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Brooker EJ, Landry SA, Mann D, Prguda E, McLeay SC, Drummond SPA, Edwards BA. The obstructive sleep apnoea endotypes are similar in elderly trauma-exposed veterans with and without diagnosed PTSD. Sleep Med 2024; 115:48-54. [PMID: 38330695 DOI: 10.1016/j.sleep.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Approximately 60% of veterans living with posttraumatic stress disorder (PTSD) experience obstructive sleep apnoea (OSA). Why OSA is so prevalent in individuals with PTSD remains unknown, though PTSD may influence the underlying endotypes known to cause OSA. We examined whether these endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) differ between those with comorbid OSA and PTSD relative to their counterparts with OSA-only. METHODS Using the ventilatory flow pattern from diagnostic polysomnography, the OSA endotypes were measured in a retrospective cohort of 21 OSA patients with PTSD and 27 OSA-only patients. All participants were trauma exposed elderly male Australian Vietnam War veterans with mild-to-severe OSA (median Apnoea-Hypopnea index: 20.2 vs. 23.6 events/h). Age and BMI were similar between groups (70.7 vs. 71.7 years, and 28.4 vs. 28.4 kg/m2). RESULTS There were no significant differences in the OSA endotype traits between PTSD + OSA and OSA-only patients for upper airway collapsibility (76.68 [71.53-83.56] vs. 78.35 [72.81-83.82] %Veupnea, median [IQR]), muscle compensation (4.27 [0.34-9.18] vs. 5.41 [1.83-7.21] %Veupnea), loop gain (0.56(0.17) vs. 0.60(0.14)), and arousal threshold (135.76 [126.59-147.54] vs. 146.95 [128.64-151.28] %Veupnea). CONCLUSION The OSA endotypes in veterans with PTSD were similar to their trauma exposed OSA-only counterparts. PTSD appears to exert little influence on the OSA endotypes beyond the effect that age and trauma exposure may have. The aetiology of increased prevalence of OSA in PTSD remains unclear. Further work examining OSA endotypes using larger and more diverse samples is needed before robust conclusions can be made.
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Affiliation(s)
- Elliot J Brooker
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, 3800, Australia
| | - Shane A Landry
- Biomedicine Discovery Institute, Department of Physiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Dwayne Mann
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Emina Prguda
- Gallipoli Medical Research Foundation, Brisbane, Queensland, 4120, Australia; The University of Queensland, Brisbane, Queensland, 4006, Australia
| | - Sarah C McLeay
- Gallipoli Medical Research Foundation, Brisbane, Queensland, 4120, Australia
| | - Sean P A Drummond
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, 3800, Australia
| | - Bradley A Edwards
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, 3800, Australia; Biomedicine Discovery Institute, Department of Physiology, Monash University, Clayton, Victoria, 3800, Australia.
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Sands SA, Collet J, Gell LK, Calianese N, Hess LB, Vena D, Azarbarzin A, Bertisch SM, Landry S, Thomson L, Joosten SA, Hamilton GS, Edwards BA. Combination pharmacological therapy targeting multiple mechanisms of sleep apnoea: a randomised controlled cross-over trial. Thorax 2024; 79:259-268. [PMID: 38286618 DOI: 10.1136/thorax-2023-220184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/23/2023] [Indexed: 01/31/2024]
Abstract
RATIONALE Acetazolamide and atomoxetine-plus-oxybutynin ('AtoOxy') can improve obstructive sleep apnoea (OSA) by stabilising ventilatory control and improving dilator muscle responsiveness respectively. Given the different pathophysiological mechanisms targeted by each intervention, we tested whether AtoOxy-plus-acetazolamide would be more efficacious than AtoOxy alone. METHODS In a multicentre randomised crossover trial, 19 patients with moderate-to-severe OSA received AtoOxy (80/5 mg), acetazolamide (500 mg), combined AtoOxy-plus-acetazolamide or placebo at bedtime for three nights (half doses on first night) with a 4-day washout between conditions. Outcomes were assessed at baseline and night 3 of each treatment period. Mixed model analysis compared the reduction in Apnoea-Hypopnoea Index (AHI) from baseline between AtoOxy-plus-acetazolamide and AtoOxy (primary outcome). Secondary outcomes included hypoxic burden and arousal index. RESULTS Although AtoOxy lowered AHI by 49 (33, 62)%baseline (estimate (95% CI)) vs placebo, and acetazolamide lowered AHI by+34 (14, 50)%baseline vs placebo, AtoOxy-plus-acetazolamide was not superior to AtoOxy alone (difference: -2 (-18, 11)%baseline, primary outcome p=0.8). Likewise, the hypoxic burden was lowered with AtoOxy (+58 (37, 71)%baseline) and acetazolamide (+37 (5, 58)%baseline), but no added benefit versus AtoOxy occurred when combined (difference: -13 (-5, 39)%baseline). Arousal index was also modestly reduced with each intervention (11%baseline-16%baseline). Mechanistic analyses revealed that similar traits (ie, higher baseline compensation, lower loop gain) were associated with both AtoOxy and acetazolamide efficacy. CONCLUSIONS While AtoOxy halved AHI, and acetazolamide lowered AHI by a third, the combination of these leading experimental interventions provided no greater efficacy than AtoOxy alone. Failure of acetazolamide to further increase efficacy suggests overlapping physiological mechanisms. TRIAL REGISTRATION NUMBER NCT03892772.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne M Bertisch
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shane Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Luke Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
- School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
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Edwards BA, O'Driscoll DM, Brooker EJ, Landry SA. A deep dive into the physiological differences responsible for obstructive sleep apnea between races. Sleep 2023; 46:zsad186. [PMID: 37429581 DOI: 10.1093/sleep/zsad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Bradley A Edwards
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Denise M O'Driscoll
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, VIC, Australia
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Elliot J Brooker
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
| | - Shane A Landry
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
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Landry SA, Beatty C, Thomson LDJ, Wong AM, Edwards BA, Hamilton GS, Joosten SA. A review of supine position related obstructive sleep apnea: Classification, epidemiology, pathogenesis and treatment. Sleep Med Rev 2023; 72:101847. [PMID: 37722317 DOI: 10.1016/j.smrv.2023.101847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023]
Abstract
Supine related obstructive sleep apnea (OSA) is the most common clinical and physiological phenotype of OSA. This condition is recognizable by patients, their families and through polysomnographic recordings. Commonly used definitions distinguish the presence of supine related OSA when respiratory events occur at twice the frequency when the patient lies in the supine compared to non-supine sleeping positions. Recent physiology studies have demonstrated that airway obstruction arises more commonly in the supine position particularly at the level of the soft palate and epiglottis. Increased airway collapsibility is reliability observed supine relative to lateral position. To a lesser extent, changes in control of breathing favour less stable ventilation when the supine sleeping posture is adopted. Many treatments have been developed and trialled to help patients avoid sleeping on their back. The last 10 years has seen the emergence of vibrotactile warning devices that are worn on the patients' neck or chest. High quality randomized controlled trial data is accumulating on the efficacy and common pitfalls of the application of these treatments.
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Affiliation(s)
- Shane A Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Caroline Beatty
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Ai-Ming Wong
- Royal Hobart Hospital (Tasmanian Health Service South), Hobart, Australia; Department of Medicine, University of Tasmania, Hobart, Australia; Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia; Monash Partners - Epworth, Victoria, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia; Monash Partners - Epworth, Victoria, Australia.
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Brooker EJ, Landry SA, Thomson LDJ, Hamilton GS, Genta PR, Drummond SPA, Edwards BA. Obstructive Sleep Apnea Is a Distinct Physiological Endotype in Individuals with Comorbid Insomnia and Sleep Apnea. Ann Am Thorac Soc 2023; 20:1508-1515. [PMID: 37390370 DOI: 10.1513/annalsats.202304-350oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/30/2023] [Indexed: 07/02/2023] Open
Abstract
Rationale: With up to 40% of individuals with either insomnia or obstructive sleep apnea (OSA) demonstrating clinically significant symptoms of the other disorder, the high degree of comorbidity among the two most common sleep disorders suggests a bidirectional relationship and/or shared underpinnings. Although the presence of insomnia disorder is believed to influence the underlying pathophysiology of OSA, this influence is yet to be examined directly. Objectives: To investigate whether the four OSA endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) are different in patients with OSA with and without comorbid insomnia disorder. Methods: Using the ventilatory flow pattern captured from routine polysomnography, the four OSA endotypes were measured in 34 patients with OSA who met the diagnostic criteria for insomnia disorder (COMISA) and 34 patients with OSA without insomnia (OSA only). Patients demonstrated mild-to-severe OSA (apnea-hypopnea index, 25.8 ± 2.0 events/h) and were individually matched according to age (50.2 ± 1.5 yr), sex (42 male: 26 female), and body mass index (29.3 ± 0.6 kg/m2). Results: Compared with patients with OSA without comorbid insomnia, patients with COMISA demonstrated significantly lower respiratory arousal thresholds (128.9 [118.1 to 137.1] vs. 147.7 [132.3 to 165.0] % eupneic ventilation ([Formula: see text]); U = 261; 95% confidence interval [CI], -38.3 to -13.9; d = 1.1; P < 0.001), less collapsible upper airways (88.2 [85.5 to 94.6] vs. 72.9 [64.7 to 79.2] %[Formula: see text]; U = 1081; 95% CI, 14.0 to 26.7; d = 2.3; P < 0.001), and more stable ventilatory control (i.e., lower loop gain: 0.51 [0.44 to 0.56] vs. 0.58 [0.49 to 0.70]; U = 402; 95% CI, -0.2 to -0.01; d = 0.05; P = 0.03). Muscle compensation was similar between groups. Moderated linear regression revealed that the arousal threshold moderated the relationship between collapsibility and OSA severity in patients with COMISA but not in patients with OSA only. Conclusions: A low arousal threshold is an overrepresented endotypic trait in individuals with COMISA and may exhibit a greater relative contribution to OSA pathogenesis in these patients. Contrastingly, the prevalence of a highly collapsible upper airway in COMISA was low, suggesting that anatomical predisposition may contribute less to OSA development in COMISA. Based on our findings, we theorize that conditioned hyperarousal perpetuating insomnia may translate to a reduced arousal threshold to respiratory events, thereby increasing the risk or severity of OSA. Therapies that target increased nocturnal hyperarousal (e.g., through cognitive behavior therapy for insomnia) may be effective in individuals with COMISA. Clinical trial registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12616000586415).
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Affiliation(s)
- Elliot J Brooker
- Turner Institute for Brain and Mental Health, School of Psychological Sciences
| | - Shane A Landry
- Biomedicine Discovery Institute, Department of Physiology, and
| | | | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Lung, Sleep, Allergy, and Immunology, Monash Health, Clayton, Victoria, Australia; and
| | - Pedro R Genta
- Laboratorio do Sono, LIM 63, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sean P A Drummond
- Turner Institute for Brain and Mental Health, School of Psychological Sciences
| | - Bradley A Edwards
- Turner Institute for Brain and Mental Health, School of Psychological Sciences
- Biomedicine Discovery Institute, Department of Physiology, and
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Hamilton GS, Edwards BA. The potential impact of GLP-1 agonists on obstructive sleep apnoea. Respirology 2023; 28:824-825. [PMID: 37419864 DOI: 10.1111/resp.14545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/09/2023]
Affiliation(s)
- Garun S Hamilton
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Biomedicine Discovery Institute, Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
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Day K, Nguo K, A Edwards B, M O'Driscoll D, C Young A, P Haines T, S Hamilton G, Ghazi L, Bristow C, Truby H. Body composition changes and their relationship with obstructive sleep apnoea symptoms, severity: The Sleeping Well Trial. Clin Nutr 2023; 42:1661-1670. [PMID: 37515844 DOI: 10.1016/j.clnu.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/12/2023] [Accepted: 07/07/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND & AIMS Obstructive sleep apnoea (OSA) and obesity share a complex bi-directional relationship as location of body fat and changes in regional body composition may be more important for OSA improvement than changes in total body weight only. The aim of this study was to evaluate the impact of a 6-month weight loss intervention for adults newly diagnosed with moderate-severe OSA and obesity on regional body composition. The secondary aims evaluated the relationship between changes in OSA symptoms and severity and anthropometry and regional body composition during the first 12-months after commencing CPAP and explored differences in outcomes between males and females. METHODS Participants (n = 59) received CPAP overnight at home alongside a 6-month modified fasting intervention with 12-months follow up. Regional body composition was measured by Dual X-ray absorptiometry, (DXA) and anthropometry before and after the lifestyle intervention. OSA severity was measured using the apnoea hypopnea index via overnight polysomnography and OSA symptoms were measured using the Epworth Sleepiness scale. RESULTS Forty-seven adults (74% male) had complete measures available with a mean age of 50.0 y (SD 11.0) and BMI 34.1 kg/m2 (SD 5.0). Following the intervention average fat mass changed by -5.27 kg (5.36), p < 0.001) and visceral adipose tissue (-0.63 kg (0.67), p < 0.001) significantly decreased in males only with a maintenance of fat-free mass (mean -0.41 kg (1.80), p = 0.18). Females (n = 12) had significant decreases in waist circumference (mean -3.36 cm (3.18) p < 0.01), android lean (-0.12 kg (0.04), p < 0.05) and android total mass (-0.28 kg (0.39), p < 0.05) only. Regional body composition changes in males were positively associated with improvements in OSA severity (p < 0.01) but not OSA symptoms. CONCLUSION Improvements in regional body composition were seen in males only which were related to improvements in OSA severity but not OSA symptoms. Females may exhibit different OSA pathophysiology and may require different treatment approaches. TRIAL REGISTRATION https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369975&isReview=trueAACTRN12616000203459 ACTRN12616000203459.
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Affiliation(s)
- Kaitlin Day
- School of Agriculture, Food and Ecosystem Sciences, Faculty of Science, The University of Melbourne, Australia; Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Monash University, Australia.
| | - Kay Nguo
- Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Monash University, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Australia; Department of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Australia
| | - Denise M O'Driscoll
- Department of Respiratory and Sleep Medicine, Eastern Health, Australia; Eastern Health Clinical School, Monash University, Australia
| | - Alan C Young
- Department of Respiratory and Sleep Medicine, Eastern Health, Australia; Eastern Health Clinical School, Monash University, Australia
| | - Terry P Haines
- School of Primary and Allied Health Care, Monash University, Australia
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Australia; Monash Lung, Sleep, Allergy and Immunology Department, Monash Health, Australia
| | - Ladan Ghazi
- Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Monash University, Australia
| | - Claire Bristow
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Helen Truby
- School of Human Movement and Nutrition Sciences, University of Queensland, Australia
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Joosten SA, Landry SA, Mann DL, Sands SA, Ryerson CJ, Sidhu C, Hamilton GS, Howard ME, Edwards BA, Khor YH. Understanding the Physiological Endotypes Responsible for Comorbid Obstructive Sleep Apnea in Patients with Interstitial Lung Disease. Am J Respir Crit Care Med 2023; 208:624-627. [PMID: 37311238 DOI: 10.1164/rccm.202301-0185le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/12/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
- Simon A Joosten
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences
- Epworth Partners, The University of Queensland, Richmond, Victoria, Australia
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Biomedicine Discovery Institute
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, and
| | - Dwayne L Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Queensland, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts
- The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Christopher J Ryerson
- Centre for Heart Lung Innovation and Department of Medicine, Providence Health Care and University of British Columbia, Vancouver, British Columbia, Canada
| | - Calvin Sidhu
- School of Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences
- Epworth Partners, The University of Queensland, Richmond, Victoria, Australia
| | - Mark E Howard
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, and
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia; and
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Biomedicine Discovery Institute
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, and
| | - Yet H Khor
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia; and
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Landry SA, Mann DL, Beare R, McIntyre R, Beatty C, Thomson LDJ, Collet J, Joosten SA, Hamilton GS, Edwards BA. Oronasal vs Nasal Masks: The Impact of Mask Type on CPAP Requirement, Pharyngeal Critical Closing Pressure (P crit), and Upper Airway Cross-Sectional Areas in Patients With OSA. Chest 2023; 164:747-756. [PMID: 36990149 DOI: 10.1016/j.chest.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/08/2023] [Accepted: 03/15/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND CPAP delivered via an oronasal mask is associated with lower adherence, higher residual apnea-hypopnea index (AHI), and increased CPAP therapeutic pressure compared with nasal masks. However, the mechanisms underlying the increased pressure requirements are not well understood. RESEARCH QUESTION How do oronasal masks affect upper airway anatomy and collapsibility? STUDY DESIGN AND METHODS Fourteen patients with OSA underwent a sleep study with both a nasal and oronasal mask, each for one-half of the night (order randomized). CPAP was manually titrated to determine therapeutic pressure. Upper airway collapsibility was assessed using the pharyngeal critical closing pressure (Pcrit) technique. Cine MRI was done to dynamically assess the cross-sectional area of the retroglossal and retropalatal airway throughout the respiratory cycle with each mask interface. Scans were repeated at 4 cm H2O and at the nasal and oronasal therapeutic pressures. RESULTS The oronasal mask was associated with higher therapeutic pressure requirements (ΔM ± SEM; +2.6 ± 0.5; P < .001) and higher Pcrit (+2.4 ± 0.5 cm H2O; P = .001) compared with the nasal mask. The change in therapeutic pressure between masks was strongly correlated with the change in Pcrit (r2 = 0.73; P = .003). Increasing CPAP increased both the retroglossal and retropalatal airway dimensions across both masks. After controlling for pressure and breath phase, the retropalatal cross-sectional area was moderately larger when using a nasal vs an oronasal mask (+17.2 mm2; 95% CI, 6.2-28.2, P < .001) while nasal breathing. INTERPRETATION Oronasal masks are associated with a more collapsible airway than nasal masks, which likely contributes to the need for a higher therapeutic pressure.
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Affiliation(s)
- Shane A Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.
| | - Dwayne L Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Richard Beare
- National Centre for Healthy Ageing and Peninsula Clinical School, Monash University, Melbourne, VIC, Australia; Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Richard McIntyre
- Monash Biomedical Imaging, Monash University, Melbourne, VIC, Australia; Monash Imaging, Monash Health, Clayton, VIC, Australia
| | - Caroline Beatty
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Monash Partners-Epworth, Clayton, VIC, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Monash Partners-Epworth, Clayton, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
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Sands SA, Edwards BA. Pro: can physiological risk factors for obstructive sleep apnea be determined by analysis of data obtained from routine polysomnography? Sleep 2023; 46:zsac310. [PMID: 36715219 PMCID: PMC10171624 DOI: 10.1093/sleep/zsac310] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
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Edwards BA, Joosten SA. Variability in the response to atomoxetine and oxybutynin for OSA: Highlighting the need for personalized medicine. Respirology 2023; 28:215-216. [PMID: 36257913 DOI: 10.1111/resp.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners - Epworth, Melbourne, Victoria, Australia
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12
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Mammel DM, Carroll JL, Warner BB, Edwards BA, Mann DL, Wallendorf MJ, Hoffmann JA, Conklin CM, Pyles H, Kemp JS. Quantitative and Qualitative Changes in Peripheral Chemoreceptor Activity in Preterm Infants. Am J Respir Crit Care Med 2023; 207:594-601. [PMID: 36173816 DOI: 10.1164/rccm.202206-1033oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Preterm infants are at risk for ventilatory control instability that may be due to aberrant peripheral chemoreceptor activity. Although term infants have increasing peripheral chemoreceptor contribution to overall ventilatory drive with increasing postnatal age, how peripheral chemoreceptor contribution changes in preterm infants with increasing postmenstrual age is not known. Objectives: To evaluate peripheral chemoreceptor activity between 32 and 52 weeks postmenstrual age in preterm infants, using both quantitative and qualitative measures. Methods: Fifty-five infants born between 24 weeks, 0 days gestation and 28 weeks, 6 days gestation underwent hyperoxic testing at one to four time points between 32 and 52 weeks postmenstrual age. Quantitative [Formula: see text] decreases were calculated, and qualitative responses were categorized as apnea, continued breathing with a clear reduction in [Formula: see text], sigh breaths, and no response. Measurements and Main Results: A total of 280 hyperoxic tests were analyzed (2.2 ± 0.3 tests per infant at each time point). Mean peripheral chemoreceptor contribution to ventilatory drive was 85.2 ± 20.0% at 32 weeks and 64.1 ± 22.0% at 52 weeks. Apneic responses were more frequent at earlier postmenstrual ages. Conclusions: Among preterm infants, the peripheral chemoreceptor contribution to ventilatory drive was greater at earlier postmenstrual ages. Apnea was a frequent response to hyperoxic testing at earlier postmenstrual ages, suggesting high peripheral chemoreceptor activity. A clearer description of how peripheral chemoreceptor activity changes over time in preterm infants may help explain how ventilatory control instability contributes to apnea and sleep-disordered breathing later in childhood. Clinical trial registered with www.clinicaltrials.gov (NCT03464396).
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Affiliation(s)
| | - John L Carroll
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Biomedicine Discovery Institute, and.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Dwayne L Mann
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Biomedicine Discovery Institute, and.,Institute for Social Science Research, The University of Queensland, Brisbane, Queensland, Australia; and
| | - Michael J Wallendorf
- Division of Statistics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Cameron M Conklin
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, and
| | - Harley Pyles
- St. Louis Children's Hospital, St. Louis, Missouri
| | - James S Kemp
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, and
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13
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Edwards BA, Jordan AS, Schmickl CN, Owens RL. POINT:: Are OSA Phenotypes Clinically Useful? Yes. Chest 2023; 163:25-28. [PMID: 36628670 DOI: 10.1016/j.chest.2022.08.2235] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/31/2022] [Accepted: 08/05/2022] [Indexed: 01/10/2023] Open
Affiliation(s)
| | - Amy S Jordan
- University of Melbourne, Melbourne, VIC, Australia
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14
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Edwards BA, Joosten SA. Understanding the links between snoring, OSA and aortic root pathologies in Marfan syndrome. Sleep Biol Rhythms 2023; 21:5-6. [PMID: 38468907 PMCID: PMC10899979 DOI: 10.1007/s41105-022-00432-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bradley A. Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC Australia
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC Australia
| | - Simon A. Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC Australia
- School of Clinical Sciences, Monash University, Melbourne, VIC Australia
- Monash Partners–Epworth, Victoria, Australia
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15
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Edwards BA, Jordan AS, Schmickl CN, Owens RL. Rebuttal From Dr Edwards et al. Chest 2023; 163:32-33. [PMID: 36628673 DOI: 10.1016/j.chest.2022.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/31/2022] [Accepted: 07/27/2022] [Indexed: 01/11/2023] Open
Affiliation(s)
| | - Amy S Jordan
- University of Melbourne, Melbourne, VIC, Australia
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16
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Truby H, Edwards BA, Day K, O'Driscoll DM, Young A, Ghazi L, Bristow C, Roem K, Bonham MP, Murgia C, Haines TP, Hamilton GS. A 12-month weight loss intervention in adults with obstructive sleep apnoea: is timing important? A step wedge randomised trial. Eur J Clin Nutr 2022; 76:1762-1769. [PMID: 35927505 PMCID: PMC9708544 DOI: 10.1038/s41430-022-01184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVES Continuous positive airway pressure (CPAP) concomitant with weight loss is a recommended treatment approach for adults with moderate-severe obstructive sleep apnoea (OSA) and obesity. This requires multiple synchronous behaviour changes. The aim of this study was to examine the effectiveness of a 6-month lifestyle intervention and to determine whether the timing of starting a weight loss attempt affects weight change and trajectory after 12 months in adults newly diagnosed with moderate-severe OSA and treated at home with overnight CPAP. METHODS Using a stepped-wedge design, participants were randomised to commence a six-month lifestyle intervention between one and six-months post-enrolment, with a 12-month overall follow-up. Adults (n = 60, 75% males, mean age 49.4 SD 10.74 years) newly diagnosed with moderate-severe OSA and above a healthy weight (mean BMI 34.1 SD 4.8) were recruited. RESULTS After 12 months, exposure to the intervention (CPAP and lifestyle) resulted in a 3.7 (95% CI: 2.6 to 4.8, p < 0.001) kg loss of weight compared to the control condition (CPAP alone). Timing of the weight loss attempt made no difference to outcomes at 12 months. When exposed to CPAP only (control period) there was no change in body weight (Coef, [95% CI] 0.03, [-0.3 to 0.36], p = 0.86). CONCLUSIONS The lifestyle intervention resulted in a modest reduction in body weight, while timing of commencement did not impact the degree of weight loss at 12 months. These findings support the recommendation of adjunctive weight-loss interventions within six-months of starting CPAP.
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Affiliation(s)
- Helen Truby
- School of Human Movement and Nutrition Sciences, University of Queensland, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Kaitlin Day
- School of Clinical Sciences, Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, Australia
| | - Denise M O'Driscoll
- Eastern Health, Department of Respiratory and Sleep Medicine, Melbourne, VIC, Australia
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Alan Young
- Eastern Health, Department of Respiratory and Sleep Medicine, Melbourne, VIC, Australia
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Ladan Ghazi
- School of Clinical Sciences, Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, Australia
| | - Claire Bristow
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Kerryn Roem
- School of Clinical Sciences, Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, Australia
| | - Maxine P Bonham
- School of Clinical Sciences, Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, Australia
| | - Chiara Murgia
- School of Agriculture and Food, Melbourne University, Melbourne, VIC, Australia
| | - Terry P Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, VIC, Australia
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
- Monash Health, Department of Lung, Sleep, Allergy and Immunology, Melbourne, VIC, Australia.
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17
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Wong AM, Landry SA, Joosten SA, Thomson LDJ, Turton A, Stonehouse J, Mansfield DR, Burgess G, Hays A, Sands SA, Andara C, Beatty CJ, Hamilton GS, Edwards BA. Examining the impact of multilevel upper airway surgery on the obstructive sleep apnoea endotypes and their utility in predicting surgical outcomes. Respirology 2022; 27:890-899. [PMID: 35598093 PMCID: PMC9542009 DOI: 10.1111/resp.14280] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial-down or clinical polysomnographic (PSG) methods. METHODS We prospectively studied 23 OSA patients before and ≥3 months after multilevel upper airway surgery. Participants underwent clinical and research PSG to measure OSA severity (apnoea-hypopnoea index [AHI]) and endotypes (measured in supine non-rapid eye movement [NREM]). Values are presented as mean ± SD or median (interquartile range). RESULTS Surgery reduced the AHITotal (38.7 [23.4 to 79.2] vs. 22.0 [13.3 to 53.5] events/h; p = 0.009). There were no significant changes in OSA endotypes, however, large but variable improvements in collapsibility were observed (CPAP dial-down method: ∆1.9 ± 4.9 L/min, p = 0.09, n = 21; PSG method: ∆3.4 [-2.8 to 49.0]%Veupnoea , p = 0.06, n = 20). Improvement in collapsibility strongly correlated with improvement in AHI (%∆AHISupineNREM vs. ∆collapsibility: p < 0.005; R2 = 0.46-0.48). None of the baseline OSA endotypes predicted response to surgery. CONCLUSION Surgery unpredictably alters upper airway collapsibility but does not alter the non-anatomical endotypes. There are no baseline predictors of response to surgery.
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Affiliation(s)
- Ai-Ming Wong
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane A Landry
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Anthony Turton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Jeremy Stonehouse
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Darren R Mansfield
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Glen Burgess
- Department of Ear, Nose and Throat, Monash Health, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew Hays
- Department of Ear, Nose and Throat, Monash Health, Melbourne, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Christopher Andara
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria
| | - Caroline J Beatty
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
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18
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Yo SW, Joosten SA, Wimaleswaran H, Mansfield D, Thomson L, Landry SA, Edwards BA, Hamilton GS. Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med 2022; 18:2103-2111. [PMID: 35459447 PMCID: PMC9435326 DOI: 10.5664/jcsm.9990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Supine-predominant obstructive sleep apnea (OSA) is highly prevalent. The proportion of time spent in the supine position may be overrepresented during polysomnography, which would impact on the apnea-hypopnea index (AHI) and have important clinical implications. We aimed to investigate the difference in body position during laboratory or home polysomnography compared to habitual sleep and estimate its effect on OSA severity. Secondary aims were to evaluate the consistency of habitual sleeping position and accuracy of self-reported sleeping position. METHODS Patients undergoing diagnostic laboratory or home polysomnography were recruited. Body position was recorded using a neck-worn device. Habitual sleeping position was the average time spent supine over 3 consecutive nights at home. Primary outcomes were the proportion of sleep time spent supine (% time supine) and AHI adjusted for habitual sleeping position. RESULTS Fifty-seven patients who underwent laboratory polysomnography and 56 who had home polysomnography were included. Compared to habitual sleep, % time supine was higher during laboratory polysomnography (mean difference 14.1% [95% confidence interval: 7.2-21.1]; P = .0002) and home polysomnography (7.1% [95% confidence interval 0.9-13.3]; P = .03). Among those with supine-predominant OSA, there was a trend toward lower adjusted AHI than polysomnography-derived AHI (P = .07), changing OSA severity in 31.6%. There was no significant between-night difference in % time supine during habitual sleep (P = .4). Self-reported % time supine was inaccurate (95% limits of agreement -49.2% to 53.9%). CONCLUSIONS More time was spent in the supine position during polysomnography compared to habitual sleep, which may overestimate OSA severity for almost one-third of patients with supine-predominant OSA. CLINICAL TRIAL REGISTRATION Registry: Australia and New Zealand Clinical Trials Registry (ANZCTR); Title: Sleeping position during sleep tests and at home; Identifier: ACTRN12618000628246; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374873&isReview=true. CITATION Yo SW, Joosten SA, Wimaleswaran H, et al. Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med. 2022;18(9):2103-2111.
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Affiliation(s)
- Shaun W. Yo
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
| | - Simon A. Joosten
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Hari Wimaleswaran
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
| | - Darren Mansfield
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
| | - Luke Thomson
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
| | - Shane A. Landry
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
| | - Bradley A. Edwards
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Garun S. Hamilton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
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19
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Thomson LDJ, Landry SA, Joosten SA, Mann D, Wong A, Cheung T, Adam M, Beatty C, Hamilton GS, Edwards BA. A single dose of noradrenergic/serotonergic reuptake inhibitors combined with an antimuscarinic does not improve obstructive sleep apnoea severity. Physiol Rep 2022; 10:e15440. [PMID: 36029192 PMCID: PMC9419156 DOI: 10.14814/phy2.15440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023] Open
Abstract
Previous trials have demonstrated that the combination of noradrenergic reuptake inhibitors with an antimuscarinic can substantially reduce the apnoea-hypopnoea index (AHI) and improve airway collapsibility in patients with obstructive sleep apnoea (OSA). However, some studies have shown that when administered individually, neither noradrenergic or serotonergic agents have been effective at alleviating OSA. This raises the possibility that serotonergic agents (like noradrenergic agents) may also need to be delivered in combination to be efficacious. Therefore, we investigated the effect of an antimuscarinic (oxybutynin) on OSA severity when administered with either duloxetine or milnacipran, two dual noradrenergic/serotonergic reuptake inhibiters. A randomized, double-blind, 4 way cross-over, placebo-controlled trial in ten OSA patients was performed. Patients received each drug condition separately across four overnight in-lab polysomnography (PSG) studies ~1-week apart. The primary outcome measure was the AHI. In addition, the four key OSA endotypes (collapsibility, muscle compensation, arousal threshold, loop gain) were measured non-invasively from the PSGs using validated techniques. There was no significant effect of either drug combinations on reducing the total AHI or improving any of the key OSA endotypes. However, duloxetine+oxybutynin did significantly increase the fraction of hypopnoeas to apnoeas (FHypopnoea ) compared to placebo (p = 0.02; d = 0.54). In addition, duloxetine+oxybutynin reduced time in REM sleep (p = 0.009; d = 1.03) which was positively associated with a reduction in the total AHI (R2 = 0.62; p = 0.02). Neither drug combination significantly improved OSA severity or modified the key OSA endotypes when administered as a single dose to unselected OSA patients.
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Affiliation(s)
- Luke D. J. Thomson
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Shane A. Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Simon A. Joosten
- School of Clinical SciencesMonash UniversityMelbourneVictoriaAustralia
- Monash Lung, Sleep, Allergy and ImmunologyMonash HealthMelbourneVictoriaAustralia
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Dwayne L. Mann
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- School of Information Technology and Electrical EngineeringThe University of QueenslandBrisbaneQueenslandAustralia
| | - Ai‐Ming Wong
- Monash Lung, Sleep, Allergy and ImmunologyMonash HealthMelbourneVictoriaAustralia
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Tim Cheung
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Mulki Adam
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
| | - Caroline J. Beatty
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Garun S. Hamilton
- School of Clinical SciencesMonash UniversityMelbourneVictoriaAustralia
- Monash Lung, Sleep, Allergy and ImmunologyMonash HealthMelbourneVictoriaAustralia
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Bradley A. Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
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Affiliation(s)
- Christopher N. Schmickl
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoSan Diego, California
| | - Bradley A. Edwards
- School of Biomedical Sciences and Biomedical Discovery Institute,Turner Institute for Brain and Mental HealthMonash UniversityMelbourne, Victoria, Australia
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoSan Diego, California
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21
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Vena D, Taranto-Montemurro L, Azarbarzin A, Op de Beeck S, Marques M, Vanderveken OM, Edwards BA, Gell L, Calianese N, Hess LB, Radmand R, Hamilton GS, Joosten SA, Verbraecken J, Braem M, White DP, Redline S, Sands SA, Wellman A. Clinical polysomnographic methods for estimating pharyngeal collapsibility in obstructive sleep apnea. Sleep 2022; 45:zsac050. [PMID: 35238379 PMCID: PMC9189952 DOI: 10.1093/sleep/zsac050] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea has major health consequences but is challenging to treat. For many therapies, efficacy is determined by the severity of underlying pharyngeal collapsibility, yet there is no accepted clinical means to measure it. Here, we provide insight into which polysomnographic surrogate measures of collapsibility are valid, applicable across the population, and predictive of therapeutic outcomes. METHODS Seven promising polysomnography-derived surrogate collapsibility candidates were evaluated: Vpassive (flow at eupneic ventilatory drive), Vmin (ventilation at nadir drive), event depth (depth of the average respiratory event), oxygen desaturation slope and mean oxygen desaturation (events-related averages), Fhypopneas (fraction of events scored as hypopneas), and apnea index. Evaluation included (1) validation by comparison to physiological gold-standard collapsibility values (critical closing pressure, Pcrit), (2) capacity to detect increased collapsibility with older age, male sex, and obesity in a large community-based cohort (Multi-Ethnic Study of Atherosclerosis, MESA), and (3) prediction of treatment efficacy (oral appliances and pharmacological pharyngeal muscle stimulation using atomoxetine-plus-oxybutynin). RESULTS Pcrit was significantly correlated with Vmin (r = -0.54), event depth (r = 0.49), Vpassive (r = -0.38), Fhypopneas (r = -0.46), and apnea index (r = -0.46; all p < .01) but not others. All measures detected greater collapsibility with male sex, age, and obesity, except Fhypopneas and apnea index which were not associated with obesity. Fhypopneas and apnea index were associated with oral appliance and atomoxetine-plus-oxybutynin efficacy (both p < .05). CONCLUSIONS Among several candidates, event depth, Fhypopneas, and apnea index were identified as preferred pharyngeal collapsibility surrogates for use in the clinical arena.
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Affiliation(s)
- Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Laboratório do sono, Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Laura Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Radmand
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Johan Verbraecken
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Marc Braem
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Division of Special Care Dentistry, Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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22
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Landry SA, Subedi D, MacDonald MI, Dix S, Kutey DM, Barr JJ, Mansfield D, Hamilton GS, Edwards BA, Joosten SA. Point of emission air filtration enhances protection of healthcare workers against skin contamination with virus aerosol. Respirology 2022; 27:465-468. [PMID: 35156259 PMCID: PMC9115427 DOI: 10.1111/resp.14227] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Shane A. Landry
- Department of Physiology, School of Biomedical Sciences & Biomedical Discovery Institute Monash University Melbourne Victoria
| | - Dinesh Subedi
- School of Biological Sciences Monash University Clayton Victoria Australia
| | - Martin I. MacDonald
- Monash Lung, Sleep, Allergy and Immunology Monash Health Clayton Victoria Australia
| | - Samantha Dix
- Monash Nursing & Midwifery Monash University Clayton Victoria Australia
| | - Donna M. Kutey
- Monash Nursing & Midwifery Monash University Clayton Victoria Australia
| | - Jeremy J. Barr
- School of Biological Sciences Monash University Clayton Victoria Australia
| | - Darren Mansfield
- Monash Lung, Sleep, Allergy and Immunology Monash Health Clayton Victoria Australia
- School of Clinical Sciences Monash University Melbourne Victoria Australia
- Monash Partners – Epworth Melbourne Victoria Australia
| | - Garun S. Hamilton
- Monash Lung, Sleep, Allergy and Immunology Monash Health Clayton Victoria Australia
- School of Clinical Sciences Monash University Melbourne Victoria Australia
- Monash Partners – Epworth Melbourne Victoria Australia
| | - Bradley A. Edwards
- Department of Physiology, School of Biomedical Sciences & Biomedical Discovery Institute Monash University Melbourne Victoria
- Turner Institute for Brain and Mental Health Monash University Melbourne Victoria Australia
| | - Simon A. Joosten
- Monash Lung, Sleep, Allergy and Immunology Monash Health Clayton Victoria Australia
- School of Clinical Sciences Monash University Melbourne Victoria Australia
- Monash Partners – Epworth Melbourne Victoria Australia
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23
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Landry SA, Subedi D, Barr JJ, MacDonald MI, Dix S, Kutey DM, Mansfield D, Hamilton GS, Edwards BA, Joosten SA. OUP accepted manuscript. J Infect Dis 2022; 226:199-207. [PMID: 35535021 PMCID: PMC9400421 DOI: 10.1093/infdis/jiac195] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Healthcare workers (HCWs) are at risk from aerosol transmission of severe acute respiratory syndrome coronavirus 2. The aims of this study were to (1) quantify the protection provided by masks (surgical, fit-testFAILED N95, fit-testPASSED N95) and personal protective equipment (PPE), and (2) determine if a portable high-efficiency particulate air (HEPA) filter can enhance the benefit of PPE. Methods Virus aerosol exposure experiments using bacteriophage PhiX174 were performed. An HCW wearing PPE (mask, gloves, gown, face shield) was exposed to nebulized viruses (108 copies/mL) for 40 minutes in a sealed clinical room. Virus exposure was quantified via skin swabs applied to the face, nostrils, forearms, neck, and forehead. Experiments were repeated with a HEPA filter (13.4 volume-filtrations/hour). Results Significant virus counts were detected on the face while the participants were wearing either surgical or N95 masks. Only the fit-testPASSED N95 resulted in lower virus counts compared to control (P = .007). Nasal swabs demonstrated high virus exposure, which was not mitigated by the surgical/fit-testFAILED N95 masks, although there was a trend for the fit-testPASSED N95 mask to reduce virus counts (P = .058). HEPA filtration reduced virus to near-zero levels when combined with fit-testPASSED N95 mask, gloves, gown, and face shield. Conclusions N95 masks that have passed a quantitative fit-test combined with HEPA filtration protects against high virus aerosol loads at close range and for prolonged periods of time.
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Affiliation(s)
- Shane A Landry
- Correspondence: Shane Landry, PhD, Monash University BASE facility, 264 Ferntree Gully Road, Ground Floor, Notting Hill, 3168, VIC, Australia ()
| | - Dinesh Subedi
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
| | - Jeremy J Barr
- School of Biological Sciences, Monash University, Clayton, Victoria, Australia
| | - Martin I MacDonald
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Clayton, Victoria, Australia
| | - Samantha Dix
- Monash Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Donna M Kutey
- Monash Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Darren Mansfield
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Partners–Epworth, Victoria, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Partners–Epworth, Victoria, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy and Immunology, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Partners–Epworth, Victoria, Victoria, Australia
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24
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Orr JE, Edwards BA, Schmickl CN, Karris M, DeYoung PN, Darquenne C, Theilmann R, Jain S, Malhotra A, Hicks CB, Owens RL. Pathogenesis of obstructive sleep apnea in people living with HIV. J Appl Physiol (1985) 2021; 131:1671-1678. [PMID: 34672765 PMCID: PMC8714978 DOI: 10.1152/japplphysiol.00591.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Obstructive sleep apnea (OSA) is highly prevalent in people living with human immunodeficiency virus (HIV) (PLWH), and it might contribute to frequently reported symptoms and comorbidities. Traditional risk factors for OSA are often absent in PLWH, suggesting that HIV or HIV medications might predispose to OSA. Therefore, we measured the anatomical and nonanatomical traits important for OSA pathogenesis in those with and without HIV. We recruited virally suppressed PLWH who had been previously diagnosed with OSA (PLWH + OSA) adherent to positive airway pressure (PAP) therapy, along with age-, sex-, and body mass index (BMI)-matched OSA controls. All participants underwent a baseline polysomnogram to assess OSA severity and a second overnight research sleep study during which the airway pressure was adjusted slowly or rapidly to measure the OSA traits. Seventeen PLWH + OSA and 17 OSA control participants were studied [median age = 58 (IQR = 54-65) yr, BMI = 30.7 (28.4-31.8) kg/m2, apnea-hypopnea index = 46 (24-74)/h]. The groups were similar, although PLWH + OSA demonstrated greater sleepiness (despite PAP) and worse sleep efficiency on baseline polysomnography. On physiological testing during sleep, there were no statistically significant differences in OSA traits (including Veupnea, Varousal, Vpassive, Vactive, and loop gain) between PLWH + OSA and OSA controls, using mixed-effects modeling to account for age, sex, and BMI and incorporating each repeated measurement (range = 72-334 measures/trait). Our data suggest that well-treated HIV does not substantially impact the pathogenesis of OSA. Given similar underlying physiology, existing available therapeutic approaches are likely to be adequate to manage OSA in PLWH, which might improve symptoms and comorbidities.NEW & NOTEWORTHY Clinical data suggest an increased risk of obstructive sleep apnea (OSA) in people living with HIV (PLWH), while OSA might account for chronic health issues in this population. We characterized the anatomical and nonanatomical OSA traits in PLWH + OSA compared with OSA controls, using detailed physiological measurements obtained during sleep. Our data suggest against a major impact of HIV on OSA pathogenesis. Available OSA management strategies should be effective to address this potentially important comorbidity in PLWH.
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Affiliation(s)
- Jeremy E Orr
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
| | - Maile Karris
- Division of Infectious Disease, University of California San Diego, San Diego, California
| | - Pamela N DeYoung
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
| | - Chantal Darquenne
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
| | - Rebecca Theilmann
- Department of Radiology, University of California San Diego, San Diego, California
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
| | - Charles B Hicks
- Division of Infectious Disease, University of California San Diego, San Diego, California
| | - Robert L Owens
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
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25
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Schmickl CN, Landry S, Orr JE, Nokes B, Edwards BA, Malhotra A, Owens RL. Effects of acetazolamide on control of breathing in sleep apnea patients: Mechanistic insights using meta-analyses and physiological model simulations. Physiol Rep 2021; 9:e15071. [PMID: 34699135 PMCID: PMC8547551 DOI: 10.14814/phy2.15071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 11/24/2022] Open
Abstract
Obstructive and central sleep apnea affects ~1 billion people globally and may lead to serious cardiovascular and neurocognitive consequences, but treatment options are limited. High loop gain (ventilatory instability) is a major pathophysiological mechanism underlying both types of sleep apnea and can be lowered pharmacologically with acetazolamide, thereby improving sleep apnea severity. However, individual responses vary and are strongly correlated with the loop gain reduction achieved by acetazolamide. To aid with patient selection for long-term trials and clinical care, our goal was to understand better the factors that determine the change in loop gain following acetazolamide in human subjects with sleep apnea. Thus, we (i) performed several meta-analyses to clarify how acetazolamide affects ventilatory control and loop gain (including its primary components controller/plant gain), and based on these results, we (ii) performed physiological model simulations to assess how different baseline conditions affect the change in loop gain. Our results suggest that (i) acetazolamide primarily causes a left shift of the chemosensitivity line thus lowering plant gain without substantially affecting controller gain; and (ii) higher controller gain, higher paCO2 at eupneic ventilation, and lower CO2 production at baseline result in a more pronounced loop gain reduction with acetazolamide. In summary, the combination of mechanistic meta-analyses with model simulations provides a unified framework of acetazolamide's effects on ventilatory control and revealed physiological predictors of response, which are consistent with empirical observations of acetazolamide's effects in different sleep apnea subgroups. Prospective studies are needed to validate these predictors and assess their value for patient selection.
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Affiliation(s)
- Christopher N. Schmickl
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Shane Landry
- Department of PhysiologySleep and Circadian Medicine LaboratorySchool of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Jeremy E. Orr
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Brandon Nokes
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Bradley A. Edwards
- Department of PhysiologySleep and Circadian Medicine LaboratorySchool of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
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26
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Maghsoudipour M, Nokes B, Bosompra NO, Jen R, Li Y, Moore S, DeYoung PN, Fine J, Edwards BA, Gilbertson D, Owens R, Morgan T, Malhotra A. A Pilot Randomized Controlled Trial of Effect of Genioglossus Muscle Strengthening on Obstructive Sleep Apnea Outcomes. J Clin Med 2021; 10:jcm10194554. [PMID: 34640575 PMCID: PMC8509668 DOI: 10.3390/jcm10194554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022] Open
Abstract
The genioglossus is a major upper airway dilator muscle. Our goal was to assess the efficacy of upper airway muscle training on Obstructive Sleep Apnea (OSA) as an adjunct treatment. Sixty-eight participants with OSA (AHI > 10/h) were recruited from our clinic. They fall into the following categories: (a) Treated with Automatic Positive Airway Pressure (APAP), (n = 21), (b) Previously failed APAP therapy (Untreated), (n = 25), (c) Treated with Mandibular Advancement Splint (MAS), (n = 22). All subjects were given a custom-made tongue strengthening device. We conducted a prospective, randomized, controlled study examining the effect of upper airway muscle training. In each subgroup, subjects were randomized to muscle training (volitional protrusion against resistance) or sham group (negligible resistance), with a 1:1 ratio over 3 months of treatment. In the baseline and the final visit, subjects completed home sleep apnea testing, Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), SF-36 (36-Item Short Form Survey), and Psychomotor Vigilance Test (PVT). Intervention (muscle training) did not affect the AHI (Apnea-Hypopnea Index), (p-values > 0.05). Based on PSQI, ESS, SF-36 scores, and PVT parameters, the changes between the intervention and sham groups were not significant, and the changes were not associated with the type of treatment (p-value > 0.05). The effectiveness of upper airway muscle training exercise as an adjunct treatment requires further study.
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Affiliation(s)
- Maryam Maghsoudipour
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Brandon Nokes
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Naa-Oye Bosompra
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Rachel Jen
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - Yanru Li
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China;
| | - Stacie Moore
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Pamela N. DeYoung
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Janelle Fine
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Bradley A. Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC 3800, Australia;
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC 3800, Australia
| | - Dillon Gilbertson
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Robert Owens
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
| | - Todd Morgan
- Department of Dentistry, Scripps Encinitas Hospital, Encinitas, CA 92024, USA;
| | - Atul Malhotra
- Department of Medicine, University of California, La Jolla, San Diego, CA 92161, USA; (M.M.); (B.N.); (N.-O.B.); (S.M.); (P.N.D.); (J.F.); (D.G.); (R.O.)
- Correspondence:
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27
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Mann DL, Georgeson T, Landry SA, Edwards BA, Azarbarzin A, Vena D, Hess LB, Wellman A, Redline S, Sands SA, Terrill PI. Frequency of flow limitation using airflow shape. Sleep 2021; 44:6317693. [PMID: 34240221 DOI: 10.1093/sleep/zsab170] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/27/2021] [Indexed: 12/26/2022] Open
Abstract
STUDY OBJECTIVES The presence of flow limitation during sleep is associated with adverse health consequences independent of obstructive sleep apnea (OSA) severity (apnea-hypopnea index, AHI), but remains extremely challenging to quantify. Here we present a unique library and an accompanying automated method that we apply to investigate flow limitation during sleep. METHODS A library of 117,871 breaths (N=40 participants) were visually classified (certain flow limitation, possible flow limitation, normal) using airflow shape and physiological signals (ventilatory drive per intra-esophageal diaphragm EMG). An ordinal regression model was developed to quantify flow limitation certainty using flow-shape features (e.g. flattening, scooping); breath-by-breath agreement (Cohen's ƙ) and overnight flow limitation frequency (R 2, %breaths in certain or possible categories during sleep) were compared against visual scoring. Subsequent application examined flow limitation frequency during arousals and stable breathing, and associations with ventilatory drive. RESULTS The model (23 features) assessed flow limitation with good agreement (breath-by-breath ƙ=0.572, p<0.001) and minimal error (overnight flow limitation frequency R 2=0.86, error=7.2%). Flow limitation frequency was largely independent of AHI (R 2=0.16) and varied widely within individuals with OSA (74[32-95]%breaths, mean[range], AHI>15/hr, N=22). Flow limitation was unexpectedly frequent but variable during arousals (40[5-85]%breaths) and stable breathing (58[12-91]%breaths), and was associated with elevated ventilatory drive (R 2=0.26-0.29; R 2<0.01 AHI v. drive). CONCLUSIONS Our method enables quantification of flow limitation frequency, a key aspect of obstructive sleep-disordered breathing that is independent of the AHI and often unavailable. Flow limitation frequency varies widely between individuals, is prevalent during arousals and stable breathing, and reveals elevated ventilatory drive.
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Affiliation(s)
- Dwayne L Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia.,Institute for Social Science Research, The University of Queensland, Brisbane, Australia.,Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Thomas Georgeson
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
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28
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Landry SA, Barr JJ, MacDonald MI, Subedi D, Mansfield D, Hamilton GS, Edwards BA, Joosten SA. Viable virus aerosol propagation by positive airway pressure circuit leak and mitigation with a ventilated patient hood. Eur Respir J 2021; 57:13993003.03666-2020. [PMID: 33303543 DOI: 10.1183/13993003.03666-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/24/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Nosocomial transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a major feature of the COVID-19 pandemic. Evidence suggests patients can auto-emit aerosols containing viable viruses; these aerosols could be further propagated when patients undergo certain treatments, including continuous positive airway pressure (PAP) therapy. Our aim was to assess 1) the degree of viable virus propagated from PAP circuit mask leak and 2) the efficacy of a ventilated plastic canopy to mitigate virus propagation. METHODS Bacteriophage phiX174 (108 copies·mL-1) was nebulised into a custom PAP circuit. Mask leak was systematically varied at the mask interface. Plates containing Escherichia coli host quantified viable virus (via plaque forming unit) settling on surfaces around the room. The efficacy of a low-cost ventilated headboard created from a tarpaulin hood and a high-efficiency particulate air (HEPA) filter was tested. RESULTS Mask leak was associated with virus contamination in a dose-dependent manner (χ2=58.24, df=4, p<0.001). Moderate mask leak (≥21 L·min-1) was associated with virus counts equivalent to using PAP with a vented mask. The highest frequency of viruses was detected on surfaces <1 m away; however, viable viruses were recorded up to 3.86 m from the source. A plastic hood with HEPA filtration significantly reduced viable viruses on all plates. HEPA exchange rates ≥170 m3·h-1 eradicated all evidence of virus contamination. CONCLUSIONS Mask leak from PAP may be a major source of environmental contamination and nosocomial spread of infectious respiratory diseases. Subclinical mask leak levels should be treated as an infectious risk. Low-cost patient hoods with HEPA filtration are an effective countermeasure.
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Affiliation(s)
- Shane A Landry
- Dept of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Jeremy J Barr
- School of Biological Sciences, Monash University, Clayton, Australia
| | | | - Dinesh Subedi
- School of Biological Sciences, Monash University, Clayton, Australia
| | - Darren Mansfield
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia.,School of Clinical Sciences, Monash University, Melbourne, Australia.,Monash Partners - Epworth, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia.,School of Clinical Sciences, Monash University, Melbourne, Australia.,Monash Partners - Epworth, Victoria, Australia
| | - Bradley A Edwards
- Dept of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Australia.,School of Clinical Sciences, Monash University, Melbourne, Australia.,Monash Partners - Epworth, Victoria, Australia
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29
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Genta PR, Schorr F, Edwards BA, Wellman A, Lorenzi-Filho G. Discriminating the severity of pharyngeal collapsibility in men using anthropometric and polysomnographic indices. J Clin Sleep Med 2021; 16:1531-1537. [PMID: 32441245 DOI: 10.5664/jcsm.8600] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVES Although obstructive sleep apnea results from the combination of different pathophysiologic mechanisms, the degree of anatomical compromise remains the main responsible factor. The passive pharyngeal critical closing pressure (Pcrit) is a technique used to assess the collapsibility of the upper airway and is often used as a surrogate measure of this anatomical compromise. Patients with a low Pcrit (ie, less collapsible airway) are potential candidates for non-continuous positive airway pressure therapies. However, Pcrit determination is a technically complex method not available in clinical practice. We hypothesized that the discrimination between low and high Pcrit can be estimated from simple anthropometric and polysomnographic indices. METHODS Men with and without obstructive sleep apnea underwent Pcrit determination and full polysomnography. Receiver operating characteristics analysis was performed to select the best cutoff of each variable to predict a high Pcrit (Pcrit ≥ 2.5 cmH₂O). Multiple logistic regression analysis was performed to create a clinical score to predict a high Pcrit. RESULTS We studied 81 men, 48 ± 13 years of age, with an apnea-hypopnea index of 32 [14-60], range 1-96 events/h), and Pcrit of -0.7 ± 3.1 (range, -9.1 to +7.2 cmH₂O). A high and low Pcrit could be accurately identified by polysomnographic and anthropometric indices. A score to discriminate Pcrit showed good performance (area under the curve = 0.96; 95% confidence interval, 0.91-1.00) and included waist circumference, non-rapid eye movement obstructive apnea index/apnea-hypopnea index, mean obstructive apnea duration, and rapid eye movement apnea-hypopnea index. CONCLUSIONS A low Pcrit (less collapsible) can be estimated from a simple clinical score. This approach may identify candidates more likely to respond to non-continuous positive airway pressure therapies for obstructive sleep apnea.
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Affiliation(s)
- Pedro R Genta
- Laboratorio do Sono, LIM 63, Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fabiola Schorr
- Laboratorio do Sono, LIM 63, Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Geraldo Lorenzi-Filho
- Laboratorio do Sono, LIM 63, Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
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Schmickl CN, Owens RL, Orr JE, Edwards BA, Malhotra A. Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence. BMJ Open Respir Res 2021; 7:7/1/e000557. [PMID: 32332024 PMCID: PMC7204833 DOI: 10.1136/bmjresp-2020-000557] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/22/2020] [Accepted: 02/29/2020] [Indexed: 02/04/2023] Open
Abstract
Introduction Acetazolamide (AZM) is used for various conditions (eg, altitude sickness, sleep apnoea, glaucoma), but therapy is often limited by its side effect profile. Our objective was to estimate the risk of commonly reported side effects based on meta-analyses. We hypothesised that these risks are dose-dependent. Methods We queried MEDLINE/EMBASE (Medical Literature Analysis and Retrieval System Online/Excerpta Medica dataBASE) up until 04/10/2019, including any randomised placebo-controlled trial in which adults received oral AZM versus placebo reporting side effects. Eligibility assessment was performed by two independent reviewers. Data were abstracted by one reviewer who verified key entries at a second time point. For side effects reported by >3 studies a pooled effect estimate was calculated, and heterogeneity assessed via I2; for outcomes reported by >5 studies effect modification by total daily dose (EMbyTDD; <400 mg/d, 400–600 mg/d, >600 mg/d) was assessed via meta-regression. For pre-specified, primary outcomes (paraesthesias, taste disturbances, polyuria and fatigue) additional subgroup analyses were performed using demographics, intervention details, laboratory changes and risk of bias. Results We included 42 studies in the meta-analyses (Nsubjects=1274/1211 in AZM/placebo groups). AZM increased the risk of all primary outcomes (p<0.01, I2 ≤16% and low-to-moderate quality of evidence for all)—the numbers needed to harm (95% CI; nStudies) for each were: paraesthesias 2.3 (95% CI 2 to 2.7; n=39), dysgeusia 18 (95% CI 10 to 38, n=22), polyuria 17 (95% CI 9 to 49; n=22), fatigue 11 (95% CI 6 to 24; n=14). The risk for paraesthesias (beta=1.8 (95% CI 1.1 to 2.9); PEMbyTDD=0.01) and dysgeusia (beta=3.1 (95% CI 1.2 to 8.2); PEMbyTDD=0.02) increased with higher AZM doses; the risk of fatigue also increased with higher dose but non-significantly (beta=2.6 (95% CI 0.7 to 9.4); PEMbyTDD=0.14). Discussion This comprehensive meta-analysis of low-to-moderate quality evidence defines risk of common AZM side effects and corroborates dose dependence of some side effects. These results may inform clinical decision making and support efforts to establish the lowest effective dose of AZM for various conditions.
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Affiliation(s)
- Christopher N Schmickl
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Robert L Owens
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Jeremy E Orr
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Clayton, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
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31
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Vena D, Azarbarzin A, Marques M, Op de Beeck S, Vanderveken OM, Edwards BA, Calianese N, Hess LB, Radmand R, Hamilton GS, Joosten SA, Taranto-Montemurro L, Kim SW, Verbraecken J, Braem M, White DP, Sands SA, Wellman A. Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow. Sleep 2021; 43:5733095. [PMID: 32043131 DOI: 10.1093/sleep/zsaa004] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/20/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Oral appliance therapy is an increasingly common option for treating obstructive sleep apnea (OSA) in patients who are intolerant to continuous positive airway pressure (CPAP). Clinically applicable tools to identify patients who could respond to oral appliance therapy are limited. METHODS Data from three studies (N = 81) were compiled, which included two sleep study nights, on and off oral appliance treatment. Along with clinical variables, airflow features were computed that included the average drop in airflow during respiratory events (event depth) and flow shape features, which, from previous work, indicates the mechanism of pharyngeal collapse. A model was developed to predict oral appliance treatment response (>50% reduction in apnea-hypopnea index [AHI] from baseline plus a treatment AHI <10 events/h). Model performance was quantified using (1) accuracy and (2) the difference in oral appliance treatment efficacy (percent reduction in AHI) and treatment AHI between predicted responders and nonresponders. RESULTS In addition to age and body mass index (BMI), event depth and expiratory "pinching" (validated to reflect palatal prolapse) were the airflow features selected by the model. Nonresponders had deeper events, "pinched" expiratory flow shape (i.e. associated with palatal collapse), were older, and had a higher BMI. Prediction accuracy was 74% and treatment AHI was lower in predicted responders compared to nonresponders by a clinically meaningful margin (8.0 [5.1 to 11.6] vs. 20.0 [12.2 to 29.5] events/h, p < 0.001). CONCLUSIONS A model developed with airflow features calculated from routine polysomnography, combined with age and BMI, identified oral appliance treatment responders from nonresponders. This research represents an important application of phenotyping to identify alternative treatments for personalized OSA management.
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Affiliation(s)
- Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Turner Institute for Brain and Mental Health, Notting Hill, Australia
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Reza Radmand
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,School of Clinical Sciences, Monash University, Clayton, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,School of Clinical Sciences, Monash University, Clayton, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sang-Wook Kim
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Department of Otorhinolaryngology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Marc Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Division of Special Care Dentistry, Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Landry SA, Edwards BA. Pharmacotherapy for sleep apnoea: A search for the right therapeutic key. Respirology 2021; 26:411-412. [PMID: 33730763 DOI: 10.1111/resp.14038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
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33
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Joosten SA, Tan M, Wong AM, Landry SA, Leong P, Sands SA, Beatty C, Thomson L, Stonehouse J, Turton A, Hamilton GS, Edwards BA. A randomized controlled trial of oxygen therapy for patients who do not respond to upper airway surgery for obstructive sleep apnea. J Clin Sleep Med 2021; 17:445-452. [PMID: 33094725 DOI: 10.5664/jcsm.8920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES We aimed to determine whether patients diagnosed with obstructive sleep apnea (OSA) who fail to respond to upper airway surgery may be successfully treated with supplemental oxygen and whether we could identify baseline physiologic endotypes (ie, collapsibility, loop gain, arousal threshold, and muscle compensation) that predict response to oxygen therapy. METHODS We conducted a single night, randomized double-blinded cross over trial in which patients with OSA who failed to respond to upper airway surgery were treated on separate nights with oxygen therapy (4 L/min) or placebo (medical air). Effect of oxygen/air on OSA on key polysomnography outcomes were assessed: apnea-hypopnea index (AHI), AHI without desaturation (ie, flow-based AHI), arousal index, and morning blood pressure. OSA endotypes were estimated from the polysomnography signals to determine whether baseline OSA physiology could be used to predict response to oxygen therapy. RESULTS There was a statistically significant reduction in AHI and flow-based AHI on oxygen vs placebo (flow-based AHI: 42.4 ± 21.5 vs 30.5 ± 17.1 events/h, P = .008). Arousal index was also reduced on oxygen vs placebo (41.1 ± 19.5 vs 33.0 ± 15.3 events/h, P = .006). There was no significant difference in morning blood pressure between oxygen and placebo. Although 7 of 20 individuals experienced a 50% reduction or greater in flow-based AHI on oxygen (responders), there was no difference in the baseline OSA endotypes (or clinical characteristics) between responders and nonresponders. CONCLUSIONS Our findings demonstrate that a proportion of patients who fail to respond to upper airway surgery for OSA respond acutely to treatment with supplemental oxygen. CLINICAL TRIAL REGISTRATION Registry: Australian New Zealand Clinical Trials Registry; Name: Oxygen therapy for treating patients with residual obstructive sleep apnea following upper airway surgery; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373566; Identifier: ACTRN12617001361392.
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Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners-Epworth, Melbourne, Victoria, Australia.,Contributed equally
| | - Michael Tan
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,Contributed equally
| | - Ai-Ming Wong
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Paul Leong
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts.,The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Caroline Beatty
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Luke Thomson
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Stonehouse
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Anthony Turton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners-Epworth, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
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Joosten SA, Landry SA, Wong AM, Edwards BA. Considering the Role of Adherence in New and Emerging Sleep Treatments. Sleep Med Clin 2021; 16:203-211. [PMID: 33485528 DOI: 10.1016/j.jsmc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There are several novel and emerging treatments for obstructive sleep apnea (OSA), including new devices and pharmacotherapies. Long-term efficacy and adherence data for these interventions in the sleep context are lacking. Future studies exploring the long-term adherence and efficacy in novel and emerging treatments of OSA are required to fully understand the place of these treatments in treatment hierarchies. Such research also should aim to evaluate the use of these novel therapies in real-world clinical settings, because many of the studies performed to date have been done under closely monitored research populations and relatively small sample sizes.
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Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton 3168, Victoria, Australia; School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia; Monash Partners - Epworth, Clayton, Victoria, Australia.
| | - Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedicine Discovery Institute, Monash University, 264 Ferntreegully Road, Notting Hill 3168, Melbourne, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Ai-Ming Wong
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton 3168, Victoria, Australia; School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedicine Discovery Institute, Monash University, 264 Ferntreegully Road, Notting Hill 3168, Melbourne, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
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35
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Khor YH, Ryerson CJ, Landry SA, Howard ME, Churchward TJ, Edwards BA, Hamilton GS, Joosten SA. Interstitial lung disease and obstructive sleep apnea. Sleep Med Rev 2021; 58:101442. [PMID: 33561604 DOI: 10.1016/j.smrv.2021.101442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/30/2020] [Accepted: 10/29/2020] [Indexed: 12/11/2022]
Abstract
Obstructive sleep apnea (OSA) is one of the most common comorbidities in patients with interstitial lung disease (ILD). Growing evidence highlights the significance of sleep disturbance on health outcomes in this population. The relationships between ILD and OSA are complex and possibly bidirectional, with multiple mechanisms postulated for the pathogenic and physiologic links. This review synthesizes current evidence and hypotheses regarding different aspects of the relationships between ILD and OSA, emphasizing the interactions between epidemiology, pathogenesis, and pathophysiology.
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Affiliation(s)
- Yet H Khor
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia; Institute for Breathing and Sleep, Heidelberg, Victoria, Australia; Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher J Ryerson
- Centre for Heart Lung Innovation, Providence Health Care, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Victoria, Australia; School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Australia
| | - Mark E Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia; Institute for Breathing and Sleep, Heidelberg, Victoria, Australia; Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia; School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Australia
| | - Thomas J Churchward
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia; Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Victoria, Australia; School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Victoria, Australia; School of Clinical Sciences, Monash University, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Victoria, Australia; School of Clinical Sciences, Monash University, Victoria, Australia.
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36
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Siriwardhana LS, Nixon GM, Davey MJ, Mann DL, Landry SA, Edwards BA, Horne RSC. Children with down syndrome and sleep disordered breathing display impairments in ventilatory control. Sleep Med 2020; 77:161-169. [PMID: 33373902 DOI: 10.1016/j.sleep.2020.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To investigate the role of ventilatory control instability (i.e. loop gain) in children with Down syndrome and sleep disordered breathing. METHODS Children (3-19 years) with Down syndrome and sleep disordered breathing (n = 14) were compared with typically developing children (n = 14) matched for age, sex and sleep disordered breathing severity. All children underwent overnight polysomnography. Spontaneous sighs were identified and a 180s analysis window (60s pre-sigh to 120s post-sigh) containing flow measurements and oxygen saturation were created. Loop gain, a measure of the sensitivity of the negative feedback loop that controls ventilation, was estimated by fitting a mathematical model of ventilatory control to the post-sigh ventilatory pattern. Results; Loop gain was significantly higher in children with Down syndrome compared to matched typically developing children (median loop gain [interquartile range]: 0.36 [0.33, 0.55] vs 0.32 [0.24, 0.38]; P = 0.0395). While children with Down syndrome also had significantly lower average oxygen saturation associated within each analysis window compared to typically developing children (mean ± standard deviation: 96.9 ± 1.3% vs 98.0 ± 1.0%; P = 0.0155), loop gain was not related to polysomnographic measures of hypoxia. CONCLUSIONS Higher loop gain in children with Down syndrome and sleep disordered breathing indicates that these children have more unstable ventilatory control, compared to age, sex and sleep disordered breathing severity matched typically developing children. This may be due to an inherent impairment in ventilatory control in children with Down syndrome contributing to their increased risk of sleep disordered breathing which may inform alternative treatment options for this population.
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Affiliation(s)
- Leon S Siriwardhana
- The Ritchie Centre, Department of Paediatrics, Monash University and Hudson Institute of Medical Research, Melbourne, Australia
| | - Gillian M Nixon
- The Ritchie Centre, Department of Paediatrics, Monash University and Hudson Institute of Medical Research, Melbourne, Australia; Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Australia
| | - Margot J Davey
- The Ritchie Centre, Department of Paediatrics, Monash University and Hudson Institute of Medical Research, Melbourne, Australia; Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Australia
| | - Dwayne L Mann
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia; Institute for Social Science Research, The University of Queensland, Brisbane, Australia
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia; School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia; School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Department of Paediatrics, Monash University and Hudson Institute of Medical Research, Melbourne, Australia.
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Schmickl CN, Lettieri CJ, Orr JE, DeYoung P, Edwards BA, Owens RL, Malhotra A. The Arousal Threshold as a Drug Target to Improve Continuous Positive Airway Pressure Adherence: Secondary Analysis of a Randomized Trial. Am J Respir Crit Care Med 2020; 202:1592-1595. [PMID: 32673496 PMCID: PMC7706152 DOI: 10.1164/rccm.202003-0502le] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Jeremy E. Orr
- University of California San Diego, San Diego, California
| | - Pamela DeYoung
- University of California San Diego, San Diego, California
| | | | | | - Atul Malhotra
- University of California San Diego, San Diego, California
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38
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Thomson LDJ, Landry SA, Singleton R, Wong AM, Joosten SA, Beatty CJ, Eckert DJ, Malhotra A, Hamilton GS, Edwards BA. The Effect of Hypopnea Scoring on the Arousal Threshold in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2020; 202:1308-1311. [PMID: 32551850 DOI: 10.1164/rccm.202003-0589le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Ai-Ming Wong
- Monash Lung and Sleep, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash University, Melbourne, Victoria, Australia.,Monash Lung and Sleep, Melbourne, Victoria, Australia
| | | | - Danny J Eckert
- Flinders University, Adelaide, South Australia, Australia, and
| | | | - Garun S Hamilton
- Monash University, Melbourne, Victoria, Australia.,Monash Lung and Sleep, Melbourne, Victoria, Australia
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Beatty CJ, Landry SA, Lee J, Joosten SA, Turton A, O’Driscoll DM, Wong AM, Thomson L, Edwards BA, Hamilton GS. Dietary intake, eating behavior and physical activity in individuals with and without obstructive sleep apnea. Sleep Biol Rhythms 2020. [DOI: 10.1007/s41105-020-00291-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Landry SA, Mann DL, Djumas L, Messineo L, Terrill PI, Thomson LDJ, Beatty CJ, Hamilton GS, Mansfield D, Edwards BA, Joosten SA. Laboratory performance of oronasal CPAP and adapted snorkel masks to entrain oxygen and CPAP. Respirology 2020; 25:1309-1312. [PMID: 32748429 PMCID: PMC7436923 DOI: 10.1111/resp.13922] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/19/2020] [Accepted: 07/06/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Dwayne L Mann
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Lee Djumas
- Woodside Innovation Centre, Department of Materials Science and Engineering, Monash University, Melbourne, VIC, Australia
| | - Ludovico Messineo
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, SA, Australia
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Luke D J Thomson
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Caroline J Beatty
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Melbourne, VIC, Australia.,School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Monash Partners - Epworth, Melbourne, VIC, Australia
| | - Darren Mansfield
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia.,Monash Lung and Sleep, Monash Medical Centre, Melbourne, VIC, Australia.,Monash Partners - Epworth, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Melbourne, VIC, Australia.,School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Monash Partners - Epworth, Melbourne, VIC, Australia
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Osman AM, Tong BK, Landry SA, Edwards BA, Joosten SA, Hamilton GS, Cori JM, Jordan AS, Stevens D, Grunstein RR, McEvoy RD, Catcheside PG, Eckert DJ. An assessment of a simple clinical technique to estimate pharyngeal collapsibility in people with obstructive sleep apnea. Sleep 2020; 43:5817777. [DOI: 10.1093/sleep/zsaa067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/31/2020] [Indexed: 01/27/2023] Open
Abstract
Abstract
Study Objectives
Quantification of upper airway collapsibility in obstructive sleep apnea (OSA) could help inform targeted therapy decisions. However, current techniques are clinically impractical. The primary aim of this study was to assess if a simple, novel technique could be implemented as part of a continuous positive airway pressure (CPAP) titration study to assess pharyngeal collapsibility.
Methods
A total of 35 participants (15 female) with OSA (mean ± SD apnea–hypopnea index = 35 ± 19 events/h) were studied. Participants first completed a simple clinical intervention during a routine CPAP titration, where CPAP was transiently turned off from the therapeutic pressure for ≤5 breaths/efforts on ≥5 occasions during stable non-rapid eye movement (non-REM) sleep for quantitative assessment of airflow responses (%peak inspiratory flow [PIF] from preceding 5 breaths). Participants then underwent an overnight physiology study to determine the pharyngeal critical closing pressure (Pcrit) and repeat transient drops to zero CPAP to assess airflow response reproducibility.
Results
Mean PIF of breaths 3–5 during zero CPAP on the simple clinical intervention versus the physiology night were similar (34 ± 29% vs. 28 ± 30% on therapeutic CPAP, p = 0.2; range 0%–90% vs. 0%–95%). Pcrit was −1.0 ± 2.5 cmH2O (range −6 to 5 cmH2O). Mean PIF during zero CPAP on the simple clinical intervention and the physiology night correlated with Pcrit (r = −0.7 and −0.9, respectively, p < 0.0001). Receiver operating characteristic curve analysis indicated significant diagnostic utility for the simple intervention to predict Pcrit < −2 and < 0 cmH2O (AUC = 0.81 and 0.92), respectively.
Conclusions
A simple CPAP intervention can successfully discriminate between patients with and without mild to moderately collapsible pharyngeal airways. This scalable approach may help select individuals most likely to respond to non-CPAP therapies.
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Affiliation(s)
- Amal M Osman
- Neuroscience Research Australia (NeuRA), School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Benjamin K Tong
- Neuroscience Research Australia (NeuRA), School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Shane A Landry
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jennifer M Cori
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Amy S Jordan
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - David Stevens
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Ronald R Grunstein
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Woolcock Institute of Medical Research and the University of Sydney, Glebe, NSW, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Peter G Catcheside
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
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42
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Siriwardhana LS, Weichard A, Nixon GM, Davey MJ, Walter LM, Edwards BA, Horne RSC. Role of ventilatory control instability in children with sleep-disordered breathing. Respirology 2020; 25:1174-1182. [PMID: 32239710 DOI: 10.1111/resp.13809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/13/2020] [Accepted: 03/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE The contribution of non-anatomical factors, such as ventilatory control instability (i.e. LG), to the pathogenesis of obstructive SDB in children is unclear. Therefore, we aimed to identify the relationship between LG and severity of SDB, demographic, anthropometric and anatomical characteristics in a clinically representative cohort of children. METHODS Children (aged 3-18 years) with various severities of SDB (n = 110) and non-snoring controls (n = 36) were studied. Children were grouped according to their OAHI. Anthropometric and upper airway anatomical characteristics were measured. Spontaneous sighs were identified on polysomnography and LG, a measure of the sensitivity of the negative feedback loop that controls ventilation, was estimated by fitting a mathematical model of ventilatory control to the post-sigh ventilatory pattern. RESULTS There was no difference in LG between controls and any of the SDB severity groups. However, LG was significantly lower in children with larger tonsils (tonsil grade 4) compared with children with smaller tonsils (tonsil grade 1) (median LG (range): 0.25 (0.20-0.42) vs 0.32 (0.25-0.44); P = 0.009) and in children with a modified Mallampati score of class III/IV compared with class I (0.28 (0.24-0.33) vs 0.37 (0.27-0.44); P = 0.009). CONCLUSION A direct relationship was not found between the severity of paediatric SDB and LG. However, an altered ventilatory control sensitivity may contribute to SDB in a subgroup of children depending on their degree of anatomical compromise of the airway.
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Affiliation(s)
- Leon S Siriwardhana
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Aidan Weichard
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Gillian M Nixon
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Margot J Davey
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Lisa M Walter
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
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43
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Orr JE, Schmickl CN, Edwards BA, DeYoung PN, Brena R, Sun XS, Jain S, Malhotra A, Owens RL. Pathogenesis of obstructive sleep apnea in individuals with the COPD + OSA Overlap syndrome versus OSA alone. Physiol Rep 2020; 8:e14371. [PMID: 32061194 PMCID: PMC7023887 DOI: 10.14814/phy2.14371] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/11/2020] [Indexed: 02/02/2023] Open
Abstract
Overlap syndrome (OVS) is the concurrence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), and is associated with poor outcomes. We hypothesized that physiological changes in COPD may affect the pathogenesis of OSA in important ways. We therefore sought to measure the anatomical and nonanatomical OSA traits in individuals with OVS and compare to those with OSA alone. Patients with established OVS were recruited, along with age, gender, and BMI matched OSA only controls. Smoking and relevant comorbidities or medications were excluded. Subjects underwent baseline polysomnography followed by an overnight physiological research study to measure the OSA traits (Veupnea , Varousal , Vpassive , Vactive , and loop gain). Fifteen subjects with OVS and 15 matched controls with OSA alone were studied (overall 66 ± 8 years, 20% women, BMI 31 ± 4 kg/m2 , apnea-hypopnea index 49 ± 36/hr). Mixed-modeling was used to incorporate each measurement (range 52-270 measures/trait), and account for age, gender, and BMI. There were no significant differences in the traits between OVS and OSA subjects, although OVS subjects potentially tolerated a lower ventilation before arousal (i.e., harder to wake; p = .06). Worsened lung function was significantly associated with worsened upper airway response and more unstable breathing (p < .05 for all). Consistent differences in key OSA traits were not observed between OVS and OSA alone. However, worse lung function does appear to exert an influence on several OSA traits. These findings indicate that a diagnosis of OVS should not generally influence the approach to OSA, but that lung function might be considered if utilizing OSA trait-specific treatment.
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Affiliation(s)
- Jeremy E. Orr
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Christopher N. Schmickl
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Bradley A. Edwards
- Sleep and Circadian Medicine LaboratoryDepartment of PhysiologyMonash UniversityMelbourneVICAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVICAustralia
| | - Pamela N. DeYoung
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Rebbecca Brena
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Xiaoying S. Sun
- Division of Biostatistics and BioinformaticsDepartment of Family Medicine and Public HealthUniversity of California San DiegoLa JollaCAUSA
| | - Sonia Jain
- Division of Biostatistics and BioinformaticsDepartment of Family Medicine and Public HealthUniversity of California San DiegoLa JollaCAUSA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Robert L. Owens
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of California San DiegoLa JollaCAUSA
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44
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Bamagoos AA, Cistulli PA, Sutherland K, Madronio M, Eckert DJ, Hess L, Edwards BA, Wellman A, Sands SA. Polysomnographic Endotyping to Select Patients with Obstructive Sleep Apnea for Oral Appliances. Ann Am Thorac Soc 2019; 16:1422-1431. [PMID: 31394914 PMCID: PMC6945467 DOI: 10.1513/annalsats.201903-190oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/15/2019] [Indexed: 01/16/2023] Open
Abstract
Rationale: Oral appliance therapy is efficacious in many patients with obstructive sleep apnea (OSA), but prediction of treatment outcome is challenging. Small, detailed physiological studies have identified key OSA endotypic traits (pharyngeal collapsibility and loop gain) as determinants of greater oral appliance efficacy.Objectives: We used a clinically applicable method to estimate OSA traits from routine polysomnography and identify an endotype-based subgroup of patients expected to show superior efficacy.Methods: In 93 patients (baseline apnea-hypopnea index [AHI], ≥20 events/h), we examined whether polysomnography-estimated OSA traits (pharyngeal: collapsibility and muscle compensation; nonpharyngeal: loop gain, arousal threshold, and ventilatory response to arousal) were associated with oral appliance efficacy (percentage reduction in AHI from baseline) and could predict responses to treatment. Multivariable regression (with interactions) defined endotype-based subgroups of "predicted" responders and nonresponders (based on 50% reduction in AHI). Treatment efficacy was compared between the predicted subgroups (with cross-validation).Results: Greater oral appliance efficacy was associated with favorable nonpharyngeal traits (lower loop gain, higher arousal threshold, and lower response to arousal), moderate (nonmild, nonsevere) pharyngeal collapsibility, and weaker muscle compensation (overall R2 = 0.30; adjusted R2 = 0.19; P = 0.003). Predicted responders (n = 54), compared with predicted nonresponders (n = 39), exhibited a greater reduction in AHI from baseline (mean [95% confidence interval], 73% [66-79] vs. 51% [38-61]; P < 0.0001) and a lower treatment AHI (8 [6-11] vs. 16 [12-20] events/h; P = 0.002). Differences persisted after adjusting for clinical covariates (including baseline AHI, body mass index, and neck circumference).Conclusions: Quantifying OSA traits using clinical polysomnography can identify an endotype-based subgroup of patients that is highly responsive to oral appliance therapy. Prospective validation is warranted.
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Affiliation(s)
- Ahmad A. Bamagoos
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Physiology, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
- Sleep and Breathing Lab, Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
| | - Peter A. Cistulli
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Melanie Madronio
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Danny J. Eckert
- Sleep and Breathing Lab, Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
| | - Lauren Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bradley A. Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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45
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Mo L, Gupta V, Modi R, Munnur K, Cameron JD, Seneviratne S, Edwards BA, Landry SA, Joosten SA, Hamilton GS, Wong DTL. Severe obstructive sleep apnea is associated with significant coronary artery plaque burden independent of traditional cardiovascular risk factors. Int J Cardiovasc Imaging 2019; 36:347-355. [PMID: 31637622 DOI: 10.1007/s10554-019-01710-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/09/2019] [Indexed: 01/27/2023]
Abstract
Obstructive Sleep Apnea (OSA) is strongly associated with adverse cardiovascular events. In these patients, increased oxidative stress has been associated with accelerated coronary atherosclerosis. However, it is unclear if OSA is associated with significant coronary artery plaque burden. Our aim is to determine whether OSA and/or markers of hypoxemia are associated with coronary plaque burden (CPB). Patients who had coronary computed tomography angiography (CCTA) and a polysomnogram within 1 year of each other between 2011 and 2016 were analyzed. Apnea-Hypopnea Index (AHI) and hypoxemic burden (ODI3%, ODI4%, nadir SpO2, average spO2 and time of spO2 < 88%) were obtained from the polysomnogram. Total CPB was assessed using the prognostically validated CT-Leaman score (CT-LeSc). Significant CPB was defined as CT-LeSc ≥ 8.3. There were 119 patients with mean (± SD) age of 59 ± 12 years. Using logistical regression analysis; AHI, ODI4% and ODI3% were the only parameters associated with significant CPB. Severe OSA (AHI ≥ 30 events/h) was associated with significant CPB with adjusted OR of 3.21 (p = 0.010) independent of traditional cardiovascular risk factors. Mechanisms associated with apnea and hypopnea events (as measured by AHI, ODI3% and ODI4%), but not the severity of arterial desaturation (nadir SpO2, burden of SpO2 < 88%) were associated with significant CPB.
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Affiliation(s)
- Lin Mo
- Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia.,Department of Lung and Sleep Medicine, Monash Health, Clayton, VIC, Australia
| | - Vivek Gupta
- Monash Heart, Monash Health, Monash Medical Centre Clayton, Clayton, VIC, Australia.,Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Rohan Modi
- Monash Heart, Monash Health, Monash Medical Centre Clayton, Clayton, VIC, Australia
| | - Kiran Munnur
- Monash Heart, Monash Health, Monash Medical Centre Clayton, Clayton, VIC, Australia.,Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia
| | - James D Cameron
- Monash Heart, Monash Health, Monash Medical Centre Clayton, Clayton, VIC, Australia.,Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Sujith Seneviratne
- Monash Heart, Monash Health, Monash Medical Centre Clayton, Clayton, VIC, Australia.,Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Shane A Landry
- Department of Physiology, School of Psychological Sciences, Monash University, Clayton, Australia
| | - Simon A Joosten
- Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia.,Department of Lung and Sleep Medicine, Monash Health, Clayton, VIC, Australia
| | - Garun S Hamilton
- Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia.,Department of Lung and Sleep Medicine, Monash Health, Clayton, VIC, Australia
| | - Dennis T L Wong
- Monash Heart, Monash Health, Monash Medical Centre Clayton, Clayton, VIC, Australia. .,Department of Medicine at Monash Health, Monash Cardiovascular Research Centre and School of Clinical Sciences, Monash University, Melbourne, Australia. .,South Australian Health & Medical Research Institute, Adelaide, Australia.
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46
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Edwards BA, Nava-Guerra L, Kemp JS, Carroll JL, Khoo MC, Sands SA, Terrill PI, Landry SA, Amin RS. Assessing ventilatory instability using the response to spontaneous sighs during sleep in preterm infants. Sleep 2019; 41:5077835. [PMID: 30137560 DOI: 10.1093/sleep/zsy161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 12/15/2022] Open
Abstract
Study Objectives Periodic breathing (PB) is common in newborns and is an obvious manifestation of ventilatory control instability. However, many infants without PB may still have important underlying ventilatory control instabilities that go unnoticed using standard clinical monitoring. Methods to detect infants with "subclinical" ventilatory control instability are therefore required. The current study aimed to assess the degree of ventilatory control instability using simple bedside recordings in preterm infants. Methods Respiratory inductance plethysmography (RIP) recordings were analyzed from ~20 minutes of quiet sleep in 20 preterm infants at 36 weeks post-menstrual age (median [range]: 36 [34-40]). The percentage time spent in PB was also calculated for each infant (%PB). Spontaneous sighs were identified and breath-by-breath measurements of (uncalibrated) ventilation were derived from RIP traces. Loop gain (LG, a measure of ventilatory control instability) was calculated by fitting a simple ventilatory control model (gain, time-constant, delay) to the post-sigh ventilatory pattern. For comparison, periodic inter-breath variability was also quantified using power spectral analysis (ventilatory oscillation magnitude index [VOMI]). Results %PB was strongly associated with LG (r2 = 0.77, p < 0.001) and moderately with the VOMI (r2 = 0.21, p = 0.047). LG (0.52 ± 0.05 vs. 0.30 ± 0.03; p = 0.0025) and the VOMI (-8.2 ± 1.1 dB vs. -11.8 ± 0.9 dB; p = 0.026) were both significantly higher in infants that displayed PB vs. those without. Conclusions LG and VOMI determined from the ventilatory responses to spontaneous sighs can provide a practical approach to assessing ventilatory control instability in preterm infants. Such simple techniques may help identify infants at particular risk for ventilatory instabilities with concomitant hypoxemia and its associated consequences.
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Affiliation(s)
- Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia.,Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Leonardo Nava-Guerra
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA
| | - James S Kemp
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Michael C Khoo
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Australia
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
| | - Raouf S Amin
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children Hospital Medical Center, Cincinnati, OH
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47
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Edwards BA, Redline S, Sands SA, Owens RL. More Than the Sum of the Respiratory Events: Personalized Medicine Approaches for Obstructive Sleep Apnea. Am J Respir Crit Care Med 2019; 200:691-703. [PMID: 31022356 PMCID: PMC6775874 DOI: 10.1164/rccm.201901-0014tr] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/22/2019] [Indexed: 11/16/2022] Open
Abstract
Traditionally, the presence and severity of obstructive sleep apnea (OSA) have been defined by the apnea-hypopnea index (AHI). Continuous positive airway pressure is generally first-line therapy despite low adherence, because it reliably reduces the AHI when used, and the response to other therapies is variable. However, there is growing appreciation that the underlying etiology (i.e., endotype) and clinical manifestation (i.e., phenotype) of OSA in an individual are not well described by the AHI. We define and review the important progress made in understanding and measuring physiological mechanisms (or endotypes) that help define subtypes of OSA and identify the potential use of genetics to further refine disease classification. This more detailed understanding of OSA pathogenesis should influence clinical treatment decisions as well as help inform research priorities and clinical study design. In short, treatments could be individualized on the basis of the underlying cause of OSA; patients could better understand which symptoms and outcomes will respond to OSA treatment and by how much; and researchers could select populations most likely to benefit from specific treatment approaches for OSA.
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Affiliation(s)
- Bradley A. Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, California
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48
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Orr JE, Sands SA, Edwards BA, Deyoung PN, Deacon N, Jen R, Li Y, Owens RL, Malhotra A. Measuring Loop Gain via Home Sleep Testing in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2019; 197:1353-1355. [PMID: 29190428 DOI: 10.1164/rccm.201707-1357le] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jeremy E Orr
- 1 University of California, San Diego La Jolla, California
| | - Scott A Sands
- 2 Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts and
| | | | | | - Naomi Deacon
- 1 University of California, San Diego La Jolla, California
| | - Rachel Jen
- 1 University of California, San Diego La Jolla, California
| | - Yanru Li
- 1 University of California, San Diego La Jolla, California
| | - Robert L Owens
- 1 University of California, San Diego La Jolla, California
| | - Atul Malhotra
- 1 University of California, San Diego La Jolla, California
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49
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O’Driscoll DM, Landry SA, Pham J, Young A, Sands SA, Hamilton GS, Edwards BA. The physiological phenotype of obstructive sleep apnea differs between Caucasian and Chinese patients. Sleep 2019; 42:5550355. [DOI: 10.1093/sleep/zsz186] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/08/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
Study Objectives
The mechanisms responsible for the development of obstructive sleep apnea (phenotypic “traits”) are known to differ between individuals and may differ across ethnicities. We aimed to examine whether loop gain, arousal threshold, pharyngeal collapsibility and muscle compensation differ between Chinese and Caucasian individuals with OSA.
Methods
We noninvasively determined the relative contribution of loop gain, arousal threshold, pharyngeal collapsibility, and muscle compensation from the ventilatory flow pattern recorded during a standard clinical polysomnography in a cohort of age and AHI matched Caucasian and Chinese patients with moderate-severe OSA (n = 90).
Results
Chinese participants had significantly more collapsible pharyngeal airways as indicated by a lower Vpassive (68.9 [51.5–75.2] vs. 74.0 [65.1–80.4] %Veupnea, U = 703, p = 0.012), but less ventilatory control instability as indicated by a lower loop gain (0.60 [0.50–0.67] vs. 0.63 [0.57–0.81], U = 762, p = 0.043) compared with Caucasian participants. Further, multiple logistic regression analyses demonstrated that the combined pharyngeal collapsibility (Vpassive) and loop gain traits help to better explain the differences between the groups beyond upper-airway collapsibility alone. No statistically significant group differences were found in muscle compensation or arousal threshold traits between groups.
Conclusion
Individuals of Chinese descent appear to have OSA that is driven much more by the relative contribution of their anatomical predisposition and to a lesser extent nonanatomical causes compared with Caucasians. Future research should focus on determining if Chinese versus Caucasian ethnicity is an important contributing factor to clinical outcomes and therapeutic responses in OSA.
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Affiliation(s)
- Denise M O’Driscoll
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
| | - Jonathan Pham
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, Australia
| | - Alan Young
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Melbourne, Australia
- Department of Lung and Sleep, Monash Health, Melbourne, Australia
- Monash Partners—Epworth, Melbourne, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Australia
- School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
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Sands SA, Terrill PI, Edwards BA, Taranto Montemurro L, Azarbarzin A, Marques M, de Melo CM, Loring SH, Butler JP, White DP, Wellman A. Quantifying the Arousal Threshold Using Polysomnography in Obstructive Sleep Apnea. Sleep 2019; 41:4608578. [PMID: 29228393 DOI: 10.1093/sleep/zsx183] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 11/07/2017] [Indexed: 11/14/2022] Open
Abstract
Study Objectives Precision medicine for obstructive sleep apnea (OSA) requires noninvasive estimates of each patient's pathophysiological "traits." Here, we provide the first automated technique to quantify the respiratory arousal threshold-defined as the level of ventilatory drive triggering arousal from sleep-using diagnostic polysomnographic signals in patients with OSA. Methods Ventilatory drive preceding clinically scored arousals was estimated from polysomnographic studies by fitting a respiratory control model (Terrill et al.) to the pattern of ventilation during spontaneous respiratory events. Conceptually, the magnitude of the airflow signal immediately after arousal onset reveals information on the underlying ventilatory drive that triggered the arousal. Polysomnographic arousal threshold measures were compared with gold standard values taken from esophageal pressure and intraoesophageal diaphragm electromyography recorded simultaneously (N = 29). Comparisons were also made to arousal threshold measures using continuous positive airway pressure (CPAP) dial-downs (N = 28). The validity of using (linearized) nasal pressure rather than pneumotachograph ventilation was also assessed (N = 11). Results Polysomnographic arousal threshold values were correlated with those measured using esophageal pressure and diaphragm EMG (R = 0.79, p < .0001; R = 0.73, p = .0001), as well as CPAP manipulation (R = 0.73, p < .0001). Arousal threshold estimates were similar using nasal pressure and pneumotachograph ventilation (R = 0.96, p < .0001). Conclusions The arousal threshold in patients with OSA can be estimated using polysomnographic signals and may enable more personalized therapeutic interventions for patients with a low arousal threshold.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Queensland, Australia
| | - Bradley A Edwards
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Department of Physiology, Sleep and Circadian Medicine Laboratory, Monash University, Melbourne, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Luigi Taranto Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Camila M de Melo
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen H Loring
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - James P Butler
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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