Pharyngeal structure and function as a determinant of sleep-related breathing disorders: a unifying hypothesis

Regional velopharyngeal compliance in the rat: influence of tongue muscle contraction

The velopharynx is the most collapsible segment of the upper airway in patients with obstructive sleep apnea. However, we do not know if velopharyngeal compliance is uniform throughout its length, or if compliance is modified by contraction of upper airway muscles. We tested the hypothesis that rostral and caudal velopharyngeal (VP) compliance differs, and that tongue muscle contraction reduces compliance. High-resolution MR images of the VP were made at nasopharyngeal pressures ranging from -9 to 9 cmH(2)O in anesthetized rats. Images were obtained twice at each pressure, once with and once without bilateral hypoglossal nerve stimulation. The volume of the caudal and rostral VP was computed at each pressure. The caudal VP was significantly (P = 0.0058) more compliant than the rostral VP, but electrical stimulation of the tongue muscles did not change compliance. VP critical pressure (Pcrit; pressure at zero airway volume) averaged -25.2 and -12.1 cmH(2)O in the rostral and caudal VP, respectively (P < 0.0001). Coactivation of tongue protrudor and retractor muscles or contraction of protrudor muscles alone dilated the VP and made Pcrit more negative (P < 0.0001), but only in the caudal VP. In the rat, the caudal VP is more collapsible than the rostral VP, and either coactivation of tongue protrudor and retractor muscles or contraction of protrudor muscles alone makes this region more difficult to close. Thus, tongue muscle contraction protects the caudal VP, which appears to be a particularly vulnerable segment of the nasopharyngeal airway. With suitable modification, the methods described here, including tongue muscle stimulation at different pharyngeal pressures, may be appropriate for experiments in human subjects.

Pharyngeal critical pressure in children with mild sleep-disordered breathing

There is evidence that narrowing or collapse of the pharynx can contribute to obstructive sleep-disordered breathing (SDB) in adults and children. However, studies in children have focused on those with relatively severe SDB who generally were recruited from sleep clinics. It is unclear whether children with mild SDB who primarily have hypopneas, and not frank apnea, also have more collapsible airways. We estimated airway collapsibility in 10 control subjects (9.4 ± 0.5 yr old; 1.9 ± 0.2 hypopneas/h) and 7 children with mild SDB (10.6 ± 0.5 yr old; 11.5 ± 0.1 hypopneas/h) during stable, non-rapid eye movement sleep. None of the subjects had clinically significant enlargement of the tonsils or adenoids, nor had any undergone previous tonsillectomy or adenoidectomy. Airway collapsibility was measured by brief (2-breath duration) and sudden reductions in pharyngeal pressure by connecting the breathing mask to a negative pressure source. Negative pressure applications ranging from −1 to −20 cmH2O were randomly applied in each subject while respiratory airflow and mask pressure were measured. Flow-pressure curves were constructed for each subject, and the x-intercept gave the pressure at zero flow, the so-called critical pressure of the upper airway (Pcrit). Pcrit was significantly higher in children with SDB than in controls (−10.8 ± 2.8 vs. −15.7 ± 1.2 cmH2O; P < 0.05). There were no significant differences in the slopes of the pressure-flow relations or in baseline airflow resistance. These data support the concept that intrinsic pharyngeal collapsibility contributes to mild SDB in children.

The roles of depression and anxiety in the understanding and treatment of Obstructive Sleep Apnea Syndrome

Obstructive Sleep Apnea Syndrome (OSAS) is a debilitating condition stemming from disruption to the respiratory system during sleep. At present, the nature of the relationship between OSAS and mood, specifically depression and anxiety, is still unclear. The purpose of this paper is to shed some light on this relationship. PsycINFO was used to locate relevant papers on this topic. This literature search formed the basis of our investigation. Results showed that the anxiety and depression methodology is weak. It is now clear that there is an urgent need to better understand the roles of anxiety and depression in OSAS. For example, the research literature suggests that depression and anxiety covary with OSAS. However, because of methodological issues, such as difficulties involved in diagnosis and the use of inappropriate instruments, this conclusion remains tenuous. Future directions are discussed.

Respiratory-related activity of the pharyngeal nerves in the rat

In anesthetized (n = 26) or decerebrate (n = 15) rats, vagotomized, paralyzed and artificially ventilated, we recorded efferent respiratory-related discharges of nerves supplying the pharyngeal muscles, i.e. the glossopharyngeal nerve (IX; n = 30) and the pharyngeal ramus of the vagus nerve (PH.X; n = 33). In both types of preparation, all IX nerves fired during inspiration (I); most PH.X fired either during I (n = 11), expiration (E, n = 12), or both phases (n = 4); some of them were continuously active, without any respiratory modulation (n = 6). We also examined the timing of inspiratory pharyngeal bursts in relation to the phrenic (inspiratory) bursts. We found that the burst onset occurred significantly earlier in pharyngeal nerves than in phrenic ones (pharyngeal-to-phrenic delay). In anesthetized animals, this pharyngeal-to-phrenic delay was long enough to reveal that inspiratory activity appeared first on IX, then on PH.X, and then on phrenic nerves. Since hypoxia did not significantly alter the pharyngeal-to-phrenic delay, we conclude that a reliable organization of the inspiratory drive on pharyngeal and diaphragmatic muscles should exist, in the rat.

Pharyngeal volume in asymptomatic snorers compared with nonsnoring volunteers

STUDY OBJECTIVE

to determine if asymptomatic snorers have smaller pharyngeal volumes than age- and height-matched nonsnorers.

DESIGN

we recruited asymptomatic heavy snorers and nonsnorers for a study. Each snorer was matched by age (+/- 3 years) and height (+/- 2 inches) with a nonsnorer. The nonsnorers were required to be near ideal body weight. All volunteers underwent overnight polysomnography, pulmonary function testing, and magnetic resonance imaging of the pharynx while awake. The volume of the pharynx was determined by a computer with data input from a digitizing instrument.

SETTING

Veterans Administration Hospital and University of Florida Teaching Hospital

PARTICIPANTS

Nine volunteers were recruited for both the snorer and nonsnorer groups. Each participant was paid $50. There were no interventions.

MEASUREMENTS AND RESULTS

There were no differences in sleep variables between the two groups. There was also no significant difference between pharyngeal volumes for the two groups.

CONCLUSIONS

The volume of the pharynx in asymptomatic snorers is similar to the volume in age- and height-matched nonsnorers.