Respiratory-related evoked potentials during sleep in children

Symbolic dynamics of respiratory cycle related sleep EEG in children with sleep disordered breathing

Childhood sleep disordered breathing (SDB) is characterized by an increased work of breathing, restless night sleep and excessive daytime sleepiness and has been associated with cognitive impairment, behavioral disturbances and early cardiovascular changes. Compared to normal controls, children with SDB have elevated arousal thresholds and their sleep EEG may elicit cortical activation associated with arousals but often too subtle to be visually scored. The aim of this study was to assess EEG complexity throughout the respiratory cycle based on symbolic dynamics in children with SDB (n=40) and matched healthy controls. EEG amplitude values were symbolized based on the quartiles of their distribution and words of length 3 were formed and classed into 4 types based on their patterns. Children with SDB showed less complex EEG dynamics in non-REM sleep that was unrelated to the respiratory phase. In REM sleep normal children showed a respiratory phase-related reduction in EEG variability during the expiratory phase compared to inspiration, which was not apparent in children with SDB. In conclusion, respiratory cycle related EEG dynamics are altered in children with SDB during REM sleep and indicate changes in cortical activity.

Respiratory cycle-related electroencephalographic changes during sleep in healthy children and in children with sleep disordered breathing

STUDY OBJECTIVE

To investigate respiratory cycle-related electroencephalographic changes (RCREC) in healthy children and in children with sleep disordered breathing (SDB) during scored event-free (SEF) breathing periods of sleep.

DESIGN

Interventional case-control repeated measurements design.

SETTING

Paediatric sleep laboratory in a hospital setting.

PARTICIPANTS

Forty children with SDB and 40 healthy, age- and sex-matched children.

INTERVENTIONS

Adenotonsillectomy in children with SDB and no intervention in controls.

MEASUREMENTS AND RESULTS

Overnight polysomnography; electroencephalography (EEG) power variations within SEF respiratory cycles in the overall and frequency band-specific EEG within stage 2 nonrapid eye movement (NREM) sleep, slow wave sleep (SWS), and rapid eye movement (REM) sleep. Within both groups there was a decrease in EEG power during inspiration compared to expiration across all sleep stages. Compared to controls, RCREC in children with SDB in the overall EEG were significantly higher during REM and frequency band specific RCRECs were higher in the theta band of stage 2 and REM sleep, alpha band of SWS and REM sleep, and sigma band of REM sleep. This between-group difference was not significant postadenotonsillectomy.

CONCLUSION

The presence of nonrandom respiratory cycle-related electroencephalographic changes (RCREC) in both healthy children and in children with sleep disordered breathing (SDB) during NREM and REM sleep has been demonstrated. The RCREC values were higher in children with SDB, predominantly in REM sleep and this difference reduced after adenotonsillectomy.

CITATION

Immanuel SA, Pamula Y, Kohler M, Martin J, Kennedy D, Saint DA, Baumert M. Respiratory cycle-related electroencephalographic changes during sleep in healthy children and in children with sleep disordered breathing.

Upper airway collapsibility during REM sleep in children with the obstructive sleep apnea syndrome

STUDY OBJECTIVES

In children, most obstructive events occur during rapid eye movement (REM) sleep. We hypothesized that children with the obstructive sleep apnea syndrome (OSAS), in contrast to age-matched control subjects, would not maintain airflow in the face of an upper airway inspiratory pressure drop during REM sleep.

DESIGN

During slow wave sleep (SWS) and REM sleep, we measured airflow, inspiratory time, inspiratory time/total respiratory cycle time, respiratory rate, tidal volume, and minute ventilation at a holding pressure at which flow limitation occurred and at 5 cm H2O below the holding pressure in children with OSAS and in control subjects.

SETTING

Sleep laboratory.

PARTICIPANTS

Fourteen children with OSAS and 23 normal control subjects.

RESULTS

In both sleep states, control subjects were able to maintain airflow, whereas subjects with OSAS preserved airflow in SWS but had a significant decrease in airflow during REM sleep (change in airflow of 18.58 +/- 12.41 mL/s for control subjects vs -44.33 +/- 14.09 mL/s for children with OSAS, P = 0.002). Although tidal volume decreased, patients with OSAS were able to maintain minute ventilation by increasing the respiratory rate and also had an increase in inspiratory time and inspiratory time per total respiratory cycle time

CONCLUSION

Children with OSAS do not maintain airflow in the face of upper-airway inspiratory-pressure drops during REM sleep, indicating a more collapsible upper airway, compared with that of control subjects during REM sleep. However, compensatory mechanisms exist to maintain minute ventilation. Local reflexes, central control mechanisms, or both reflexes and control mechanisms need to be further explored to better understand the pathophysiology of this abnormality and the compensation mechanism.

Cortical processing of respiratory occlusion stimuli in children with central hypoventilation syndrome

RATIONALE

The ability of patients with central hypoventilation syndrome (CHS) to produce and process mechanoreceptor signals is unknown.

OBJECTIVES

Children with CHS hypoventilate during sleep, although they generally breathe adequately during wakefulness. Previous studies suggest that they have compromised central integration of afferent stimuli, rather than abnormal sensors or receptors. Cortical integration of afferent mechanical stimuli caused by respiratory loading or upper airway occlusion can be tested by measuring respiratory-related evoked potentials (RREPs). We hypothesized that patients with CHS would have blunted RREP during both wakefulness and sleep.

METHODS

RREPs were produced with multiple upper airway occlusions and were obtained during wakefulness, stage 2, slow-wave, and REM sleep. Ten patients with CHS and 20 control subjects participated in the study, which took place at the Children's Hospital of Philadelphia. Each patient was age- and sex-matched to two control subjects. Wakefulness data were collected from 9 patients and 18 control subjects.

MEASUREMENTS AND MAIN RESULTS

During wakefulness, patients demonstrated reduced Nf and P300 responses compared with control subjects. During non-REM sleep, patients demonstrated a reduced N350 response. In REM sleep, patients had a later P2 response.

CONCLUSIONS

CHS patients are able to produce cortical responses to mechanical load stimulation during both wakefulness and sleep; however, central integration of the afferent signal is disrupted during wakefulness, and responses during non-REM are damped relative to control subjects. The finding of differences between patients and control subjects during REM may be due to increased intrinsic excitatory inputs to the respiratory system in this state.

Cortical processing of respiratory afferent stimuli during sleep in children with the obstructive sleep apnea syndrome

STUDY OBJECTIVES

Children with the obstructive sleep apnea syndrome (OSAS) have blunted upper airway responses to negative pressure, but the underlying cause remains unknown. Cortical processing of respiratory afferent information can be tested by measuring respiratory-related evoked potentials (RREPs). We hypothesized that children with OSAS have blunted RREP responses compared to normal children during sleep.

DESIGN

During sleep, RREPs were obtained from EEG electrodes Fz, Cz, Pz during stage 2 sleep, slow wave sleep (SWS), and REM sleep. RREPs were produced with multiple short occlusions of the upper airway.

SETTING

Sleep laboratory.

PARTICIPANTS

9 children with OSAS and 12 normal controls.

MEASUREMENTS AND RESULTS

Children with OSAS had significantly decreased evoked K-complex production in stage 2 sleep and slow wave sleep and significantly reduced RREP N350 and P900 components in slow wave sleep. There were no significant differences in any of the measured RREP components in stage 2 sleep, and the only REM difference was decreased P2 amplitude.

CONCLUSIONS

Results indicate that in children with OSAS, cortical processing of respiratory-related information measured with RREPs persists throughout sleep; however, RREPs during SWS are blunted compared to those seen in control children. Possible causes for this difference include a congenital deficit in neural processing reflective of a predisposition to develop OSAS, or changes in the upper airway rendering the airway less capable of transducing pressure changes following occlusion. Further research is required to evaluate RREPs after effective surgical treatment of OSAS in children, in order to distinguish between these alternatives.