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Safi M. Assessing Discomfort Levels During Facial Neuromuscular Electrical Stimulation Using Discomfort Level Scale: A Preliminary Study. Indian J Otolaryngol Head Neck Surg 2022; 74:5275-5279. [PMID: 36742910 PMCID: PMC9895512 DOI: 10.1007/s12070-020-02173-5] [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: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023] Open
Abstract
The primary aim of the current study was to evaluate discomfort levels of facial NMES in healthy volunteers. Eight participants completed the Discomfort Level Scale (DLS) following each motor level facial neuromuscular electrical stimulation (NMES) session. Each participant completed 12 sessions of facial NMES for a total of 96 NMES treatments. Pearson product-moment correlation coefficient demonstrated a significant correlation between the facial NMES intensity level and DLS (p < 0.001). This study demonstrated that the DLS is a useful tool to check for discomfort levels in patients who receive facial NMES. Further, this study provides strong support for the tolerability of facial NMES.
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Affiliation(s)
- Mohammed Safi
- Speech Language Pathology, United Arab Emirates University, Al Ain, UAE
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2
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Ruehland WR, Rochford PD, Pierce RJ, Trinder J, Jordan AS, Cori JM, O'Donoghue FJ. Genioglossus muscle responses to resistive loads in severe OSA patients and healthy control subjects. J Appl Physiol (1985) 2019; 127:1586-1598. [PMID: 31647723 DOI: 10.1152/japplphysiol.00186.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study aimed to determine whether there is impairment of genioglossus neuromuscular responses to small negative pressure respiratory stimuli, close to the conscious detection threshold, in obstructive sleep apnea (OSA). We compared genioglossus electromyogram (EMGgg) responses to midinspiratory resistive loads of varying intensity (≈1.2-6.2 cmH2O·L-1·s), delivered via a nasal mask, between 16 severe OSA and 17 control participants while the subjects were awake and in a seated upright position. We examined the relationship between stimulus intensity and peak EMGgg amplitude in a 200-ms poststimulus window and hypothesized that OSA patients would have an increased activation threshold and reduced sensitivity in the relationship between EMGgg activation and stimulus intensity. There was no significant difference between control and OSA participants in the threshold (P = 0.545) or the sensitivity (P = 0.482) of the EMGgg amplitude vs. stimulus intensity relationship, where change in epiglottic pressure relative to background epiglottic pressure represented stimulus intensity. These results do not support the hypothesis that deficits in neuromuscular response to negative upper airway pressure exist in OSA during wakefulness; however, the results are likely influenced by a counterintuitive and novel genioglossus muscle suppression response observed in a significant proportion of both OSA and healthy control participants. This suppression response may relate to the inhibition seen in inspiratory muscles such as the diaphragm in response to sudden-onset negative pressure, and its presence provides new insight into the upper airway neuromuscular response to the collapsing force of negative pressure.NEW & NOTEWORTHY Our study used a novel midinspiratory resistive load stimulus to study upper airway neuromuscular responses to negative pressure during wakefulness in obstructive sleep apnea (OSA). Although no differences were found between OSA and healthy groups, the study uncovered a novel and unexpected suppression of neuromuscular activity in a large proportion of both OSA and healthy participants. The unusual response provides new insight into the upper airway neuromuscular response to the collapsing force of negative pressure.
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Affiliation(s)
- Warren R Ruehland
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Peter D Rochford
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Robert J Pierce
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - John Trinder
- School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Amy S Jordan
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer M Cori
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Fergal J O'Donoghue
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
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3
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Fleury Curado T, Oliven A, Sennes LU, Polotsky VY, Eisele D, Schwartz AR. Neurostimulation Treatment of OSA. Chest 2018; 154:1435-1447. [PMID: 30222959 DOI: 10.1016/j.chest.2018.08.1070] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/02/2018] [Accepted: 08/30/2018] [Indexed: 01/04/2023] Open
Abstract
Over the past 30 years, hypoglossal nerve stimulation has moved through a development pathway to become a viable treatment modality for patients with OSA. Initial pilot studies in animals and humans laid the conceptual foundation for this approach, leading to the development of fully implantable stimulating systems for therapeutic purposes. These devices were then shown to be both safe and efficacious in feasibility studies. One such closed-loop stimulating device was found to be effective in treating a limited spectrum of apneic patients and is currently approved by the US Food and Drug Administration for this purpose. Another open-loop stimulating system is currently being rigorously tested in a pivotal trial. Collectively, clinical trials of hypoglossal nerve stimulating systems have yielded important insights that can help optimize therapeutic responses to hypoglossal nerve stimulation. These insights include specific patient selection criteria and methods for delivering stimulation to specific portions of the hypoglossal nerve and/or genioglossus muscle. New approaches for activating efferent and afferent motor pathways are currently in early-stage laboratory development and hold some long-term promise as a novel therapy.
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Affiliation(s)
- Thomaz Fleury Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Otorhinolaryngology, University of São Paulo Medical School, São Paulo, Brazil.
| | - Arie Oliven
- Department of Medicine, Bnai Zion Medical Center, Technion, Haifa, Israel
| | - Luiz U Sennes
- Department of Otorhinolaryngology, University of São Paulo Medical School, São Paulo, Brazil
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Eisele
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University, Baltimore, MD
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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Effect of Neuromuscular Electrical Stimulation on Labial and Lingual Weakness. TOPICS IN GERIATRIC REHABILITATION 2018. [DOI: 10.1097/tgr.0000000000000185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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Bisogni V, Pengo MF, De Vito A, Maiolino G, Rossi GP, Moxham J, Steier J. Electrical stimulation for the treatment of obstructive sleep apnoea: a review of the evidence. Expert Rev Respir Med 2017; 11:711-720. [PMID: 28730908 DOI: 10.1080/17476348.2017.1358619] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Obstructive sleep apnoea is an increasingly prevalent clinical condition with significant impact on individuals and public health. Continuous positive airway pressure therapy is the standard treatment, but adherence is limited and alternative treatments are needed. In this context, non-invasive and invasive methods for the electrical stimulation of upper airway dilator muscles have been demonstrated to be effective in selected patients. Areas covered: This review will cover investigations on the clinical effects, safety, and tolerability of non-invasive and invasive electrical stimulation of the upper airway for the management of obstructive sleep apnoea. Following a search of the relevant literature published on PubMed this review is focused mainly on data obtained from randomized clinical trials and clinical studies. Expert commentary: The available evidence provides a rationale to consider upper airway electrical stimulation as treatment for selected patients with obstructive sleep apnoea, who have poor adherence or experience difficulties with continuous positive airway pressure therapy. Non-invasive stimulation using transcutaneous electrodes and implantable hypoglossal nerve stimulator technologies may provide an alternative to continuous positive airway pressure for the treatment of obstructive sleep apnoea via restoration of neuromuscular tone and improved upper airway patency.
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Affiliation(s)
- Valeria Bisogni
- a Clinica dell'Ipertensione Arteriosa, Department of Internal Medicine - DIMED , University of Padova , Padua , Italy
| | - Martino F Pengo
- b Hypertension Unit, Ospedale S. Bortolo , University of Padova , Vicenza , Italy
| | - Andrea De Vito
- c Special Surgery Department, Head and Neck Department , Ear-Nose-Throat Unit, Morgagni-Pierantoni Hospital , Forlì , Italy
| | - Giuseppe Maiolino
- a Clinica dell'Ipertensione Arteriosa, Department of Internal Medicine - DIMED , University of Padova , Padua , Italy
| | - Gian Paolo Rossi
- a Clinica dell'Ipertensione Arteriosa, Department of Internal Medicine - DIMED , University of Padova , Padua , Italy
| | - John Moxham
- d King's College London , Faculty of Life Sciences and Medicine , London , UK
| | - Joerg Steier
- d King's College London , Faculty of Life Sciences and Medicine , London , UK.,e Guy's and St Thomas' NHS Foundation Trust , Lane Fox Respiratory Unit/Sleep Disorders Centre , London , UK
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6
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Effect of surface neuromuscular electrical stimulation on labial and lingual muscles in healthy volunteers. Int J Rehabil Res 2017; 40:119-126. [DOI: 10.1097/mrr.0000000000000217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Njoh AA, Mbong EN, Mbi VO, Mengnjo MK, Nfor LN, Ngarka L, Chokote SE, Fonsah JY, Kingue S, Ntone FE, Njamnshi AK. Likelihood of obstructive sleep apnea in people living with HIV in Cameroon – preliminary findings. SLEEP SCIENCE AND PRACTICE 2017. [DOI: 10.1186/s41606-016-0003-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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8
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Schwartz AR. Hypoglossal nerve stimulation--optimizing its therapeutic potential in obstructive sleep apnea. J Neurol Sci 2014; 346:1-3. [PMID: 25190292 DOI: 10.1016/j.jns.2014.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 08/16/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Alan R Schwartz
- Division of Pulmonary, Critical Care and Sleep Medicine, Johns Hopkins School of Medicine, USA; Johns Hopkins Sleep Disorders Center (Bayview Campus), USA; Center for Interdisciplinary Sleep Research and Education, USA; Johns Hopkins Sleep Medicine Fellowship Training Program, USA.
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9
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Horner RL. Neural control of the upper airway: integrative physiological mechanisms and relevance for sleep disordered breathing. Compr Physiol 2013; 2:479-535. [PMID: 23728986 DOI: 10.1002/cphy.c110023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The various neural mechanisms affecting the control of the upper airway muscles are discussed in this review, with particular emphasis on structure-function relationships and integrative physiological motor-control processes. Particular foci of attention include the respiratory function of the upper airway muscles, and the various reflex mechanisms underlying their control, specifically the reflex responses to changes in airway pressure, reflexes from pulmonary receptors, chemoreceptor and baroreceptor reflexes, and postural effects on upper airway motor control. This article also addresses the determinants of upper airway collapsibility and the influence of neural drive to the upper airway muscles, and the influence of common drugs such as ethanol, sedative hypnotics, and opioids on upper airway motor control. In addition to an examination of these basic physiological mechanisms, consideration is given throughout this review as to how these mechanisms relate to integrative function in the intact normal upper airway in wakefulness and sleep, and how they may be involved in the pathogenesis of clinical problems such obstructive sleep apnea hypopnea.
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10
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Pelteret JPV, Reddy BD. Development of a computational biomechanical model of the human upper-airway soft-tissues toward simulating obstructive sleep apnea. Clin Anat 2013; 27:182-200. [PMID: 24515574 DOI: 10.1002/ca.22313] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/27/2013] [Accepted: 07/27/2013] [Indexed: 11/11/2022]
Abstract
Numerous challenges are faced in investigations aimed at developing a better understanding of the pathophysiology of obstructive sleep apnea (OSA). The anatomy of the tongue and other upper-airway tissues, and the ability to model their behavior, are central to such investigations. We present details of the construction and development of a soft-tissue model of the human upper airway, with the ultimate goal of simulating obstructive sleep apnea. The steps taken to produce a representative anatomical geometry, of which the associated muscle histology is also captured, are documented. An overview of the mathematical models used to describe tissue behavior, both at a macro- and microscopic level, is given. A neurological model, which mimics the proprioceptive capabilities of the body, is described as it is applies to control of the active dynamics of the tongue. A simplified scenario, which allows for the manipulation of several environmental influences, is presented. It is demonstrated that the response of the genioglossus is qualitatively similar to that determined through experimental techniques. Furthermore, insights into the stress distribution developed within the tongue are discussed. It is shown that changes in almost any aspect of the breathing or physiological conditions invoke a significant change in the response of the airway dilators. The results of this study provide further evidence of the importance of modeling and simulation techniques as an aid in understanding the complex behavior of the human body.
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Affiliation(s)
- Jean-Paul V Pelteret
- Centre for Research in Computational and Applied Mechanics, University of Cape Town, Cape Town, Western Cape, South Africa
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11
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Schwartz AR, Smith PL, Oliven A. Electrical stimulation of the hypoglossal nerve: a potential therapy. J Appl Physiol (1985) 2013; 116:337-44. [PMID: 23813525 DOI: 10.1152/japplphysiol.00423.2013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Obstructive sleep apnea is characterized by recurrent episodes of pharyngeal collapse, which result from a decrease in pharyngeal dilator muscle tone. The genioglossus is a major pharyngeal dilator that maintains airway patency during sleep. Early studies in animal and humans have demonstrated that electrical stimulation of this muscle reduces pharyngeal collapsibility, increases airflow, and mitigates obstructive sleep apnea. These findings impelled the development of fully implantable hypoglossal nerve stimulating systems (HGNS), for which feasibility trial results are now available. These pilot studies have confirmed that hypoglossal nerve stimulation can prevent pharyngeal collapse without arousing patients from sleep. Potentially, a substantial segment of the patient population with obstructive sleep apnea can be treated with this novel approach. Furthermore, the feasibility trial findings suggest that the therapeutic potential of HGNS can be optimized by selecting patients judiciously, titrating the stimulus intensity optimally, and characterizing the underlying function and anatomy of the pharynx. These strategies are currently being examined in ongoing pivotal trials of HGNS.
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Affiliation(s)
- Alan R Schwartz
- Johns Hopkins Sleep Disorders Center, Johns Hopkins School of Medicine, Baltimore, Maryland
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12
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Jafari B, Roux F. Non-positive airway pressure therapy for obstructive sleep apnea. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13665-012-0016-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Isono S. Obesity and obstructive sleep apnoea: mechanisms for increased collapsibility of the passive pharyngeal airway. Respirology 2012; 17:32-42. [PMID: 22023094 DOI: 10.1111/j.1440-1843.2011.02093.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Epidemiological evidence suggests there are significant links between obesity and obstructive sleep apnoea (OSA), with a particular emphasis on the importance of fat distribution in the development of OSA. In patients with OSA, the structure of the pharyngeal airway collapses. A collapsible tube within a rigid box collapses either due to decreased intraluminal pressure or increased external tissue pressure (i.e. reduction in transmural pressure), or due to reduction in the longitudinal tension of the tube. Accordingly, obesity should structurally increase the collapsibility of the pharyngeal airway due to excessive fat deposition at two distinct locations. In the pharyngeal airway region, excessive soft tissue for a given maxillomandibular enclosure size (upper airway anatomical imbalance) can increase tissue pressure surrounding the pharyngeal airway, thereby narrowing the airway. Even mild obesity may cause anatomical imbalance in individuals with a small maxilla and mandible. Lung volume reduction due to excessive central fat deposition may decrease longitudinal tracheal traction forces and pharyngeal wall tension, changing the 'tube law' in the pharyngeal airway (lung volume dependence of the upper airway). The lung volume dependence of pharyngeal airway patency appears to contribute more significantly to the development of OSA in morbidly obese, apnoeic patients. Neurostructural interactions required for stable breathing may be influenced by obesity-related hormones and cytokines. Accumulating evidence strongly supports these speculations, but further intensive research is needed.
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Affiliation(s)
- Shiroh Isono
- Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan.
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14
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Oliven A, Kaufman E, Kaynan R, Oliven R, Steinfeld U, Tov N, Odeh M, Gaitini L, Schwartz AR, Kimmel E. Mechanical parameters determining pharyngeal collapsibility in patients with sleep apnea. J Appl Physiol (1985) 2010; 109:1037-44. [DOI: 10.1152/japplphysiol.00019.2010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The relative impact of mechanical factors on pharyngeal patency in patients with obstructive sleep apnea is poorly understood. The present study was designed to evaluate parameters of the “tube law” on pharyngeal pressure-flow relationships and collapsibility in patients with obstructive sleep apnea. We developed a mathematical model that considered the collapsible segment of the pharynx to represent an orifice of varying diameter. The model enabled us to assess the effects of pharyngeal compliance ( C), neutral cross-sectional area ( A o), external peripharyngeal pressure (Pex), and the resistance proximal to the site of collapse on flow mechanics and pharyngeal collapsibility [critical pressure (Pcrit)]. All parameters were measured in 15 patients with obstructive sleep apnea under propofol anesthesia, both at rest and during mandibular advancement and electrical stimulation of the genioglossus. The data was used both to confirm the validity of the model and to compare expected and actual relationships between the tube-law parameters and the pharyngeal pressure-flow relationship and collapsibility. We found a close correlation between predicted and measured Pcrit ( R = 0.98), including changes observed during pharyngeal manipulations. C and A o were closely and directly interrelated ( R = 0.93) and did not correlate with Pcrit. A significant correlation was found between Pex and Pcrit ( R = 0.77; P < 0.01). We conclude that the pharynx of patients with obstructive sleep apnea can be modeled as an orifice with varying diameter. Pharyngeal compliance and A o are closely interrelated. Pharyngeal collapsibility depends primarily on the surrounding pressure.
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Affiliation(s)
| | - Eran Kaufman
- Faculty of Biomedical Engineering, Technion, Haifa, Israel; and
| | - Rotem Kaynan
- Faculty of Biomedical Engineering, Technion, Haifa, Israel; and
| | | | | | | | | | - Luis Gaitini
- Anesthesiology, Bnai-Zion Medical Center, Technion, Haifa
| | | | - Eitan Kimmel
- Faculty of Biomedical Engineering, Technion, Haifa, Israel; and
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15
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Valbuza JS, de Oliveira MM, Conti CF, Prado LBF, de Carvalho LBC, do Prado GF. Methods for increasing upper airway muscle tonus in treating obstructive sleep apnea: systematic review. Sleep Breath 2010; 14:299-305. [PMID: 20563659 DOI: 10.1007/s11325-010-0377-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 05/24/2010] [Accepted: 05/26/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment of obstructive sleep apnea (OSA) using methods for increasing upper airway muscle tonus has been controversial and poorly reported. Thus, a review of the evidence is needed to evaluate the effectiveness of these methods. DESIGN The design used was a systematic review of randomized controlled trials. DATA SOURCES Data sources are from the Cochrane Library, Medline, Embase and Scielo, registries of ongoing trials, theses indexed at Biblioteca Regional de Medicina/Pan-American Health Organization of the World Health Organization and the reference lists of all the trials retrieved. REVIEW METHODS This was a review of randomized or quasi-randomized double-blind trials on OSA. Two reviewers independently applied eligibility criteria. One reviewer assessed study quality and extracted data, and these processes were checked by a second reviewer. The primary outcome was a decrease in the apnea/hypopnea index (AHI) of below five episodes per hour. Other outcomes were subjective sleep quality, sleep quality measured by night polysomnography, quality of life measured subjectively and adverse events associated with the treatments. DATA SYNTHESIS Three eligible trials were included. Two studies showed improvements through the objective and subjective analyses, and one study showed improvement of snoring, but not of AHI while the subjective analyses showed no improvement. The adverse events were reported and they were not significant. CONCLUSIONS There is no accepted scientific evidence that methods aiming to increase muscle tonus of the stomatognathic system are effective in reducing AHI to below five events per hour. Well-designed randomized controlled trials are needed to assess the efficacy of such methods.
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Affiliation(s)
- Juliana Spelta Valbuza
- Department of Emergency Medicine and Evidence-Based Medicine, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Sao Paulo, Brazil.
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16
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Saboisky JP, Chamberlin NL, Malhotra A. Potential therapeutic targets in obstructive sleep apnoea. Expert Opin Ther Targets 2009; 13:795-809. [PMID: 19530985 DOI: 10.1517/14728220903005608] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Obstructive sleep apnoea (OSA) is a disease of ever-increasing importance due to its association with multiple impairments and rising prevalence in an increasingly susceptible demographic. The syndrome is linked with loud snoring, disrupted sleep and observed apnoeas. Serious co-morbidities associated with OSA appear to be reversed by continuous positive airway pressure (CPAP) treatment; however, CPAP is variably tolerated leaving many patients untreated and emphasising the need for alternative treatments. Virtually all OSA patients have airways that are anatomically vulnerable to collapse, but numerous pathophysiological factors underlie when and how OSA is manifested. This review describes how the complexity of OSA requires multiple treatment approaches that are individually targeted. This approach may take the form of more specific diagnoses in terms of the mechanisms underlying OSA as well as rational pharmacological treatment directed toward such disparate ends as arousal threshold and ventilatory control/chemosensitivity, and mechanical treatment in the form of surgery and augmentation of lung volumes.
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Affiliation(s)
- Julian P Saboisky
- Brigham and Women's Hospital, Harvard Medical School, Division of Sleep Medicine, 221 Longwood Avenue, Boston, Massachusetts 02115, USA.
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17
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Kairaitis K, Verma M, Fish V, Wheatley JR, Amis TC. Pharyngeal muscle contraction modifies peri-pharyngeal tissue pressure in rabbits. Respir Physiol Neurobiol 2009; 166:95-101. [DOI: 10.1016/j.resp.2009.02.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 02/05/2009] [Accepted: 02/18/2009] [Indexed: 12/14/2022]
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18
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McGinley BM, Schwartz AR, Schneider H, Kirkness JP, Smith PL, Patil SP. Upper airway neuromuscular compensation during sleep is defective in obstructive sleep apnea. J Appl Physiol (1985) 2008; 105:197-205. [PMID: 18403451 DOI: 10.1152/japplphysiol.01214.2007] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Obstructive sleep apnea is the result of repeated episodes of upper airway obstruction during sleep. Recent evidence indicates that alterations in upper airway anatomy and disturbances in neuromuscular control both play a role in the pathogenesis of obstructive sleep apnea. We hypothesized that subjects without sleep apnea are more capable of mounting vigorous neuromuscular responses to upper airway obstruction than subjects with sleep apnea. To address this hypothesis we lowered nasal pressure to induce upper airway obstruction to the verge of periodic obstructive hypopneas (cycling threshold). Ten patients with obstructive sleep apnea and nine weight-, age-, and sex-matched controls were studied during sleep. Responses in genioglossal electromyography (EMG(GG)) activity (tonic, peak phasic, and phasic EMG(GG)), maximal inspiratory airflow (V(I)max), and pharyngeal transmural pressure (P(TM)) were assessed during similar degrees of sustained conditions of upper airway obstruction and compared with those obtained at a similar nasal pressure under transient conditions. Control compared with sleep apnea subjects demonstrated greater EMG(GG), V(I)max, and P(TM) responses at comparable levels of mechanical and ventilatory stimuli at the cycling threshold, during sustained compared with transient periods of upper airway obstruction. Furthermore, the increases in EMG(GG) activity in control compared with sleep apnea subjects were observed in the tonic but not the phasic component of the EMG response. We conclude that sustained periods of upper airway obstruction induce greater increases in tonic EMG(GG), V(I)max, and P(TM) in control subjects. Our findings suggest that neuromuscular responses protect individuals without sleep apnea from developing upper airway obstruction during sleep.
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Affiliation(s)
- Brian M McGinley
- Johns Hopkins Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
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19
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Fregosi RF. Influence of tongue muscle contraction and dynamic airway pressure on velopharyngeal volume in the rat. J Appl Physiol (1985) 2008; 104:682-93. [DOI: 10.1152/japplphysiol.01043.2007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The mammalian pharynx is a collapsible tube that narrows during inspiration as transmural pressure becomes negative. The velopharynx (VP), which lies posterior to the soft palate, is considered to be one of the most collapsible pharyngeal regions. I tested the hypothesis that negative transmural pressure would narrow the VP, and that electrical stimulation of extrinsic tongue muscles would reverse this effect. Pressure (−6, −3, 3, and 6 cmH2O) was applied to the isolated pharyngeal airway of anesthetized rats that were positioned in a 4.7-T MRI scanner. The volume of eight axial slices encompassing the length of the VP was computed at each level of pressure, with and without bilateral hypoglossal nerve stimulation (0.1-ms pulse, one-third maximum force, 80 Hz). Negative pressure narrowed the VP, and either whole hypoglossal nerve stimulation (coactivation of protrudor and retractor muscles) or medial nerve branch stimulation (independent activation of tongue protrudor muscles) reversed this effect, with the greatest impact in the caudal one-third of the VP. The dilating effects of medial branch stimulation were slightly larger than whole nerve stimulation. Positive pressure dilated the VP, but tongue muscle contraction did not cause further dilation under these conditions. I conclude that the narrowest and most collapsible segment of the rat pharynx is in the caudal VP, posterior to the tip of the soft palate. Either coactivation of protrudor and retractor muscles or independent contraction of protrudor muscles caused dilation of this region, but the latter was slightly more effective.
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20
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Oliven A, Odeh M, Geitini L, Oliven R, Steinfeld U, Schwartz AR, Tov N. Effect of coactivation of tongue protrusor and retractor muscles on pharyngeal lumen and airflow in sleep apnea patients. J Appl Physiol (1985) 2007; 103:1662-8. [PMID: 17673558 DOI: 10.1152/japplphysiol.00620.2007] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present study evaluated the effect of coactivation of tongue protrusors and retractors on pharyngeal patency in patients with obstructive sleep apnea. The effect of genioglossus (GG), hyoglossus (HG), and coactivation of both on nasal pressure (Pn):flow relationships was evaluated in a sleep study (SlS, n = 7) and during a propofol anesthesia study (AnS, n = 7). GG was stimulated with sublingual surface electrodes in SlS and with intramuscular electrodes in AnS, while HG was stimulated with surface electrodes in both groups. In the AnS, the cross-sectional area (CSA):Pn relationships was measured with a pharyngoscope to estimate velopharyngeal compliance . In the SlS, surface stimulation of GG had no effect on the critical pressure (Pcrit), HG increased Pcrit from 2.8 +/- 1.7 to 3.7 +/- 1.6 cmH(2)O, but coactivation lowered Pcrit to 0.2 +/- 1.9 cmH(2)O (P < 0.01 for both). In the AnS, intramuscular stimulation of GG lowered Pcrit from 2.6 +/- 1.3 to 1.0 +/- 2.8 cmH(2)O, HG increased Pcrit to 6.2 +/- 2.5 cmH(2)O (P < 0.01), and coactivation had a similar effect to that of GG (Pcrit = 1.2 +/- 2.4 cmH(2)O, P < 0.05). None of the interventions affected significantly velopharyngeal compliance. We conclude that the beneficial effect of coactivation depends on the pattern of GG fiber recruitment: although surface stimulation of GG failed to protrude the tongue, it prevented the occlusive effect of the retractor, thereby improving pharyngeal patency during coactivation. Stimulation of deeper GG fibers with intramuscular electrodes enlarged the pharynx, and coactivation had no additive effect.
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Affiliation(s)
- Arie Oliven
- Dept. of Internal Medicine, Bnai Zion Medical Center, Technion, 47 Golomb St., Haifa, Israel.
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Isono S. Optimal combination of head, mandible and body positions for pharyngeal airway maintenance during perioperative period: lesson from pharyngeal closing pressures. ACTA ACUST UNITED AC 2007. [DOI: 10.1053/j.sane.2007.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Brennick MJ, Gefter WB, Margulies SS. Mechanical effects of genioglossus muscle stimulation on the pharyngeal airway by MRI in cats. Respir Physiol Neurobiol 2006; 156:154-64. [PMID: 17005455 DOI: 10.1016/j.resp.2006.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Revised: 08/22/2006] [Accepted: 08/22/2006] [Indexed: 10/24/2022]
Abstract
To examine the regional mechanical effects of selective genioglossus muscle activation on pharyngeal airway size and function, magnetic resonance images of the pharyngeal airway were obtained in five paralyzed, anesthetized cats over a range of positive and negative pressures in an isolated, sealed upper airway. When all results across pressure levels and pharyngeal regions were analyzed, genioglossus stimulation significantly increased the cross-sectional area (CSA) of the nasopharyngeal airway. Within specific regions, stimulation tended toward significantly increasing cross-sectional airway area in the mid-nasopharynx. Despite its dilating effect, genioglossus muscle stimulation did not alter compliance in the nasopharyngeal airway, as evidenced by the similar slopes of the pressure versus cross-sectional area relationships with and without stimulation. Finally, airway shape in the mid pharynx became more circular with either increased airway pressure or genioglossus stimulation. The results indicate that selective stimulation of the genioglossus muscle dilates the nasopharynx and provide evidence that stimulation of the genioglossus alone does not alter airway compliance.
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Affiliation(s)
- Michael J Brennick
- Center for Sleep and Respiratory Neurobiology, Department of Medicine, University of Pennsylvania, 991 Maloney Building, 3600 Spruce Street, Philadelphia, PA 19104, United States.
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Randerath W, Bauer M, Blau A, Fietze I, Galetke W, Hein H, Maurer JT, Orth M, Rasche K, Ruhle KH, Sanner B, Stuck BA, Verse T. Stellenwert der Nicht-nCPAP-Verfahren in der Therapie des obstruktiven Schlafapnoe-Syndroms. Relevance of Non-CPAP Treatment Options in the Therapy of the Obstructive Sleep Apnoea Syndrome. SOMNOLOGIE 2006. [DOI: 10.1111/j.1439-054x.2006.00082.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stellenwert der Nicht-nCPAP-Verfahren in der Therapie des obstruktiven Schlafapnoe-Syndroms. SOMNOLOGIE 2006. [DOI: 10.1007/j.1439-054x.2006.00082.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- S H Launois
- Laboratoire Hypoxie PhysioPathologie, Université Joseph Fourier, CHU de Grenoble, Grenoble, France.
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Oliven A, O'Hearn DJ, Boudewyns A, Odeh M, De Backer W, van de Heyning P, Smith PL, Eisele DW, Allan L, Schneider H, Testerman R, Schwartz AR. Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol (1985) 2004; 95:2023-9. [PMID: 14555669 DOI: 10.1152/japplphysiol.00203.2003] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Contraction of the genioglossus (GG) has been shown to improve upper airway patency. In the present study, we evaluated responses in upper airway pressure-flow relationships during sleep to electrical stimulation (ES) of the GG in patients with obstructive sleep apnea. Five patients with chronically implanted hypoglossal nerve (HG) electrodes and nine patients with fine-wire electrodes inserted into the GG were studied. Airflow was measured at multiple levels of nasal pressure, and upper airway collapsibility was defined by the nasal pressure below which airflow ceased ["critical" pressure (Pcrit)]. ES shifted the pressure-flow relationships toward higher flow levels in all patients over the entire range of nasal pressure applied. Pcrit decreased similarly during both HG-ES and GG-ES (deltaPcrit was 3.98 +/- 2.31 and 3.18 +/- 1.70 cmH2O, respectively) without a significant change in upstream resistance. The site of collapse (velo- vs. oropharynx) did not influence the response to GG-ES. Moreover, ES-induced reductions in the apnea-hypopnea index of the HG-ES patients were associated with substantial decreases in Pcrit. Our findings imply that responses in apnea severity to HG-ES can be predicted by characterizing the patient's baseline pressure-flow relationships and response to GG-ES.
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Affiliation(s)
- Arie Oliven
- Department of Medicine B, Bnai Zion Medical Center, Technion, Haifa 31048, Israel.
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Randerath WJ, Galetke W, Domanski U, Weitkunat R, Ruhle KH. Zungenmuskeltraining durch Elektrostimulation in der Therapie des obstruktiven Schlafapnoesyndroms. Tongue muscle training by electrical neurostimulation in the treatment of obstructive sleep apnoea syndrome. SOMNOLOGIE 2004. [DOI: 10.1111/j.1439-054x.2003.00012.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bailey EF, Fregosi RF. Pressure-volume behaviour of the rat upper airway: effects of tongue muscle activation. J Physiol 2003; 548:563-8. [PMID: 12640023 PMCID: PMC2342843 DOI: 10.1113/jphysiol.2002.029298] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Our hypothesis was that the simultaneous activation of tongue protrudor and retractor muscles (co-activation) would constrict and stiffen the pharyngeal airway more than the independent activation of tongue protrudor muscles. Upper airway stiffness was determined by injecting known volumes of air into the sealed pharyngeal airway of the anaesthetized rat while measuring nasal pressure under control (no-stimulus) and stimulus conditions (volume paired with hypoglossal (XII) nerve stimulation). Stimulation of the whole XII nerves (co-activation) or the medial XII branches (protrudor activation) effected similar increases in total pharyngeal airway stiffness. Importantly, co-activation produced volume compression (airway narrowing) at large airway volumes (P < 0.05), but had no effect on airway dimension at low airway volumes. In comparison, protrudor activation resulted in significant volume expansion (airway dilatation) at low airway volumes and airway narrowing at high airway volumes (P < 0.05). In conclusion, both co-activation and independent protrudor muscle activation increase airway stiffness. However, their effects on airway size are complex and depend on the condition of the airway at the time of activation.
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Affiliation(s)
- E Fiona Bailey
- Department of Physiology, College of Medicine, The University of Arizona, Tucson 85721-0093, USA.
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Kuna ST, Brennick MJ. Effects of pharyngeal muscle activation on airway pressure-area relationships. Am J Respir Crit Care Med 2002; 166:972-7. [PMID: 12359656 DOI: 10.1164/rccm.200203-214oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fiberoptic imaging in an isolated, sealed upper airway was performed in 10 decerebrate cats to determine the effect of pharyngeal muscle activation on airway pressure-area relationships. Bilateral cuff electrodes stimulated the distal cut ends of the following nerves: medial and lateral hypoglossus, glossopharyngeus, and pharyngeal branch of vagus. At given intraluminal pressures ranging from +6 to -6 cm H2O, cross-sectional area was measured in the rostral oropharynx, velopharynx, and caudal oropharynx, with and without nerve stimulation. A mixed model analysis of variance indicated a relatively constant increase in area across the pressure range with glossopharyngeal stimulation at any given level. Significant interactions between pressure and stimulation were present in the rostral oropharynx with medial hypoglossus stimulation and in the caudal oropharynx with independent and combined hypoglossal branch stimulation and pharyngeal branch of vagus stimulation. With stimulation of the hypoglossal nerves, greater increases in area in these regions occurred in the lower pressure ranges. Stimulation of the pharyngeal branch of the vagus caused a greater decrease in area at the higher pressure ranges in the caudal oropharynx and velopharynx. The results indicate that the mechanical effects of pharyngeal muscle activation depend not only on the region and muscles activated but also on the intraluminal pressure.
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Affiliation(s)
- Samuel T Kuna
- Pulmonary, Allergy, and Critical Care Division, Department of Internal Medicine and Center for Sleep and Respiratory Neurobiology, University of Pennsylvania, Philadelphia, PA, USA.
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Garrigue S, Bordier P, Jaïs P, Shah DC, Hocini M, Raherison C, Tunon De Lara M, Haïssaguerre M, Clementy J. Benefit of atrial pacing in sleep apnea syndrome. N Engl J Med 2002; 346:404-12. [PMID: 11832528 DOI: 10.1056/nejmoa011919] [Citation(s) in RCA: 253] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many patients with sleep apnea syndrome have nocturnal bradycardia, paroxysmal tachyarrhythmias, or both, which can be prevented by permanent atrial pacing. We evaluated the effect of using cardiac pacing to increase the heart rate during sleep in patients with sleep apnea syndrome. METHODS We studied 15 patients (11 men and 4 women; mean [+/-SD] age, 69+/-9 years) with central or obstructive sleep apnea who had received permanent atrial-synchronous ventricular pacemakers for symptomatic sinus bradycardia. All patients underwent three polysomnographic evaluations on consecutive nights, the first night for base-line evaluation and then, in random order, one night in spontaneous rhythm and one in dual-chamber pacing mode with atrial overdrive (basic rate, 15 beats per minute faster than the mean nocturnal sinus rate). The total duration and number of episodes of central or obstructive sleep apnea or hypopnea were analyzed and compared. RESULTS The mean 24-hour sinus rate during spontaneous rhythm was 57 +/- 5 beats per minute at base line, as compared with 72 +/- 3 beats per minute with atrial overdrive pacing (P<0.001). The total duration of sleep was 321 +/- 49 minutes in spontaneous rhythm, as compared with 331 +/- 46 minutes with atrial overdrive pacing (P=0.48). The hypopnea index (the total number of episodes of hypopnea divided by the number of hours of sleep) was reduced from 9 +/- 4 in spontaneous rhythm to 3 +/-3 with atrial overdrive pacing (P<0.001). For both apnea and hypopnea, the value for the index was 28 +/- 22 in spontaneous rhythm, as compared with 11 +/- 14 with atrial overdrive pacing (P<0.001). CONCLUSIONS In patients with sleep apnea syndrome, atrial overdrive pacing significantly reduces the number of episodes of central or obstructive sleep apnea without reducing the total sleep time.
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Affiliation(s)
- Stephane Garrigue
- Hôpital Cardiologique du Haut-Lévêque, University of Bordeaux, Bordeaux, France.
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Abstract
Fiberoptic imaging was performed in six decerebrate, tracheotomized cats to determine the effect of pharyngeal muscle activation on the pharyngeal airway. The fiberoptic scope was advanced through the rostral trachea into the pharynx. Computer-based planimetry was used to measure airway area and maximum anteroposterior and lateral diameters in the rostral oropharynx, velopharynx, and caudal oropharynx. Cuff electrodes stimulated the bilateral distal cut ends of the following nerves: medial hypoglossus (MHG), lateral hypoglossus (LHG), glossopharyngeus, and pharyngeal branch of vagus (PBV). The velopharyngeal area increased with stimulation of the MHG, MHG plus LHG, and glossopharyngeus. The velopharyngeal area decreased with PBV stimulation. Similar effects occurred in the caudal oropharynx. The percent increase in velopharyngeal area with combined MHG and LHG stimulation was greater than the sum of the increases stimulating either branch alone. In the rostral oropharynx, airway area increased with individual and combined stimulation of the MHG and LHG. Changes in airway area at the different levels were concentric with the HG stimulations, but glossopharyngeal stimulation resulted in a greater increase in lateral than anteroposterior wall movement. The results indicate that the mechanical effects of pharyngeal muscle contraction depend on the airway level and the specific muscles that are activated.
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Affiliation(s)
- S T Kuna
- Department of Internal Medicine, University of Pennsylvania and Philadelphia VAMC, Philadelphia, Pennsylvania 19104, USA.
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Oliven A, Schnall RP, Pillar G, Gavriely N, Odeh M. Sublingual electrical stimulation of the tongue during wakefulness and sleep. RESPIRATION PHYSIOLOGY 2001; 127:217-26. [PMID: 11504591 DOI: 10.1016/s0034-5687(01)00254-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pharyngeal obstruction in patients with obstructive sleep apnea (OSA) is thought to result from decreased upper airway muscle tone during sleep. The goal of the present study was to estimate the role of the tongue muscles in maintaining pharyngeal patency during sleep. Using non-invasive, sub-lingual surface electrical stimulation (ES), we measured tongue protrusion force during wakefulness and upper airway resistance during sleep in seven healthy subjects and six patients with OSA. During wakefulness, ES produced similar protrusion forces in healthy subjects and patients with OSA. ES of the anterior sublingual surface, causing preferential contraction of the genioglossus, resulted in smaller effects than combined ES of the anterior and lateral surface, which also stimulated tongue retractors. During sleep, trans-pharyngeal resistance decreased and peak inspiratory flow rate increased from 319+/-24 to 459+/-27 and from 58+/-16 to 270+/-35 ml/sec for healthy subjects and OSA patients, respectively (P<0.001). However, ES was usually unsuccessful in reopening the upper airway in the presence of complete apneas. We conclude that non-invasive ES of the tongue improves flow dynamics during sleep. Combined activation of tongue protrusors and retractors may have a beneficial mechanical effect. The magnitude of responses observed suggests that in addition to the stimulated muscles, other muscles and/or forces have a substantial impact on pharyngeal patency.
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Affiliation(s)
- A Oliven
- Department of Internal Medicine B, Bnai Zion Medical Center, Golomb Str. 47, 31048, Haifa, Israel.
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