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Testelmans D, Kalkanis A, Papadopoulos D, Demolder S, Buyse B. Central sleep apnea: emphasizing recognition and differentiation. Expert Rev Respir Med 2024:1-12. [PMID: 38878064 DOI: 10.1080/17476348.2024.2369256] [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: 03/25/2024] [Accepted: 06/13/2024] [Indexed: 06/19/2024]
Abstract
INTRODUCTION Central sleep apnea (CSA) is a sleep-related breathing disorder in which the effort to breathe is intermittently diminished or absent. CSA is a common disorder among patients with different cardiovascular disorders, including heart failure. In addition, a growing number of medications have been shown to induce CSA and CSA can emerge after initiation of treatment for obstructive sleep apnea. Accumulating evidence shows that CSA is a heterogeneous disorder with individual differences in clinical and biological characteristics and/or underlying pathophysiological mechanisms. AREAS COVERED This narrative review offers an overview of the diagnostic aspects and classification of CSA, with an emphasis on heart failure patients, patients with CSA due to a medication and treatment-emergent CSA. The importance of evaluation of prognostic biomarkers in patients with different types of CSA is discussed. This narrative review synthesizes literature on CSA sourced from the PubMed database up to February 2024. EXPERT OPINION CSA presents a remarkably diverse disorder, with treatment modalities exhibiting potentially varied efficacy across its various phenotypes. This highlights the imperative for tailored management strategies that are rooted in phenotype classification.
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Affiliation(s)
- Dries Testelmans
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Alexandros Kalkanis
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Dimitrios Papadopoulos
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Saartje Demolder
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Bertien Buyse
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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Berik Safçi S. The prevalence and polysomnographic characteristics of treatment-emergent central sleep apnea with obstructive sleep apnea. Sleep Breath 2024:10.1007/s11325-024-02999-1. [PMID: 38308750 DOI: 10.1007/s11325-024-02999-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE To investigate the prevalence of treatment-emergent central sleep apnea (TECSA) in individuals with obstructive sleep apnea syndrome (OSAS) during continuous positive airway pressure (CPAP) titration and assess their polysomnographic characteristics. METHODS A total of 116 patients with OSAS who underwent full-night CPAP titration at the Sleep Laboratory of Adana City Research and Education Hospital from September 2017 to January 2018 were recruited for the study. The patients' polysomnographic data related to respiratory events and sleep stages were reviewed in a retrospective manner. RESULTS While on CPAP titration, 20 of the 116 patients developed central sleep apnea (CSA). The prevalence of TECSA in the patients with OSAS was 17.2%, being separately determined as 16.3% and 2.2% for the male and female patients, respectively. In the baseline PSG, the groups did not statistically significantly differ in relation to the apnea hypopnea index (AHI), central apnea index (CAI), arousal index (AI), or oxygen desaturation index (ODI). However, the TECSA group had a significantly higher mean oxygen saturation value compared to the non-TECSA group (p = 0.01). The total AHI, CAI, and AI values of the TECSA group were significantly higher during the whole CPAP titration compared to the non-TECSA group. No significant difference was observed in the comparison of the two groups in relation to the titration pressure and ODI. CONCLUSION TECSA is a phenomenon that can occur with obstructive sleep apnea treatment and mostly regress spontaneously following appropriate CPAP treatment. TECSA is observed at different rates of prevalence. In this study, the prevalence of TECSA was higher than previously reported.
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Hellemans S, Van de Perck E, Braem MJ, Verbraecken J, Dieltjens M, Vanderveken OM. The prevalence of treatment-emergent central sleep apnea with mandibular advancement device therapy. J Clin Sleep Med 2023; 19:2035-2041. [PMID: 37539639 PMCID: PMC10692941 DOI: 10.5664/jcsm.10742] [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: 04/17/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVES Treatment-emergent central sleep apnea (TECSA) describes the appearance or persistence of central sleep apnea while undergoing treatment for obstructive sleep apnea. TECSA is well studied in continuous positive airway pressure therapy with an estimated prevalence of 8%. Based on a few case reports, mandibular advancement devices (MAD) may also provoke TECSA. This study aims to gain insight into the prevalence of TECSA with MAD therapy. METHODS This retrospective study includes a total of 129 patients with moderate to severe obstructive sleep apnea who were treated with a custom-made titratable MAD. Baseline and follow-up sleep studies were compared to identify patients with TECSA. Since different diagnostic criteria to define TECSA are used in literature, prevalence was calculated according to three definitions (TECSA-1, -2, and -3). Demographics, MAD treatment variables, and findings of the diagnostic polysomnography were compared between TECSA and non-TECSA patients to identify possible predictors. RESULTS Depending on the definition used, TECSA was found in 3.1%-7.8% of patients undergoing MAD therapy. TECSA patients had a higher apnea index (9.2 vs 2.0 events/h, P = .042), central apnea-hypopnea index (4.1 vs 0.2 events/h, P = .045) and oxygen desaturation index (23.9 vs 16.3 events/h, P = .018) at baseline compared to non-TECSA patients. No differences were found in demographics and treatment variables. CONCLUSIONS These findings demonstrate that TECSA also occurs in patients starting MAD treatment. Patients with TECSA had a higher apnea index, central apnea-hypopnea index, and oxygen desaturation index at baseline compared to non-TECSA patients. CITATION Hellemans S, Van de Perck E, Braem MJ, Verbraecken J, Dieltjens M, Vanderveken OM. The prevalence of treatment-emergent central sleep apnea with mandibular advancement device therapy. J Clin Sleep Med. 2023;19(12):2035-2041.
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Affiliation(s)
- Simon Hellemans
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Eli Van de Perck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc J. Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
- Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M. Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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Ni YN, Thomas RJ. Predictors and consequences of residual apnea during positive airway pressure therapy. Sleep Med 2023; 106:42-51. [PMID: 37044000 DOI: 10.1016/j.sleep.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023]
Abstract
STUDY OBJECTIVES Determine the risk factors for, and consequences of, residual apnea during long-term positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA). METHODS A prospective cohort study of 195 subjects after a split-night polysomnogram. Estimation of residual respiratory events on PAP were done by both automated and manual scoring of data in EncoreAnywhere™. Clinical and polysomnographic predictors of residual apnea were estimated. RESULTS There were 166 and 101 patients still on PAP at the 3 and 12 months, respectively. Seventy four (44.6%) and 46 (45.5%) had a residual scored respiratory event index-flow (sREIFLOW) ≥ 15/hour of use and 46 (45.5%) at the 3rd and 12th month, respectively. Treatment phase central apnea hypopnea index (TCAHI), a surrogate of high loop gain, was the main predictor for residual sREIFLOW (β = 0.345, p: 0.025) at the 3rd and 12th month (β = 0.147, p: 0.020). TCAHI also predicted unstable breathing (U) %. The body mass index (hazard ratio [HR] 1.034, 95% CI 1.008-1.062, p: 0.012) and effective sREIFLOW>15/hour in the first month (HR 2.477, 95% CI 1.510-4.065, p < 0.001) were the key predictors for drop out of PAP use at the 12th month. Effective sREIFLOW>15/hour in the first month was also a predictor for median usage duration >4 h for 70% of the night at both the 3rd month (odds ratio [OR] 0.947, 95% CI 0.909-0.986, p: 0.008) and 12th month (OR 0.973, 95% CI 0.951-0.994, p: 0.014). CONCLUSIONS Treatment-phase CAHI predicts long-term residual apnea on PAP. High residual disease adversely impacts adherence.
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Are We Underestimating the Central Components of the Mixed Apneas?-A Hypothesis for Revised Scoring. J Clin Neurophysiol 2023; 40:165-172. [PMID: 34049365 DOI: 10.1097/wnp.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Apneas are classified in three categories, as obstructive, central, and mixed types. Mixed apneas are calculated together with the obstructive events in diagnosing obstructive sleep apnea syndrome (SAS). The clinical significance of mixed apneas needs to be specified. METHODS Patients with obstructive SAS having an index of mixed apneas ≥5/hour were evaluated. A new approach was developed to score the mixed apneas, and calculated them together with either obstructive or central type of events, depending on their obstructive and central components. The relationship between the development of complex SAS and the indices of abnormal respiratory events per standard and revised scoring was evaluated. RESULTS Ten of 56 patients (17.9%) developed complex SAS at titration polysomnography. The mean index of mixed apneas per standard scoring was significantly higher in patients who did not develop complex SAS ( P = 0.006). The use of newly developed method in scoring mixed apneas resulted that three patients (5.4%) fulfilled the diagnostic criteria for the central SAS at first-night polysomnography ( P < 0.001), and all of them had developed complex SAS at titration night requiring other modes of positive airway pressure therapy than the continuous mode ( P = 0.004). Curve estimation models showed that the change from mixed apneas to central apneas was highly significant in patients developing complex SAS ( r2 = 0.501; P = 0.022). CONCLUSIONS Our study showed that the summation of mixed apneas with the obstructive events conventionally underestimates the central components and the diagnosis of central SAS, which are fundamental in the risk stratification of complex SAS.
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Rossetto A, Midelet A, Baillieul S, Tamisier R, Borel JC, Prigent A, Bailly S, Pépin JL. Factors Associated With Residual Apnea-Hypopnea Index Variability During CPAP Treatment. Chest 2023; 163:1258-1265. [PMID: 36642368 DOI: 10.1016/j.chest.2022.12.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/12/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND CPAP is the first-line therapy for OSA. A high or variable residual apnea-hypopnea index (rAHI) reflects treatment failure and potentially is triggered by exacerbation of cardiovascular comorbidities. Previous studies showed that high rAHI and large rAHI variability are associated with underlying comorbidities, OSA characteristics at diagnosis, and CPAP equipment, including mask type and settings. RESEARCH QUESTION What factors are associated with predefined groups with low to high rAHI variability? STUDY DESIGN AND METHODS This registry-based study included patients with a diagnosis of OSA who were receiving CPAP treatment with at least 90 days of CPAP remote monitoring. We applied the hidden Markov model to analyze the day-to-day trajectories of rAHI variability using telemonitoring data. An ordinal logistic regression analysis identified factors associated with a risk of having a higher and more variable rAHI with CPAP treatment. RESULTS The 1,126 included patients were middle-aged (median age, 66 years; interquartile range [IQR], 57-73 years), predominantly male (n = 791 [70.3%]), and obese (median BMI, 30.6 kg/m2 (IQR, 26.8-35.2 kg/m2). Three distinct groups of rAHI trajectories were identified using hidden Markov modeling: low rAHI variability (n = 393 [35%]), moderate rAHI variability group (n = 420 [37%]), and high rAHI variability group (n = 313 [28%]). In multivariate analysis, factors associated with high rAHI variability were age, OSA severity at diagnosis, heart failure, opioids and alcohol consumption, mental and behavioral disorders, transient ischemic attack and stroke, an oronasal mask, and level of leaks when using CPAP. INTERPRETATION Identifying phenotypic traits and factors associated with high rAHI variability will allow early intervention and the development of personalized follow-up pathways for CPAP treatment.
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Affiliation(s)
- Anaïs Rossetto
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France
| | - Alphanie Midelet
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; Probayes, Montbonnot-Saint-Martin, France
| | - Sébastien Baillieul
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; Service Universitaire de Pneumologie Physiologie, CHU Grenoble Alpes, Grenoble, France
| | - Renaud Tamisier
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; Service Universitaire de Pneumologie Physiologie, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Christian Borel
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; AGIR à dom. HomeCare Charity, Meylan, France
| | - Arnaud Prigent
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; Groupe Medical de Pneumologie, Polyclinique Saint-Laurent, Rennes, France
| | - Sébastien Bailly
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; Service Universitaire de Pneumologie Physiologie, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Louis Pépin
- HP2 Laboratory, Inserm U1300, Université Grenoble Alpes, Grenoble, France; Service Universitaire de Pneumologie Physiologie, CHU Grenoble Alpes, Grenoble, France.
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Duarte RLDM, Togeiro SMGP, Palombini LDO, Rizzatti FPG, Fagondes SC, Magalhães-da-Silveira FJ, Cabral MM, Genta PR, Lorenzi-Filho G, Clímaco DCS, Drager LF, Codeço VM, Viegas CADA, Rabahi MF. Brazilian Thoracic Association Consensus on Sleep-disordered Breathing. JORNAL BRASILEIRO DE PNEUMOLOGIA : PUBLICACAO OFICIAL DA SOCIEDADE BRASILEIRA DE PNEUMOLOGIA E TISILOGIA 2022; 48:e20220106. [PMID: 35830079 PMCID: PMC9262434 DOI: 10.36416/1806-3756/e20220106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/23/2022] [Indexed: 12/02/2022]
Abstract
Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.
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Affiliation(s)
| | - Sonia Maria Guimarães Pereira Togeiro
- . Disciplina de Clínica Médica, Escola Paulista de Medicina - EPM - Universidade Federal de São Paulo - UNIFESP - São Paulo (SP) Brasil.,. Instituto do Sono, São Paulo (SP) Brasil
| | | | | | - Simone Chaves Fagondes
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | | | | | - Pedro Rodrigues Genta
- . Laboratório de Investigação Médica 63 - LIM 63 (Laboratório do Sono) - Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - HCFMUSP - São Paulo (SP) Brasil
| | - Geraldo Lorenzi-Filho
- . Laboratório de Investigação Médica 63 - LIM 63 (Laboratório do Sono) - Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - HCFMUSP - São Paulo (SP) Brasil
| | | | - Luciano Ferreira Drager
- . Unidade de Hipertensão, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - HCFMUSP - São Paulo (SP) Brasil
| | - Vitor Martins Codeço
- . Hospital Regional da Asa Norte, Secretaria de Estado de Saúde do Distrito Federal, Brasília (DF) Brasil
| | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás - UFG - Goiânia (GO) Brasil
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Hutter T, Horvath C, Hefti JP, Brill AK. [Treatment-Emergent Central Sleep Apnea - Detection and Treatment]. PRAXIS 2022; 111:436-443. [PMID: 35673844 DOI: 10.1024/1661-8157/a003848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Treatment-Emergent Central Sleep Apnea - Detection and Treatment Abstract. In treatment-emergent central sleep apnea (TECSA), affected patients with obstructive sleep apnea newly develop central sleep apnea (AHI central ≥5/h) under therapy with positive pressure ventilation which cannot be explained by other causes. The pathophysiology of TECSA is incompletely understood. PaCO2 and the associated apnea threshold seem to play a central role. The incidence of TECSA varies (1.8-20%), and in about 2/3 of cases it is self-limiting in the course of the therapy. If persistence or new onset occurs later in the course of positive pressure therapy, a further evaluation (e.g., echocardiography, neurologic examination, medication history) is indicated. Effective treatment options include a change in ventilation therapy (adaptive servoventilation or bilevel ventilation with back-up frequency) or additional nocturnal oxygen supplementation; these options should be decided case by case.
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Affiliation(s)
- Tabea Hutter
- Universitätsklinik für Pneumologie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Christian Horvath
- Universitätsklinik für Pneumologie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
- Sleep Research Laboratories of the University Health Network Toronto Rehabilitation Institute (KITE) and Toronto General Hospital and Department of Medicine of the University of Toronto, Toronto, Kanada
| | | | - Anne-Kathrin Brill
- Universitätsklinik für Pneumologie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Too Much of a Good Thing? Ann Am Thorac Soc 2021; 18:893-897. [PMID: 33929305 DOI: 10.1513/annalsats.202008-1030cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Central sleep apnea (CSA) is characterized by intermittent repetitive cessation and/or decreased breathing without effort caused by an abnormal ventilatory drive. Although less prevalent than obstructive sleep apnea, it is frequently encountered. CSA can be primary (idiopathic) or secondary in association with Cheyne-Stokes respiration, drug-induced, medical conditions such as chronic renal failure, or high-altitude periodic breathing. Risk factors have been proposed, including gender, age, heart failure, opioid use, stroke, and other chronic medical conditions. This article discusses the prevalence of CSA in the general population and within each of these at-risk populations, and clinical presentation, diagnostic methods, and treatment.
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Affiliation(s)
- Oki Ishikawa
- Department of Pulmonary and Critical Care, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Lenox Hill Hospital, 100 East 77th Street, 4 East, New York, NY 10075, USA.
| | - Margarita Oks
- Department of Pulmonary and Critical Care, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Lenox Hill Hospital, 100 East 77th Street, 4 East, New York, NY 10075, USA
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Abstract
Treatment-emergent central sleep apnea (TECSA) is a specific form of sleep-disordered breathing, characterized by the emergence or persistence of central apneas during treatment for obstructive sleep apnea. The purpose of this review was to summarize the definition, epidemiology, potential mechanisms, clinical characteristics, and treatment of TECSA. We searched for relevant articles up to January 31, 2020, in the PubMed database. The prevalence of TECSA varied widely in different studies. The potential mechanisms leading to TECSA included ventilatory control instability, low arousal threshold, activation of lung stretch receptors, and prolonged circulation time. TECSA may be a self-limited disorder in some patients and could be resolved spontaneously over time with ongoing treatment of continuous positive airway pressure (CPAP). However, central apneas persist even with the regular CPAP therapy in some patients, and new treatment approaches such as adaptive servo-ventilation may be necessary. We concluded that several questions regarding TECSA remain, despite the findings of many studies, and it is necessary to carry out large surveys with basic scientific design and clinical trials for TECSA to clarify these irregularities. Further, it will be vital to evaluate the baseline demographic and polysomnographic data of TECSA patients more carefully and comprehensively.
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Oppersma E, Ganglberger W, Sun H, Thomas RJ, Westover MB. Algorithm for automatic detection of self-similarity and prediction of residual central respiratory events during continuous positive airway pressure. Sleep 2021; 44:5924368. [PMID: 33057718 PMCID: PMC8631077 DOI: 10.1093/sleep/zsaa215] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/05/2020] [Indexed: 12/02/2022] Open
Abstract
Study Objectives Sleep-disordered breathing is a significant risk factor for cardiometabolic and neurodegenerative diseases. High loop gain (HLG) is a driving mechanism of central sleep apnea or periodic breathing. This study presents a computational approach that identifies “expressed/manifest” HLG via a cyclical self-similarity feature in effort-based respiration signals. Methods Working under the assumption that HLG increases the risk of residual central respiratory events during continuous positive airway pressure (CPAP), the full night similarity, computed during diagnostic non-CPAP polysomnography (PSG), was used to predict residual central events during CPAP (REC), which we defined as central apnea index (CAI) higher than 10. Central apnea labels are obtained both from manual scoring by sleep technologists and from an automated algorithm developed for this study. The Massachusetts General Hospital sleep database was used, including 2466 PSG pairs of diagnostic and CPAP titration PSG recordings. Results Diagnostic CAI based on technologist labels predicted REC with an area under the curve (AUC) of 0.82 ± 0.03. Based on automatically generated labels, the combination of full night similarity and automatically generated CAI resulted in an AUC of 0.85 ± 0.02. A subanalysis was performed on a population with technologist-labeled diagnostic CAI higher than 5. Full night similarity predicted REC with an AUC of 0.57 ± 0.07 for manual and 0.65 ± 0.06 for automated labels. Conclusions The proposed self-similarity feature, as a surrogate estimate of expressed respiratory HLG and computed from easily accessible effort signals, can detect periodic breathing regardless of admixed obstructive features such as flow limitation and can aid the prediction of REC.
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Affiliation(s)
- Eline Oppersma
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, The Netherlands
| | | | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Robert J Thomas
- Department of Medicine, Beth Israel Deaconess Medical Center, Division of Pulmonary, Critical Care & Sleep Medicine, Harvard Medical School, Boston, MA
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Zeineddine S, Badr MS. Treatment-Emergent Central Apnea: Physiologic Mechanisms Informing Clinical Practice. Chest 2021; 159:2449-2457. [PMID: 33497650 DOI: 10.1016/j.chest.2021.01.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022] Open
Abstract
The purpose of this review was to describe our management approach to patients with treatment-emergent central sleep apnea (TECSA). The emergence of central sleep apnea during positive airway pressure therapy occurs in approximately 8% of titration studies for OSA, and it has been associated with several demographic, clinical, and polysomnographic factors, as well as factors related to the titration study itself. TECSA shares similar pathophysiology with central sleep apnea. In fact, central and OSA pathophysiologic mechanisms are inextricably intertwined, with ventilatory instability and upper airway narrowing occurring in both entities. TECSA is a "dynamic" process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients. Management strategy for TECSA aims to eliminate abnormal respiratory events, stabilize sleep architecture, and improve the underlying contributing medical comorbidities. CPAP therapy remains a standard therapy for TECSA. Expectant management is appropriate given its transient nature in most cases, whereas select patients would benefit from an early switch to an alternative positive airway pressure modality. Other treatment options include supplemental oxygen and pharmacologic therapy.
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Affiliation(s)
- Salam Zeineddine
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI.
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Selim B, Ramar K. Sleep-Related Breathing Disorders: When CPAP Is Not Enough. Neurotherapeutics 2021; 18:81-90. [PMID: 33150546 PMCID: PMC8116389 DOI: 10.1007/s13311-020-00955-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Three decades ago, continuous positive airway pressure (CPAP) was introduced to treat obstructive sleep apnea (OSA). Shortly after, bilevel positive airway pressure devices (BPAP) that independently adjusted inspiratory and expiratory positive airway pressure were developed to treat complex sleep-related breathing disorders unresponsive to CPAP. Based on the bilevel positive airway pressure platform (hardware) governed by propriety algorithms (software), advanced modes of noninvasive ventilation (NIV) were developed to address complex cardiorespiratory pathophysiology beyond OSA. This review summarizes key aspects of different bilevel PAP therapies (BPAP with/without backup rate, adaptive servoventilation, and volume-assured pressure support) to treat common sleep-related hypoventilation disorders, treatment-emergent central sleep apnea, and central sleep apnea syndromes.
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Affiliation(s)
- Bernardo Selim
- Pulmonary and Critical Care Division, Center for Sleep Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Kannan Ramar
- Pulmonary and Critical Care Division, Center for Sleep Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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15
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Bailly S, Daabek N, Jullian-Desayes I, Joyeux-Faure M, Sapène M, Grillet Y, Borel JC, Tamisier R, Pépin JL. Partial failure of CPAP treatment for sleep apnoea: Analysis of the French national sleep database. Respirology 2019; 25:104-111. [PMID: 31336407 DOI: 10.1111/resp.13650] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Continuous positive airway pressure (CPAP) is the first-line therapy for obstructive sleep apnoea (OSA). Residual apnoea and/or hypopnoea events, that is an apnoea-hypopnoea index (AHI) > 5, during CPAP contribute to treatment drop-out. The clinical scenarios triggering residual events during CPAP use are poorly described. Underlying co-morbidities, especially cardiovascular diseases, lifestyle factors, OSA characteristics at diagnosis and type of mask have been suggested as potential contributors. METHODS Patients from the prospective French sleep apnoea registry diagnosed with OSA (AHI ≥ 15 events/h) treated with CPAP were included. Logistic regression analysis identified factors associated with a risk of residual AHI > 5 events/h on CPAP. RESULTS The 12 285 OSA patients were predominantly men (n = 8715, 70.9%), middle-aged (58.2 (49.8; 66.1) years) and obese (median body mass index: 31.3 (27.7; 35.6) kg/m2 ). Most had an AHI ≤ 5 events/h (n = 9573, 77.9%) versus 22.1% with AHI > 5/h. The latter were less CPAP adherent (5.75 (4.01; 7.00) vs 6.00 (4.53; 7.00) h/night). In multivariable analysis, factors associated with residual AHI >5/h were male sex, age, sedentary lifestyle, OSA severity, cardiovascular co-morbidities (heart failure and arrhythmia) and type of interface (orofacial mask versus nasal mask: OR = 2.15 (95%CI: 1.95; 2.37)). A subgroup analysis found that patients using pressures above 10 cm H2 O were 1.43 (95% CI: 1.3; 1.57) times more likely to have residual AHI > 5/h. CONCLUSION Knowing about risk factors for residual apnoeic-hypopnoeic events may assist in the timely provision of personalized care including the type of PAP therapy, attention to co-morbidities and choice of interface.
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Affiliation(s)
- Sébastien Bailly
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Najeh Daabek
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,AGIR à dom, Non-Profit Homecare Organisation, Meylan, France
| | - Ingrid Jullian-Desayes
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Marie Joyeux-Faure
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Marc Sapène
- Private Practice Sleep and Respiratory Disease Centre, Nouvelle Clinique Bel Air, Bordeaux, France
| | - Yves Grillet
- Private Practice Sleep and Respiratory Disease Centre, Valence, France
| | - Jean-Christian Borel
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France.,AGIR à dom, Non-Profit Homecare Organisation, Meylan, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Pépin
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France.,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
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16
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Herkenrath SD, Randerath WJ. More than Heart Failure: Central Sleep Apnea and Sleep-Related Hypoventilation. Respiration 2019; 98:95-110. [PMID: 31291632 DOI: 10.1159/000500728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/02/2019] [Indexed: 12/29/2022] Open
Abstract
Central sleep apnea (CSA) comprises a variety of breathing patterns and clinical entities. They can be classified into 2 categories based on the partial pressure of carbon dioxide in the arterial blood. Nonhypercapnic CSA is usually characterized by a periodic breathing pattern, while hypercapnic CSA is based on hypoventilation. The latter CSA form is associated with central nervous, neuromuscular, and rib cage disorders as well as obesity and certain medication or substance intake. In contrast, nonhypercapnic CSA is typically accompanied by an overshoot of the ventilation and often associated with heart failure, cerebrovascular diseases, and stay in high altitude. CSA and hypoventilation syndromes are often considered separately, but pathophysiological aspects frequently overlap. An integrative approach helps to recognize underlying pathophysiological mechanisms and to choose adequate therapeutic strategies. Research in the last decades improved our insights; nevertheless, diagnostic tools are not always appropriately chosen to perform comprehensive sleep studies. This supports misinterpretation and misclassification of sleep disordered breathing. The purpose of this article is to highlight unresolved problems, raise awareness for different pathophysiological components and to discuss the evidence for targeted therapeutic strategies.
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17
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Piper AJ. Advances in non‐invasive positive airway pressure technology. Respirology 2019; 25:372-382. [DOI: 10.1111/resp.13631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/28/2019] [Accepted: 06/10/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Amanda J. Piper
- Department of Respiratory and Sleep MedicineRoyal Prince Alfred Hospital Sydney NSW Australia
- Faculty of Medicine and HealthUniversity of Sydney Sydney New South Wales Australia
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18
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Abstract
Complex sleep apnea syndrome (Comp-SAS) is the term used to describe a specific form of sleep disordered breathing characterized by the arise of central sleep apnea in patient with previous obstructive sleep apnea syndrome (OSAS) treated with continuous positive airway pressure devices (CPAP). The mechanisms of its occurrence are not well understood, but partly it seems to be a consequence of increased carbon dioxide elimination under positive airway pressure treatment and related improvement of pulmonary ventilation. The prevalence of Comp-SAS ranges from 5% to 20% of OSAS patient getting CPAP therapy with no significant predictors in comparison with simple obstructive sleep apnea, but more likely to happened in older males with more severe OSAS and accompanying cardiovascular pathology such as ischemic heart disease, atrial fibrillation and heart failure. In most cases of Comp-SAS, central apnea events are transient and disappear after continuous CPAP therapy use for 1 to 2 months. Novel treatment options like adaptive servo-ventilation or BiPAP-ST are available for such non-responders to CPAP but contra-indicated to patients with systolic heart failure. From the other hand, still not clear is it mandatory to treat all affected individuals with Comp-SAS if the disease is uncomplicated and patient is asymptomatic.
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Affiliation(s)
- A D Palman
- Sechenov First Moscow State Medical University, Moscow, Russia
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19
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Pépin JL, Woehrle H, Liu D, Shao S, Armitstead JP, Cistulli PA, Benjafield AV, Malhotra A. Adherence to Positive Airway Therapy After Switching From CPAP to ASV: A Big Data Analysis. J Clin Sleep Med 2018; 14:57-63. [PMID: 29198291 DOI: 10.5664/jcsm.6880] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/03/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES There is a lack of data regarding adherence trajectories when switching from continuous positive airway pressure (CPAP) to adaptive servoventilation (ASV) in the context of persistent or treatment-emergent central sleep apnea (CSA). This study investigated 90-day adherence rates in patients with sleep apnea based on the type of positive airway pressure (PAP) device used and any switching of PAP modality over time. METHODS Telemonitoring data were obtained from a United States PAP database. Eligible patients were a 30% random sample who started PAP, plus all who started ASV, from January 1, 2015 to October 2, 2015. All received PAP and had at least one session with usage of 1 hour or more. Adherence and device usage were determined in three groups: started on CPAP and stayed on CPAP (CPAP only); started on ASV and stayed on ASV (ASV only); started on CPAP, switched to ASV (Switch). The United States Medicare definition of adherence was used. RESULTS The study included 198,890 patients; 189,724 (CPAP only), 8,957 (ASV only) and 209 (Switch). In the Switch group, average apnea-hypopnea index decreased significantly on ASV versus CPAP. At 90 days, adherence rates were 73.8% and 73.2% in the CPAP only and ASV only groups. In the Switch group, CPAP adherence was 62.7%, improving to 76.6% after the switch to ASV. Mean device usage at 90 days was 5.27, 5.31, and 5.73 h/d in the CPAP only, ASV only, and Switch groups, respectively. CONCLUSIONS Treatment-emergent or persistent CSA during CPAP reduced therapy adherence, but adherence improved early after switching from CPAP to ASV.
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Affiliation(s)
- Jean-Louis Pépin
- Institut National de la Santé et de la Recherche Médicale (INSERM), HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University, Grenoble, France
| | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany.,ResMed Science Center, Sydney, Australia
| | | | | | | | - Peter A Cistulli
- Charles Perkins Centre, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
| | | | - Atul Malhotra
- University of California San Diego, La Jolla, California
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20
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Nigam G, Riaz M, Chang ET, Camacho M. Natural history of treatment-emergent central sleep apnea on positive airway pressure: A systematic review. Ann Thorac Med 2018; 13:86-91. [PMID: 29675059 PMCID: PMC5892094 DOI: 10.4103/atm.atm_321_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION: Treatment-emergent central sleep apnea (TECSA) is observed in some patients when they are treated with positive airway pressure (PAP) after significant resolution of the preexisting obstructive events in patients with obstructive sleep apnea. The objective of this study was to systematically review the literature for studies describing the natural history of TECSA. METHODS: PubMed, Medline, Scopus, Web of Science, and Cochran Library databases were searched through June 29, 2017. RESULTS: Five studies were identified that discussed the natural history of TECSA. TECSA developed in 3.5%–19.8% of PAP-treated patients. Treatment-persistent central sleep apnea (TPCSA), representing protracted periods of PAP therapy-related central apneas, was noted in 14.3%–46.2% of patients with TECSA. Delayed-TECSA (D-TECSA) represents an anomalous TECSA entity appearing weeks to months after initial PAP therapy. D-TECSA was observed in 0.7%–4.2% of OSA patients undergoing PAP treatment (after at least 1 month). In patients with TECSA, a higher apnea–hypopnea index (AHI) and central apnea index at their baseline study or a higher residual AHI at their titration study may be associated with an increased likelihood of conversion to TPCSA. CONCLUSIONS: Overall, TECSA developed in 3.5%–19.8% of PAP-treated patients with OSA. The vast majority will experience complete resolution of central apneas over a few weeks to months. Unfortunately, about a third of patients with TECSA may continue to exhibit persistence of central sleep apnea on reevaluation. A small proportion may experience D-TECSA after few weeks to several months of initial exposure to PAP therapy.
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Affiliation(s)
- Gaurav Nigam
- Division of Sleep Medicine, Clay County Hospital, Flora, IL, USA
| | - Muhammad Riaz
- Division of Sleep Medicine, Astria Health Center, Grandview, WA, USA
| | - Edward T Chang
- Division of Otolaryngology, Sleep Surgery, and Sleep Medicine, Tripler Army Medical Center, HI, USA
| | - Macario Camacho
- Division of Otolaryngology, Sleep Surgery, and Sleep Medicine, Tripler Army Medical Center, HI, USA
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21
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Complex sleep apnea after full-night and split-night polysomnography: the Greek experience. Sleep Breath 2017; 22:713-719. [PMID: 29222618 DOI: 10.1007/s11325-017-1601-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/18/2017] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Treatment-emergent central sleep apnea (TE-CSA) is defined as the emergence or persistence of central respiratory events during the initiation of positive airway pressure (PAP) without a back-up rate in obstructive sleep apnea (OSA) patients and after significant resolution of obstructive events. Previous studies have estimated a prevalence from 0.56 to 20.3%. The aim of this study was to establish the prevalence of TE-CSA in a Greek adult population. METHODS One thousand fifty nine patients with newly diagnosed OSA, who were referred to the Sleep Disorders Center of Evangelismos Hospital of Athens over an 18-month period, were included in this study. A split-night polysomnography (PSG), or two formal overnight PSGs (diagnostic and continuous PAP (CPAP) titration study), were performed. RESULTS Patients with OSA were divided in two groups; the first group included 277 patients, who underwent two separate studies (diagnostic and CPAP titration study), and the second group 782 patients, who underwent split-night studies. The prevalence of TE-CSA in the first group was 2.53% (7 patients), and in the second group was 5.63% (44 patients). CONCLUSIONS The prevalence of TE-CSA in Greece was lower compared to most previous reported studies. The significant variation in the prevalence of TE-CSA between different centers throughout the world is mainly associated with the used diagnostic criteria as well as methodological and technical aspects.
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22
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Mador MJ. Emergent central sleep apnea during CPAP therapy-clinical implications. J Thorac Dis 2017; 9:4182-4184. [PMID: 29268465 DOI: 10.21037/jtd.2017.09.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- M Jeffery Mador
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Western New York Veterans Affairs Healthcare System, University at Buffalo, NY, USA
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23
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Lombardi C, Caravita S, Parati G. Central sleep apnea during continuous positive airway pressure therapy in obstructive sleep apnea patients: from the compliance to adaptation, maladaptation and reflexes. J Thorac Dis 2017; 9:4152-4156. [PMID: 29268457 DOI: 10.21037/jtd.2017.09.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Carolina Lombardi
- Sleep Disorders Center, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Gianfranco Parati
- Sleep Disorders Center, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
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24
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Liu D, Armitstead J, Benjafield A, Shao S, Malhotra A, Cistulli PA, Pepin JL, Woehrle H. Trajectories of Emergent Central Sleep Apnea During CPAP Therapy. Chest 2017; 152:751-760. [PMID: 28629918 PMCID: PMC6026232 DOI: 10.1016/j.chest.2017.06.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 05/04/2017] [Accepted: 06/01/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The emergence of central sleep apnea (CSA) during positive airway pressure (PAP) therapy has been observed clinically in approximately 10% of obstructive sleep apnea titration studies. This study assessed a PAP database to investigate trajectories of treatment-emergent CSA during continuous PAP (CPAP) therapy. METHODS U.S. telemonitoring device data were analyzed for the presence/absence of emergent CSA at baseline (week 1) and week 13. Defined groups were as follows: obstructive sleep apnea (average central apnea index [CAI] < 5/h in week 1, < 5/h in week 13); transient CSA (CAI ≥ 5/h in week 1, < 5/h in week 13); persistent CSA (CAI ≥ 5/h in week 1, ≥ 5/h in week 13); emergent CSA (CAI < 5/h in week 1, ≥ 5/h in week 13). RESULTS Patients (133,006) used CPAP for ≥ 90 days and had ≥ 1 day with use of ≥ 1 h in week 1 and week 13. The proportion of patients with CSA in week 1 or week 13 was 3.5%; of these, CSA was transient, persistent, or emergent in 55.1%, 25.2%, and 19.7%, respectively. Patients with vs without treatment-emergent CSA were older, had higher residual apnea-hypopnea index and CAI at week 13, and more leaks (all P < .001). Patients with any treatment-emergent CSA were at higher risk of therapy termination vs those who did not develop CSA (all P < .001). CONCLUSIONS Our study identified a variety of CSA trajectories during CPAP therapy, identifying several different clinical phenotypes. Identification of treatment-emergent CSA by telemonitoring could facilitate early intervention to reduce the risk of therapy discontinuation and shift to more efficient ventilator modalities.
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Affiliation(s)
| | | | | | | | | | - Peter A Cistulli
- Charles Perkins Centre at University of Sydney, Sydney, Australia; Royal North Shore Hospital, Sydney, Australia
| | - Jean-Louis Pepin
- Institut National de la Santé et de la Recherche Médicale (INSERM) U 1042, HP2 Laboratory, Grenoble Alpes University, Grenoble, France
| | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany.
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25
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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26
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S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen – Kapitel „Schlafbezogene Atmungsstörungen“. SOMNOLOGIE 2016. [DOI: 10.1007/s11818-016-0093-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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27
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Nigam G, Pathak C, Riaz M. A systematic review on prevalence and risk factors associated with treatment- emergent central sleep apnea. Ann Thorac Med 2016; 11:202-10. [PMID: 27512510 PMCID: PMC4966223 DOI: 10.4103/1817-1737.185761] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION: Treatment-emergent central sleep apnea (TECSA) is the appearance of central apneas and hypopneas after significant resolution of the obstructive events has been attained using positive airway pressure (PAP) therapy. The aim of the study was to determine the prevalence of TECSA and to understand what factors are associated with its development. METHODS: PubMed, MEDLINE, Scopus, Web of Science and Cochran Library databases were searched with Mesh headings to locate studies linking TECSA and obstructive sleep apnea (OSA). RESULTS: Nine studies were identified that reported the prevalence of TECSA ranging from 5.0% to 20.3%. Prevalence of TECSA for studies using only full night titration was between 5.0% and 12.1% where as it was between 6.5% and 20.3% for studies using split-night polysomnogram. The mean effective continuous PAP (CPAP) setting varied between 7.5 cm and 15.2 cm of water for patients in TECSA group and between 7.4 cm and 13.6 cm of water for the group without TECSA. CONCLUSIONS: The aggregate point prevalence of TECSA is about 8% with the estimated range varying from 5% to 20% in patients with untreated OSA. The prevalence tends to be higher for split-night studies compared to full night titration studies. TECSA can occur at any CPAP setting although extremely high CPAP settings could increase the likelihood. Male gender, higher baseline apnea-hypopnea index, and central apnea index at the time of diagnostic study could be associated with the development of TECSA at a subsequent titration study.
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Affiliation(s)
- Gaurav Nigam
- Department of Sleep Medicine, Clay County Hospital, Flora, IL, USA
| | - Charu Pathak
- Department of Obstetrics and Gynecology, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Muhammad Riaz
- Department of Hospital Medicine, Twin Cities Community Hospital, Templeton, CA, USA
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28
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Moro M, Gannon K, Lovell K, Merlino M, Mojica J, Bianchi MT. Clinical predictors of central sleep apnea evoked by positive airway pressure titration. Nat Sci Sleep 2016; 8:259-66. [PMID: 27555802 PMCID: PMC4968988 DOI: 10.2147/nss.s110032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Treatment-emergent central sleep apnea (TECSA), also called complex apnea, occurs in 5%-15% of sleep apnea patients during positive airway pressure (PAP) therapy, but the clinical predictors are not well understood. The goal of this study was to explore possible predictors in a clinical sleep laboratory cohort, which may highlight those at risk during clinical management. METHODS We retrospectively analyzed 728 patients who underwent PAP titration (n=422 split-night; n=306 two-night). Demographics and self-reported medical comorbidities, medications, and behaviors as well as standard physiological parameters from the polysomnography (PSG) data were analyzed. We used regression analysis to assess predictors of binary presence or absence of central apnea index (CAI) ≥5 during split-night PSG (SN-PSG) versus full-night PSG (FN-PSG) titrations. RESULTS CAI ≥5 was present in 24.2% of SN-PSG and 11.4% of FN-PSG patients during titration. Male sex, maximum continuous positive airway pressure, and use of bilevel positive airway pressure were predictors of TECSA, and rapid eye movement dominance was a negative predictor, for both SN-PSG and FN-PSG patients. Self-reported narcotics were a positive predictor of TECSA, and the time spent in stage N2 sleep was a negative predictor only for SN-PSG patients. Self-reported history of stroke and the CAI during the diagnostic recording predicted TECSA only for FN-PSG patients. CONCLUSION Clinical predictors of treatment-evoked central apnea spanned demographic, medical history, sleep physiology, and titration factors. Improved predictive models may be increasingly important as diagnostic and therapeutic modalities move away from the laboratory setting, even as PSG remains the gold standard for characterizing primary central apnea and TECSA.
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Affiliation(s)
| | | | | | | | - James Mojica
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matt T Bianchi
- Neurology Department; Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
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29
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Tomita Y, Kasai T. Effectiveness of adaptive servo-ventilation. World J Respirol 2015; 5:112-125. [DOI: 10.5320/wjr.v5.i2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 04/16/2015] [Accepted: 06/11/2015] [Indexed: 02/06/2023] Open
Abstract
Adaptive servo-ventilation (ASV) has been developed as a specific treatment for sleep-disordered breathing, in particular Cheyne-Stokes respiration with central sleep apnea (CSA). Heart failure patients often have sleep-disordered breathing, which consists of either obstructive sleep apnea (OSA) or CSA. Other medical conditions, such as stroke, acromegaly, renal failure, and opioid use may be associated with CSA. Continuous positive airway pressure (CPAP) therapy is widely used for patients with OSA, but some of these patients develop CSA on CPAP, which is called treatment-emergent CSA. CPAP can be useful as a treatment for these various forms of CSA, but it is insufficient to eliminate respiratory events in approximately half of patients with CSA. As compared to CPAP, ASV may be a better option to treat CSA, with sufficient alleviation of respiratory events as well as improvement of cardiac function in heart failure patients. In patients without heart failure, ASV can also alleviate CSA and relieve their symptom. Recently, ASV has been widely used for patients with various forms of CSA. ASV may be also used in the setting without CSA, but it should be assessed more carefully. Clinicians should have a better understanding of the indications for ASV in each setting.
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30
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Neu D, Balkissou AD, Mairesse O, Pefura-Yone EW, Noseda A. Complex sleep apnea at auto-titrating CPAP initiation: prevalence, significance and predictive factors. CLINICAL RESPIRATORY JOURNAL 2015; 11:200-209. [DOI: 10.1111/crj.12325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/22/2015] [Accepted: 05/14/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel Neu
- Sleep Laboratory and Unit for Chronobiology U78; Brugmann University Hospital, Université Libre de Bruxelles (U.L.B.); Brussels Belgium
- UNI Neuroscience Institute, ULB312 Faculty of Medicine, and Faculty of Motor Sciences, Université Libre de Bruxelles (U.L.B.); Brussels Belgium
| | - Adamou Dodo Balkissou
- Sleep Laboratory and Unit for Chronobiology U78; Brugmann University Hospital, Université Libre de Bruxelles (U.L.B.); Brussels Belgium
- Department of Pneumology; Brugmann University Hospital U.L.B.; Brussels Belgium
- Department of Internal Medicine and Subspecialties, Faculty of Medicine and Biomedical Sciences; University of Yaounde I; Yaounde Cameroon
| | - Olivier Mairesse
- Sleep Laboratory and Unit for Chronobiology U78; Brugmann University Hospital, Université Libre de Bruxelles (U.L.B.); Brussels Belgium
- Department of Experimental and Applied Psychology (EXTO); Vrije Universiteit Brussel (V.U.B.); Brussels Belgium
- Department LIFE; Royal Military Academy; Brussels Belgium
| | - Eric Walter Pefura-Yone
- Department of Internal Medicine and Subspecialties, Faculty of Medicine and Biomedical Sciences; University of Yaounde I; Yaounde Cameroon
| | - André Noseda
- Department of Pneumology; Brugmann University Hospital U.L.B.; Brussels Belgium
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Lee SA, Lee GH, Chung YS, Kim WS. Clinical, polysomnographic, and CPAP titration features of obstructive sleep apnea: Mixed versus purely obstructive type. J Neurol Sci 2015; 355:150-4. [PMID: 26066559 DOI: 10.1016/j.jns.2015.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE To determine whether obstructive sleep apnea syndrome (OSAS) patients with mixed sleep apnea (MSA) have different clinical, polysomnographic, and continuous positive airway pressure (CPAP) titration findings compared to OSAS patients without MSA. METHODS We retrospectively reviewed the records of OSAS patients who had undergone CPAP titration and categorized them into pure-OSA and mixed-OSA groups. Demographic features, daytime sleepiness, and apnea severity were compared between the two groups using univariate and multivariate analyses. CPAP titration findings were also compared between the two groups. RESULTS One hundred and ninety-five subjects (n=126 pure-OSA; n=69 mixed-OSA) were included in the analysis. Compared to the pure-OSA group, the mixed-OSA group had a higher percentage of males (p=0.003) and a higher body mass index (p=0.044), Epworth Sleepiness Scale score (p=0.028), and apnea-hypopnea index (AHI) (p<0.001). In logistic regression analysis, older age, male sex, and higher body mass index were independently associated with mixed-OSA before PSG study. When using AHI as a covariable, the higher AHI with older age, male sex, and daytime sleepiness was independently related to mixed-OSA. The mixed-OSA group had a higher percentage of patients with complex sleep apnea, a lower percentage of patients with optimal titration, and a higher titrated pressure than the pure-OSA group. CONCLUSIONS Severe OSA, older age, male sex, obesity, and daytime sleepiness were related to mixed-OSA. Complex sleep apnea, less optimal titration, and a higher titrated CPAP were also associated with MSA in OSAS patients.
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Affiliation(s)
- Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Gha-Hyun Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yoo-Sam Chung
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Sung Kim
- Department of Pulmonary Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Shapiro CM, Chung SA, Wylie PE, Hossain NK, Holle RHO, Rosenberg RP, Muehlbach MJ, Doekel RC, Pegram GV, Jasko JG. Home-use servo-ventilation therapy in chronic pain patients with central sleep apnea: initial and 3-month follow-up. Sleep Breath 2015; 19:1285-92. [PMID: 25813356 PMCID: PMC4662950 DOI: 10.1007/s11325-015-1161-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 02/19/2015] [Accepted: 03/10/2015] [Indexed: 01/24/2023]
Abstract
PURPOSE Opioid treatment of non-malignant chronic pain can result in hypoxemia, hypercarbia, and central sleep apnea. The aim of this study was to determine the initial efficacy of auto servo-ventilation (ASV) and after 3 months of home use. METHODS This prospective multicenter interventional study recruited chronic pain patients prescribed ≥100 morphine equivalents for at least 4 months. PARTICIPANTS Following full-night polysomnography (PSG) to confirm the presence of sleep-disordered breathing, patients were randomized to three additional full-night-attended PSGs with continuous positive airway pressure (CPAP), ASV, and servo-ventilation with an initial mandatory pressure support of 6 cm H2O (ASV manual PSmin 6). Following the PSGs, patients were sent home with EncoreAnywhere and ASV with or without mandatory pressure support. RESULTS Based on the initial PSG studies, CPAP improved but did not normalize the apnea-hypopnea index (AHI), central apnea index (CAI), or hypopnea index (HI), as all remained elevated. Clinically significant reductions were noted after just one night of ASV and ASV manual (PSmin 6). After 3 months of ASV home use, the AHI, CAI, and obstructive apnea index (OAI) were significantly reduced when compared to baseline diagnostic levels and even when compared to respiratory disturbance indices with CPAP treatment. CONCLUSIONS Initial and home use of ASV for 3 months resulted in significantly lower AHI, CAI, and OAI. This reduction attests to the efficacy of ASV treatment in chronic pain patients on high doses of opioids.
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Affiliation(s)
- Colin M Shapiro
- Department of Psychiatry, Toronto Western Hospital, University Health Network, 399 Bathurst Street, 7 Main - 429, Toronto, Ontario, M5T 2S8, Canada.,Youthdale Treatment Centres, Toronto, Canada
| | - Sharon A Chung
- Department of Psychiatry, Toronto Western Hospital, University Health Network, 399 Bathurst Street, 7 Main - 429, Toronto, Ontario, M5T 2S8, Canada. .,Youthdale Treatment Centres, Toronto, Canada.
| | - Paul E Wylie
- Arkansas Center of Sleep Medicine, Little Rock, AR, USA
| | - Naheed K Hossain
- Department of Psychiatry, Toronto Western Hospital, University Health Network, 399 Bathurst Street, 7 Main - 429, Toronto, Ontario, M5T 2S8, Canada
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Kuźniar TJ. Treatment-emergent central sleep apnea at high altitude. Sleep Med 2014; 16:313-4. [PMID: 25465532 DOI: 10.1016/j.sleep.2014.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/05/2014] [Indexed: 02/04/2023]
Affiliation(s)
- Tomasz J Kuźniar
- Division of Pulmonary and Critical Care Medicine, NorthShore University HealthSystem, Evanston, IL, USA Tel.: +1 847 570 2714; fax: +1 847 733 5109..
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Nicolini A, Banfi P, Grecchi B, Lax A, Walterspacher S, Barlascini C, Robert D. Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:324-35. [PMID: 24954545 DOI: 10.1016/j.rppneu.2014.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 02/08/2014] [Accepted: 03/29/2014] [Indexed: 12/14/2022] Open
Abstract
Non-invasive mechanical ventilation (NIV) was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation. Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea, the overlap syndrome (COPD and obstructive sleep apnea), neuromuscular disorders, obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure. In this review we discuss the different types of NIV, the specific conditions in which they can be used as well as the indications, recommendations, and evidence supporting the efficacy of NIV.
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Affiliation(s)
- A Nicolini
- Respiratory Diseases Unit, Hospital of Sestri Levante, Italy.
| | - P Banfi
- Neuromuscular Diseases Unit, Don Gnocchi Foundation, Milan, Italy
| | - B Grecchi
- Rehabilitation Department ASL 4 Chiavarese, Italy
| | - A Lax
- Neuromuscular Diseases Unit, Don Gnocchi Foundation, Milan, Italy
| | - S Walterspacher
- Department of Pulmonology, University Hospital, Freiburg, Germany
| | | | - D Robert
- Emeritus Professor of Medicine, Claude Bernard University Lyon, France
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Morgenthaler TI, Kuzniar TJ, Wolfe LF, Willes L, McLain WC, Goldberg R. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. Sleep 2014; 37:927-34. [PMID: 24790271 DOI: 10.5665/sleep.3662] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Prior studies show that adaptive servoventilation (ASV) is initially more effective than continuous positive airway pressure (CPAP) for patients with complex sleep apnea syndrome (CompSAS), but choosing therapies has been controversial because residual central breathing events may resolve over time in many patients receiving chronic CPAP therapy. We conducted a multicenter, randomized, prospective trial comparing clinical and polysomnographic outcomes over prolonged treatment of patients with CompSAS, with CPAP versus ASV. METHODS Qualifying participants meeting criteria for CompSAS were randomized to optimized CPAP or ASV treatment. Clinical and polysomnographic data were obtained at baseline and after 90 days of therapy. RESULTS We randomized 66 participants (33 to each treatment). At baseline, the diagnostic apnea-hypopnea index (AHI) was 37.7 ± 27.8 (central apnea index [CAI] = 3.2 ± 5.8) and best CPAP AHI was 37.0 ± 24.9 (CAI 29.7 ± 25.0). After second-night treatment titration, the AHI was 4.7 ± 8.1 (CAI = 1.1 ± 3.7) on ASV and 14.1 ± 20.7 (CAI = 8.8 ± 16.3) on CPAP (P ≤ 0.0003). At 90 days, the ASV versus CPAP AHI was 4.4 ± 9.6 versus 9.9 ± 11.1 (P = 0.0024) and CAI was 0.7 ± 3.4 versus 4.8 ± 6.4 (P < 0.0001), respectively. In the intention-to-treat analysis, success (AHI < 10) at 90 days of therapy was achieved in 89.7% versus 64.5% of participants treated with ASV and CPAP, respectively (P = 0.0214). Compliance and changes in Epworth Sleepiness Scale and Sleep Apnea Quality of Life Index were not significantly different between treatment groups. CONCLUSION Adaptive servoventilation (ASV) was more reliably effective than CPAP in relieving complex sleep apnea syndrome. While two thirds of participants experienced success with CPAP, approximately 90% experienced success with ASV. Because both methods produced similar symptomatic changes, it is unclear if this polysomnographic effectiveness may translate into other desired outcomes. CLINICAL TRIALS Clinicaltrials.Gov NCT00915499.
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Affiliation(s)
- Timothy I Morgenthaler
- Mayo Clinic Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Lisa F Wolfe
- Northwestern University Feinberg School of Medicine, Chicago, IL
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Complex sleep apnea syndrome. SLEEP DISORDERS 2014; 2014:798487. [PMID: 24693440 PMCID: PMC3945285 DOI: 10.1155/2014/798487] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/10/2013] [Accepted: 11/23/2013] [Indexed: 12/16/2022]
Abstract
Complex sleep apnea is the term used to describe a form of sleep disordered breathing in which repeated central apneas (>5/hour) persist or emerge when obstructive events are extinguished with positive airway pressure (PAP) and for which there is not a clear cause for the central apneas such as narcotics or systolic heart failure. The driving forces in the pathophysiology are felt to be ventilator instability associated oscillation in PaCO2 arterial partial pressure of Carbon Dioxide, continuous cositive airway pressure (CPAP) related increased CO2 carbon dioxide elimination, and activation of airway and pulmonary stretch receptors triggering these central apneas. The prevalence ranges from 0.56% to 18% with no clear predictive characteristics as compared to simple obstructive sleep apnea. Prognosis is similar to obstructive sleep apnea. The central apnea component in most patients on followup using CPAP therap, has resolved. For those with continued central apneas on simple CPAP therapy, other treatment options include bilevel PAP, adaptive servoventilation, permissive flow limitation and/or drugs.
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Ryu HU, Lee EM, Lee GH, Kim B, Lee SA. Prevalence and Predicting Factors of Complex Sleep Apnea in Patients with Obstructive Sleep Apnea Syndrome. ACTA ACUST UNITED AC 2013. [DOI: 10.13078/jksrs.13010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
OPINION STATEMENT Complex sleep apnea currently refers to the emergence and persistence of central apneas and hypopneas following the application of positive airway pressure therapy in patients with obstructive sleep apnea. However, this narrow definition is an "outcome" and does not capture the spectrum of pathological activation of the respiratory chemoreflex in sleep apnea. The International Classification of Sleep Disorders - 3rd edition recognizes the phenomenon of Treatment-Related Central Sleep Apnea, but the phenotype is usually evident prior to onset of therapy. The key polysomnographic characteristics of chemoreflex modulated and mediated sleep apnea are nonrapid eye movement (NREM) dominance of respiratory events, short (<30 seconds) or long (>60 seconds) cycle time with a self-similar metronomic timing, and spontaneous improvement during rapid eye movement (REM) sleep. Thus, the majority of chemoreflex effects go unrecognized due to the bias toward obstructive sleep apnea's current scoring criteria. Any treatment of apparently obstructive sleep apnea, including surgery and oral appliances, can expose chemoreflex-driven instabilities. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable NREM sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation yet can induce ventilator-patient desynchrony, while enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) and CO2 manipulation directly stabilize respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Novel pharmacological approaches may target mediators of carotid body hypoxic sensitization, such as the balance between gas neurotransmitters. In complex apnea patients, single mode therapy is unlikely to be successful, and the power of multi-modality therapy should be harnessed for optimal outcomes.
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Dellweg D, Kerl J, Hoehn E, Wenzel M, Koehler D. Randomized controlled trial of noninvasive positive pressure ventilation (NPPV) versus servoventilation in patients with CPAP-induced central sleep apnea (complex sleep apnea). Sleep 2013; 36:1163-71. [PMID: 23904676 DOI: 10.5665/sleep.2878] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
STUDY OBJECTIVES To compare the treatment effect of noninvasive positive pressure ventilation (NPPV) and anticyclic servoventilation in patients with continuous positive airway pressure (CPAP)-induced central sleep apnea (complex sleep apnea). DESIGN Randomized controlled trial. SETTING Sleep center. PATIENTS Thirty patients who developed complex sleep apnea syndrome (CompSAS) during CPAP treatment. INTERVENTIONS NPPV or servoventilation. MEASUREMENTS AND RESULTS Patients were randomized to NPPV or servo-ventilation. Full polysomnography (PSG) was performed after 6 weeks. On CPAP prior to randomization, patients in the NPPV and servoventilator arm had comparable apnea-hypopnea indices (AHI, 28.6 ± 6.5 versus 27.7 ± 9.7 events/h (mean ± standard deviation [SD])), apnea indices (AI,19 ± 5.6 versus 21.1 ± 8.6 events/h), central apnea indices (CAI, 16.7 ± 5.4 versus 18.2 ± 7.1 events/h), oxygen desaturation indices (ODI,17.5 ± 13.1 versus 24.3 ± 11.9 events/h). During initial titration NPPV and servoventilation significantly improved the AHI (9.1 ± 4.3 versus 9 ± 6.4 events/h), AI (2 ± 3.1 versus 3.5 ± 4.5 events/h) CAI (2 ± 3.1 versus 2.5 ± 3.9 events/h) and ODI (10.1 ± 4.5 versus 8.9 ± 8.4 events/h) when compared to CPAP treatment (all P < 0.05). After 6 weeks we observed the following differences: AHI (16.5 ± 8 versus 7.4 ± 4.2 events/h, P = 0.027), AI (10.4 ± 5.9 versus 1.7 ± 1.9 events/h, P = 0.001), CAI (10.2 ± 5.1 versus 1.5 ± 1.7 events/h, P < 0.0001)) and ODI (21.1 ± 9.2 versus 4.8 ± 3.4 events/h, P < 0.0001) for NPPV and servoventilation, respectively. Other sleep parameters were unaffected by any form of treatment. CONCLUSIONS After 6 weeks, servoventilation treated respiratory events more effectively than NPPV in patients with complex sleep apnea syndrome.
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Affiliation(s)
- Dominic Dellweg
- Kloster Grafschaft, Pulmonary Medicine I, Home Mechanical Ventilation Unit and Sleep Laboratory, Schmallenberg, Germany.
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Abstract
Complex sleep apnea syndrome (CompSAS) describes the coexistence or appearance and persistence of central apneas or hypopneas in patients with obstructive sleep apnea upon successful restoration of airway patency. We review data on treatment of CompSAS with CPAP, bilevel positive airway pressure, and adaptive servoventilation and discuss evidence for the addition of medications (analgesics, hypnotics, acetazolamide) and gases (oxygen, CO2) to positive airway pressure therapy. Future research should focus on defining outcomes in patients with CompSAS and allow for more accurate tailoring of therapy to the pathophysiology present in the individual patient.
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Affiliation(s)
- Tomasz J Kuźniar
- Department of Internal Medicine, 4th Clinical Military Hospital, Wrocław, Poland
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Kuźniar TJ, Kasibowska-Kuźniar K, Ray DW, Freedom T. Clinical heterogeneity of patients with complex sleep apnea syndrome. Sleep Breath 2013; 17:1209-14. [PMID: 23436008 PMCID: PMC3898341 DOI: 10.1007/s11325-013-0825-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/31/2013] [Accepted: 02/11/2013] [Indexed: 12/31/2022]
Abstract
Background The definition of complex sleep apnea (CompSAS) encompasses patients with obstructive sleep apnea (OSA) who develop central apnea activity upon restitution of airway patency. Presence of arterial hypertension (HTN), coronary artery disease (CAD) and heart failure (HF) have been proposed as risk factors for CompSAS among OSA patients. Using our database of patients with CompSAS, we examined the prevalence of these risk factors and defined other clinical characteristics of patients with CompSAS. Methods Through retrospective search of the database, we examined the medical and clinical characteristics of consecutive patients diagnosed with CompSAS between 11/1/2006 and 6/30/2011 at NorthShore University HealthSystem. Results One hundred and fifty patients with CompSAS were identified. Among patients included in the study, 97 (64.7 %) had at least one risk factor for CompSAS, while 53 (35.3 %) did not have any of them. Prevalence of low left ventricular ejection fraction and hypocapnia were low. Therapeutic interventions consisted of several positive airway pressure therapies, mainly adaptive servo ventilation. A hundred and ten patients (73.3 %) complied with recommended therapy and improved clinically. Conclusions Although most patients with CompSAS have cardiac comorbidities, about one third of patients do not have any risk factors of CompSAS prior to sleep testing. Further research on factors involved in development of CompSAS will allow for better tailoring of therapy to pathophysiology involved in an individual case.
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Affiliation(s)
- Tomasz J Kuźniar
- Division of Pulmonary and Critical Care Medicine, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL, USA,
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Abstract
Complex sleep apnea syndrome (CompSAS) is a distinct form of sleep-disordered breathing characterized as central sleep apnea (CSA), and presents in obstructive sleep apnea (OSA) patients during initial treatment with a continuous positive airway pressure (CPAP) device. The mechanisms of why CompSAS occurs are not well understood, though we have a high loop gain theory that may help to explain it. It is still controversial regarding the prevalence and the clinical significance of CompSAS. Patients with CompSAS have clinical features similar to OSA, but they do exhibit breathing patterns like CSA. In most CompSAS cases, CSA events during initial CPAP titration are transient and they may disappear after continued CPAP use for 4~8 weeks or even longer. However, the poor initial experience of CompSAS patients with CPAP may not be avoided, and nonadherence with continued therapy may often result. Treatment options like adaptive servo-ventilation are available now that may rapidly resolve the disorder and relieve the symptoms of this disease with the potential of increasing early adherence to therapy. But these approaches are associated with more expensive and complicated devices. In this review, the definition, potential plausible mechanisms, clinical characteristics, and treatment approaches of CompSAS will be summarized.
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Affiliation(s)
- Juan Wang
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Yan Wang
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jing Feng
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
- Correspondence: Jing Feng, Respiratory Department of Tianjin Medical University General Hospital, Tianjin 300052, People’s Republic of China Email ;
| | - Bao-yuan Chen
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jie Cao
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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De Paolis F, Colizzi E, Milioli G, Grassi A, Riccardi S, Parrino L, Terzano MG. Complex sleep apnea syndrome in stroke patients. Sleep Med 2012; 14:224. [PMID: 23218538 DOI: 10.1016/j.sleep.2012.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 10/03/2012] [Indexed: 11/26/2022]
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Hoffman M, Schulman DA. The appearance of central sleep apnea after treatment of obstructive sleep apnea. Chest 2012; 142:517-522. [PMID: 22871763 DOI: 10.1378/chest.11-2562] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Patients with a primary diagnosis of obstructive sleep apnea frequently demonstrate central sleep apnea that emerges during treatment with CPAP. Although a number of mechanisms for this finding have been hypothesized, the pathophysiology is not definitively known. Controversy exists as to whether the concomitant appearance of the two phenomena represents a distinct meaningful entity. Regardless, the coincidence of these diseases may have important clinical implications. Herein, we review the proposed mechanisms for obstructive sleep apnea complicated by central sleep apnea. Future research is needed to elucidate the relative importance and susceptibility to intervention of the various pathophysiologic mechanisms responsible for this phenomenon, and whether a treatment approach distinct from that of pure obstructive apnea is justified.
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The missing link between heart failure and sleep disordered breathing: Increased left ventricular wall stress. Int J Cardiol 2012; 157:294-7. [DOI: 10.1016/j.ijcard.2012.03.123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/10/2012] [Indexed: 12/23/2022]
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Mehta AJ, Miedinger D, Keidel D, Bettschart R, Bircher A, Bridevaux PO, Curjuric I, Kromhout H, Rochat T, Rothe T, Russi EW, Schikowski T, Schindler C, Schwartz J, Turk A, Vermeulen R, Probst-Hensch N, Künzli N. Occupational exposure to dusts, gases, and fumes and incidence of chronic obstructive pulmonary disease in the Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults. Am J Respir Crit Care Med 2012; 185:1292-300. [PMID: 22492989 DOI: 10.1164/rccm.201110-1917oc] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE There is limited evidence from population-based studies demonstrating incidence of spirometric-defined chronic obstructive pulmonary disease (COPD) in association with occupational exposures. OBJECTIVES We evaluated the association between occupational exposures and incidence of COPD in the Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults (SAPALDIA). MEASUREMENTS AND MAIN RESULTS Prebronchodilator ratio of forced expiratory volume in 1 second over forced vital capacity (FEV(1)/FVC) was measured in 4,267 nonasthmatic SAPALDIA participants ages 18-62 at baseline in 1991 and at follow-up in 2001-2003. COPD was defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criterion (FEV(1)/FVC < 0.70) and Quanjer reference equation (FEV(1)/FVC < lower limit of normal [LLN]), and categorized by severity (≥ 80% and <80% predicted FEV(1) for stage I and stage II+, respectively). Using a job-exposure matrix, self-reported occupations at baseline were assigned exposures to biological dusts, mineral dusts, gases/fumes, and vapors, gases, dusts, or fumes (VGDF) (high, low, or unexposed as reference). Adjusted incident rate ratios (IRRs) of stage I and stage II+ COPD were estimated in mixed Poisson regression models. Statistically significant (P < 0.05) IRRs of stage II+ GOLD and LLN-COPD, indicating risks between two- and fivefold, were observed for all occupational exposures at high levels. Occupational exposure-associated risk of stage II+ COPD was observed mainly in males and ages ≥ 40 years, and remained elevated when restricted to nonsmokers. CONCLUSIONS In a Swiss working adult population, occupational exposures to biological dusts, mineral dusts, gases/fumes, and VGDF were associated with incidence of COPD of at least moderate severity.
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Affiliation(s)
- Amar J Mehta
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
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Mechanisms of sleep-disordered breathing: causes and consequences. Pflugers Arch 2011; 463:213-30. [DOI: 10.1007/s00424-011-1055-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/14/2011] [Accepted: 10/26/2011] [Indexed: 11/27/2022]
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