pathophysiology, and clinical features of obstructive sleep apnea. Oral Maxillofac Surg Clin North Am 2010; 21:369-75. [PMID: 19944337 DOI: 10.1016/j.coms.2009.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The normal cycle of respiration includes a unique balancing force between many upper airway structures that control its dilation and closure. Alteration of this delicate equilibrium, possibly by an increased airflow resistance, can cause various degrees of obstructive sleep apnea (OSA). OSA is now recognized as a major illness, an important cause of medical morbidity and mortality affecting millions of people worldwide, and a major predisposing factor for several systemic conditions, such as hypertension, cardiovascular disease, stroke, diabetes, and even sexual dysfunction. Initial evaluation for possible OSA may be done by dental professionals who can provide guidance for its comprehensive evaluation and management. Because of the complexity of the disease, factors contributing to its development must be identified. Some factors caused by the patient's anatomic structures are slightly easier to rectify, whereas others may relate to the patient's age, sex, habits, or associated illnesses, including obesity. In this article, various epidemiologic, pathophysiologic, and clinical features of OSA are discussed.
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Affiliation(s)
- Mansoor Madani
- Department of Oral and Maxillofacial Surgery, Capital Health, Trenton, NJ 08638, USA.
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Abstract
Sleep-induced apnea and disordered breathing refers to intermittent, cyclical cessations or reductions of airflow, with or without obstructions of the upper airway (OSA). In the presence of an anatomically compromised, collapsible airway, the sleep-induced loss of compensatory tonic input to the upper airway dilator muscle motor neurons leads to collapse of the pharyngeal airway. In turn, the ability of the sleeping subject to compensate for this airway obstruction will determine the degree of cycling of these events. Several of the classic neurotransmitters and a growing list of neuromodulators have now been identified that contribute to neurochemical regulation of pharyngeal motor neuron activity and airway patency. Limited progress has been made in developing pharmacotherapies with acceptable specificity for the treatment of sleep-induced airway obstruction. We review three types of major long-term sequelae to severe OSA that have been assessed in humans through use of continuous positive airway pressure (CPAP) treatment and in animal models via long-term intermittent hypoxemia (IH): 1) cardiovascular. The evidence is strongest to support daytime systemic hypertension as a consequence of severe OSA, with less conclusive effects on pulmonary hypertension, stroke, coronary artery disease, and cardiac arrhythmias. The underlying mechanisms mediating hypertension include enhanced chemoreceptor sensitivity causing excessive daytime sympathetic vasoconstrictor activity, combined with overproduction of superoxide ion and inflammatory effects on resistance vessels. 2) Insulin sensitivity and homeostasis of glucose regulation are negatively impacted by both intermittent hypoxemia and sleep disruption, but whether these influences of OSA are sufficient, independent of obesity, to contribute significantly to the "metabolic syndrome" remains unsettled. 3) Neurocognitive effects include daytime sleepiness and impaired memory and concentration. These effects reflect hypoxic-induced "neural injury." We discuss future research into understanding the pathophysiology of sleep apnea as a basis for uncovering newer forms of treatment of both the ventilatory disorder and its multiple sequelae.
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Affiliation(s)
- Jerome A Dempsey
- The John Rankin Laboratory of Pulmonary Medicine, Departments of Population Health Sciences and of Orthopedics and Rehabilitation, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin 53706, USA.
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Upper airway function in the pathogenesis of obstructive sleep apnea: a review of the current literature. Curr Opin Pulm Med 2008; 14:519-24. [PMID: 18812828 DOI: 10.1097/mcp.0b013e3283130f66] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Obstructive sleep apnea is an increasingly prevalent disease, with a considerable societal burden. The disease is defined by recurrent intermittent collapse of the upper airway. Understanding of and treatment for the disease is largely confined to relief of the mechanical obstruction of the upper airway by application of continuous positive airway pressure, and less commonly weight loss or surgery. However, recent work has focused on the function, rather than structure alone, of the upper airway. RECENT FINDINGS The following contributors to upper airway structure and function have been studied: traditional fixed anatomical abnormalities, dynamic anatomical changes, upper airway dilator muscle dysfunction, lung volumes, and instability in control of breathing. In each patient with obstructive sleep apnea, the relative contribution of each of these components may be quite variable. The studies reviewed here describe methods to evaluate these factors, and some attempts at treatment. SUMMARY Ongoing studies are attempting to classify patients on the basis of the underlying pathophysiology. This work suggests that obstructive sleep apnea is a heterogeneous disease with multiple root causes. Ultimately, such a classification may allow more individualized treatment, not only relying on mechanical relief of the upper airway obstruction.
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Lam JCM, Kairaitis K, Verma M, Wheatley JR, Amis TC. Saliva production and surface tension: influences on patency of the passive upper airway. J Physiol 2008; 586:5537-47. [PMID: 18818243 DOI: 10.1113/jphysiol.2008.159822] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Pharyngeal patency is influenced by the surface tension (gamma) of the upper airway lining liquid (UAL), of which saliva is a major component. We investigated the influences of saliva production on gamma of the UAL, and upper airway re-opening and closing pressures. In 10 supine, male, anaesthetized, tracheostomised, mechanically ventilated New Zealand White rabbits, we measured re-opening and closing of the passive isolated upper airway at baseline and following graded (cumulative) doses of methacholine or atropine. Upper airway liquid volume index (UALVI) was assessed using a standardized suction procedure (secretion weight obtained per second) expressed as the natural logarithm (LnUALVI). The gamma of UAL samples were measured using the 'pull-off' force technique. Across all animals, baseline values were: LnUALVI -6.2 (-8.6 to -5.4) median (interquartile range), gamma of UAL 58.9 (56.6-59.9) mN m(-1), re-opening 8.6 (6.9-11.1) cmH(2)O, and closing pressures 3.2 (1.8-5.7) cmH(2)O. LnUALVI increased by approximately 0.17 per microg kg(-1) methacholine and decreased by approximately 0.14 per 100 microg kg(-1) atropine (both P < 0.03, linear mixed effects modelling). Surface tension was unchanged by methacholine but increased by approximately 0.6 mN m(-1) per 100 microg kg(-1) atropine (P < 0.004). When data were analysed across all animals, both re-opening and closing pressures increased as surface tension increased (by approximately 0.4 cmH(2)O mN(-1) and by approximately 0.7 cmH(2)O mN(-1), respectively; both P < 0.05). We conclude that saliva production influences upper airway mechanical properties partly via alterations in gamma of UAL. We speculate that in obstructive sleep apnoea, altered autonomic activity may reduce saliva production and increase surface tension of the upper airway lining liquid, thus increasing the likelihood of upper airway obstruction.
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Affiliation(s)
- J C M Lam
- Division of Respiratory and Critical Care Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, SAR, China
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Younes M. Role of respiratory control mechanisms in the pathogenesis of obstructive sleep disorders. J Appl Physiol (1985) 2008; 105:1389-405. [PMID: 18787092 DOI: 10.1152/japplphysiol.90408.2008] [Citation(s) in RCA: 169] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Obstructive sleep disorders develop when the normal reduction in pharyngeal dilator activity at sleep onset occurs in an individual whose pharynx requires a relatively high level of dilator activity to remain sufficiently open. They range from steady snoring, to slowly evolving hypopneas, to fast-recurring obstructive hypopneas and apneas. A fundamental observation is that the polysomnographic picture differs substantially among subjects with the same pharyngeal collapsibility, and even in the same subject at different times, indicating that the type and severity of the disorder is determined to a large extent by the individual's response to the obstruction. The present report reviews the various mechanisms involved in the response to sleep-induced obstructive events. When the obstructive event takes the form of mild-moderate flow limitation, compensation can take place through an increase in the fraction of time spent in inspiration (Ti/Ttot) without any increase in maximum flow (V(MAX)). With more severe obstructions, V(MAX) must increase. Recent data indicate that the obstructed upper airway can reopen reflexly, without arousal, if chemical drive is allowed to reach a threshold (T(ER)) but that this is often preempted by a low arousal threshold. The relation between T(ER) and arousal threshold, as well as the lung-to-carotid circulation time and the rate of rise of chemical drive during the obstructive event, determine the magnitude of ventilatory overshoot at the end of an event and, by extension, whether initial obstructive events will be followed by stable breathing, slow evolving hypopneas with occasional arousals, or repetitive events.
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Affiliation(s)
- Magdy Younes
- Sleep Centre, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada.
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Kirkness JP, Schwartz AR, Schneider H, Punjabi NM, Maly JJ, Laffan AM, McGinley BM, Magnuson T, Schweitzer M, Smith PL, Patil SP. Contribution of male sex, age, and obesity to mechanical instability of the upper airway during sleep. J Appl Physiol (1985) 2008; 104:1618-24. [PMID: 18420722 PMCID: PMC2474771 DOI: 10.1152/japplphysiol.00045.2008] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Male sex, obesity, and age are risk factors for obstructive sleep apnea, although the mechanisms by which these factors increase sleep apnea susceptibility are not entirely understood. This study examined the interrelationships between sleep apnea risk factors, upper airway mechanics, and sleep apnea susceptibility. In 164 (86 men, 78 women) participants with and without sleep apnea, upper airway pressure-flow relationships were characterized to determine their mechanical properties [pharyngeal critical pressure under hypotonic conditions (passive Pcrit)] during non-rapid eye movement sleep. In multiple linear regression analyses, the effects of body mass index and age on passive Pcrit were determined in each sex. A subset of men and women matched by body mass index, age, and disease severity was used to determine the sex effect on passive Pcrit. The passive Pcrit was 1.9 cmH(2)O [95% confidence interval (CI): 0.1-3.6 cmH(2)O] lower in women than men after matching for body mass index, age, and disease severity. The relationship between passive Pcrit and sleep apnea status and severity was examined. Sleep apnea was largely absent in those individuals with a passive Pcrit less than -5 cmH(2)O and increased markedly in severity when passive Pcrit rose above -5 cmH(2)O. Passive Pcrit had a predictive power of 0.73 (95% CI: 0.65-0.82) in predicting sleep apnea status. Upper airway mechanics are differentially controlled by sex, obesity, and age, and partly mediate the relationship between these sleep apnea risk factors and obstructive sleep apnea.
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Affiliation(s)
- Jason P Kirkness
- Div. of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, MD, USA
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Hilditch CJ, McEvoy RD, George KE, Thompson CC, Ryan MK, Rischmueller M, Catcheside PG. Upper airway surface tension but not upper airway collapsibility is elevated in primary Sjögren's syndrome. Sleep 2008; 31:367-74. [PMID: 18363313 DOI: 10.1093/sleep/31.3.367] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Primary Sjögren's syndrome is an autoimmune disease typified by xerostomia (dry mouth) that, in turn, could lead to increased saliva surface tension (gamma) and increased upper airway collapsibility. Fatigue, of unknown etiology, is also frequently reported by patients with primary Sjögren's syndrome. Recent preliminary data indicate a high prevalence of obstructive sleep apnea in healthy-weight women with primary Sjögren's syndrome. Concurrent research highlights a significant role of gamma in the maintenance of upper airway patency. The aim of this study was to compare oral mucosal wetness, saliva gamma, and upper airway collapsibility during wake and sleep between women with primary Sjögren's syndrome and matched control subjects. SETTING Participants slept in a sound-insulated room with physiologic measurements controlled from an adjacent room. PARTICIPANTS Eleven women with primary Sjögren's syndrome and 8 age- and body mass index-matched control women. INTERVENTIONS Upper airway collapsibility index (minimum choanal-epiglottic pressure expressed as a percentage of delivered choanal pressure) was determined from brief negative-pressure pulses delivered to the upper airway during early inspiration in wakefulness and sleep. MEASUREMENTS AND RESULTS Patients with primary Sjögren's syndrome had significantly higher saliva gamma ("pull-off" force method) compared with control subjects (67.2 +/- 1.1 mN/m versus 63.2 +/- 1.7 mN/m, P < 0.05). Upper airway collapsibility index significantly increased from wake to sleep (Stage 2 and slow wave sleep) but was not different between groups during wake (primary Sjögren's syndrome versus controls; 36.3% +/- 8.0% vs 46.0 +/- 13.8%), stage 2 sleep (53.1% +/- 11.9% vs 63.4% +/- 7.2%), or slow-wave sleep (60.8% +/- 12.2% vs 60.5% +/- 9.3%). CONCLUSIONS Despite having a significantly "stickier" upper airway, patients with primary Sjögren's syndrome do not appear to have abnormal upper airway collapsibility, at least as determined from upper airway collapsibility index.
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Affiliation(s)
- Cassie J Hilditch
- Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, Australia
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Abstract
Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive narrowing or collapse of the pharyngeal airway during sleep. The disorder is associated with major comorbidities including excessive daytime sleepiness and increased risk of cardiovascular disease. The underlying pathophysiology is multifactorial and may vary considerably between individuals. Important risk factors include obesity, male sex, and aging. However, the physiological mechanisms underlying these risk factors are not clearly understood. This brief review summarizes the current understanding of OSA pathophysiology in adults and highlights the potential mechanisms underlying the principal risk factors. In addition, some of the pathophysiological characteristics associated with OSA that may modulate disease severity are illustrated. Finally, the potential for novel treatment strategies, based on an improved understanding of the underlying pathophysiology, is also discussed with the ultimate aim of stimulating research ideas in areas where knowledge is lacking.
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