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Harding CD, Fuentes AL, Malhotra A. Tackling obstructive sleep apnea with pharmacotherapeutics: expert guidance. Expert Opin Pharmacother 2024; 25:1019-1026. [PMID: 38913403 PMCID: PMC11227253 DOI: 10.1080/14656566.2024.2365329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/04/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION The efficacy of non-pharmacotherapeutic treatment of obstructive sleep apnea, a highly prevalent condition with serious cardiometabolic and neurocognitive health consequences, is well established. Supplementing traditional treatment strategies with medications can improve symptoms and reduce side effects. Efforts to identify medications that target the causes of sleep apnea have met with mixed success. However, this remains a worthwhile objective for researchers to pursue, given the potential benefit pharmacotherapy could bring to those patients who reject or struggle to adhere to existing treatments. AREAS COVERED This article presents the case for obstructive sleep apnea pharmacotherapy including drugs that reduce the occurrence of apnea events, such as weight loss agents, ventilation activators and muscle and nervous system stimulants, drugs that alleviate symptoms, such as wake-promoting agents for excessive daytime sleepiness, and drugs that improve adherence to existing treatments, such as hypnotics. Literature was accessed from PubMed between 1 March 2024 and 18 April 2024. EXPERT OPINION Exciting recent advances in both our understanding of obstructive sleep apnea pathology and in the techniques used to identify therapeutic agents and their targets combine to embolden a positive outlook for the expanded use of drugs in tackling this consequential disease.
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Affiliation(s)
- Christian D. Harding
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Ana Lucia Fuentes
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
- Pulmonary and Critical Care Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
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2
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Nokes B, Orr JE, White S, Luu S, Chen Z, Alex R, Sands SA, Wojeck BS, Owens RL, Malhotra A, Schmickl CN. Effect of obesity on sleep apnea pathogenesis differs in women versus men: multiple mediation analyses in the retrospective SNOOzzzE cohort. J Appl Physiol (1985) 2024; 136:1516-1525. [PMID: 38660729 DOI: 10.1152/japplphysiol.00925.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/16/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024] Open
Abstract
There are multiple mechanisms underlying obstructive sleep apnea (OSA) development. However, how classic OSA risk factors such as body mass index (BMI) and sex portend to OSA development has not been fully described. Thus we sought to evaluate how obesity leads to OSA and assess how these mechanisms differ between men and women. The San Diego Multi-Outcome OSA Endophenotype (SNOOzzzE) cohort includes 3,319 consecutive adults who underwent a clinical in-laboratory polysomnography at the University of California, San Diego, sleep clinic between January 2017 and December 2019. Using routine polysomnography signals, we determined OSA endotypes. We then performed mediation analyses stratified by sex to determine how BMI influenced the apnea-hypopnea index (AHI) using OSA pathophysiological traits as mediators, adjusting for age, race, and ethnicity. We included 2,146 patients of whom 919 (43%) were women and 1,227 (57%) were obese [body mass index (BMI) > 30 kg/m2]. BMI was significantly associated with AHI in both women and men. In men, the adjusted effect of BMI on AHI was partially mediated by a reduction in upper airway stiffness (βstandardized = 0.124), a reduction in circulatory delay (βstandardized = 0.063), and an increase in arousal threshold (βstandardized = 0.029; Pboot-strapped,all < 0.05). In women, the adjusted effect of BMI on AHI was partially mediated by a reduction in upper airway stiffness (βstandardized = 0.05) and circulatory delay (βstandardized = 0.037; Pboot-strapped,all < 0.05). BMI-related OSA pathogenesis differs by sex. An increase in upper airway collapsibility is consistent with prior studies. A reduction in circulatory delay may lead to shorter and thus more events per hour (higher AHI), while the relationship between arousal threshold and OSA is likely complex.NEW & NOTEWORTHY Our data provide important insights into obesity-related obstructive sleep apnea (OSA) pathogenesis, thereby validating, and extending, prior research findings. This is the largest sample size study to examine the relationships between obesity and gender on OSA pathogenesis. The influence of obesity on sleep apnea severity is mediated by different mechanistic traits (endotypes).
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Affiliation(s)
- Brandon Nokes
- Sleep Medicine Section, Veterans Affairs San Diego Healthcare System, San Diego, California, United States
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Jeremy E Orr
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Stephanie White
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Steven Luu
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Zihan Chen
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Raichel Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Brian S Wojeck
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, United States
| | - Robert L Owens
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego, California, United States
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Schiza S, Schwarz EI, Bonsignore MR, McNicholas WT, Pataka A, Bouloukaki I. Co-existence of OSA and respiratory diseases and the influence of gender. Expert Rev Respir Med 2023; 17:1221-1235. [PMID: 38198636 DOI: 10.1080/17476348.2024.2304065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Sleep-disordered breathing (SDB), especially obstructive sleep apnea (OSA), is commonly associated with respiratory diseases, such as COPD, asthma and interstitial lung disease. AREAS COVERED This narrative review aims to comprehensively synthesize the existing information on SDB in respiratory diseases, investigate the role of gender in this association, and highlight the importance of OSA management in improving sleep, quality of life, and disease prognosis in these specific patient populations. EXPERT OPINION Research indicates a synergistic link between OSA and chronic respiratory diseases, which leads to greater morbidity and mortality compared to each disorder alone. Given the lack of an optimal OSA screening tool for these patients, a comprehensive patient approach and overnight diagnostic sleep study are imperative. Despite the limited evidence available, it seems that gender has an impact on the prevalence, severity, and susceptibility of this coexistence. Recognizing the role of gender in the coexistence of OSA and other respiratory diseases can enhance everyday medical practice and enable clinicians to adopt a more personalized approach toward optimal screening and diagnosis of these patients.
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Affiliation(s)
- Sophia Schiza
- Sleep Disorders Center, Department of Respiratory Medicine, University of Crete School of Medicine, Crete, Greece
| | - Esther I Schwarz
- Department of Pulmonology, University Hospital Zurich and University of Zurich, University of Zurich Faculty of Medicine, Zurich, Switzerland
| | - Maria R Bonsignore
- Division of Respiratory Medicine, PROMISE Department, University of Palermo Faculty of Medicine and Surgery, Palermo, Italy
| | - Walter T McNicholas
- Department of Respiratory and Sleep Medicine, St Vincent's Hospital Group, University College Dublin, Dublin, Ireland
| | - Athanasia Pataka
- Respiratory Failure Unit, G Papanikolaou Hospital, Medical School, Aristoteleio Panepistemio Thessalonikes Schole Epistemon Ygeias, Thessaloniki, Greece
| | - Izolde Bouloukaki
- Sleep Disorders Center, Department of Respiratory Medicine, University of Crete School of Medicine, Crete, Greece
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Bradicich M, Siciliano M, Donfrancesco F, Cherneva R, Ferraz B, Testelmans D, Sánchez-de-la-Torre M, Randerath W, Schiza S, Cruz J. Sleep and Breathing Conference highlights 2023: a summary by ERS Assembly 4. Breathe (Sheff) 2023; 19:230168. [PMID: 38020339 PMCID: PMC10644110 DOI: 10.1183/20734735.0168-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
This paper presents some of the highlights of the Sleep and Breathing Conference 2023 https://bit.ly/46MxJml.
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Affiliation(s)
- Matteo Bradicich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Spital Zollikerberg, Zollikerberg, Switzerland
| | - Matteo Siciliano
- Università Cattolica del Sacro Cuore, Campus di Roma, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- These authors contributed equally
| | - Federico Donfrancesco
- Università Cattolica del Sacro Cuore, Campus di Roma, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- These authors contributed equally
| | - Radostina Cherneva
- Medical University, University Hospital “Ivan Rilski”, Respiratory Intensive Care Unit, Sofia, Bulgaria
- These authors contributed equally
| | - Beatriz Ferraz
- Pulmonology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- These authors contributed equally
| | - Dries Testelmans
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
- These authors contributed equally
| | - Manuel Sánchez-de-la-Torre
- Respiratory Department, Hospital Universitari Arnau de Vilanova-Santa María, IRB Lleida, Lleida, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Winfried Randerath
- Institute of Pneumology, University Cologne, Bethanien Hospital, Solingen, Germany
- These authors contributed equally
| | - Sophia Schiza
- Department of Respiratory Medicine, School of Medicine, University of Crete, Heraklion, Greece
- These authors contributed equally
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences (ESSLei), Polytechnic of Leiria, Leiria, Portugal
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Turnbull CD, Stradling JR. Endotyping, phenotyping and personalised therapy in obstructive sleep apnoea: are we there yet? Thorax 2023; 78:726-732. [PMID: 37217289 DOI: 10.1136/thorax-2023-220037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
Obstructive sleep apnoea (OSA) was traditionally thought to be mainly caused by obesity and upper airway crowding, and hence OSA management was not personalised according to particular characteristics, with most symptomatic patients receiving continuous positive airway pressure therapy. Recent advances in our understanding have identified additional potential and distinct causes of OSA (endotypes), and subgroups of patients (phenotypes) with increased risk of cardiovascular complications. In this review, we discuss the evidence to date as to whether there are distinct clinically useful endotypes and phenotypes of OSA, and the challenges to the field in moving towards delivering personalised therapy in OSA.
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Affiliation(s)
- Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John R Stradling
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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O'Neill E, Ryan S, McNicholas WT. Chronic obstructive pulmonary disease and obstructive sleep apnoea overlap: co-existence, co-morbidity, or causality? Curr Opin Pulm Med 2022; 28:543-551. [PMID: 36124997 DOI: 10.1097/mcp.0000000000000922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The chronic obstructive pulmonary disease and obstructive sleep apnoea overlap syndrome is associated with higher morbidity and mortality rates than either disease alone. There is evidence of a bidirectional relationship between the two conditions, with the overlap syndrome encompassing a spectrum of clinical phenotypes. RECENT FINDINGS This review examines the evidence for the various factors that determine the overlap syndrome, the impact overlap syndrome has on co-morbidities, and implications for diagnosis and treatment. SUMMARY The accurate diagnosis of the overlap syndrome is critical given its implications for treatment optimisation and reduction in healthcare utilisation and costs.
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Affiliation(s)
- Emily O'Neill
- School of Medicine, University College Dublin, Department of Respiratory and Sleep Medicine, St. Vincent's University Hospital, Dublin, Ireland
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Schmickl CN, Edwards BA, Malhotra A. Drug Therapy for Obstructive Sleep Apnea: Are We There Yet? Am J Respir Crit Care Med 2022; 205:1379-1381. [PMID: 35320066 PMCID: PMC9875900 DOI: 10.1164/rccm.202202-0301ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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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Nokes B, Schmickl CN, Brena R, Bosompra NN, Gilbertson D, Sands SA, Bhattacharjee R, Mann DL, Owens RL, Malhotra A, Orr JE. The impact of daytime transoral neuromuscular stimulation on upper airway physiology - A mechanistic clinical investigation. Physiol Rep 2022; 10:e15360. [PMID: 35748091 PMCID: PMC9226850 DOI: 10.14814/phy2.15360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 06/15/2023] Open
Abstract
There is a need for alternatives to positive airway pressure for the treatment of obstructive sleep apnea and snoring. Improving upper airway dilator function might alleviate upper airway obstruction. We hypothesized that transoral neuromuscular stimulation would reduce upper airway collapse in concert with improvement in genioglossal muscle function. Subjects with simple snoring and mild OSA (AHI < 15/h on screening) underwent in-laboratory polysomnography with concurrent genioglossal electromyography (EMGgg) before and after 4-6 weeks of twice-daily transoral neuromuscular stimulation. Twenty patients completed the study: Sixteen males, mean ± SD age 40 ± 13 years, and BMI 26.3 ± 3.8 kg/m2 . Although there was no change in non-rapid eye movement EMGgg phasic (p = 0.66) or tonic activity (p = 0.83), and no decrease in snoring or flow limitation, treatment was associated with improvements in tongue endurance, sleep quality, and sleep efficiency. In this protocol, transoral neurostimulation did not result in changes in genioglossal activity or upper airway collapse, but other beneficial effects were noted suggesting a need for additional mechanistic investigation.
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Affiliation(s)
- Brandon Nokes
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
- VA San DiegoDivision of Sleep MedicineSan DiegoCaliforniaUSA
| | - Christopher N. Schmickl
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
| | - Rebbecca Brena
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
| | - Nana Naa‐Oye Bosompra
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
| | - Dillon Gilbertson
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
| | - Scott A. Sands
- Division of Sleep and Circadian DisordersBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Dwayne L. Mann
- Institute for Social Science ResearchUniversity of QueenslandBrisbaneAustralia
| | - Robert L. Owens
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
| | - Atul Malhotra
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
| | - Jeremy E. Orr
- University of CaliforniaDivision of Pulmonary, Critical Care, Sleep Medicine, and PhysiologyLa JollaCaliforniaUSA
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9
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Schmickl CN, Orr JE, Kim P, Nokes B, Sands S, Manoharan S, McGinnis L, Parra G, DeYoung P, Owens RL, Malhotra A. Point-of-care prediction model of loop gain in patients with obstructive sleep apnea: development and validation. BMC Pulm Med 2022; 22:158. [PMID: 35468829 PMCID: PMC9036750 DOI: 10.1186/s12890-022-01950-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background High loop gain (unstable ventilatory control) is an important—but difficult to measure—contributor to obstructive sleep apnea (OSA) pathogenesis, predicting OSA sequelae and/or treatment response. Our objective was to develop and validate a clinical prediction tool of loop gain. Methods A retrospective cohort of consecutive adults with OSA (apnea–hypopnea index, AHI > 5/hour) based on in-laboratory polysomnography 01/2017–12/2018 was randomly split into a training and test-set (3:1-ratio). Using a customized algorithm (“reference standard”) loop gain was quantified from raw polysomnography signals on a continuous scale and additionally dichotomized (high > 0.7). Candidate predictors included general patient characteristics and routine polysomnography data. The model was developed (training-set) using linear regression with backward selection (tenfold cross-validated mean square errors); the predicted loop gain of the final linear regression model was used to predict loop gain class. More complex, alternative models including lasso regression or random forests were considered but did not meet pre-specified superiority-criteria. Final model performance was validated on the test-set. Results The total cohort included 1055 patients (33% high loop gain). Based on the final model, higher AHI (beta = 0.0016; P < .001) and lower hypopnea-percentage (beta = −0.0019; P < .001) predicted higher loop gain values. The predicted loop gain showed moderate-to-high correlation with the reference loop gain (r = 0.48; 95% CI 0.38–0.57) and moderate discrimination of patients with high versus low loop gain (area under the curve = 0.73; 95% CI 0.67–0.80). Conclusion To our knowledge this is the first prediction model of loop gain based on readily-available clinical data, which may facilitate retrospective analyses of existing datasets, better patient selection for clinical trials and eventually clinical practice.
Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01950-y.
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Affiliation(s)
- Christopher N Schmickl
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA.
| | - Jeremy E Orr
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Paul Kim
- Division of Cardiology, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Brandon Nokes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Scott Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sreeganesh Manoharan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Lana McGinnis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Gabriela Parra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Pamela DeYoung
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego (UCSD), San Diego, CA, 92037, USA
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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: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [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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11
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Pun M, Beaudin AE, Raneri JK, Anderson TJ, Hanly PJ, Poulin MJ. Impact of nocturnal oxygen and CPAP on the ventilatory response to hypoxia in OSA patients free of overt cardiovascular disease. Exp Neurol 2021; 346:113852. [PMID: 34461058 DOI: 10.1016/j.expneurol.2021.113852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 11/20/2022]
Abstract
A primary characteristic of obstructive sleep apnea (OSA) is chronic exposure to intermittent hypoxia (IH) due to repeated upper airway obstruction. Chronic IH exposure is believed to increase OSA severity over time by enhancing the acute ventilatory response to hypoxia (AHVR), thus promoting ventilatory overshoot when apnea ends and perpetuation of apnea during sleep. Continuous positive airway pressure (CPAP), the gold-standard treatment of OSA, reduces the AHVR, believed to result from correction of IH. However, CPAP also corrects ancillary features of OSA such as intermittent hypercapnia, negative intrathoracic pressure and surges in sympathetic activity, which may also contribute to the reduction in AHVR. Therefore, the objective of this study was to investigate the impact of nocturnal oxygen therapy (to remove IH only) and CPAP (to correct IH and ancillary features of OSA) on AHVR in newly diagnosed OSA patients. Fifty-two OSA patients and twenty-two controls were recruited. The AHVR was assessed using a 5 min iscopanic-hypoxic challenge before, and after, treatment of OSA by nocturnal oxygen therapy and CPAP. Following baseline measurements, OSA patients were randomly assigned to nocturnal oxygen therapy (Oxygen, n = 26) or no treatment (Air; n = 26). The AHVR was re-assessed following two weeks of oxygen therapy or no treatment, after which all patients were treated with CPAP. The AHVR was quantified following ~4 weeks of adherent CPAP therapy (n = 40). Both nocturnal oxygen and CPAP treatments improved hypoxemia (p < 0.05), and, as expected, nocturnal oxygen therapy did not completely abolish respiratory events (i.e., apneas/hypopneas). Averaged across all OSA patients, nocturnal oxygen therapy did not change AHVR from baseline to post-oxygen therapy. Similarly, the AHVR was not altered pre- and post-CPAP (p > 0.05). However, there was a significant decrease in AHVR with both nocturnal oxygen therapy and CPAP in patients in the highest OSA severity quartile (p < 0.05). Nocturnal oxygen therapy and CPAP both reduce the AHVR in patients with the most severe OSA. Therefore, IH appears to be the primary mechanism producing ventilatory instability in patients with severe OSA via enhancement of the AHVR.
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Affiliation(s)
- Matiram Pun
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew E Beaudin
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jill K Raneri
- Sleep Centre, Foothills Medical Centre, Calgary, AB, Canada
| | - Todd J Anderson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Science, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Patrick J Hanly
- Sleep Centre, Foothills Medical Centre, Calgary, AB, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Marc J Poulin
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada.
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Malhotra A, Nokes B, DeYoung P, Owens R. Why do we sometimes ignore the chief complaint in patients evaluated for obstructive sleep apnea? J Clin Sleep Med 2021; 16:657-659. [PMID: 32022681 DOI: 10.5664/jcsm.8310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Atul Malhotra
- Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California
| | - Brandon Nokes
- Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California
| | - Pamela DeYoung
- Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California
| | - Robert Owens
- Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, California
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Acetazolamide for OSA and Central Sleep Apnea: A Comprehensive Systematic Review and Meta-Analysis. Chest 2020; 158:2632-2645. [PMID: 32768459 DOI: 10.1016/j.chest.2020.06.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Therapy options for OSA and central sleep apnea (CSA) are limited, thus many patients remain untreated. Clinically, acetazolamide is sometimes used for CSA; however, given overlapping pathophysiologic properties of OSA and CSA, we hypothesized that acetazolamide is equally effective for both types. Prior reviews focused on specific subtypes of sleep apnea, study designs, and languages, thus including few studies (typically ≤3) limiting insights. RESEARCH QUESTION How efficacious is acetazolamide for sleep apnea, and is its effect modified by sleep apnea type or acetazolamide dose? STUDY DESIGN AND METHODS We queried MEDLINE, EMBASE, and ClinicalTrials.gov from inception until March 11, 2019. Any study in which adults with OSA/CSA received oral acetazolamide vs no acetazolamide (control) that reported sleep apnea-related outcomes was eligible, independent of study design or language. Two reviewers independently assessed eligibility and abstracted data. Primary outcomes were apnea-hypopnea index (AHI) and oxygen saturation nadir. Quality of evidence (QoE) was rated with the use of Grades of Recommendation Assessment, Development and Evaluation methods. RESULTS We included 28 studies (13 OSA/15 CSA; NSubjects,Acetazolamide = 542; NSubjects,Control = 553) that enabled meta-analyses for 24 outcomes. Acetazolamide doses ranged from 36 to 1000 mg/d and treatment duration from 1 to 90 d (median, 6 d). Overall, acetazolamide vs control lowered the AHI by -0.7 effect sizes (95% CI, -0.83 to -0.58; I2 = 0%; moderate QoE) that corresponded to a reduction of 37.7% (95% CI, -44.7 to -31.3) or 13.8/h (95% CI, -16.3 to -11.4; AHIControl = 36.5/h). The AHI reduction was similar in OSA vs CSA, but significantly greater with higher doses (at least up to 500 mg/d). Furthermore, acetazolamide improved oxygen saturation nadir by +4.4% (95% CI, 2.3 to 6.5; I2 = 63%; no evidence of effect modification; very low QoE) and several secondary outcomes that included sleep quality measures and BP (mostly low QoE). INTERPRETATION Short-term acetazolamide improved both OSA and CSA. Rigorous studies with long-term follow up are warranted to assess Acetazolamide's value for the chronic treatment of patients with sleep apnea. CLINICAL TRIAL REGISTRATION PROSPERO (CRD42019147504).
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Effect of Venlafaxine on Apnea-Hypopnea Index in Patients With Sleep Apnea: A Randomized, Double-Blind Crossover Study. Chest 2020; 158:765-775. [PMID: 32278781 DOI: 10.1016/j.chest.2020.02.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/11/2020] [Accepted: 02/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND One of the key mechanisms underlying OSA is reduced pharyngeal muscle tone during sleep. Data suggest that pharmacologic augmentation of central serotonergic/adrenergic tone increases pharyngeal muscle tone. RESEARCH QUESTION We hypothesized that venlafaxine, a serotonin-norepinephrine reuptake inhibitor, would improve OSA severity. STUDY DESIGN AND METHODS In this mechanistic, randomized, double-blind, placebo-controlled crossover trial, 20 patients with OSA underwent two overnight polysomnograms ≥ 4 days apart, receiving either 50 mg of immediate-release venlafaxine or placebo before bedtime. Primary outcomes were the apnea-hypopnea index (AHI) and peripheral oxygen saturation (Spo2) nadir, and secondary outcomes included sleep parameters and pathophysiologic traits with a view toward understanding the impact of venlafaxine on mechanisms underlying OSA. RESULTS Overall, there was no significant difference between venlafaxine and placebo regarding AHI (mean reduction, -5.6 events/h [95% CI, -12.0 to 0.9]; P = .09) or Spo2 nadir (median increase, +1.0% [-0.5 to 5]; P = .11). Venlafaxine reduced total sleep time, sleep efficiency, and rapid eye movement (REM) sleep, while increasing non-REM stage 1 sleep (Pall < .05). On the basis of exploratory post hoc analyses venlafaxine decreased ("improved") the ventilatory response to arousal (-30%; P = .049) and lowered ("worsened") the predicted arousal threshold (-13%; [P = .02]; ie, more arousable), with no effects on other pathophysiologic traits (Pall ≥ .3). Post hoc analyses further suggested effect modification by arousal threshold (P = .002): AHI improved by 19% in patients with a high arousal threshold (-10.9 events/h [-3.9 to -17.9]) but tended to increase in patients with a low arousal threshold (+7 events/h [-2.0 to 16]). Other predictors of response were elevated AHI and less collapsible upper airway anatomy at baseline (|r| > 0.5, P ≤ .02). INTERPRETATION In unselected patients, venlafaxine simultaneously worsened and improved various pathophysiologic traits, resulting in a zero net effect. Careful patient selection based on pathophysiologic traits, or combination therapy with drugs countering its alerting effects, may produce a more robust response. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02714400; URL: www.clinicaltrials.gov.
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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] [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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