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Ayappa I, Tolbert TM, Rapoport DM. Flow Limitation Frequency: A Metric to Assess Consequences of OSA? Chest 2024; 165:769-770. [PMID: 38599750 DOI: 10.1016/j.chest.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/07/2024] [Indexed: 04/12/2024] Open
Affiliation(s)
- Indu Ayappa
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Thomas M Tolbert
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David M Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Amorim MR, Wang X, Aung O, Bevans-Fonti S, Anokye-Danso F, Ribeiro C, Escobar J, Freire C, Pho H, Dergacheva O, Branco LGS, Ahima RS, Mendelowitz D, Polotsky VY. Leptin signaling in the dorsomedial hypothalamus couples breathing and metabolism in obesity. Cell Rep 2023; 42:113512. [PMID: 38039129 PMCID: PMC10804286 DOI: 10.1016/j.celrep.2023.113512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 10/25/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023] Open
Abstract
Mismatch between CO2 production (Vco2) and respiration underlies the pathogenesis of obesity hypoventilation. Leptin-mediated CNS pathways stimulate both metabolism and breathing, but interactions between these functions remain elusive. We hypothesized that LEPRb+ neurons of the dorsomedial hypothalamus (DMH) regulate metabolism and breathing in obesity. In diet-induced obese LeprbCre mice, chemogenetic activation of LEPRb+ DMH neurons increases minute ventilation (Ve) during sleep, the hypercapnic ventilatory response, Vco2, and Ve/Vco2, indicating that breathing is stimulated out of proportion to metabolism. The effects of chemogenetic activation are abolished by a serotonin blocker. Optogenetic stimulation of the LEPRb+ DMH neurons evokes excitatory postsynaptic currents in downstream serotonergic neurons of the dorsal raphe (DR). Administration of retrograde AAV harboring Cre-dependent caspase to the DR deletes LEPRb+ DMH neurons and abolishes metabolic and respiratory responses to leptin. These findings indicate that LEPRb+ DMH neurons match breathing to metabolism through serotonergic pathways to prevent obesity-induced hypoventilation.
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Affiliation(s)
- Mateus R Amorim
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA.
| | - Xin Wang
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA
| | - O Aung
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Shannon Bevans-Fonti
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
| | | | - Caitlin Ribeiro
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA
| | - Joan Escobar
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA
| | - Carla Freire
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Huy Pho
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Olga Dergacheva
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA
| | - Luiz G S Branco
- University of São Paulo, Ribeirão Preto, São Paulo 14040-904, Brazil
| | - Rexford S Ahima
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA
| | - David Mendelowitz
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA
| | - Vsevolod Y Polotsky
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA; Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA.
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Javaheri S, Rapoport DM, Schwartz AR. Distinguishing central from obstructive hypopneas on a clinical polysomnogram. J Clin Sleep Med 2023; 19:823-834. [PMID: 36661093 PMCID: PMC10071374 DOI: 10.5664/jcsm.10420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 01/21/2023]
Abstract
Among sleep-related disordered breathing events, hypopneas are the most frequent. Like obstructive and central apneas, hypopneas may be obstructive or central (reduced drive) in origin. Nevertheless, unlike apneas, categorizing hypopneas as either "obstructive" or "central" is often difficult or ambiguous. It has been suggested that hypopneas could be categorized as obstructive when associated with snoring, inspiratory flow limitation, or paradoxical thoraco-abdominal excursions. This approach, however, has not been extensively tested and misclassification of hypopneas is unavoidable. Yet, much rides on the accurate distinction of these events to guide therapy with medical devices or pharmacological therapy in each patient. Additionally, accurate hypopnea classification is critical for design of clinical trials, because therapeutic responses differ depending on the subtype of hypopnea. Correctly classifying hypopneas can also allay concerns about obtaining coverage for therapies that specifically target either central or obstructive sleep-disordered breathing events. The present paper expands on the current criteria for differentiating obstructive from central hypopneas and provides illustrative tracings that can help classify these events. CITATION Javaheri S, Rapoport DM, Schwartz AR. Distinguishing central from obstructive hypopneas on a clinical polysomnogram. J Clin Sleep Med. 2023;19(4):823-834.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep, Bethesda North Hospital, Cincinnati, Ohio
| | - David M. Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alan R. Schwartz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Wang H, Wu H, Ji C, Wang M, Xiong H, Huang X, Fan T, Gao S, Huang Y. Mechanical mechanism to induce inspiratory flow limitation in obstructive sleep apnea patients revealed from in-vitro studies. J Biomech 2023; 146:111409. [PMID: 36521227 DOI: 10.1016/j.jbiomech.2022.111409] [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: 04/03/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Inspiratory flow limitation means that when the flowrate reaches a certain value, it no longer increases, or even decreases, which is called negative effort dependence flow limitation, even if the inspiration effort is increased. This occurs often in obstructive sleep apnea patients, but its mechanism remains unclear. To reveal the mechanism of inspiratory flow limitation, we constructed a unique partially collapsible in-vitro upper airway model of obstructive sleep apnea patients to observe the change of airway resistance with inspiratory driving pressure. The important findings demonstrate that with the increase of inspiratory effort, the driving pressure increases faster than the airway resistance in the early stages, and then the reverse occurs as the airway becomes narrower. The airway collapse caused by the transmural pressure can lead to a rapid increase in downstream resistance with the increase of inspiratory effort, which is the key reason causing the flow reduction and the formation of typical negative effort dependence flow limitation. The mechanical mechanism revealed in this study will lead to fully new insights into the study and treatment of obstructive sleep apnea.
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Affiliation(s)
- Hui Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Haijun Wu
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Changjin Ji
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Mengmeng Wang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Huahui Xiong
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Xiaoqing Huang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Tingting Fan
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Simiao Gao
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Yaqi Huang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China.
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Freire C, Ramsey JD, Pho H, Kojima R, Zhao Y, Kim L, Anokye-Danso F, Berger S, Ahima RS, Batrakova EV, Kabanov AV, Polotsky VY. Leptin-loaded Extracellular Vesicles Treat Sleep-disordered Breathing in Mice with Obesity. Am J Respir Cell Mol Biol 2022; 67:720-723. [PMID: 36454084 PMCID: PMC9743189 DOI: 10.1165/rcmb.2022-0229le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Carla Freire
- The Johns Hopkins School of MedicineBaltimore, Maryland
| | - Jacob D. Ramsey
- University of North Carolina at Chapel HillChapel Hill, North Carolina
| | - Huy Pho
- The Johns Hopkins School of MedicineBaltimore, Maryland
| | - Ryo Kojima
- University of North Carolina at Chapel HillChapel Hill, North Carolina
| | - Yuling Zhao
- University of North Carolina at Chapel HillChapel Hill, North Carolina
| | - Lenise Kim
- The Johns Hopkins School of MedicineBaltimore, Maryland
| | | | - Slava Berger
- The Johns Hopkins School of MedicineBaltimore, Maryland
| | | | | | - Alexander V. Kabanov
- University of North Carolina at Chapel HillChapel Hill, North Carolina
- M.V. Lomonosov Moscow State UniversityMoscow, Russia
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Pho H, Amorim MR, Qiu Q, Shin M, Kim LJ, Anokye‐Danso F, Jun JJ, Ahima RS, Branco LGS, Kuhn DM, Mateika JH, Polotsky VY. The effect of brain serotonin deficiency on breathing is magnified by age. Physiol Rep 2022; 10:e15245. [PMID: 35581741 PMCID: PMC9114658 DOI: 10.14814/phy2.15245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/25/2022] [Accepted: 03/13/2022] [Indexed: 11/24/2022] Open
Abstract
Serotonin is an important mediator modulating behavior, metabolism, sleep, control of breathing, and upper airway function, but the role of aging in serotonin-mediated effects has not been previously defined. Our study aimed to examine the effect of brain serotonin deficiency on breathing during sleep and metabolism in younger and older mice. We measured breathing during sleep, hypercapnic ventilatory response (HCVR), CO2 production (VCO2 ), and O2 consumption (VO2 ) in 16-18-week old and 40-44-week old mice with deficiency of tryptophan hydroxylase 2 (Tph2), which regulates serotonin synthesis specifically in neurons, compared to Tph2+/+ mice. As expected, aging decreased VCO2 and VO2 . Tph2 knockout resulted in an increase in both metabolic indexes and no interaction between age and the genotype was observed. During wakefulness, neither age nor genotype had an effect on minute ventilation. The genotype did not affect hypercapnic sensitivity in younger mice. During sleep, Tph2-/- mice showed significant decreases in maximal inspiratory flow in NREM sleep, respiratory rate, and oxyhemoglobin saturation in REM sleep, compared to wildtype, regardless of age. Neither serotonin deficiency nor aging affected the frequency of flow limited breaths (a marker of upper airway closure) or apneas. Serotonin deficiency increased the amount and efficiency of sleep only in older animals. In conclusion, younger Tph2-/- mice were able to defend their ventilation and phenotypically did not differ from wildtype during wakefulness. In contrast, both young and old Tph2-/- mice showed sleep-related hypoventilation, which was manifested by hypoxemia during REM sleep.
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Affiliation(s)
- Huy Pho
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Mateus R. Amorim
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Qingchao Qiu
- Department of PhysiologyWayne State UniversityDetroitMichiganUSA
| | - Mi‐Kyung Shin
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Lenise J. Kim
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Frederick Anokye‐Danso
- Division of Endocrinology, Diabetes, and MetabolismDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jonathan J. Jun
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Rexford S. Ahima
- Division of Endocrinology, Diabetes, and MetabolismDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Luiz G. S. Branco
- Dental School of Ribeirão PretoUniversity of São PauloSão PauloBrazil
| | - Donald M. Kuhn
- Department of Psychiatry and Behavioral NeurosciencesWayne State University School of MedicineDetroitMichiganUSA
- John D. Dingell Veterans Affairs Medical CenterDetroitMichiganUSA
| | - Jason H. Mateika
- Department of PhysiologyWayne State UniversityDetroitMichiganUSA
- John D. Dingell Veterans Affairs Medical CenterDetroitMichiganUSA
- Department of Internal MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Vsevolod Y. Polotsky
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Immediate Physiological Responses to Inspiratory Flow Limited Events in Mild Obstructive Sleep Apnea. Ann Am Thorac Soc 2022; 19:99-108. [PMID: 34347573 PMCID: PMC9797037 DOI: 10.1513/annalsats.202001-004oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Rationale: Inspiratory flow limitation (IFL), characterized by flattening of individual breaths on the airflow/time tracing, is a noninvasive indicator of elevated upper airway resistance. An IFL "event" in isolation has not been defined, nor has the ability to reproducibly identify event occurrence been tested. IFL events and their association with immediate physiological responses-as well as the impact of characteristics such as age, sex, sleep stage, sleepiness, and event duration on their association with such outcomes-have not been studied. Symptomatic patients with a normal to mildly abnormal apnea-hypopnea index who have predominant IFL on their polysomnography may benefit from treatment. Objectives: To test the reproducibility of identifying IFL events and their termination and to determine the frequency of the immediate physiological response to their occurrence, including desaturation, electroencephalography (EEG) arousal, and increased heart rate (HR). Methods: Fifty-eight patients with obstructive sleep apnea (OSA) underwent full diagnostic polysomnography. IFL events and their termination were identified manually using predefined rules from the unscored nasal cannula flow channel alone and were evaluated for responses such as EEG arousal, oxygen desaturation of ⩾3%, and HR increase. Results: Interscorer reliability was acceptable, with an average percent agreement for occurrence of 82% ± 3%. Of all IFL events, 24% (regardless of the definition) were not associated with an EEG arousal, an increase in HR, or O2 desaturation. Of all IFL events scored, 25% caused O2 desaturation, 40% were associated with an EEG arousal, and 55% were associated with an increase in HR; 67% caused either an EEG arousal and/or an increase in HR. Responses were observed to occur either in isolation or in combination. IFL events that terminated with at least two non-IFL breaths, one of which had a 200% increase in amplitude, were significantly associated with O2 desaturation, EEG arousal, and increase in HR compared with events that ended in one non-IFL breath. IFL events that had a >50% reduction in flow amplitude compared with baseline were significantly associated with O2 desaturation compared with events that had a 30% reduction or less. Conclusions: Most IFL events resulted in immediate physiological responses, and no single consequence reliably occurred after every event. We propose a framework that can incorporate the scoring of IFL events into assessing the diagnosis and severity of OSA and suggest that no single consequence be used to define IFL as a respiratory event. The relationship of IFL events to OSA outcomes remains to be tested.
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Parekh A, Tolbert TM, Mooney AM, Ramos-Cejudo J, Osorio RS, Treml M, Herkenrath SD, Randerath WJ, Ayappa I, Rapoport DM. Endotyping Sleep Apnea One Breath at a Time: An Automated Approach for Separating Obstructive from Central Sleep Disordered Breathing. Am J Respir Crit Care Med 2021; 204:1452-1462. [PMID: 34449303 PMCID: PMC8865720 DOI: 10.1164/rccm.202011-4055oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Determining whether an individual has obstructive or central sleep apnea is fundamental to selecting the appropriate treatment. Objectives Here we derive an automated breath-by-breath probability of obstruction, as a surrogate of gold-standard upper airway resistance, using hallmarks of upper airway obstruction visible on clinical sleep studies. Methods From five nocturnal polysomnography signals (airflow, thoracic and abdominal effort, oxygen saturation, and snore), nine features were extracted and weighted to derive the breath-by-breath probability of obstruction (Pobs). A development and initial test set of 29 subjects (development = 6, test = 23) (New York, NY) and a second test set of 39 subjects (Solingen, Germany), both with esophageal manometry, were used to develop Pobs and validate it against gold-standard upper airway resistance. A separate dataset of 114 subjects with 2 consecutive nocturnal polysomnographies (New York, NY) without esophageal manometry was used to assess the night-to-night variability of Pobs. Measurements and Main Results A total of 1,962,229 breaths were analyzed. On a breath-by-breath level, Pobs was strongly correlated with normalized upper airway resistance in both test sets (set 1: cubic adjusted [adj.] R2 = 0.87, P < 0.001, area under the receiver operating characteristic curve = 0.74; set 2: cubic adj. R2 = 0.83, P < 0.001, area under the receiver operating characteristic curve = 0.7). On a subject level, median Pobs was associated with the median normalized upper airway resistance (set 1: linear adj. R2 = 0.59, P < 0.001; set 2: linear adj. R2 = 0.45, P < 0.001). Median Pobs exhibited low night-to-night variability [intraclass correlation(2, 1) = 0.93]. Conclusions Using nearly 2 million breaths from 182 subjects, we show that breath-by-breath probability of obstruction can reliably predict the overall burden of obstructed breaths in individual subjects and can aid in determining the type of sleep apnea.
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Affiliation(s)
- Ankit Parekh
- Icahn School of Medicine at Mount Sinai, 5925, Pulmonary, Critical Care and Sleep Medicine, New York, New York, United States;
| | - Thomas M Tolbert
- Mount Sinai School of Medicine, 5925, New York, New York, United States
| | - Anne M Mooney
- Icahn School of Medicine at Mount Sinai, 5925, Pulmonary, Critical Care and Sleep Medicine, New York, New York, United States
| | | | | | - Marcel Treml
- Krankenhaus Bethanien gGmbH, Department of Pneumology, Allergology and Sleep Medicine, Solingen, Germany.,Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Simon-Dominik Herkenrath
- Krankenhaus Bethanien gGmbH, Department of Pneumology, Allergology and Sleep Medicine, Solingen, Germany.,Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Winfried J Randerath
- Krankenhaus Bethanien gGmbH, Department of Pneumology, Allergology and Sleep Medicine, Solingen, Germany.,Institute of Pneumology at the University of Witten / Herdecke, Pneumology, Solingen, Germany
| | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, 5925, Pulmonary, Critical Care and Sleep Medicine, New York, New York, United States
| | - David M Rapoport
- Icahn School of Medicine at Mount Sinai, 5925, New York, New York, United States
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Parekh A, Kam K, Mullins AE, Castillo B, Berkalieva A, Mazumdar M, Varga AW, Eckert DJ, Rapoport DM, Ayappa I. Altered K-complex morphology during sustained inspiratory airflow limitation is associated with next-day lapses in vigilance in obstructive sleep apnea. Sleep 2021; 44:zsab010. [PMID: 33433607 PMCID: PMC8271137 DOI: 10.1093/sleep/zsab010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/14/2020] [Indexed: 01/25/2023] Open
Abstract
STUDY OBJECTIVES Determine if changes in K-complexes associated with sustained inspiratory airflow limitation (SIFL) during N2 sleep are associated with next-day vigilance and objective sleepiness. METHODS Data from thirty subjects with moderate-to-severe obstructive sleep apnea who completed three in-lab polysomnograms: diagnostic, on therapeutic continuous positive airway pressure (CPAP), and on suboptimal CPAP (4 cmH2O below optimal titrated CPAP level) were analyzed. Four 20-min psychomotor vigilance tests (PVT) were performed after each PSG, every 2 h. Changes in the proportion of spontaneous K-complexes and spectral characteristics surrounding K-complexes were evaluated for K-complexes associated with both delta (∆SWAK), alpha (∆αK) frequencies. RESULTS Suboptimal CPAP induced SIFL (14.7 (20.9) vs 2.9 (9.2); %total sleep time, p < 0.001) with a small increase in apnea-hypopnea index (AHI3A: 6.5 (7.7) vs 1.9 (2.3); p < 0.01) versus optimal CPAP. K-complex density (num./min of stage N2) was higher on suboptimal CPAP (0.97 ± 0.7 vs 0.65±0.5, #/min, mean ± SD, p < 0.01) above and beyond the effect of age, sex, AHI3A, and duration of SIFL. A decrease in ∆SWAK with suboptimal CPAP was associated with increased PVT lapses and explained 17% of additional variance in PVT lapses. Within-night during suboptimal CPAP K-complexes appeared to alternate between promoting sleep and as arousal surrogates. Electroencephalographic changes were not associated with objective sleepiness. CONCLUSIONS Sustained inspiratory airflow limitation is associated with altered K-complex morphology including the increased occurrence of K-complexes with bursts of alpha as arousal surrogates. These findings suggest that sustained inspiratory flow limitation may be associated with nonvisible sleep fragmentation and contribute to increased lapses in vigilance.
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Affiliation(s)
- Ankit Parekh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Korey Kam
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anna E Mullins
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bresne Castillo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Asem Berkalieva
- Institute for Healthcare Delivery and Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Madhu Mazumdar
- Institute for Healthcare Delivery and Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew W Varga
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Danny J Eckert
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, SA, Australia
| | - David M Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Indu Ayappa
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Amorim MR, Dergacheva O, Fleury-Curado T, Pho H, Freire C, Mendelowitz D, Branco LGS, Polotsky VY. The Effect of DREADD Activation of Leptin Receptor Positive Neurons in the Nucleus of the Solitary Tract on Sleep Disordered Breathing. Int J Mol Sci 2021; 22:6742. [PMID: 34201760 PMCID: PMC8269100 DOI: 10.3390/ijms22136742] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Obstructive sleep apnea (OSA) is recurrent obstruction of the upper airway due to the loss of upper airway muscle tone during sleep. OSA is highly prevalent, especially in obesity. There is no pharmacotherapy for OSA. Previous studies have demonstrated the role of leptin, an adipose-tissue-produced hormone, as a potent respiratory stimulant. Leptin signaling via a long functional isoform of leptin receptor, LEPRb, in the nucleus of the solitary tract (NTS), has been implicated in control of breathing. We hypothesized that leptin acts on LEPRb positive neurons in the NTS to increase ventilation and maintain upper airway patency during sleep in obese mice. We expressed designer receptors exclusively activated by designer drugs (DREADD) selectively in the LEPRb positive neurons of the NTS of Leprb-Cre-GFP mice with diet-induced obesity (DIO) and examined the effect of DREADD ligand, J60, on tongue muscle activity and breathing during sleep. J60 was a potent activator of LEPRb positive NTS neurons, but did not stimulate breathing or upper airway muscles during NREM and REM sleep. We conclude that, in DIO mice, the stimulating effects of leptin on breathing during sleep are independent of LEPRb signaling in the NTS.
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Affiliation(s)
- Mateus R. Amorim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; (T.F.-C.); (H.P.); (C.F.)
- Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo 14040-904, Brazil;
| | - Olga Dergacheva
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA; (O.D.); (D.M.)
| | - Thomaz Fleury-Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; (T.F.-C.); (H.P.); (C.F.)
| | - Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; (T.F.-C.); (H.P.); (C.F.)
| | - Carla Freire
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; (T.F.-C.); (H.P.); (C.F.)
| | - David Mendelowitz
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA; (O.D.); (D.M.)
| | - Luiz G. S. Branco
- Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo 14040-904, Brazil;
| | - Vsevolod Y. Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA; (T.F.-C.); (H.P.); (C.F.)
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Pho H, Berger S, Freire C, Kim LJ, Shin MK, Streeter SR, Hosamane N, Cabassa ME, Anokye-Danso F, Dergacheva O, Amorim MR, Fleury-Curado T, Jun JC, Schwartz AR, Ahima RS, Mendelowitz D, Polotsky VY. Leptin receptor expression in the dorsomedial hypothalamus stimulates breathing during NREM sleep in db/db mice. Sleep 2021; 44:6149135. [PMID: 33624805 PMCID: PMC8193564 DOI: 10.1093/sleep/zsab046] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/06/2021] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES Obesity leads to obstructive sleep apnea (OSA), which is recurrent upper airway obstruction during sleep, and obesity hypoventilation syndrome (OHS), hypoventilation during sleep resulting in daytime hypercapnia. Impaired leptin signaling in the brain was implicated in both conditions, but mechanisms are unknown. We have previously shown that leptin stimulates breathing and treats OSA and OHS in leptin-deficient ob/ob mice and leptin-resistant diet-induced obese mice and that leptin's respiratory effects may occur in the dorsomedial hypothalamus (DMH). We hypothesized that leptin receptor LepRb-deficient db/db mice have obesity hypoventilation and that restoration of leptin signaling in the DMH will increase ventilation during sleep in these animals. METHODS We measured arterial blood gas in unanesthetized awake db/db mice. We subsequently infected these animals with Ad-LepRb or control Ad-mCherry virus into the DMH and measured ventilation during sleep as well as CO2 production after intracerebroventricular (ICV) infusions of phosphate-buffered saline or leptin. RESULTS Awake db/db mice had elevated CO2 levels in the arterial blood. Ad-LepRb infection resulted in LepRb expression in the DMH neurons in a similar fashion to wildtype mice. In LepRb-DMH db/db mice, ICV leptin shortened REM sleep and increased inspiratory flow, tidal volume, and minute ventilation during NREM sleep without any effect on the quality of NREM sleep or CO2 production. Leptin had no effect on upper airway obstruction in these animals. CONCLUSION Leptin stimulates breathing and treats obesity hypoventilation acting on LepRb-positive neurons in the DMH.
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Affiliation(s)
- Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Slava Berger
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carla Freire
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lenise J Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mi-Kyung Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stone R Streeter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nishitha Hosamane
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meaghan E Cabassa
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frederick Anokye-Danso
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olga Dergacheva
- Department of Pharmacology and Physiology, George Washington University, Washington, DC, USA
| | - Mateus R Amorim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomaz Fleury-Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan C Jun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rexford S Ahima
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Mendelowitz
- Department of Pharmacology and Physiology, George Washington University, Washington, DC, USA
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Corresponding author. Vsevolod (Seva) Y. Polotsky, Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Johns Hopkins Asthma and Allergy Center, Rm 4B65, Baltimore, MD 21224.
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12
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Lee EM, Lee TH, Park OL, Nam JG. Effective Continuous Positive Airway Pressure Changes Related to Sleep Stage and Body Position in Obstructive Sleep Apnea during Upward and Downward Titration: An Experimental Study. J Clin Neurol 2020; 16:90-95. [PMID: 31942763 PMCID: PMC6974841 DOI: 10.3988/jcn.2020.16.1.90] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose The aim of this study was to determine how the sleep stage and body position influence the effective pressure (Peff) in standard upward titration and experimental downward titration. Methods This study applied successful manual titration of continuous positive airway pressure over 3 hours [including at least 15 min in supine rapid eye movement (REM) sleep] followed by consecutive downward titration for at least 1 hour to 22 patients with moderate-to-severe obstructive sleep apnea. We analyzed baseline polysomnography variables and compared the effective pressures (Peff1upward and Peff2downward) between non-REM and REM sleep and between supine and lateral positions using the paired t-test or Wilcoxon signed-rank test. Results During upward titration, Peff1 increased during REM sleep compared to non-REM sleep [9.5±2.9 vs. 8.9±2.7 cm H2O (mean±SD), ΔPeff1REM–non-REM=0.6±1.1 cm H2O; p=0.024]. During downward titration, Peff2 was higher in a supine than a lateral position (7.3±1.7 vs. 4.8±1.5 cm H2O, ΔPeff2supine-lateral=2.5±1.3 cm H2O; p=0.068). When comparing both upward and downward titration conditions, we found that Peff2 was significantly lower than Peff1 in all sleep stages, especially during REM sleep (Peff1REM vs. Peff2REM=9.5±2.9 vs. 7.4±3.3 cm H2O) with an overall difference of 2.1±1.7 cm H2O (p<0.001). Peff in supine sleep decreased from 9.4±3.0 cm H2O (Peff1supine) to 7.6±3.3 cm H2O (Peff2supine), with an overall difference of 1.8±1.6 cm H2O (p<0.001). Conclusions This study has revealed that the collapsibility of the upper airway is influenced by sleep stage and body position. After achieving an initial Peff1, a lower pressure was acceptable to maintain airway patency during the rest of the sleep. The observed pressure decrease may support the use of an automated titration device that integrates real-time positional and sleep-stage factors, and the use of a lower pressure may improve fixed-pressure-related intolerance.
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Affiliation(s)
- Eun Mi Lee
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Tae Hoon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ol Lim Park
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jung Gwon Nam
- Department of Otorhinolaryngology-Head and Neck Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
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13
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Krakow B, McIver ND, Ulibarri VA. Respiratory arousal control needed for insomnia OSA patients-authors' reply. EClinicalMedicine 2019; 17:100207. [PMID: 31891140 PMCID: PMC6933255 DOI: 10.1016/j.eclinm.2019.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 11/02/2022] Open
Affiliation(s)
- Barry Krakow
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Corresponding author at: Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA.
| | - Natalia D. McIver
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
| | - Victor A. Ulibarri
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
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14
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Krakow BJ, McIver ND, Obando JJ, Ulibarri VA. Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study. Mil Med Res 2019; 6:15. [PMID: 31072385 PMCID: PMC6507057 DOI: 10.1186/s40779-019-0204-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors. METHODS OSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates. RESULTS The C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group (P = 0.019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0.001; SC-RU, P = 0.027; NC-MU, P = 0.007). Hours of weekly PAP use and insomnia severity were inversely correlated (P = 0.001, r = - 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents. CONCLUSIONS In a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.
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Affiliation(s)
- Barry J Krakow
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA. .,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA. .,Los Alamos Medical Center, 3917 W Rd, Los Alamos, NM, 87544, USA.
| | - Natalia D McIver
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA
| | - Jessica J Obando
- Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Institution: Mozaik Solutions, Solana Beach, CA, 92075, USA
| | - Victor A Ulibarri
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA
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15
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Arnold WC, Guilleminault C. Upper airway resistance syndrome 2018: non-hypoxic sleep-disordered breathing. Expert Rev Respir Med 2019; 13:317-326. [PMID: 30689957 DOI: 10.1080/17476348.2019.1575731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Upper airway resistance syndrome (UARS) as obstructive sleep apnea syndrome (OSAS) has been described as abnormal breathing during sleep, based on the recording technologies and knowledge of the time. These terms have advanced the field, but are they still useful? Area Covered: Historically, the definition of UARS syndrome was aimed at recognizing pathology not covered by 'OSAS' and to prompt specialists to go further than the obvious. It aimed at pushing specialists to recognize pathologies earlier and to elicit research in the developmental features of sleep-disordered-breathing (SDB). The technology used to monitor SDB changed over-time, allowing recognition of SDB differently but not necessarily better. Expert Commentary: Currently, we have a better understanding of the development of SDB, and its evolution with aging, leading to co-morbid-OSA. However, the real issue is to recognize the problems much earlier, and to understand what can be done to prevent its development. The notions of OSA, UARS, apnea hypopnea index are only historical. There is enough knowledge to date to go beyond these definitions, to recognize problems differently and to lead to the prevention of the factors leading to SDB. The recognition of non-hypoxic sleep-disordered breathing is a step in this direction.
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Affiliation(s)
- William C Arnold
- a Sleep Medicine , Stanford University , Redwood City , CA , USA
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16
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Johnson KG, Johnson DC, Thomas RJ, Feldmann E, Lindenauer PK, Visintainer P, Kryger MH. Flow limitation/obstruction with recovery breath (FLOW) event for improved scoring of mild obstructive sleep apnea without electroencephalography. Sleep Med 2018; 67:249-255. [PMID: 30583916 DOI: 10.1016/j.sleep.2018.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/06/2018] [Accepted: 11/21/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Apnea/hypopnea index (AHI), especially without arousal criteria, does not adequately risk stratify patients with mild obstructive sleep apnea (OSA). We describe and test scoring reliability of an event, Flow Limitation/Obstruction With recovery breath (FLOW), representing obstructive airflow disruptions using only pressure transducer and snore signals available without electroencephalography. METHODS The following process was used (i) Development of FLOW event definition, (ii) Training period and definition refinement, and (iii) Reliability testing on 10 100-epoch polysomnography (PSG) samples and two 100-sample tests. Twenty full-night in-laboratory baseline PSGs in OSA patients with AHI with ≥4% desaturations <15 were rescored for FLOW events, traditional hypopneas with desaturations, respiratory-related arousal (RRA) events (hypopneas with arousals and respiratory-effort related arousals) and non-respiratory arousals (NRA). RESULTS Scoring of FLOW events in 100-epoch samples had good reliability with intraclass correlation (ICC) of 0.91. The overall kappa for presence of events on two sets of 100 sample events was 0.84 and 0.87 demonstrating good agreement. Moreover, 80% of RRA and 8% of NRA were concurrent with FLOW events. Furthermore, 56% of FLOW events were independent of RRA events. FLOW stratifies patients in traditional AHI categories with 50%/8% of AHI with ≥3% desaturations (AHI3) <5 and 12%/63% of AHI3 >5 in lowest/highest tertiles of AHI3 plus FLOW index. CONCLUSIONS Scoring of FLOW after training is reliable. FLOW scores a high proportion of RRA and many currently unrepresented obstructive airflow disruptions. FLOW allows for stratification within the current normal-mild OSA category, which may better identify patients who will benefit from treatment.
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Affiliation(s)
- Karin Gardner Johnson
- Department of Neurology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, 759 Chestnut St, Springfield, MA, 01199, USA; Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.
| | - Douglas Clark Johnson
- Department of Medicine, Baystate Medical Center, University of Massachusetts Medical School-Baystate, 759 Chestnut St, Springfield, MA, 01199, USA
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care & Sleep, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Edward Feldmann
- Department of Neurology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, 759 Chestnut St, Springfield, MA, 01199, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA; Department of Medicine, Baystate Medical Center, University of Massachusetts Medical School-Baystate, 759 Chestnut St, Springfield, MA, 01199, USA; Department of Quantitative Health Sciences University of Massachusetts Medical School, Worcester, MA, USA
| | - Paul Visintainer
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Meir H Kryger
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale New Haven Medical Center, Yale School of Medicine, 20 York Street New Haven, CT, 06510, USA.
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17
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Zhi YX, Vena D, Popovic MR, Bradley TD, Yadollahi A. Detecting inspiratory flow limitation with temporal features of nasal airflow. Sleep Med 2018; 48:70-78. [DOI: 10.1016/j.sleep.2018.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 03/01/2018] [Accepted: 04/17/2018] [Indexed: 12/25/2022]
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18
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Himanen SL, Martikkala L, Sulkamo S, Rutanen A, Huupponen E, Tenhunen M, Saunamäki T. Prolonged partial obstruction during sleep is a NREM phenomenon. Respir Physiol Neurobiol 2018; 255:43-49. [PMID: 29803760 DOI: 10.1016/j.resp.2018.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Prolonged partial obstruction (PPO) is a common finding in sleep studies. Although not verified, it seems to emerge in deep sleep. We study the effect of PPO on sleep architecture or sleep electroencephalography (EEG) frequency. METHODS Fifteen OSA patients, 15 PPO + OSA patients and 15 healthy subjects underwent a polysomnography. PPO was detected from Emfit mattress signal. Visual sleep parameters and median NREM sleep frequency of the EEG channels were evaluated. RESULTS The amount of deep sleep (N3) did not differ between the PPO + OSA and control groups (medians 11.8% and 13.8%). PPO + OSA-patients' N3 consisted mostly of PPO. PPO + OSA patients had lighter sleep than healthy controls in three brain areas (Fp2-A1, C4-A1, O1-A2, p-values < 0.05). CONCLUSION PPO evolved in NREM sleep and especially in N3 indicating that upper airway obstruction does not always ameliorate in deep sleep but changes the type. Even if PPO + OSA-patients had N3, their NREM sleep was lighter in three EEG locations. This might reflect impaired recovery function of sleep.
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Affiliation(s)
- Sari-Leena Himanen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
| | - Lauri Martikkala
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland
| | - Saramia Sulkamo
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Antti Rutanen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Eero Huupponen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland
| | - Mirja Tenhunen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland; Department of Medical Physics, Tampere University Hospital, Medical Imaging Centre, Pirkanmaa Hospital District, Tampere, Finland
| | - Tiia Saunamäki
- Tampere University Hospital, Department of Neurology and Rehabilitation, Tampere, Finland
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19
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Sands SA, Edwards BA, Terrill PI, Taranto-Montemurro L, Azarbarzin A, Marques M, Hess LB, White DP, Wellman A. Phenotyping Pharyngeal Pathophysiology using Polysomnography in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2018; 197:1187-1197. [PMID: 29327943 PMCID: PMC6019932 DOI: 10.1164/rccm.201707-1435oc] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 01/11/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Therapies for obstructive sleep apnea (OSA) could be administered on the basis of a patient's own phenotypic causes ("traits") if a clinically applicable approach were available. OBJECTIVES Here we aimed to provide a means to quantify two key contributors to OSA-pharyngeal collapsibility and compensatory muscle responsiveness-that is applicable to diagnostic polysomnography. METHODS Based on physiological definitions, pharyngeal collapsibility determines the ventilation at normal (eupneic) ventilatory drive during sleep, and pharyngeal compensation determines the rise in ventilation accompanying a rising ventilatory drive. Thus, measuring ventilation and ventilatory drive (e.g., during spontaneous cyclic events) should reveal a patient's phenotypic traits without specialized intervention. We demonstrate this concept in patients with OSA (N = 29), using a novel automated noninvasive method to estimate ventilatory drive (polysomnographic method) and using "gold standard" ventilatory drive (intraesophageal diaphragm EMG) for comparison. Specialized physiological measurements using continuous positive airway pressure manipulation were employed for further comparison. The validity of nasal pressure as a ventilation surrogate was also tested (N = 11). MEASUREMENTS AND MAIN RESULTS Polysomnography-derived collapsibility and compensation estimates correlated favorably with those quantified using gold standard ventilatory drive (R = 0.83, P < 0.0001; and R = 0.76, P < 0.0001; respectively) and using continuous positive airway pressure manipulation (R = 0.67, P < 0.0001; and R = 0.64, P < 0.001; respectively). Polysomnographic estimates effectively stratified patients into high versus low subgroups (accuracy, 69-86% vs. ventilatory drive measures; P < 0.05). Traits were near-identical using nasal pressure versus pneumotach (N = 11, R ≥ 0.98, both traits; P < 0.001). CONCLUSIONS Phenotypes of pharyngeal dysfunction in OSA are evident from spontaneous changes in ventilation and ventilatory drive during sleep, enabling noninvasive phenotyping in the clinic. Our approach may facilitate precision therapeutic interventions for OSA.
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Affiliation(s)
- Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Allergy, Immunology and Respiratory Medicine, Melbourne, Victoria, Australia
- Central Clinical School
| | - Bradley A. Edwards
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Philip I. Terrill
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Queensland, Australia; and
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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20
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Zhu K, Farré R, Katz I, Hardy S, Escourrou P. Mimicking a flow-limited human upper airway using a collapsible tube: relationships between flow patterns and pressures in a respiratory model. J Appl Physiol (1985) 2018; 125:605-614. [PMID: 29672227 DOI: 10.1152/japplphysiol.00877.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The upper airway (UA) in humans is commonly modeled as a Starling resistor. However, negative effort dependence (NED) observed in some patients with obstructive sleep apnea (OSA) contradicts predictions based on the Starling resistor model in which inspiratory flow is independent of inspiratory driving pressure when flow is limited. In a respiratory bench model consisting of a collapsible tube and an active lung model (ASL5000), inspiratory flow characteristics were investigated in relation to upstream, downstream, and extra-luminal pressures (denoted as Pus, Pds, and Pout, respectively) by varying inspiratory effort (muscle pressure) from -1 to -20 cmH2O in the active lung. Pus was provided by a constant airway pressure device and varied from 4 to 20 cmH2O, and Pout was set at 10 and 15 cmH2O. Upstream resistance at onset of flow limitation and critical transmural pressure (Ptm) corresponding to opening of the UA were found to be independent of Pus, Pds, and Pout. With fixed Ptm, when Pds fell below a specific value (Pds'), inspiratory peak flow became constant and independent of Pds. NED plateau flow patterns at mid-inspiration (V̇n) were produced within the current bench setting when Pds fell below Pds'. V̇n was proportional to Pds, and the slope (ΔV̇n/ΔPds) increased linearly with Ptm. Ptm and Pds were the two final independent determinants of inspiratory flow. Our bench model closely mimics a flow-limited human UA, and the findings have implications for OSA treatment and research, especially for bench-testing auto-titrating devices in a more physiological way. NEW & NOTEWORTHY A respiratory model consisting of a collapsible tube was used to mimic a flow-limited human upper airway. Flow-limited breathing patterns including negative effort dependence were produced. Transmural and downstream pressures acting on the tube are the two independent determinants of the resulting inspiratory flow during flow limitation. The findings have implications for obstructive sleep apnea treatment and research, especially for bench-testing auto-titrating devices in a more physiological way.
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Affiliation(s)
- Kaixian Zhu
- Centre Explor, Air Liquide Healthcare, Gentilly, France
| | - Ramon Farré
- Unit of Biophysics and Bioengineering, Faculty of Medicine and Health Sciences, University of Barcelona-Institut Investigacions Biomediques August Pi Sunyer , Barcelona , Spain.,Centro de Investigacion Biomedica en Red (CIBER) de Enfermedades Respiratorias, Madrid, Spain
| | - Ira Katz
- Medical Research & Development, Air Liquide Santé International, Centre de Recherche Paris-Saclay, Les Loges-en-Josas, France.,Department of Mechanical Engineering, Lafayette College , Easton, Pennsylvania
| | | | - Pierre Escourrou
- Department of Physiology, Université Paris-Saclay, AP-HP Hôpital Antoine-Béclère, Clamart, France
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21
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An Official American Thoracic Society Workshop Report: Noninvasive Identification of Inspiratory Flow Limitation in Sleep Studies. Ann Am Thorac Soc 2018; 14:1076-1085. [PMID: 28665698 DOI: 10.1513/annalsats.201704-318ws] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This report summarizes the proceedings of the American Thoracic Society Workshop on the Noninvasive Identification of Inspiratory Flow Limitation in Sleep Studies held on May 16, 2015, in Denver, Colorado. The goal of the workshop was to discuss methods for standardizing the scoring of flow limitation from nasal cannula pressure tracings. The workshop began with presentations on the physiology underlying flow limitation, existing methods of scoring flow limitation, the effects of signal acquisition and filtering on flow shapes, and a review of the literature examining the adverse outcomes related to flow limitation. After these presentations, the results from online scoring exercises, which were crowdsourced to workshop participants in advance of the workshop, were reviewed and discussed. Break-out sessions were then held to discuss potential algorithms for scoring flow limitation. Based on these discussions, subsequent online scoring exercises, and webinars after the workshop, a consensus-based set of recommendations for a scoring algorithm for flow limitation was developed. Key conclusions from the workshop were: (1) a standardized and automated approach to scoring flow limitation is needed to provide a metric of nonepisodic elevated upper airway resistance, which can then be related to clinical outcomes in large cohorts and patient groups; (2) at this time, the most feasible method for standardization is by proposing a consensus-based framework, which includes scoring rules, developed by experts (3) hardware and software settings of acquisition devices, including filter settings, affect the shape of the flow curve, and should be clearly specified; and (4) a priority for future research is the generation of an open-source, expert-derived training set to encourage and support validation of automated flow limitation scoring algorithms.
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22
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de Melo CM, Taranto-Montemurro L, Butler JP, White DP, Loring SH, Azarbarzin A, Marques M, Berger PJ, Wellman A, Sands SA. Stable Breathing in Patients With Obstructive Sleep Apnea Is Associated With Increased Effort but Not Lowered Metabolic Rate. Sleep 2017; 40:4004820. [PMID: 28977669 PMCID: PMC5805127 DOI: 10.1093/sleep/zsx128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Study objectives In principle, if metabolic rate were to fall during sleep in a patient with obstructive sleep apnea (OSA), ventilatory requirements could be met without increased respiratory effort thereby favoring stable breathing. Indeed, most patients achieve periods of stable flow-limited breathing without respiratory events for periods during the night for reasons that are unclear. Thus, we tested the hypothesis that in patients with OSA, periods of stable breathing occur when metabolic rate (VO2) declines. Methods Twelve OSA patients (apnea-hypopnea index >15 events/h) completed overnight polysomnography including measurements of VO2 (using ventilation and intranasal PO2) and respiratory effort (esophageal pressure). Results Contrary to our hypothesis, VO2 did not differ between stable and unstable breathing periods in non-REM stage 2 (208 ± 20 vs. 213 ± 18 mL/min), despite elevated respiratory effort during stable breathing (26 ± 2 versus 23 ± 2 cmH2O, p = .03). However, VO2 was lowered during deeper sleep (244 to 179 mL/min from non-REM stages 1 to 3, p = .04) in conjunction with more stable breathing. Further analysis revealed that airflow obstruction curtailed metabolism in both stable and unstable periods, since CPAP increased VO2 by 14% in both cases (p = .02, .03, respectively). Patients whose VO2 fell most during sleep avoided an increase in PCO2 and respiratory effort. Conclusions OSA patients typically convert from unstable to stable breathing without lowering metabolic rate. During sleep, OSA patients labor with increased respiratory effort but fail to satisfy metabolic demand even in the absence of overt respiratory events.
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Affiliation(s)
- Camila M de Melo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Department of Psychobiology, Universidade Federal de Sao Paulo UNIFESP, Sao Paulo, SP, Brazil
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - James P Butler
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Stephen H Loring
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Sleep Laboratory, Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Philip J Berger
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Department of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, VIC, Australia
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Brown LK, Javaheri S. Positive Airway Pressure Device Technology Past and Present: What's in the "Black Box"? Sleep Med Clin 2017; 12:501-515. [PMID: 29108606 DOI: 10.1016/j.jsmc.2017.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since the introduction of continuous positive airway pressure (PAP) for the treatment of obstructive sleep apnea (OSA) in 1981, PAP technology has diversified exponentially. Compact and quiet fixed continuous PAP flow generators, autotitrating PAP devices, and bilevel PAP devices that can treat multiple sleep-disordered breathing phenotypes including OSA, central sleep apnea (CSA), combinations of OSA and CSA, and hypoventilation are available. Adaptive servo-ventilators can suppress Hunter-Cheyne-Stokes breathing and CSA and treat coexisting obstructive events. Volume-assured pressure support PAP apparatus purports to provide a targeted degree of ventilatory assistance while also treating cooccurring OSA and/or CSA.
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Affiliation(s)
- Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, University of New Mexico Sleep Disorders Center, 1101 Medical Arts Avenue NE, Building #2, Albuquerque, NM 87102, USA; Department of Electrical and Computer Engineering, University of New Mexico School of Engineering, University of New Mexico Sleep Disorders Center, 1101 Medical Arts Avenue NE, Building #2, Albuquerque, NM 87102, USA.
| | - Shahrokh Javaheri
- Sleep Laboratory, Bethesda North Hospital, 10475 Montgomery Road, Cincinnati, OH 45242, USA; TriHealth Sleep Center, Pulmonary and Sleep Division, Bethesda North Hospital, University of Cincinnati College of Medicine, 10500 Montgomery Road, Cincinnati, OH 45242, USA; The Ohio State University College of Medicine, 473 West 12th Avenue, Columbus, OH 43210, USA
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24
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Douglas JA, Chai-Coetzer CL, McEvoy D, Naughton MT, Neill AM, Rochford P, Wheatley J, Worsnop C. Guidelines for sleep studies in adults – a position statement of the Australasian Sleep Association. Sleep Med 2017. [DOI: 10.1016/j.sleep.2017.03.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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25
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Weighted Polynomial Approximation for Automated Detection of Inspiratory Flow Limitation. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017. [PMID: 28634497 PMCID: PMC5467386 DOI: 10.1155/2017/2750701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inspiratory flow limitation (IFL) is a critical symptom of sleep breathing disorders. A characteristic flattened flow-time curve indicates the presence of highest resistance flow limitation. This study involved investigating a real-time algorithm for detecting IFL during sleep. Three categories of inspiratory flow shape were collected from previous studies for use as a development set. Of these, 16 cases were labeled as non-IFL and 78 as IFL which were further categorized into minor level (20 cases) and severe level (58 cases) of obstruction. In this study, algorithms using polynomial functions were proposed for extracting the features of IFL. Methods using first- to third-order polynomial approximations were applied to calculate the fitting curve to obtain the mean absolute error. The proposed algorithm is described by the weighted third-order (w.3rd-order) polynomial function. For validation, a total of 1,093 inspiratory breaths were acquired as a test set. The accuracy levels of the classifications produced by the presented feature detection methods were analyzed, and the performance levels were compared using a misclassification cobweb. According to the results, the algorithm using the w.3rd-order polynomial approximation achieved an accuracy of 94.14% for IFL classification. We concluded that this algorithm achieved effective automatic IFL detection during sleep.
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Cao MT, Sternbach JM, Guilleminault C. Continuous positive airway pressure therapy in obstuctive sleep apnea: benefits and alternatives. Expert Rev Respir Med 2017; 11:259-272. [PMID: 28287009 DOI: 10.1080/17476348.2017.1305893] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a highly prevalent condition affecting persons of all age with an increasing public health burden. It is implicated in cardiovascular disease, metabolic syndrome, neurocognitive impairment, reductions in quality of life, and increased motor vehicle accidents. The goals of OSA treatment are to improve sleep and daytime symptoms, and minimize cardiovascular risks.Areas covered: Continuous positive airway pressure (CPAP) is considered the gold standard therapy that delivers pressurized air into the upper airway to relieve obstruction during sleep. Although CPAP is an effective modality of treatment for OSA, adherence to therapy is highly variable. This article highlights the benefits of CPAP therapy, along with alternative treatment options including oral appliance, implantable and wearable devices, and surgery. Expert commentary: CPAP therapy is the gold standard treatment option and should continue to be offered to those who suffer from OSA. Alternative options are available for those who are unable to adhere to CPAP or choose an alternative treatment modality. The most interesting advances have been incorporating orthodontic procedures in conjunction with myofunctional therapy in prepubertal children, raising the possibility of OSA prevention by initiating treatment early in life.
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Affiliation(s)
- Michelle T Cao
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
| | - Joshua M Sternbach
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
| | - C Guilleminault
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
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27
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Comparison of Efficacy and Tolerance of Automatic Continuous Positive Airway Pressure Devices With the Optimum Continuous Positive Airway Pressure. Am J Ther 2017; 23:e1532-e1536. [PMID: 25923226 DOI: 10.1097/mjt.0000000000000168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients diagnosed with obstructive sleep apnea syndrome were randomly placed on automatic continuous positive airway pressure (ACPAP) for 2 hours followed by manual titration for the rest of the night. One hundred sixty-one patients entered the study, with at least 50 patients titrated with each of 3 ACPAP devices. The optimum continuous positive airway pressure (CPAP) was defined as the lowest pressure with an apnea-hypoxia index of ≤5/hr, which ranged from 4 cm to 18 cm. Success with ACPAP was approximately 60%-80% when the optimum CPAP was 4-6 cm but fell to below 30% if the optimum CPAP was ≥8 cm (P = 0.001). Average ACPAP ranged from 2 to 10 cm below the optimum level if the optimum CPAP was ≥8 cm. Patients who responded to a low CPAP but deteriorated on higher pressures failed to respond to any of the automatic devices. We recommend that CPAP titration be performed manually before initiation of ACPAP in patients with obstructive sleep apnea. The basal pressure for ACPAP should be the optimum pressure obtained by manual titration. Limits on the upper level of ACPAP may be necessary for patients who deteriorate on higher positive pressures.
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28
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Krakow BJ, Obando JJ, Ulibarri VA, McIver ND. Positive airway pressure adherence and subthreshold adherence in posttraumatic stress disorder patients with comorbid sleep apnea. Patient Prefer Adherence 2017; 11:1923-1932. [PMID: 29200833 PMCID: PMC5700760 DOI: 10.2147/ppa.s148099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY OBJECTIVES Patients with comorbid posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) manifest low adherence to continuous positive airway pressure (CPAP) due to fixed, pressure-induced expiratory pressure intolerance (EPI), a subjective symptom and objective sign aggravated by anxiety sensitivity and somatosensory amplification. As advanced PAP therapy modes (ie, auto-bilevel PAP [ABPAP] or adaptive servo-ventilation [ASV]) may address these side effects, we hypothesized such treatment would be associated with decreased expiratory intolerance and increased adherence in posttraumatic stress patients with co-occurring OSA. METHODS We reviewed charts of 147 consecutive adult patients with moderately severe posttraumatic stress symptoms and objectively diagnosed OSA. All patients failed or rejected CPAP and were manually titrated on auto-adjusting, dual-pressure ABPAP or ASV modes in the sleep laboratory, a technique to eliminate flow limitation breathing events while resolving EPI. Patients were then prescribed either mode of therapy. Follow-up encounters assessed patient use, and objective data downloads (ODDs) measured adherence. RESULTS Of 147 charts reviewed, 130 patients were deemed current PAP users, and 102 provided ODDs: 64 used ASV and 38 used ABPAP. ODDs yielded three groups: 59 adherent per insurance conventions, 19 subthreshold compliant partial users, and 24 noncompliant. Compliance based on available downloads was 58%, notably higher than recently reported rates in PTSD patients with OSA. Among the 19 partial users, 17 patients were minutes of PAP use or small percentages of nights removed from meeting insurance compliance criteria for PAP devices. CONCLUSION Research is warranted on advanced PAP modes in managing CPAP failure in PTSD patients with comorbid OSA. Subthreshold adherence constructs may inform clinical care in a patient-centric model distinct from insurance conventions. Speculatively, clinical application of this transitional zone ("subthreshold" number of hours) may increase PAP use and eventual adherence.
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Affiliation(s)
- Barry J Krakow
- Sleep & Human Health Institute
- Maimonides Sleep Arts & Sciences, Albuquerque
- Los Alamos Medical Center, Los Alamos, NM, USA
- Correspondence: Barry J Krakow, Sleep & Human Health Institute, 6739 Academy Northeast, Suite 380, Albuquerque, NM 87109, USA, Email
| | | | - Victor A Ulibarri
- Sleep & Human Health Institute
- Maimonides Sleep Arts & Sciences, Albuquerque
| | - Natalia D McIver
- Sleep & Human Health Institute
- Maimonides Sleep Arts & Sciences, Albuquerque
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Anttalainen U, Tenhunen M, Rimpilä V, Polo O, Rauhala E, Himanen SL, Saaresranta T. Prolonged partial upper airway obstruction during sleep - an underdiagnosed phenotype of sleep-disordered breathing. Eur Clin Respir J 2016; 3:31806. [PMID: 27608271 PMCID: PMC5015642 DOI: 10.3402/ecrj.v3.31806] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/10/2016] [Indexed: 12/31/2022] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a well-recognized disorder conventionally diagnosed with an elevated apnea-hypopnea index. Prolonged partial upper airway obstruction is a common phenotype of sleep-disordered breathing (SDB), which however is still largely underreported. The major reasons for this are that cyclic breathing pattern coupled with arousals and arterial oxyhemoglobin saturation are easy to detect and considered more important than prolonged episodes of increased respiratory effort with increased levels of carbon dioxide in the absence of cycling breathing pattern and repetitive arousals. There is also a growing body of evidence that prolonged partial obstruction is a clinically significant form of SDB, which is associated with symptoms and co-morbidities which may partially differ from those associated with OSAS. Partial upper airway obstruction is most prevalent in women, and it is treatable with the nasal continuous positive pressure device with good adherence to therapy. This review describes the characteristics of prolonged partial upper airway obstruction during sleep in terms of diagnostics, pathophysiology, clinical presentation, and comorbidity to improve recognition of this phenotype and its timely and appropriate treatment.
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Affiliation(s)
- Ulla Anttalainen
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, Turku, Finland
- Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
- Sleep Research Centre, Department of Physiology, University of Turku, Turku, Finland;
| | - Mirja Tenhunen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere University Hospital, Tampere, Finland
- Department of Medical Physics, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere University Hospital, Tampere, Finland
| | - Ville Rimpilä
- School of Medicine, University of Tampere, Tampere, Finland
| | - Olli Polo
- Unesta Research Center, Tampere, Finland
- Department of Pulmonary Diseases, Tampere University Hospital, Tampere, Finland
| | - Esa Rauhala
- Department of Clinical Neurophysiology, Satakunta Hospital District, Pori, Finland
| | - Sari-Leena Himanen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere University Hospital, Tampere, Finland
- School of Medicine, University of Tampere, Tampere, Finland
| | - Tarja Saaresranta
- Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, Turku, Finland
- Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland
- Sleep Research Centre, Department of Physiology, University of Turku, Turku, Finland
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30
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Pien GW, Keenan BT, Marcus CL, Staley B, Ratcliffe SJ, Jackson NJ, Wieland W, Sun Y, Schwab RJ. An Examination of Methodological Paradigms for Calculating Upper Airway Critical Pressures during Sleep. Sleep 2016; 39:977-87. [PMID: 26951393 PMCID: PMC4835319 DOI: 10.5665/sleep.5736] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/18/2016] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES The goal of this study was to examine different paradigms for determining critical closing pressures (Pcrit). Methods of determining Pcrit were compared, including direct observation of occluded (no flow) breaths versus inferring Pcrit from extrapolated data, and Pcrit generated by aggregating pressure-flow data from multiple runs versus Pcrit averaged across individual pressure-flow runs. The relationship between Pcrit and obstructive sleep apnea (OSA) was examined. METHODS A total of 351 participants with and without OSA underwent overnight polysomnography with pressure-flow measurements to determine Pcrit. A series of filters were applied to raw data to provide consistent, objective criteria for determining which data to include in Pcrit calculations. Observed Pcrit values were computed as the mean nasal pressure level at which a subject had at least two breaths with peak inspiratory flow < 50 mL/sec. Extrapolated Pcrit was calculated in two ways: (1) separately for each individual run and then averaged; and (2) using all valid data from individual runs combined into one plot. RESULTS Observed Pcrit was calculated in 67% to 69% of participants, a similar or higher proportion of study subjects compared to extrapolated Pcrit values using a ± 3 cm H2O filter. Although raw (unfiltered) extrapolated Pcrit measures were able to be calculated among a greater proportion of participants than filtered, extrapolated Pcrit values, and thus had fewer missing values, they had larger variability. Both extrapolated and observed Pcrit were higher among individuals with OSA compared to those without OSA. CONCLUSIONS Observed Pcrit provides a reliable descriptor of hypotonic upper airway collapsibility. Different methods for determining Pcrit were able to distinguish subjects with and without OSA.
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Affiliation(s)
- Grace W. Pien
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brendan T. Keenan
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Carole L. Marcus
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Sleep Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bethany Staley
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sarah J. Ratcliffe
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicholas J. Jackson
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - William Wieland
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yi Sun
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Richard J. Schwab
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Sleep Medicine Division and Pulmonary and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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31
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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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32
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M'saad S, Yangui I, Feki W, Abid N, Bahloul N, Marouen F, Chakroun A, Kammoun S. [The syndrome of increased upper airways resistance: What are the clinical features and diagnostic procedures?]. Rev Mal Respir 2015; 32:1002-15. [PMID: 26525135 DOI: 10.1016/j.rmr.2015.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 02/15/2015] [Indexed: 11/17/2022]
Abstract
The upper airway resistance syndrome "UARS" is a poorly defined entity, often described as a moderate variant of the obstructive sleep apnea syndrome. It is associated with respiratory effort-related arousal, absence of obstructive sleep apnea, and absence of significant desaturation. It is a relatively common condition that predominantly affects non-obese young adults, with no predominance in either sex. The degree of upper airway collapsibility during sleep of patients with UARS is intermediate between that of normal subjects and that of patients with mild-to-moderate sleep apnea syndrome. Craniofacial and palatal abnormalities are often noted. Patients frequently complain of a functional somatic syndrome, especially daytime sleepiness and chronic fatigue. Polysomnography with esophageal pressure measurements remains the gold standard diagnostic test. The absence of any neurological abnormality gives UARS a good prognosis and it is potentially reversible if treated early. However, some studies suggest that untreated UARS has an increased risk of arterial hypertension. It can also evolve into obstructive sleep apnea.
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Affiliation(s)
- S M'saad
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie.
| | - I Yangui
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - W Feki
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - N Abid
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - N Bahloul
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - F Marouen
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - A Chakroun
- Service d'oto-rhino-laryngologie, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - S Kammoun
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
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33
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The role of flow limitation as an important diagnostic tool and clinical finding in mild sleep-disordered breathing. ACTA ACUST UNITED AC 2015; 8:134-42. [PMID: 26779320 PMCID: PMC4688581 DOI: 10.1016/j.slsci.2015.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/05/2015] [Accepted: 08/17/2015] [Indexed: 11/25/2022]
Abstract
Obstructive sleep apnea (OSA) is defined by quantifying apneas and hypopneas along with symptoms suggesting sleep disruption. Subtler forms of sleep-disordered breathing can be missed when this criteria is used. Newer technologies allow for non-invasive detection of flow limitation, however consensus classification is needed. Subjects with flow limitation demonstrate electroencephalogram changes and clinical symptoms indicating sleep fragmentation. Flow limitation may be increased in special populations and treatment with nasal continuous positive airway pressure (CPAP) has been shown to improve outcomes. Titrating CPAP to eliminate flow limitation may be associated with improved clinical outcomes compared to treating apneas and hypopneas.
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de Godoy LB, Palombini LO, Guilleminault C, Poyares D, Tufik S, Togeiro SM. Treatment of upper airway resistance syndrome in adults: Where do we stand? Sleep Sci 2015; 8:42-8. [PMID: 26483942 PMCID: PMC4608900 DOI: 10.1016/j.slsci.2015.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To evaluate the available literature regarding Upper Airway Resistance Syndrome (UARS) treatment. METHODS Keywords "Upper Airway Resistance Syndrome," "Sleep-related Breathing Disorder treatment," "Obstructive Sleep Apnea treatment" and "flow limitation and sleep" were used in main databases. RESULTS We found 27 articles describing UARS treatment. Nasal continuous positive airway pressure (CPAP) has been the mainstay therapy prescribed but with limited effectiveness. Studies about surgical treatments had methodological limitations. Oral appliances seem to be effective but their efficacy is not yet established. CONCLUSION Randomized controlled trials with larger numbers of patients and long-term follow-up are important to establish UARS treatment options.
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Affiliation(s)
- Luciana B.M. de Godoy
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Luciana O. Palombini
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Dalva Poyares
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Sergio Tufik
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Sonia M. Togeiro
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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Affiliation(s)
- Barry Krakow
- Sleep & Human Health Institute, Albuquerque, NM ; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM ; Los Alamos Medical Center, Los Alamos, NM
| | - Victor A Ulibarri
- Sleep & Human Health Institute, Albuquerque, NM ; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
| | - Natalia D McIver
- Sleep & Human Health Institute, Albuquerque, NM ; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
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Krakow B, Krakow J, Ulibarri VA, McIver ND. Frequency and accuracy of "RERA" and "RDI" terms in the Journal of Clinical Sleep Medicine from 2006 through 2012. J Clin Sleep Med 2014; 10:121-4. [PMID: 24532993 DOI: 10.5664/jcsm.3432] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Barry Krakow
- Sleep & Human Health Institute, Albuquerque, NM ; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
| | - Jacoby Krakow
- Sleep & Human Health Institute, Albuquerque, NM ; University of Rochester, Rochester, NY
| | - Victor A Ulibarri
- Sleep & Human Health Institute, Albuquerque, NM ; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
| | - Natalia D McIver
- Sleep & Human Health Institute, Albuquerque, NM ; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
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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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Palombini LO, Tufik S, Rapoport DM, Ayappa IA, Guilleminault C, de Godoy LBM, Castro LS, Bittencourt L. Inspiratory flow limitation in a normal population of adults in São Paulo, Brazil. Sleep 2013; 36:1663-8. [PMID: 24179299 PMCID: PMC3792383 DOI: 10.5665/sleep.3122] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Inspiratory flow limitation (IFL) during sleep occurs when airflow remains constant despite an increase in respiratory effort. This respiratory event has been recognized as an important parameter for identifying sleep breathing disorders. The purpose of this study was to investigate how much IFL normal individuals can present during sleep. DESIGN Cross-sectional study derived from a general population sample. SETTING A "normal" asymptomatic sample derived from the epidemiological cohort of São Paulo. PATIENTS AND PARTICIPANTS This study was derived from a general population study involving questionnaires and nocturnal polysomnography of 1,042 individuals. A subgroup defined as a nonsymptomatic healthy group was used as the normal group. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS All participants answered several questionnaires and underwent full nocturnal polysomnography. IFL was manually scored, and the percentage of IFL of total sleep time was considered for final analysis. The distribution of the percentage of IFL was analyzed, and associated factors (age, sex, and body mass index) were calculated. There were 95% of normal individuals who exhibited IFL during less than 30% of the total sleep time. Body mass index was positively associated with IFL. CONCLUSIONS Inspiratory flow limitation can be observed in the polysomnography of normal individuals, with an influence of body weight on percentage of inspiratory flow limitation. However, only 5% of asymptomatic individuals will have more than 30% of total sleep time with inspiratory flow limitation. This suggests that only levels of inspiratory flow limitation > 30% be considered in the process of diagnosing obstructive sleep apnea in the absence of an apnea-hypopnea index > 5 and that < 30% of inspiratory flow limitation may be a normal finding in many patients.
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Affiliation(s)
- Luciana O. Palombini
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - Sergio Tufik
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - David M. Rapoport
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY
| | - Indu A. Ayappa
- Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, New York, NY
| | | | - Luciana B. M. de Godoy
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - Laura S. Castro
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - Lia Bittencourt
- Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
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Nerfeldt P, Aoki F, Friberg D. Polygraphy vs. polysomnography: missing osas in symptomatic snorers--a reminder for clinicians. Sleep Breath 2013; 18:297-303. [PMID: 23942981 DOI: 10.1007/s11325-013-0884-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/18/2013] [Accepted: 07/23/2013] [Indexed: 11/25/2022]
Abstract
PURPOSES The purposes of this study are to investigate the usefulness of polygraphy (PG) in diagnosing obstructive sleep apnea (OSA) in sleepy/tired snorers compared to polysomnography (PSG) and, further, to search for suspected respiratory arousals in the PG. METHODS One hundred eighty-seven adults suffering from sleepiness/tiredness and snoring had undergone ambulant PG and were considered to be normal, using American Academy of Sleep Medicine's 2007 hypopnea criteria A. After approximately 7 months, in-lab PSG was performed using hypopnea criteria B, where arousals are also recognized. Validated questionnaires (Hospital Anxiety and Depression Scale, self-rated general health) were answered. In a subgroup, the sensitivity and specificity were calculated for flow limitation index (FLI) and flattening index (FlatI) in PG compared with the respiratory distress index (RDI) in PSG. RESULTS Despite the normal PG, at PSG, the median RDI was 11.0 (range, 0-89.1). One hundred sixty-eight out of one hundred seventy-eight (90%) were found to have at least mild OSA and 119/187 (64%) with moderate-severe OSA according to the RDI values. The sensitivity and specificity were low (<70%) for FLI and FlatI. Forty-nine percent of the patients rated anxiety at borderline or pathological levels, 35% rated corresponding depression levels, and 45% rated poor or fair general health. CONCLUSIONS PG was insufficient to rule out OSA when the respiratory events were mainly associated with arousals. Almost half of these patients experience low general health and psychiatric problems. We recommend a full-night PSG when PG is "normal", and patients have symptoms of snoring and sleepiness/tiredness.
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Affiliation(s)
- P Nerfeldt
- Department of Oto-Rhino-Laryngology, Karolinska University Hospital, Stockholm, Sweden,
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Loube DI, Andrada T, Shanmagum N, Singer MT. Successful treatment of upper airway resistance syndrome with an oral appliance. Sleep Breath 2013; 2:98-101. [PMID: 19412721 DOI: 10.1007/bf03039004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/1997] [Accepted: 12/10/1997] [Indexed: 11/25/2022]
Abstract
This case report is the first description of the treatment response to an oral appliance (OA) in a patient with upper airway resistance syndrome (UARS). OAs are devices inserted into the mouth in order to modify the position of the mandible and tongue, thus relieving pharyngeal obstruction during sleep in obstructive sleep apnea (OSA) patients. Findings from this case report suggest that an OA may be a useful treatment option for UARS patients.
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Affiliation(s)
- D I Loube
- Sleep Disorders Center, Pulmonary/Critical Care Medicine Service, Walter Reed Army Medical Center, 20307-5001, Washington, DC,
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Obstructive pressure peak: a new method for differentiation of obstructive and central apneas under auto-CPAP therapy. Sleep Breath 2013; 17:111-5. [PMID: 22302201 DOI: 10.1007/s11325-012-0657-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 01/13/2012] [Accepted: 01/17/2012] [Indexed: 10/14/2022]
Abstract
PURPOSE Auto-CPAP devices (APAP) are controlled, e.g.,by the respiratory flow and pressure to adjust the treatment pressure to the variable obstruction in sleep apnea syndromes.By obstruction of the upper airway during inspiration,a pressure difference between the lower airways and the mask can be measured. In case of an opening of the pharynx at the end of the obstruction, the pressure decreases immediately. This brief negative pressure, the so-called obstructive pressure peak (OPP) can be used to identify obstruction or open airways with the algorithm of an APAP device. Useless pressure increases, e.g., after central apneas without obstruction may be avoided. We therefore investigated the association of the OPP signal with respiratory events during APAP therapy. METHODS In this pilot study, 13 patients with obstructive sleep apnea syndrome were evaluated. Attended automatic CPAP titration (SOMNO balance, Fa Weinmann Hamburg/Germany)was performed. The OPP signal was recorded synchronous lyin parallel with the polysomnographic data. If the OPP signal was within a time range of ± 5 s of the resumption of normal breathing, it was assigned to the event. RESULTS A total of 480 sleep-related breathing disorders events were studied. The most common were the mixed apneas associated with more than 90% of all cases with an OPP signal, followed by obstructive sleep apneas (66.7%)and central apneas (38%). The difference in OPP frequency distribution between central apneas and obstructive apneas was significant with p<0.001. CONCLUSIONS The analysis of the pressure characteristics of APAP treatment with the registration of OPP allows a further differentiation in obstructed and not obstructed upper airways.
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Callahan CY, Norman RG, Taxin Z, Mooney AM, Rapoport DM, Ayappa I. Multinight recording and analysis of continuous positive airway pressure airflow in the home for titration and management of sleep disordered breathing. Sleep 2013; 36:535-545F. [PMID: 23543909 DOI: 10.5665/sleep.2540] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The authors examined magnitude/variability of residual sleep disordered breathing (SDB) at pressures around the therapeutic continuous positive airway pressure (CPAP), and described a multinight approach to CPAP titration/retitration consisting of recording airflow and summarizing SDB over multiple nights at multiple pressures and choosing an optimal pressure from these summarized data. DESIGN Prospective, single-center nonblinded study. PATIENTS Ten female/18 male patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) (respiratory disturbance index [RDI] 67/h), 17 newly-initiated, 11 chronic CPAP users. INTERVENTIONS A custom CPAP device (Fisher & Paykel Healthcare) recording airflow and pre-programmed to vary CPAP between 2-3 cm H2O below and 1-2 cm H2O above prescription pressure as determined by a full laboratory titration. RESULTS Airflow and pressure continuously recorded for multiple nights (15.9 ± 5.1 nights) at four to seven different pressures in each patient. SDB events manually scored from the airflow as apnea (airflow reduction > 90%), hypopnea (airflow reduction > 30% lasting 10 to 120 sec with inspira-tory flow limitation [IFL]) and runs of sustained IFL > 2 min identified. RDI = (apnea + hypopnea)/total sleep time calculated for each night and an obstruction index, including sustained IFL, also was calculated. PressureMultinight was obtained for each patient from multiple nights of data using two mathematical techniques. Night-to-night variability of SDB indices was low in some patients and significant in others. PressureMultinight could be determined in 17 of 28 patients and was similar to the in-laboratory pressure. CONCLUSIONS This study showed that recording multiple nights of CPAP airflow in the home and analyzing these data for residual SDB provided useful information, including the possibility of determining a therapeutic prescription for fixed CPAP in most patients and identification of others with significant physiologic variability of SDB.
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Affiliation(s)
- Cynthia Y Callahan
- NYU School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York, NY, USA
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Abstract
Sleep disordered breathing is a common chronic condition in the general population. This review will highlight the prevalence of different types of sleep apnea in general and obstructive type in particular in the United States and Middle East. Despite the extensive research studies on the sleep apnea pathogenesis, the exact mechanism is not well known. Obesity, however, is the leading risk factor to upper airway narrowing and obstruction and main contributor to the escalating prevalence of morbidity worldwide including the Arab countries. Due to the serious consequences of the untreated sleep disordered breathing, this article will emphasize on the importance of early recognition, key clinical manifestations, and how to treat and prevent the disease.
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Affiliation(s)
- Abdul Ghani Sankri-Tarbichi
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University- School of Medicine, John D. Dingell VA Medical Center and Detroit Medical Center, Detroit, USA
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Morales CR, Hurley S, Wick LC, Staley B, Pack FM, Gooneratne NS, Maislin G, Pack A, Gurubhagavatula I. In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly. Sleep 2012; 35:1491-501. [PMID: 23115398 DOI: 10.5665/sleep.2196] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is common and treatable among the elderly. Yet, few older adults seek evaluation for OSA at sleep disorders centers. The authors assessed the feasibility of a two-stage screening procedure for obstructive sleep apnea syndrome (OSAS) in a community-based sample of older adults. DESIGN Prospective cohort study. SETTING Participants' domicile (in-home) and academic sleep research center. PARTICIPANTS There were 452 Medicare recipients residing in the greater Philadelphia metropolitan area with the complaint of daytime sleepiness. INTERVENTIONS None. MEASUREMENTS AND RESULTS All participants underwent in-home unattended sleep studies that recorded airflow, and standard in-laboratory polysomnography. Additional measures included symptoms of sleep apnea, body mass index, neck circumference, age, and sex. When comparing diagnostic approaches, the best-performing single-stage model was one that combined apnea symptoms with age and neck circumference. This model had an area under the receiver operating characteristic curve (AUC) of 0.774 and negative posttest probability of 1.2%. The best-performing two-stage model combined symptoms, neck circumference, age, and sex in the first stage, followed by an unattended portable study with a corresponding AUC of 0.85 and negative posttest probability of 0.5%. CONCLUSIONS Unattended, self-assembled, in-home sleep studies recording airflow and respiratory effort are most useful if applied in tandem with clinical data, including a carefully obtained sleep history. This two-stage model is accurate in identifying severe OSAS in older adults and represents a practical diagnostic approach for older adults. Incorporating clinical data was vital and increased accuracy well above that of unattended studies of airflow and effort alone.
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Affiliation(s)
- Christian R Morales
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2012; 8:597-619. [PMID: 23066376 DOI: 10.5664/jcsm.2172] [Citation(s) in RCA: 3343] [Impact Index Per Article: 278.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Academy of Sleep Medicine (AASM) Sleep Apnea Definitions Task Force reviewed the current rules for scoring respiratory events in the 2007 AASM Manual for the Scoring and Sleep and Associated Events to determine if revision was indicated. The goals of the task force were (1) to clarify and simplify the current scoring rules, (2) to review evidence for new monitoring technologies relevant to the scoring rules, and (3) to strive for greater concordance between adult and pediatric rules. The task force reviewed the evidence cited by the AASM systematic review of the reliability and validity of scoring respiratory events published in 2007 and relevant studies that have appeared in the literature since that publication. Given the limitations of the published evidence, a consensus process was used to formulate the majority of the task force recommendations concerning revisions.The task force made recommendations concerning recommended and alternative sensors for the detection of apnea and hypopnea to be used during diagnostic and positive airway pressure (PAP) titration polysomnography. An alternative sensor is used if the recommended sensor fails or the signal is inaccurate. The PAP device flow signal is the recommended sensor for the detection of apnea, hypopnea, and respiratory effort related arousals (RERAs) during PAP titration studies. Appropriate filter settings for recording (display) of the nasal pressure signal to facilitate visualization of inspiratory flattening are also specified. The respiratory inductance plethysmography (RIP) signals to be used as alternative sensors for apnea and hypopnea detection are specified. The task force reached consensus on use of the same sensors for adult and pediatric patients except for the following: (1) the end-tidal PCO(2) signal can be used as an alternative sensor for apnea detection in children only, and (2) polyvinylidene fluoride (PVDF) belts can be used to monitor respiratory effort (thoracoabdominal belts) and as an alternative sensor for detection of apnea and hypopnea (PVDFsum) only in adults.The task force recommends the following changes to the 2007 respiratory scoring rules. Apnea in adults is scored when there is a drop in the peak signal excursion by ≥ 90% of pre-event baseline using an oronasal thermal sensor (diagnostic study), PAP device flow (titration study), or an alternative apnea sensor, for ≥ 10 seconds. Hypopnea in adults is scored when the peak signal excursions drop by ≥ 30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study), or an alternative sensor, for ≥ 10 seconds in association with either ≥ 3% arterial oxygen desaturation or an arousal. Scoring a hypopnea as either obstructive or central is now listed as optional, and the recommended scoring rules are presented. In children an apnea is scored when peak signal excursions drop by ≥ 90% of pre-event baseline using an oronasal thermal sensor (diagnostic study), PAP device flow (titration study), or an alternative sensor; and the event meets duration and respiratory effort criteria for an obstructive, mixed, or central apnea. A central apnea is scored in children when the event meets criteria for an apnea, there is an absence of inspiratory effort throughout the event, and at least one of the following is met: (1) the event is ≥ 20 seconds in duration, (2) the event is associated with an arousal or ≥ 3% oxygen desaturation, (3) (infants under 1 year of age only) the event is associated with a decrease in heart rate to less than 50 beats per minute for at least 5 seconds or less than 60 beats per minute for 15 seconds. A hypopnea is scored in children when the peak signal excursions drop is ≥ 30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study), or an alternative sensor, for ≥ the duration of 2 breaths in association with either ≥ 3% oxygen desaturation or an arousal. In children and adults, surrogates of the arterial PCO(2) are the end-tidal PCO(2) or transcutaneous PCO(2) (diagnostic study) or transcutaneous PCO(2) (titration study). For adults, sleep hypoventilation is scored when the arterial PCO(2) (or surrogate) is > 55 mm Hg for ≥ 10 minutes or there is an increase in the arterial PCO(2) (or surrogate) ≥ 10 mm Hg (in comparison to an awake supine value) to a value exceeding 50 mm Hg for ≥ 10 minutes. For pediatric patients hypoventilation is scored when the arterial PCO(2) (or surrogate) is > 50 mm Hg for > 25% of total sleep time. In adults Cheyne-Stokes breathing is scored when both of the following are met: (1) there are episodes of ≥ 3 consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds), and (2) there are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of 2 hours of monitoring.
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Affiliation(s)
- Richard B Berry
- University of Florida Health Science Center, Gainesville, FL 32610, USA.
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Huang J, Pinto SJ, Yuan H, Katz ES, Karamessinis LR, Bradford RM, Gallagher PR, Hannigan JT, Nixon T, Ward MB, Lee YN, Marcus CL. Upper airway collapsibility and genioglossus activity in adolescents during sleep. Sleep 2012; 35:1345-52. [PMID: 23024432 PMCID: PMC3443760 DOI: 10.5665/sleep.2110] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Obese patients develop obstructive sleep apnea syndrome (OSAS), at least in part because of a narrowed upper airway. However, many obese adolescents do not develop OSAS, despite having a presumably narrower airway. The reasons for this phenomenon are unclear. The authors hypothesized that obese controls have a compensatory neuromuscular response to subatmospheric pressure loads during sleep, making them less likely to develop upper airway collapse. DESIGN Patients underwent pressure-flow measurements during sleep while wearing intraoral electrodes to measure genioglossal electromyography (EMGgg). Two techniques were applied to decrease nasal pressure (P(N)) to subatmospheric levels, resulting in an activated and relatively hypotonic upper airway. SETTING Sleep laboratory. PARTICIPANTS There were 35 obese patients with OSAS, 28 obese controls, and 43 lean controls. RESULTS In the activated state, the two control groups had a flatter slope of the pressure-flow relationship and a more negative critical closing pressure (less collapsible) than the OSAS group. In the hypotonic state, the lean controls had a flatter slope of the pressure-flow relationship than the OSAS and obese control groups. In the activated state, the slope of EMGgg versus P(N) was greater in the obese control group than in the OSAS or lean control groups (P = 0.002 and P = 0.028, respectively); there were no differences in the hypotonic state. CONCLUSIONS Obese controls have vigorous upper airway neuromuscular responses during sleep. Upper airway reflexes normally decline during adolescent development. It is speculated that obese adolescents without OSAS maintain protective upper airway reflexes during adolescent development, whereas those who go on to develop OSAS do not.
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Affiliation(s)
- Jingtao Huang
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Swaroop J. Pinto
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Haibo Yuan
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
- Division of Respiratory Diseases, the First Hospital of Jilin University, Changchun, Jilin, China
| | - Eliot S. Katz
- Children's Hospital Boston, Harvard Medical School, Boston, MA
| | - Laurie R. Karamessinis
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Ruth M. Bradford
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Paul R. Gallagher
- Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - James T. Hannigan
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Thomas Nixon
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Michelle B. Ward
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Yin N. Lee
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Carole L. Marcus
- The Sleep Center and Biostatistics Core, Clinical and Translational Research Center, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
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Yuan H, Pinto SJ, Huang J, McDonough JM, Ward MB, Lee YN, Bradford RM, Gallagher PR, Shults J, Konstantinopoulou S, Samuel JM, Katz ES, Hua S, Tapia IE, Marcus CL. Ventilatory responses to hypercapnia during wakefulness and sleep in obese adolescents with and without obstructive sleep apnea syndrome. Sleep 2012; 35:1257-67. [PMID: 22942504 DOI: 10.5665/sleep.2082] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Abnormal ventilatory drive may contribute to the pathophysiology of the childhood obstructive sleep apnea syndrome (OSAS). Concomitant with the obesity epidemic, more adolescents are developing OSAS. However, few studies have specifically evaluated the obese adolescent group. The authors hypothesized that obese adolescents with OSAS would have a blunted hypercapnic ventilatory response (HCVR) while awake and blunted ventilatory responses to carbon dioxide (CO(2)) during sleep compared with obese and lean adolescents without OSAS. DESIGN CVR was measured during wakefulness. During nonrapid eye movement (NREM) and rapid eye movement (REM) sleep, respiratory parameters and genioglossal electromyogram were measured during CO(2) administration in comparison with room air in obese adolescents with OSAS, obese control study participants, and lean control study participants. SETTING Sleep laboratory. PARTICIPANTS Twenty-eight obese patients with OSAS, 21 obese control study participants, and 37 lean control study participants. RESULTS The obese OSAS and obese control groups had a higher HCVR compared with the lean control group during wakefulness. During both sleep states, all 3 groups had a response to CO(2); however, the obese OSAS group had lower percentage changes in minute ventilation, inspiratory flow, inspiratory time, and tidal volume compared with the 2 control groups. There were no significance differences in genioglossal activity between groups. CONCLUSIONS HCVR during wakefulness is increased in obese adolescents. Obese adolescents with OSAS have blunted ventilatory responses to CO(2) during sleep and do not have a compensatory prolongation of inspiratory time, despite having normal CO(2) responsivity during wakefulness. Central drive may play a greater role than upper airway neuromotor tone in adapting to hypercapnia.
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Affiliation(s)
- Haibo Yuan
- Division of Respiratory Diseases, First Hospital of Jilin University, Changchun, Jilin, China
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GOFF ELIZABETHA, NICHOLAS CHRISTIANL, KLEIMAN JAN, SPEAR OWEN, MORRELL MARYJ, TRINDER JOHN. The effect of flow limitation on the cardiorespiratory response to arousal from sleep under controlled conditions of chemostimulation in healthy older adults. J Sleep Res 2012; 21:718-23. [DOI: 10.1111/j.1365-2869.2012.01019.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mooney AM, Abounasr KK, Rapoport DM, Ayappa I. Relative prolongation of inspiratory time predicts high versus low resistance categorization of hypopneas. J Clin Sleep Med 2012; 8:177-85. [PMID: 22505863 PMCID: PMC3311415 DOI: 10.5664/jcsm.1774] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVES Sleep disordered breathing events conceptually separate into "obstructive" and "central" events. Esophageal manometry is the definitive but invasive means of classifying hypopneas. The purpose of this project was to identify noninvasive markers for discriminating high vs. low resistance hypopneas. METHODS Forty subjects with obstructive or central sleep apnea underwent diagnostic polysomnography with nasal cannula airflow and esophageal manometry; 200% resistance relative to reference breaths was used to define "high" resistance. Noninvasive parameters from 292 randomly selected hypopneas in 20 subjects were analyzed and correlated to resistance. The best parameter and cutoff for predicting high relative resistance was determined and tested prospectively in 2 test sets in the 20 remaining subjects. Test Set A: 15 randomly selected hypopneas in each subject; Test Set B: all hypopneas in 7 subjects. RESULTS In the development set, prolongation of inspiratory time during the 2 smallest breaths of a hypopnea (T(i)) relative to baseline had the best correlation to high relative resistance. In the Test Set A, relative T(i) > 110% classified obstructive events with sensitivity = 72%, specificity = 77%, PPV = 64%, NPV = 83%. Similar numbers were obtained for classification of hypopneas based on presence of flow limitation (FL) alone. When either relative T(i) or presence of FL were used to define high resistance, sensitivity = 84%, specificity = 74%, PPV = 65%, NPV = 89%. Similar results were obtained for Test Set B. CONCLUSIONS Relative prolongation of T(i) is a good noninvasive predictor of high/low resistance in a dataset with both FL and NFL hypopneas. Combination of FL and relative T(i) improves this classification. The use of T(i) to separate obstructive and central hypopneas needs to be further tested for clinical utility (outcomes and treatment effects).
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Affiliation(s)
- Anne M Mooney
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU School of Medicine, New York, NY 10016, USA.
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Schwartz AR, Barnes M, Hillman D, Malhotra A, Kezirian E, Smith PL, Hoegh T, Parrish D, Eastwood PR. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J Respir Crit Care Med 2011; 185:420-6. [PMID: 22135343 DOI: 10.1164/rccm.201109-1614oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Hypoglossal nerve stimulation (HGNS) recruits lingual muscles, reduces pharyngeal collapsibility, and treats sleep apnea. OBJECTIVES We hypothesized that graded increases in HGNS relieve pharyngeal obstruction progressively during sleep. METHODS Responses were examined in 30 patients with sleep apnea who were implanted with an HGNS system. Current (milliampere) was increased stepwise during non-REM sleep. Frequency and pulse width were fixed. At each current level, stimulation was applied on alternating breaths, and responses in maximal inspiratory airflow (V(I)max) and inspiratory airflow limitation (IFL) were assessed. Pharyngeal responses to HGNS were characterized by the current levels at which V(I)max first increased and peaked (flow capture and peak flow thresholds), and by the V(I)max increase from flow capture to peak (ΔV(I)max). MEASUREMENTS AND MAIN RESULTS HGNS produced linear increases in V(I)max from unstimulated levels at flow capture to peak flow thresholds (215 ± 21 to 509 ± 37 ml/s; mean ± SE; P < 0.001) with increasing current from 1.05 ± 0.09 to 1.46 ± 0.11 mA. V(I)max increased in all patients and IFL was abolished in 57% of patients (non-IFL subgroup). In the non-IFL compared with IFL subgroup, the flow response slope was greater (1241 ± 199 vs. 674 ± 166 ml/s/mA; P < 0.05) and the stimulation amplitude at peak flow was lower (1.23 ± 0.10 vs. 1.80 ± 0.20 mA; P < 0.05) without differences in peak flow. CONCLUSIONS HGNS produced marked dose-related increases in airflow without arousing patients from sleep. Increases in airflow were of sufficient magnitude to eliminate IFL in most patients and IFL and non-IFL subgroups achieved normal or near-normal levels of flow, suggesting potential HGNS efficacy across a broad range of sleep apnea severity.
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