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Albadi AM, Alshahrani MM, Allehebi RO. Sleep-related breathing disorder (central sleep apnoea) improved coincidentally by medical therapy with fumarates (dimethyl fumarate). Drugs Context 2023; 12:2023-6-3. [PMID: 38046472 PMCID: PMC10688778 DOI: 10.7573/dic.2023-6-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/24/2023] [Indexed: 12/05/2023] Open
Abstract
Central sleep apnoea (CSA) is a sleep disorder characterized by the repeated cessation or reduction of both airflow and ventilatory effort when sleeping. Individuals with central breathing disorders have difficulty in receiving appropriate medical treatment. In this article, we describe a case study of a 31-year-old woman known to have multiple sclerosis and concomitant severe CSA. She received the medication dimethyl fumarate for the treatment of multiple sclerosis, and her CSA significantly improved to mild CSA after the treatment.
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Affiliation(s)
- Abdulmajeed M Albadi
- Department of Pulmonary Medicine, Sleep Medicine Unit, King Fahad Medical City, Riyadh, Saudi Arabia
- Prince Mohammad bin Abdulaziz Medical City, Aljouf, Saudi Arabia
| | - Mana M Alshahrani
- Department of Pulmonary Medicine, Sleep Medicine Unit, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Riyad O Allehebi
- Department of Pulmonary Medicine, Sleep Medicine Unit, King Fahad Medical City, Riyadh, Saudi Arabia
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2
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Dempsey JA, Welch JF. Control of Breathing. Semin Respir Crit Care Med 2023; 44:627-649. [PMID: 37494141 DOI: 10.1055/s-0043-1770342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Substantial advances have been made recently into the discovery of fundamental mechanisms underlying the neural control of breathing and even some inroads into translating these findings to treating breathing disorders. Here, we review several of these advances, starting with an appreciation of the importance of V̇A:V̇CO2:PaCO2 relationships, then summarizing our current understanding of the mechanisms and neural pathways for central rhythm generation, chemoreception, exercise hyperpnea, plasticity, and sleep-state effects on ventilatory control. We apply these fundamental principles to consider the pathophysiology of ventilatory control attending hypersensitized chemoreception in select cardiorespiratory diseases, the pathogenesis of sleep-disordered breathing, and the exertional hyperventilation and dyspnea associated with aging and chronic diseases. These examples underscore the critical importance that many ventilatory control issues play in disease pathogenesis, diagnosis, and treatment.
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Affiliation(s)
- Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin
| | - Joseph F Welch
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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3
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Dempsey JA, Gibbons TD. Rethinking O 2 , CO 2 and breathing during wakefulness and sleep. J Physiol 2023. [PMID: 37750243 DOI: 10.1113/jp284551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
We have examined the importance of three long-standing questions concerning chemoreceptor influences on cardiorespiratory function which are currently experiencing a resurgence of study among physiologists and clinical investigators. Firstly, while carotid chemoreceptors (CB) are required for hypoxic stimulation of breathing, use of an isolated, extracorporeally perfused CB preparation in unanaesthetized animals with maintained tonic input from the CB, reveals that extra-CB hypoxaemia also provides dose-dependent ventilatory stimulation sufficient to account for 40-50% of the total ventilatory response to steady-state hypoxaemia. Extra-CB hyperoxia also provides a dose- and time-dependent hyperventilation. Extra-CB sites of O2 -driven ventilatory stimulation identified to date include the medulla, kidney and spinal cord. Secondly, using the isolated or denervated CB preparation in awake animals and humans has demonstrated a hyperadditive effect of CB sensory input on central CO2 sensitivity, so that tonic CB activity accounts for as much as 35-40% of the normal, air-breathing eupnoeic drive to breathe. Thirdly, we argue for a key role for CO2 chemoreception and the neural drive to breathe in the pathogenesis of upper airway obstruction during sleep (OSA), based on the following evidence: (1) removal of the wakefulness drive to breathe enhances the effects of transient CO2 changes on breathing instability; (2) oscillations in respiratory motor output precipitate pharyngeal obstruction in sleeping subjects with compliant, collapsible airways; and (3) in the majority of patients in a large OSA cohort, a reduced neural drive to breathe accompanied reductions in both airflow and pharyngeal airway muscle dilator activity, precipitating airway obstruction.
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Affiliation(s)
| | - Travis D Gibbons
- University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
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4
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Piccirillo F, Crispino SP, Buzzelli L, Segreti A, Incalzi RA, Grigioni F. A State-of-the-Art Review on Sleep Apnea Syndrome and Heart Failure. Am J Cardiol 2023; 195:57-69. [PMID: 37011555 DOI: 10.1016/j.amjcard.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/19/2023] [Accepted: 02/25/2023] [Indexed: 04/05/2023]
Abstract
Heart failure (HF) affects many patients worldwide every year. It represents a leading cause of hospitalization and still, today, mortality remains high, albeit the progress in treatment strategies. Several factors contribute to the development and progression of HF. Among these, sleep apnea syndrome represents a common but still underestimated factor because its prevalence is substantially higher in patients with HF than in the general population and is related to a worse prognosis. This review summarizes the current knowledge about sleep apnea syndrome coexisting with HF in terms of morbidity and mortality to provide actual and future perspectives about the diagnosis, evaluation, and treatment of this association.
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Affiliation(s)
- Francesco Piccirillo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy.
| | - Simone Pasquale Crispino
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
| | - Lorenzo Buzzelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
| | - Andrea Segreti
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Raffaele Antonelli Incalzi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Geriatrics, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
| | - Francesco Grigioni
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
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5
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Ahmad B, Sankari A, Eshraghi M, Aldwaikat A, Yarandi H, Zeineddine S, Salloum A, Badr MS. Effect of Zolpidem on nocturnal arousals and susceptibility to central sleep apnea. Sleep Breath 2023; 27:173-180. [PMID: 35286569 PMCID: PMC9470768 DOI: 10.1007/s11325-022-02593-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE Arousals may contribute to the pathogenesis of sleep-disordered breathing (SDB) and central sleep apnea (CSA). We aimed to determine the effect of the nonbenzodiazepine hypnotic zolpidem on the frequency of respiratory-related arousals and central apnea in patients with moderate-to-severe SDB. We hypothesized that zolpidem decreases the severity of SDB by decreasing the frequency of respiratory-related arousals. METHODS Patients with apnea-hypopnea index ≥ 15 events/hour and central apnea-hypopnea index ≥ 5 events/hour underwent a sleep study on zolpidem 5 mg and a sleep study with no medication in a randomized order. The respiratory arousal index was compared between the two studies using a randomized crossover design. Sleep, respiratory, and physiologic parameters, including the CO2 reserve and the respiratory arousal threshold, were also compared. RESULTS Eleven participants completed the study. Compared to no treatment, zolpidem reduced the respiratory arousal index (39.7 ± 7.7 vs. 23.3 ± 4.4 events/h, P = 0.031). Zolpidem also lowered the total apnea-hypopnea index (55.6 ± 8.5 vs. 41.3 ± 7.5 events/hour, P = 0.033) but did not affect other clinical and physiologic parameters. Compared to control, zolpidem did not widen CO2 reserve (- 0.44 ± 1.47 vs. - 0.63 ± 0.86 mmHg, P = 0.81). The respiratory arousal threshold did not show a significant change on zolpidem compared to control (- 8.72 ± 2.1 vs. - 8.25 ± 2.81 cmH2O, P = 0.41). CONCLUSION Nocturnal arousals and overall SDB severity were reduced with a single dose of zolpidem in patients with moderate-to-severe sleep-disordered breathing with increased susceptibility for central apnea. Zolpidem did not widen the CO2 reserve or increase the arousal threshold. TRIAL REGISTRATION Clinicaltrials.gov. Sleep and Breathing in the General Population - Chemical Stimuli (NCT04720547).
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Affiliation(s)
- Bachar Ahmad
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
| | - Abdulghani Sankari
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA.
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA.
- Department of Medical Education, Ascension Providence Hospital, Southfield, MI, USA.
| | - Mehdi Eshraghi
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
| | - Ahmad Aldwaikat
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
| | - Hossein Yarandi
- Department of Biostatistics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Salam Zeineddine
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Anan Salloum
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - M Safwan Badr
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA
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6
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Bastier PL, Gallet de Santerre O, Bartier S, De Jong A, Trzepizur W, Nouette-Gaulain K, Bironneau V, Blumen M, Chabolle F, de Bonnecaze G, Dufour X, Ameline E, Kérimian M, Latournerie V, Monteyrol PJ, Thiery A, Tronche S, Vergez S, Bequignon E. Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome. Eur Ann Otorhinolaryngol Head Neck Dis 2022; 139:216-225. [PMID: 35871981 DOI: 10.1016/j.anorl.2022.05.003] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome. DESIGN A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data. METHODS The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results. RESULTS Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion. CONCLUSION Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.
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Affiliation(s)
- P-L Bastier
- Pôle Tête et Cou, Maison de Santé Protestante de Bordeaux-Bagatelle, 203, route de Toulouse, 33401 Talence, France
| | | | - S Bartier
- Service d'ORL et de Chirurgie Cervico-Faciale, Hôpital Henri-Mondor, 1, rue Gustave-Eiffel, 94000 Créteil, France
| | - A De Jong
- Département d'Anesthésie-Réanimation Saint-Éloi, Hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - W Trzepizur
- Département de Pneumologie et de Médecine du Sommeil, CHU d'Angers, 4, rue Larrey, 49100 Angers, France
| | - K Nouette-Gaulain
- Service d'Anesthésie-Réanimation, Hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33700 Bordeaux, France
| | - V Bironneau
- Service de Pneumologie, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - M Blumen
- Centre Médical Veille Sommeil, 59, avenue de Villiers, 75017 Paris, France; Service d'ORL, Hôpital Foch, 40, rue Worth, 92140 Suresnes, France
| | - F Chabolle
- Cabinet d'ORL, 20, rue Parmentier, 92200 Neuilly-sur-Seine, France
| | - G de Bonnecaze
- Service d'ORL et Chirurgie Cervico-Faciale, Hôpital Larrey, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - X Dufour
- Service d'ORL et Chirurgie Cervico-faciale, CHU de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
| | - E Ameline
- Cabinet d'ORL, 1, rue des Iris, 41260 La Chaussée-Saint-Victor, France
| | - M Kérimian
- Service d'ORL et de Chirurgie Cervico-Faciale, Hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33700 Bordeaux, France
| | - V Latournerie
- Service d'ORL, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France
| | - P-J Monteyrol
- Nouvelle Clinique Bordeaux Tondu, avenue Jean-Alfonséa, 33270 Floirac, France
| | - A Thiery
- Service d'ORL, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France
| | - S Tronche
- SFORL, 26, rue Lalo, 75016 Paris, France
| | - S Vergez
- Service d'ORL et Chirurgie Cervico-Faciale, Hôpital Larrey, 24, chemin de Pouvourville, 31059 Toulouse, France
| | - E Bequignon
- Service d'ORL, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France.
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7
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McNicholas WT, Pevernagie D. Obstructive sleep apnea: transition from pathophysiology to an integrative disease model. J Sleep Res 2022; 31:e13616. [PMID: 35609941 PMCID: PMC9539471 DOI: 10.1111/jsr.13616] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 12/12/2022]
Abstract
Obstructive sleep apnea (OSA) is characterised by recurring episodes of upper airway obstruction during sleep and the fundamental abnormality reflects the inability of the upper airway dilating muscles to withstand the negative forces generated within the upper airway during inspiration. Factors that result in narrowing of the oropharynx such as abnormal craniofacial anatomy, soft tissue accumulation in the neck, and rostral fluid shift in the recumbent position increase the collapsing forces within the airway. The counteracting forces of upper airway dilating muscles, especially the genioglossus, are negatively influenced by sleep onset, inadequacy of the genioglossus responsiveness, ventilatory instability, especially post arousal, and loop gain. OSA is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary, and neuropsychiatric, and there is growing evidence of bidirectional relationships between OSA and comorbidity, especially for heart failure, metabolic syndrome, and stroke. A detailed understanding of the complex pathophysiology of OSA encourages the development of therapies targeted at pathophysiological endotypes and facilitates a move towards precision medicine as a potential alternative to continuous positive airway pressure therapy in selected patients.
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Affiliation(s)
- Walter T McNicholas
- Department of Respiratory and Sleep Medicine, St Vincent's Hospital Group, School of Medicine, University College Dublin, Dublin, Ireland
| | - Dirk Pevernagie
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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8
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Sleep Breathing Disorders in Heart Failure. Cardiol Clin 2022; 40:183-189. [DOI: 10.1016/j.ccl.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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9
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Abstract
Central sleep apnea (CSA) is characterized by intermittent repetitive cessation and/or decreased breathing without effort caused by an abnormal ventilatory drive. Although less prevalent than obstructive sleep apnea, it is frequently encountered. CSA can be primary (idiopathic) or secondary in association with Cheyne-Stokes respiration, drug-induced, medical conditions such as chronic renal failure, or high-altitude periodic breathing. Risk factors have been proposed, including gender, age, heart failure, opioid use, stroke, and other chronic medical conditions. This article discusses the prevalence of CSA in the general population and within each of these at-risk populations, and clinical presentation, diagnostic methods, and treatment.
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Affiliation(s)
- Oki Ishikawa
- Department of Pulmonary and Critical Care, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Lenox Hill Hospital, 100 East 77th Street, 4 East, New York, NY 10075, USA.
| | - Margarita Oks
- Department of Pulmonary and Critical Care, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Lenox Hill Hospital, 100 East 77th Street, 4 East, New York, NY 10075, USA
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Orr JE, Ayappa I, Eckert DJ, Feldman JL, Jackson CL, Javaheri S, Khayat RN, Martin JL, Mehra R, Naughton MT, Randerath WJ, Sands SA, Somers VK, Badr MS. Research Priorities for Patients with Heart Failure and Central Sleep Apnea. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 203:e11-e24. [PMID: 33719931 PMCID: PMC7958519 DOI: 10.1164/rccm.202101-0190st] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Central sleep apnea (CSA) is common among patients with heart failure and has been strongly linked to adverse outcomes. However, progress toward improving outcomes for such patients has been limited. The purpose of this official statement from the American Thoracic Society is to identify key areas to prioritize for future research regarding CSA in heart failure. Methods: An international multidisciplinary group with expertise in sleep medicine, pulmonary medicine, heart failure, clinical research, and health outcomes was convened. The group met at the American Thoracic Society 2019 International Conference to determine research priority areas. A statement summarizing the findings of the group was subsequently authored using input from all members. Results: The workgroup identified 11 specific research priorities in several key areas: 1) control of breathing and pathophysiology leading to CSA, 2) variability across individuals and over time, 3) techniques to examine CSA pathogenesis and outcomes, 4) impact of device and pharmacological treatment, and 5) implementing CSA treatment for all individuals Conclusions: Advancing care for patients with CSA in the context of heart failure will require progress in the arenas of translational (basic through clinical), epidemiological, and patient-centered outcome research. Given the increasing prevalence of heart failure and its associated substantial burden to individuals, society, and the healthcare system, targeted research to improve knowledge of CSA pathogenesis and treatment is a priority.
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11
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Zeineddine S, Rowley JA, Chowdhuri S. Oxygen Therapy in Sleep-Disordered Breathing. Chest 2021; 160:701-717. [PMID: 33610579 DOI: 10.1016/j.chest.2021.02.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022] Open
Abstract
Sleep-disordered breathing (SDB) is highly prevalent in adults and leads to significant cardiovascular and neurologic sequelae. Intermittent hypoxia during sleep is a direct consequence of SDB. Administration of nocturnal supplemental oxygen (NSO) has been used as a therapeutic alternative to positive airway pressure (PAP) in SDB. NSO significantly improves oxygen saturation in OSA but is inferior to PAP in terms of reducing apnea severity and may prolong the duration of obstructive apneas. The effect of NSO on daytime sleepiness remains unclear, but NSO may improve physical function-related quality of life in OSA. Its effects on BP reduction remain inconclusive. The effects of NSO vs PAP in OSA with comorbid COPD (overlap syndrome) are unknown. NSO is effective in reducing central sleep apnea related to congestive heart failure; however, its impact on mortality and cardiovascular clinical outcomes are being investigated in an ongoing clinical trial. In conclusion, studies are inconclusive or limited regarding clinical outcomes with oxygen therapy compared with sham or PAP therapy in patients with OSA and overlap syndrome. Oxygen does mitigate central sleep apnea. This review examines the crucial knowledge gaps and suggests future research priorities to clarify the effects of optimal dose and duration of NSO, alone or in combination with PAP, on cardiovascular, sleep, and cognitive outcomes.
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Affiliation(s)
- Salam Zeineddine
- Medical Service, Sleep Medicine Section, John D. Dingell Veterans Affairs Medical Center, Detroit, MI; Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Wayne State University School of Medicine, Detroit, MI
| | - James A Rowley
- Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Susmita Chowdhuri
- Medical Service, Sleep Medicine Section, John D. Dingell Veterans Affairs Medical Center, Detroit, MI; Division of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Wayne State University School of Medicine, Detroit, MI.
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12
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Zeineddine S, Badr MS. Treatment-Emergent Central Apnea: Physiologic Mechanisms Informing Clinical Practice. Chest 2021; 159:2449-2457. [PMID: 33497650 DOI: 10.1016/j.chest.2021.01.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022] Open
Abstract
The purpose of this review was to describe our management approach to patients with treatment-emergent central sleep apnea (TECSA). The emergence of central sleep apnea during positive airway pressure therapy occurs in approximately 8% of titration studies for OSA, and it has been associated with several demographic, clinical, and polysomnographic factors, as well as factors related to the titration study itself. TECSA shares similar pathophysiology with central sleep apnea. In fact, central and OSA pathophysiologic mechanisms are inextricably intertwined, with ventilatory instability and upper airway narrowing occurring in both entities. TECSA is a "dynamic" process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients. Management strategy for TECSA aims to eliminate abnormal respiratory events, stabilize sleep architecture, and improve the underlying contributing medical comorbidities. CPAP therapy remains a standard therapy for TECSA. Expectant management is appropriate given its transient nature in most cases, whereas select patients would benefit from an early switch to an alternative positive airway pressure modality. Other treatment options include supplemental oxygen and pharmacologic therapy.
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Affiliation(s)
- Salam Zeineddine
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI.
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13
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Sanchez AM, Germany R, Lozier MR, Schweitzer MD, Kosseifi S, Anand R. Central sleep apnea and atrial fibrillation: A review on pathophysiological mechanisms and therapeutic implications. IJC HEART & VASCULATURE 2020; 30:100527. [PMID: 33102683 PMCID: PMC7573647 DOI: 10.1016/j.ijcha.2020.100527] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/06/2023]
Abstract
Precipitating factors and chronic diseases associated with atrial fibrillation (AF) are detailed in the literature. Emerging evidence over the last several decades suggests a potential causal relationship between central sleep apnea (CSA) and AF. Mechanisms including apnea-induced hypoxia with intermittent arousal, fluctuating levels of carbon dioxide, enhanced sympathetic/neurohormonal activation and oxidative stress causing inflammation have been implicated as etiologic causes of AF within this subpopulation. CSA affects the efficacy of pharmacologic and catheter-based antiarrhythmic treatments, which is why treating CSA prior to these interventions may lead to lower rates of AF. Subsequently, a reduction in the AF burden with transvenous phrenic nerve stimulation (TPNS) has become a topic of interest. The present review describes the relationship between these conditions, pathophysiologic mechanisms implicating the role of CSA in development of AF, and emerging therapeutic interventions.
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Affiliation(s)
- Alexandra M. Sanchez
- University of Miami at Holy Cross Hospital, Internal Medicine Residency Program, Ft Lauderdale, FL, USA
| | - Robin Germany
- Division of Cardiovascular Disease, University of Oklahoma, Respicardia Inc, Oklahoma City, OK, USA
| | - Matthew R. Lozier
- University of Miami at Holy Cross Hospital, Internal Medicine Residency Program, Ft Lauderdale, FL, USA
| | - Michael D. Schweitzer
- University of Miami at Holy Cross Hospital, Internal Medicine Residency Program, Ft Lauderdale, FL, USA
| | - Semaan Kosseifi
- Pulmonary, Critical Care and Sleep Medicine, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Rishi Anand
- Cardiology, Jim Moran Heart and Vascular Research Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA
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14
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Ginter G, Sankari A, Eshraghi M, Obiakor H, Yarandi H, Chowdhuri S, Salloum A, Badr MS. Effect of acetazolamide on susceptibility to central sleep apnea in chronic spinal cord injury. J Appl Physiol (1985) 2020; 128:960-966. [PMID: 32078469 DOI: 10.1152/japplphysiol.00532.2019] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Spinal cord injury (SCI) is an established risk factor for central sleep apnea. Acetazolamide (ACZ), a carbonic anhydrase inhibitor, has been shown to decrease the frequency of central apnea by inducing mild metabolic acidosis. We hypothesized that ACZ would decrease the propensity to develop hypocapnic central apnea and decrease the apneic threshold. We randomized 16 participants with sleep-disordered breathing (8 SCI and 8 able-bodied controls) to receive ACZ (500 mg twice a day for 3 days) or placebo with a 1-wk washout before crossing over to the other drug arm. Study nights included polysomnography and determination of the hypocapnic apneic threshold and CO2 reserve using noninvasive ventilation. For participants with spontaneous central apnea, CO2 was administered until central apnea was abolished, and CO2 reserve was measured as the difference in end-tidal Pco2 (PETCO2) before and after. Steady-state plant gain, the response of end-tidal Pco2 to changes in ventilation, was calculated from PETCO2 and V̇e ratio during stable sleep. Controller gain, the response of ventilatory drive to changes in end-tidal Pco2, was defined as the ratio of change in V̇e between control and hypopnea to the ΔCO2 during stable non-rapid eye movement sleep. Treatment with ACZ for three days resulted in widening of the CO2 reserve (-4.0 ± 1.2 vs. -3.0 ± 0.7 mmHg for able-bodied, -3.4 ± 1.9 vs. -2.2 ± 2.2 mmHg for SCI, P < 0.0001), and a corresponding decrease in the hypocapnic apnea threshold (28.3 ± 5.2 vs. 37.1 ± 5.6 mmHg for able-bodied, 29.9 ± 5.4 vs. 34.8 ± 6.9 mmHg for SCI, P < 0.0001), respectively. ACZ significantly reduced plant gain when compared with placebo (4.1 ± 1.7 vs. 5.4 ± 1.8 mmHg/L min for able-bodied, 4.1 ± 2.0 vs. 5.1 ± 1.7 mmHg·L-1·min for SCI, P < 0.01). Acetazolamide decreased apnea-hypopnea index (28.8 ± 22.9 vs. 39.3 ± 24.1 events/h; P = 0.05), central apnea index (0.6 ± 1.5 vs. 6.3 ± 13.1 events/h; P = 0.05), and oxyhemoglobin desaturation index (7.5 ± 8.3 vs. 19.2 ± 15.2 events/h; P = 0.01) compared with placebo. Our results suggest that treatment with ACZ decreases susceptibility to hypocapnic central apnea due to decreased plant gain. Acetazolamide may attenuate central sleep apnea and improve nocturnal oxygen saturation, but its clinical utility requires further investigation in a larger sample of patients.NEW & NOTEWORTHY Tetraplegia is a risk factor for central sleep-disordered breathing (SDB) and is associated with narrow CO2 reserve (a marker of susceptibility to central apnea). Treatment with high-dose acetazolamide for 3 days decreased susceptibility to hypocapnic central apnea and reduced the frequency of central respiratory events during sleep. Acetazolamide may play a therapeutic role in alleviating central SDB in patients with cervical spinal cord injury, but larger clinical trials are needed.
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Affiliation(s)
- Geoffrey Ginter
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Abdulghani Sankari
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Mehdi Eshraghi
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Harold Obiakor
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | | | - Susmita Chowdhuri
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Anan Salloum
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - M Safwan Badr
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
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16
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Randerath W, Deleanu O, Schiza S, Pepin JL. Central sleep apnoea and periodic breathing in heart failure: prognostic significance and treatment options. Eur Respir Rev 2019; 28:28/153/190084. [PMID: 31604817 PMCID: PMC9488867 DOI: 10.1183/16000617.0084-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/30/2019] [Indexed: 12/27/2022] Open
Abstract
Central sleep apnoea (CSA) including periodic breathing is prevalent in more than one-third of patients with heart failure and is highly and independently associated with poor outcomes. Optimal treatment is still debated and well-conducted studies regarding efficacy and impact on outcomes of available treatment options are limited, particularly in cardiac failure with preserved ejection fraction. While continuous positive airway pressure and oxygen reduce breathing disturbances by 50%, adaptive servoventilation (ASV) normalises breathing disturbances by to controlling the underlying mechanism of CSA. Results are contradictory regarding impact of ASV on hard outcomes. Cohorts and registry studies show survival improvement under ASV, while secondary analyses of the large SERVE-HF randomised trial showed an excess mortality in cardiac failure with reduced ejection fraction. The current priority is to understand which phenotypes of cardiac failure patients may benefit from treatment guiding individualised and personalised management.
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Affiliation(s)
- Winfried Randerath
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Oana Deleanu
- University of Medicine and Pharmacy "Carol Davila" and Institute of Pneumology "Marius Nasta" Bucharest, Bucharest, Romania
| | - Sofia Schiza
- Sofia Schiza, University of Crete, Heraklion, Greece
| | - Jean-Louis Pepin
- Laboratoire du sommeil explorations fonctionnelle Respire, Centre Hospitalier Universitaire Grenoble, Grenoble, France
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17
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Abstract
Central sleep apnea is prevalent in patients with heart failure, healthy individuals at high altitudes, and chronic opiate users and in the initiation of "mixed" (that is, central plus obstructive apneas). This brief review focuses on (a) the causes of repetitive, cyclical central apneas as mediated primarily through enhanced sensitivities in the respiratory control system and (b) treatment of central sleep apnea through modification of key components of neurochemical control as opposed to the current universal use of positive airway pressure.
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Affiliation(s)
- Jerome A. Dempsey
- Department of Population Health Sciences, University of Wisconsin - Madison, WARF Building, 7th Floor, 614 Walnut Street, Madison, WI 53726, USA
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Baillieul S, Revol B, Jullian-Desayes I, Joyeux-Faure M, Tamisier R, Pépin JL. Diagnosis and management of central sleep apnea syndrome. Expert Rev Respir Med 2019; 13:545-557. [PMID: 31014146 DOI: 10.1080/17476348.2019.1604226] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Central sleep apnea (CSA) syndrome has gained a considerable interest in the sleep field within the last 10 years. It is overrepresented in particular subpopulations such as patients with stroke or heart failure. Early detection and diagnosis, as well as appropriate treatment of central breathing disturbances during sleep remain challenging. Areas covered: Based on a systematic review of CSA in adults the clinical evidence and polysomnographic patterns useful for discerning central from obstructive events are discussed. Current therapeutic indications of CSA and perspectives are presented, according to the type of respiratory disturbances during sleep, alterations in blood gases and ventilatory control. Expert opinion: The precise identification of central events during polysomnographic recording is mandatory. Therapeutic choices for CSA depend on the typology of respiratory disturbances observed by polysomnography, changes in blood gases and ventilatory control. In CSA with normocapnia and ventilatory instability, adaptive servo-ventilation is recommended. In CSA with hypercapnia and/or rapid-eye movement sleep hypoventilation, non-invasive ventilation is required. Further studies are required as strong evidence is lacking regarding the long-term consequences of CSA and the long-term impact of current treatment strategies.
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Affiliation(s)
- Sébastien Baillieul
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Bruno Revol
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Ingrid Jullian-Desayes
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Marie Joyeux-Faure
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Renaud Tamisier
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Jean-Louis Pépin
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
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Abstract
Complex sleep apnea syndrome (Comp-SAS) is the term used to describe a specific form of sleep disordered breathing characterized by the arise of central sleep apnea in patient with previous obstructive sleep apnea syndrome (OSAS) treated with continuous positive airway pressure devices (CPAP). The mechanisms of its occurrence are not well understood, but partly it seems to be a consequence of increased carbon dioxide elimination under positive airway pressure treatment and related improvement of pulmonary ventilation. The prevalence of Comp-SAS ranges from 5% to 20% of OSAS patient getting CPAP therapy with no significant predictors in comparison with simple obstructive sleep apnea, but more likely to happened in older males with more severe OSAS and accompanying cardiovascular pathology such as ischemic heart disease, atrial fibrillation and heart failure. In most cases of Comp-SAS, central apnea events are transient and disappear after continuous CPAP therapy use for 1 to 2 months. Novel treatment options like adaptive servo-ventilation or BiPAP-ST are available for such non-responders to CPAP but contra-indicated to patients with systolic heart failure. From the other hand, still not clear is it mandatory to treat all affected individuals with Comp-SAS if the disease is uncomplicated and patient is asymptomatic.
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Affiliation(s)
- A D Palman
- Sechenov First Moscow State Medical University, Moscow, Russia
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20
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Bordier P, Lataste A. Death in patients with adaptive servo-ventilation for sleep apnea and no specific SERVE-HF profile: A case series study. Respir Med Case Rep 2018; 26:68-72. [PMID: 30555779 PMCID: PMC6277244 DOI: 10.1016/j.rmcr.2018.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 11/22/2018] [Accepted: 11/23/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose The SERVE-HF study reported a risk of cardiovascular death associated with adaptive servo-ventilation (ASV) for central sleep apnea in patients with chronic heart failure with reduced left ventricular ejection fraction (LVEF). Therefore, we adopted in May 2015 a safety procedure in our 32 patients with ASV since 2006. It led to ASV removal in four patients due to ≤45% LVEF. At the end of the procedure we noted eight cases of death. This high 25% mortality rate led us to study these cases. Methods The study population was derived from our database of patient follow-up from the sleep unit of our cardiovascular department. Results All deceased patients but one had cardiac disorders but only one matched the SERVE-HF patient profile. ASV was due to predominant central (n = 4) or mixed (n = 4) sleep apnea. Six patients died prior to our procedure including two patients who died several months after ASV cessation, one from ventricular fibrillation and one from respiratory infection. The cases with ongoing ASV consisted in one case of end-stage heart failure with asystole, two cases of cancer and one case of suicide. Two patients died after their safety procedure with no contra-indications to ASV and before study completion in all the patients, one from cancer and one from pulmonary and renal disorders. Conclusions In this series, no relationship became apparent between sleep apnea or ASV and death. Cardiovascular deaths were not predominant. Further study will be required to clarify the risks associated with ASV in patients with cardiovascular disease.
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Affiliation(s)
- Philippe Bordier
- Corresponding author. Hopital Cardiologique du Haut-Leveque, Unité de Maladie Coronarienne, Avenue de Magellan, 33604, Pessac cedex, France.
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Oates CP, Ananthram M, Gottlieb SS. Management of Sleep Disordered Breathing in Patients with Heart Failure. Curr Heart Fail Rep 2018; 15:123-130. [PMID: 29616491 DOI: 10.1007/s11897-018-0387-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW This paper reviews treatment options for sleep disordered breathing (SDB) in patients with heart failure. We sought to identify therapies for SDB with the best evidence for long-term use in patients with heart failure and to minimize uncertainties in clinical practice by examining frequently discussed questions: what is the role of continuous positive airway pressure (CPAP) in patients with heart failure? Is adaptive servo-ventilation (ASV) safe in patients with heart failure? To what extent is SDB a modifiable risk factor? RECENT FINDINGS Consistent evidence has demonstrated that the development of SDB in patients with heart failure is a poor prognostic indicator and a risk factor for cardiovascular mortality. However, despite numerous available interventions for obstructive sleep apnea and central sleep apnea, it remains unclear what effect these therapies have on patients with heart failure. To date, all major randomized clinical trials have failed to demonstrate a survival benefit with SDB therapy and one major study investigating the use of adaptive servo-ventilation demonstrated harm. Significant questions persist regarding the management of SDB in patients with heart failure. Until appropriately powered trials identify a treatment modality that increases cardiovascular survival in patients with SDB and heart failure, a patient's heart failure management should remain the priority of medical care.
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Affiliation(s)
- Connor P Oates
- School of Medicine, University of Maryland, Baltimore, MD, USA
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Cheyne-Stokes-Atmung. SOMNOLOGIE 2018. [DOI: 10.1007/s11818-017-0142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Melani AS, Sestini P, Rottoli P. Home oxygen therapy: re-thinking the role of devices. Expert Rev Clin Pharmacol 2018; 11:279-289. [PMID: 29272974 DOI: 10.1080/17512433.2018.1421457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION A range of devices are available for delivering and monitoring home oxygen therapy (HOT). Guidelines do not give indications for the choice of the delivery device but recommend the use of an ambulatory system in subjects on HOT whilst walking. Areas covered: We provide a clinical overview of HOT and review traditional and newer delivery and monitoring devices for HOT. Despite relevant technology advancements, clinicians, faced with many challenges when they prescribe oxygen therapy, often remain familiar to traditional devices and continuous flow delivery of oxygen. Some self-filling delivery-less devices could increase the users' level of independence with ecological advantage and, perhaps, reduced cost. Some newer portable oxygen concentrators are being available, but more work is needed to understand their performances in different diseases and clinical settings. Pulse oximetry has gained large diffusion worldwide and some models permit long-term monitoring. Some closed-loop portable monitoring devices are also able to adjust oxygen flow automatically in accordance with the different needs of everyday life. This might help to improve adherence and the practice of proper oxygen titration that has often been omitted because difficult to perform and time-consuming. Expert commentary: The prescribing physicians should know the characteristics of newer devices and use technological advancements to improve the practice of HOT.
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Affiliation(s)
- Andrea S Melani
- a Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Piersante Sestini
- b Clinica delle Malattie dell'Apparato Respiratorio, Dipartimento di Medicine Specialistica, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Paola Rottoli
- a Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy.,b Clinica delle Malattie dell'Apparato Respiratorio, Dipartimento di Medicine Specialistica, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
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Borrelli C, Aimo A, Mirizzi G, Passino C, Vergaro G, Emdin M, Giannoni A. How to take arms against central apneas in heart failure. Expert Rev Cardiovasc Ther 2017; 15:743-755. [PMID: 28777017 DOI: 10.1080/14779072.2017.1364626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Introduction Despite being a risk mediator in several observational studies, central apneas are currently orphan of treatment in heart failure. After the neutral effects on survival of two randomized controlled trials (RCTs) based on the use of positive airway pressure (the CANPAP and SERVE-HF trials), two alternative hypotheses have been formulated: 1) Periodic breathing/Cheyne-Stokes respiration (PB/CSR) in HF is protective. Indeed, the Naughton's hypothesis assumes that hyperventilation leads to increased cardiac output, lung volume, oxygen storage and reduced muscle sympathetic nerve activity, while central apnea to respiratory muscle rest and hypoxia-induced erythropoiesis. 2) The use of positive airway pressure is just a wrong treatment for PB/CSR. If this is the case, the search for novel potential alternative treatment approaches is mandatory in HF. Areas covered This review will focus on the crucial issue of whether PB/CSR should be treated or not in HF, first by outlining the ideal design of pathophysiological studies to test the Naughton's hypothesis and second by summarizing the treatment strategies so far proposed for PB/CSR in HF and identifying the most promising options to be tested in future RCTs. Expert commentary It is likely that PB/CSR may be compensatory in some cases, but after a certain threshold (to be defined) it becomes maladaptive with negative prognostic meaning in HF. The development of a pathophysiologically based treatment targeting feedback resetting and neurohormonal activation underlying PB/CSR is likely to be the best option to obtain survival benefits in HF.
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Affiliation(s)
- Chiara Borrelli
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy
| | - Alberto Aimo
- b Cardiology Division , University of Pisa , Pisa , Italy
| | - Gianluca Mirizzi
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
| | - Claudio Passino
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
| | - Giuseppe Vergaro
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy
| | - Michele Emdin
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
| | - Alberto Giannoni
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
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Abstract
Central sleep apnea (CSA) and obstructive sleep apnea (OSA) are prevalent in heart failure (HF) and associated with a worse prognosis. Nocturnal oxygen therapy may decrease CSA events, sympathetic tone, and improve left ventricular ejection fraction, although mortality benefit is unknown. Although treatment of OSA in patients with HF is recommended, therapy for CSA remains controversial. Continuous positive airway pressure use in HF-CSA may improve respiratory events, hemodynamics, and exercise capacity, but not mortality. Adaptive servo ventilation is contraindicated in patients with symptomatic HF with predominant central sleep-disordered events. The role of phrenic nerve stimulation in CSA therapy is promising.
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Affiliation(s)
- Bernardo J Selim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Center for Sleep Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Center for Sleep Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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