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Palma JA, Gileles-Hillel A, Norcliffe-Kaufmann L, Kaufmann H. Chemoreflex failure and sleep-disordered breathing in familial dysautonomia: Implications for sudden death during sleep. Auton Neurosci 2019; 218:10-15. [PMID: 30890343 DOI: 10.1016/j.autneu.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/11/2019] [Indexed: 01/04/2023]
Abstract
Familial dysautonomia (Riley-Day syndrome, hereditary sensory and autonomic neuropathy type III) is a rare autosomal recessive disease characterized by impaired development of primary sensory and autonomic neurons resulting in a severe neurological phenotype, which includes arterial baroreflex and chemoreflex failure with high frequency of sleep-disordered breathing and sudden death during sleep. Although a rare disease, familial dysautonomia represents a unique template to study the interactions between sleep-disordered breathing and abnormal chemo- and baroreflex function. In patients with familial dysautonomia, ventilatory responses to hypercapnia are reduced, and to hypoxia are almost absent. In response to hypoxia, these patients develop paradoxical hypoventilation, hypotension, bradycardia, and potentially, death. Impaired ventilatory control due to chemoreflex failure acquires special relevance during sleep when conscious control of respiration withdraws. Overall, almost all adult (85%) and pediatric (95%) patients have some degree of sleep-disordered breathing. Obstructive apnea events are more frequent in adults, whereas central apnea events are more severe and frequent in children. The annual incidence rate of sudden death during sleep in patients with familial dysautonomia is 3.4 per 1000 person-year, compared to 0.5-1 per 1000 person-year of sudden unexpected death in epilepsy. This review summarizes recent developments in the understanding of sleep-disordered breathing in patients with familial dysautonomia, the risk factors for sudden death during sleep, and the specific interventions that could prevent it.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America
| | - Alex Gileles-Hillel
- Departments of Pediatrics, Pediatric Pulmonology and Sleep, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America.
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Kazachkov M, Palma JA, Norcliffe-Kaufmann L, Bar-Aluma BE, Spalink CL, Barnes EP, Amoroso NE, Balou SM, Bess S, Chopra A, Condos R, Efrati O, Fitzgerald K, Fridman D, Goldenberg RM, Goldhaber A, Kaufman DA, Kothare SV, Levine J, Levy J, Lubinsky AS, Maayan C, Moy LC, Rivera PJ, Rodriguez AJ, Sokol G, Sloane MF, Tan T, Kaufmann H. Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations. Respir Med 2018; 141:37-46. [PMID: 30053970 PMCID: PMC6084453 DOI: 10.1016/j.rmed.2018.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/14/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia. METHODS We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy. CONCLUSIONS Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.
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Affiliation(s)
- Mikhail Kazachkov
- Department of Pediatric Pulmonology, New York University School of Medicine, New York, NY, United States; Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, NY, United States
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Bat-El Bar-Aluma
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Christy L Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Erin P Barnes
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Nancy E Amoroso
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Stamatela M Balou
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY, United States
| | - Shay Bess
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, United States
| | - Arun Chopra
- Department of Pediatrics, Division of Pediatric Critical Care, New York University School of Medicine, New York, NY, United States
| | - Rany Condos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ori Efrati
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Kathryn Fitzgerald
- Department of Pediatric Pulmonology, New York University School of Medicine, New York, NY, United States
| | - David Fridman
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ronald M Goldenberg
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ayelet Goldhaber
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - David A Kaufman
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Sanjeev V Kothare
- Department of Neurology, Pediatric Sleep Medicine Unit, New York University School of Medicine, New York, NY, United States
| | - Jeremiah Levine
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Joseph Levy
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Anthony S Lubinsky
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Channa Maayan
- Department of Pediatrics. Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Libia C Moy
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Pedro J Rivera
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Alcibiades J Rodriguez
- Department of Neurology, Sleep Laboratory, New York University School of Medicine, New York, NY, United States
| | - Gil Sokol
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Mark F Sloane
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Tina Tan
- Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, NY, United States
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States.
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Singh K, Palma JA, Kaufmann H, Tkachenko N, Norcliffe-Kaufmann L, Spalink C, Kazachkov M, Kothare SV. Prevalence and characteristics of sleep-disordered breathing in familial dysautonomia. Sleep Med 2018; 45:33-38. [PMID: 29680425 PMCID: PMC5918267 DOI: 10.1016/j.sleep.2017.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/30/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Familial dysautonomia (FD) is an autosomal recessive disorder characterized by impaired development of sensory and afferent autonomic nerves. Untreated sleep-disordered breathing (SDB) has been reported to increase the risk of sudden unexpected death in FD. We aimed to describe the prevalence and characteristics of SDB in FD. PATIENTS/METHODS Seventy-five patients with FD (20 adults and 55 children) underwent in-lab polysomnography, including peripheral capillary oxygen saturation (SpO2) and end-tidal capnography (EtCO2) measurements. A t-test and Spearman's correlation analysis were performed to evaluate the impact of age on sleep, occurrence of apneas, SpO2 and EtCO2 levels; and to determine the relationship between apneas and SpO2/EtCO2 measurements during different sleep stages. RESULTS Overall, 85% of adults and 91% of pediatric patients had some degree of SDB. Obstructive sleep apneas were more severe in adults (8.5 events/h in adults vs. 3.5 events/h in children, p = 0.04), whereas central apneas were more severe (10.8 vs. 2.8 events/h, p = 0.04) and frequent (61.8% vs. 45%, p = 0.017) in children. Overall, a higher apnea-hypopnea index was associated with increased severity of hypoxia and hypoventilation, although in a significant fraction of patients (67% and 46%), hypoxemia and hypoventilation occurred independent of apneas. CONCLUSION Most adult and pediatric patients with FD suffer from some degree of SDB. There was a differential effect of age in the pattern of SDB observed. In some FD patients, hypoventilation and hypoxia occurred independently of apneas. Therefore, we recommend including EtCO2 monitoring during polysomnography in all patients with FD to detect SDB.
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Affiliation(s)
- Kanwaljit Singh
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Nataliya Tkachenko
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Christy Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Mikhail Kazachkov
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Sanjeev V Kothare
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
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Palma JA, Norcliffe-Kaufmann L, Perez MA, Spalink CL, Kaufmann H. Sudden Unexpected Death During Sleep in Familial Dysautonomia: A Case-Control Study. Sleep 2017; 40:3831157. [PMID: 28521050 DOI: 10.1093/sleep/zsx083] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Study Objectives Sudden unexpected death during sleep (SUDS) is the most common cause of death in patients with familial dysautonomia (FD), an autosomal recessive disease characterized by sensory and autonomic dysfunction. It remains unknown what causes SUDS in these patients and who is at highest risk. We tested the hypothesis that SUDS in FD is linked to sleep-disordered breathing. Methods We retrospectively identified patients with FD who died suddenly and unexpectedly during sleep and had undergone polysomnography within the 18-month period before death. For each case, we sampled one age-matched surviving subject with FD that had also undergone polysomnography within the 18-month period before study. Data on polysomnography, EKG, ambulatory blood pressure monitoring, arterial blood gases, blood count, and metabolic panel were analyzed. Results Thirty-two deceased cases and 31 surviving controls were included. Autopsy was available in six cases. Compared with controls, participants with SUDS were more likely to be receiving treatment with fludrocortisone (odds ratio [OR]; 95% confidence interval) (OR 29.7; 4.1-213.4), have untreated obstructive sleep apnea (OR 17.4; 1.5-193), and plasma potassium levels <4 mEq/L (OR 19.5; 2.36-161) but less likely to use noninvasive ventilation at night (OR 0.19; 0.06-0.61). Conclusions Initiation of noninvasive ventilation when required and discontinuation of fludrocortisone treatment may reduce the high incidence rate of SUDS in patients with FD. Our findings contribute to the understanding of the link between autonomic, cardiovascular, and respiratory risk factors in SUDS.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Miguel A Perez
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Christy L Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
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