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Wang J, Ye Y, Shang Z, Zheng Q, Zhang S, Li L, Liu W. Effect of norepinephrine reuptake inhibitors combined with antimuscarinic agents vs monotherapy for OSA: a systematic review and meta-analysis. J Clin Sleep Med 2024; 20:1363-1372. [PMID: 38494994 PMCID: PMC11294128 DOI: 10.5664/jcsm.11130] [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: 10/26/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Abstract
STUDY OBJECTIVES Randomized controlled trials have shown that combining norepinephrine reuptake inhibitors and antimuscarinics can ameliorate the severity of obstructive sleep apnea. This article explores whether the effectiveness and safety of combining norepinephrine reuptake inhibitors with antimuscarinic agents surpass monotherapy for treating obstructive sleep apnea. METHODS We searched randomized controlled trials including adult patients with obstructive sleep apnea who received combination therapy and monotherapy in 8 databases from inception until April 5, 2023 and evaluated the studies' quality and conducted a meta-analysis and systematic review. The primary outcome was the apnea-hypopnea index. Secondary outcome measures included loop gain, hypoxic burden, oxygen desaturation index, and ventilation at low ventilatory drive, among other indicators. We assessed the quality of the studies using Cochrane Methods criteria. RESULTS We identified 4 randomized controlled trials for systematic review and 2 for meta-analysis. The results of the meta-analysis showed that norepinephrine reuptake inhibitors combined with antimuscarinic agents in patients with obstructive sleep apnea prolonged total sleep time by a mean of 28.20 minutes [95% confidence interval (5.78, 50.61), P = .01] and increased sleep efficiency by 4.73% [95% confidence interval (0.50, 8.97), P = .03] compared with norepinephrine reuptake inhibitors alone. Other indices and adverse events were of no statistical significance. The systematic reviews revealed that norepinephrine reuptake inhibitors combined with antimuscarinics may be superior to monotherapy in improving apnea-hypopnea index and endotypic traits. CONCLUSIONS This evaluation demonstrated the potential advantages of combining norepinephrine reuptake inhibitors plus antimuscarinics for treating OSA compared with norepinephrine reuptake inhibitors alone and revealed no statistically significant difference in drug safety. CITATION Wang J, Ye Y, Shang Z, et al. Effect of norepinephrine reuptake inhibitors combined with antimuscarinic agents vs monotherapy for OSA: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(8):1363-1372.
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Affiliation(s)
- Juan Wang
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Yucai Ye
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Zhizhong Shang
- Department of Orthopedics, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Qingyong Zheng
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Sha Zhang
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Leping Li
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Weiying Liu
- Department of Respiratory and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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Li C, Ma R, Wu X, Wang D, Chen L, Huang Z, Ji D, Wen W, Wu Y. Identifying the pathophysiological traits of obstructive sleep apnea during dexmedetomidine sedation. J Sleep Res 2024; 33:e14079. [PMID: 37876325 DOI: 10.1111/jsr.14079] [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: 06/26/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023]
Abstract
Dexmedetomidine (DEX) has been described as a safe sedative in clinical practice, but its effects on the pathophysiological traits of obstructive sleep apnea (OSA) are unclear. We estimated the effects of DEX sedation on the four key pathophysiological traits of OSA (pharyngeal collapsibility, dilator muscle function, arousal threshold, and loop gain) in adult patients with OSA by conducting a secondary analysis of a prospective diagnostic trial. Pathophysiological traits estimated from polysomnography and the respiratory parameters under natural sleep and DEX-induced sleep were compared. Bivariate and multivariate linear regression analyses were used to estimate the relationship between pathophysiological traits and OSA severity for both sleep states. Adult patients with OSA had a significantly higher pharyngeal collapsibility (Vpassive: 44.9 [15.7 to 53.8] vs. 53.3 [34.2 to 66.3] %eupnea, p < 0.001), arousal threshold (178.5 [132.5 to 234.6] vs. 140.5 [123.2 to 192.3] %eupnea, p < 0.001), and loop gain (LG1: 0.74 ± 0.25 vs. 0.60 ± 0.17, p < 0.001; LGn: 0.52 ± 0.12 vs. 0.44 ± 0.08, p < 0.001) during DEX-induced sleep compared with natural sleep. There was no significant difference in dilator muscle function or PSG respiratory parameters between natural versus DEX-induced sleep states. Bivariate regression analysis showed varying degrees of correlation between OSA traits and severity. Multiple regression analysis indicated that collapsibility was the strongest predictor of the apnea-hypopnea index for both sleep states. Dexmedetomidine sedation in patients with OSA increased the pharyngeal collapsibility without impairing dilator muscle function, while elevating arousal threshold and increasing loop gain.
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Affiliation(s)
- Chunbo Li
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Renqiang Ma
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Xingmei Wu
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Dan Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Lin Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Zixuan Huang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Ding Ji
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Weiping Wen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Yan Wu
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Anwar AI, Byrne S, Sharma A, Sands S, Wellman A, Redeker NS, Yaggi H, Zinchuk AV. Novel physiologic predictors of positive airway pressure effectiveness (NICEPAP) study: rationale, design and methods. Sleep Breath 2024:10.1007/s11325-024-03099-w. [PMID: 38995327 DOI: 10.1007/s11325-024-03099-w] [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: 04/03/2024] [Revised: 06/10/2024] [Accepted: 06/28/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE Continuous positive airway pressure (CPAP) is the primary therapy for obstructive sleep apnea (OSA); however the effectiveness of CPAP remains suboptimal. We describe the Novel PhysIologiC prEdictors of Positive Airway Pressure Effectiveness (NICEPAP) study. Its purpose is to determine whether physiological traits of OSA contribute to CPAP effectiveness. METHODS NICEPAP (NCT05067088) is a prospective, observational cohort study conducted at an academic sleep center. Adults newly diagnosed with OSA (n = 267) are assessed for OSA traits of loop gain, arousal threshold, pharyngeal collapsibility, and muscle compensation from baseline polysomnography. We perform a comprehensive assessment of covariates relevant to CPAP adherence, efficacy, and patient-centered outcomes. Participants are followed for 12 months. Primary outcomes include (1) CPAP adherence (hours/night), (2) CPAP efficacy (apneas-hypopneas/hour), and (3) quality of life at six months measured by objective CPAP data and Functional Outcomes of Sleep Questionnaire. Secondary outcomes include sleep quality, sleepiness, insomnia, and neurocognitive function. RESULTS Data on covariates, including demographics, sleep symptoms, medical history, medications, sleep quality, OSA and treatment self-efficacy, decisional balance, and socio-economic and social and partner support, are collected using validated instruments. The analysis for primary outcomes includes a generalized linear mixed model for an outcome (e.g., CPAP adherence) with OSA traits as exposures followed by the addition of relevant covariates. CONCLUSION The findings of the NICEPAP study will inform research aimed to enhance CPAP effectiveness. Understanding the role of physiological OSA traits in CPAP effectiveness is a crucial step toward a precision medicine approach to OSA.
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Affiliation(s)
- Andira I Anwar
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA
| | - Sean Byrne
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA
| | - Akanksha Sharma
- University of Pittsburgh Medical Center Mercy, Pittsburgh, PA, USA
| | - Scott Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing, Connecticut, USA
| | - Henry Yaggi
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA
| | - Andrey V Zinchuk
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA.
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Thomas RJ. REM sleep breathing: Insights beyond conventional respiratory metrics. J Sleep Res 2024:e14270. [PMID: 38960862 DOI: 10.1111/jsr.14270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024]
Abstract
Breathing and sleep state are tightly linked. The traditional approach to evaluation of breathing in rapid eye movement sleep has been to focus on apneas and hypopneas, and associated hypoxia or hypercapnia. However, rapid eye movement sleep breathing offers novel insights into sleep physiology and pathology, secondary to complex interactions of rapid eye movement state and cardiorespiratory biology. In this review, morphological analysis of clinical polysomnogram data to assess respiratory patterns and associations across a range of health and disease is presented. There are several relatively unique insights that may be evident by assessment of breathing during rapid eye movement sleep. These include the original discovery of rapid eye movement sleep and scoring of neonatal sleep, control of breathing in rapid eye movement sleep, rapid eye movement sleep homeostasis, sleep apnea endotyping and pharmacotherapy, rapid eye movement sleep stability, non-electroencephalogram sleep staging, influences on cataplexy, mimics of rapid eye movement behaviour disorder, a reflection of autonomic health, and insights into cardiac arrhythmogenesis. In summary, there is rich clinically actionable information beyond sleep apnea encoded in the respiratory patterns of rapid eye movement sleep.
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Affiliation(s)
- Robert Joseph Thomas
- Department of Medicine, Division of Pulmonary Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
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Wang X, Zhou T, Huang W, Zhang J, Zou J, Guan J, Yi H, Yin S. Differences in Physiologic Endotypes Between Nonpositional and Positional OSA: Results From the Shanghai Sleep Health Study Cohort. Chest 2024; 166:212-225. [PMID: 38218217 DOI: 10.1016/j.chest.2024.01.021] [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: 03/23/2023] [Revised: 12/04/2023] [Accepted: 01/07/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Positional OSA (POSA) is a recognized subtype of OSA that exhibits distinct endotypic characteristics when compared with nonpositional OSA (NPOSA). The basis for the disparity in endotypes between these subtypes remains poorly understood. RESEARCH QUESTION (1) Do individuals with NPOSA and POSA have different underlying OSA endotypes? (2) Which endotypic characteristics are critical in determining NPOSA and POSA severity? STUDY DESIGN AND METHODS Within the Shanghai Sleep Health Study cohort, individuals with OSA were recruited and classified as having POSA or NPOSA. Endotypes were calculated using polysomnography. RESULTS Endotype analysis was conducted in 1,036 individuals with OSA. Compared with individuals with NPOSA, those with POSA had lower loop gain calculated during all sleep stages and all sleep positions (0.55; interquartile range [IQR], 0.46-0.66 vs 0.68, IQR, 0.52-0.90; P < .001), lower arousal threshold calculated during all sleep stages and all sleep positions (ArTHAll) (138.67; IQR, 118.94-180.87 percentage of the eupneic ventilation [%Veupnea] vs 189.00; IQR, 129.71-257.76 %Veupnea; P < .001), lower pharyngeal collapsibility calculated during all sleep stages and all sleep positions (VpassiveAll) (91.85; IQR, 83.13-95.15 %Veupnea vs 76.38; IQR, 23.77-92.08 %Veupnea; P < .001), and higher muscle compensation calculated during all sleep stages and all sleep positions (6.50; IQR, -6.77 to 16.39 %Veupnea vs 3.65; IQR, -10.47 to 12.14 %Veupnea; P = .003). Logistic regression analyses indicated that higher VpassiveAll was associated with increased odds of POSA vs NPOSA. In NPOSA, fully adjusted linear regression analyses indicated that VpassiveAll (β = -0.55; 95% CI, -0.68 to -0.42; P < .001) and lower loop gain calculated during all sleep stages and all sleep positions (β = 0.19; 95% CI, 0.08-0.30; P < .001) were significant independent predictors of the apnea hypopnea index, with VpassiveAll being the most critical factor. In contrast, in POSA, collapsibility appeared to be less influential (β = -0.09; 95% CI, -0.21 to 0.03; P = .138). Nonanatomic endotypic characteristics (LGAll: β = 0.29; 95% CI, 0.18-0.41; P < .001; arousal threshold in all sleep stages and all sleep positions: β = 0.15; 95% CI, 0.01-0.28; P = .031; muscle compensation in all sleep stages and all sleep positions: β = -0.21; 95% CI, -0.29 to -0.12; P < .001) were significant in determining the severity of POSA, with loop gain being the most crucial factor. INTERPRETATION This study highlights the differences in endotypes between NPOSA and POSA. In Chinese individuals, anatomic factors were more significant in determining the severity of NPOSA, whereas nonanatomic traits were more likely to determine the severity of POSA. Future research should focus on developing personalized management strategies for individuals with NPOSA and POSA based on their endotypes. TRIAL REGISTRATION Chinese Clinical Trial Registry; No.: ChiCTR1900025714; URL: https://www.chictr.org.cn/indexEN.html.
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Affiliation(s)
- Xiaoting Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Tianjiao Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Weijun Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.
| | - Jingyu Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jianyin Zou
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jian Guan
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Hongliang Yi
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.
| | - Shankai Yin
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
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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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Malhotra A, Bednarik J, Chakladar S, Dunn JP, Weaver T, Grunstein R, Fietze I, Redline S, Azarbarzin A, Sands SA, Schwab RJ, Bunck MC. Tirzepatide for the treatment of obstructive sleep apnea: Rationale, design, and sample baseline characteristics of the SURMOUNT -OSA phase 3 trial. Contemp Clin Trials 2024; 141:107516. [PMID: 38547961 PMCID: PMC11168245 DOI: 10.1016/j.cct.2024.107516] [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: 01/08/2024] [Revised: 03/04/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Weight reduction is a standard recommendation for obstructive sleep apnea (OSA) treatment in people with obesity or overweight; however, weight loss can be challenging to achieve and maintain without bariatric surgery. Currently, no approved anti-obesity medication has demonstrated effectiveness in OSA management. This study is evaluating the efficacy and safety of tirzepatide for treatment of moderate to severe OSA in people with obesity. METHODS SURMOUNT-OSA, a randomized, placebo -controlled, 52-week phase 3 trial, is investigating the efficacy and safety of tirzepatide for treatment of moderate to severe OSA (apnea hypopnea- index ≥15 events/h) in participants with obesity (body mass index ≥30 kg/m2) and an established OSA diagnosis. SURMOUNT-OSA is made of 2 intervention-specific appendices (ISAs): ISA-1 includes participants with no current OSA treatment, and ISA-2 includes participants using positive airway pressure therapy. Overall, 469 participants have been randomized 1:1 to receive tirzepatide or placebo across the master protocol (ISA-1, n = 234; ISA-2, n = 235). All participants are also receiving lifestyle intervention for weight reduction. RESULTS The primary endpoint for the individual ISAs is the difference in apnea hypopnea- index response, as measured by polysomnography, between tirzepatide and placebo arms at week 52. Secondary endpoints include sleep apnea-specific hypoxic burden, functional outcomes, and cardiometabolic biomarkers. The trial employs digital wearables, including home sleep testing to capture time to improvement and accelerometry for daily physical activity assessment, to evaluate exploratory outcomes. CONCLUSION SURMOUNT-OSA brings a novel design to investigate if tirzepatide provides clinically meaningful improvement in obesity-related OSA by targeting the underlying etiology. TRIAL REGISTRATION ClinicalTrials.gov, NCT05412004.
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Affiliation(s)
- Atul Malhotra
- University of California San Diego, La Jolla, CA, USA.
| | | | | | | | - Terri Weaver
- College of Nursing, University of Illinois Chicago, Chicago, IL, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Ron Grunstein
- Woolcock Institute of Medical Research and Royal Prince Alfred Hospital, Sydney, Australia
| | - Ingo Fietze
- Centre of Sleep Medicine, Charité University Hospital Berlin, Berlin, Germany
| | | | | | | | - Richard J Schwab
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Gell LK, Reynolds KJ, McEvoy RD, Nguyen DP, Catcheside PG. A novel method to quantify breathing effort from respiratory mechanics and esophageal pressure. J Appl Physiol (1985) 2024; 136:1418-1428. [PMID: 38602001 DOI: 10.1152/japplphysiol.00028.2024] [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: 01/11/2024] [Revised: 03/20/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024] Open
Abstract
Breathing effort is important to quantify to understand mechanisms underlying central and obstructive sleep apnea, respiratory-related arousals, and the timing and effectiveness of invasive or noninvasive mechanically assisted ventilation. Current quantitative methods to evaluate breathing effort rely on inspiratory esophageal or epiglottic pressure swings or changes in diaphragm electromyographic (EMG) activity, where units are problematic to interpret and compare between individuals and to measured ventilation. This paper derives a novel method to quantify breathing effort in units directly comparable with measured ventilation by applying respiratory mechanics first principles to convert continuous transpulmonary pressure measurements into "attempted" airflow expected to have arisen without upper airway obstruction. The method was evaluated using data from 11 subjects undergoing overnight polysomnography, including six patients with obesity with severe obstructive sleep apnea (OSA), including one who also had frequent central events, and five healthy-weight controls. Classic respiratory mechanics showed excellent fits of airflow and volume to transpulmonary pressures during wake periods of stable unobstructed breathing (means ± SD, r2 = 0.94 ± 0.03), with significantly higher respiratory system resistance in patients compared with healthy controls (11.2 ± 3.3 vs. 7.1 ± 1.9 cmH2O·L-1·s, P = 0.032). Subsequent estimates of attempted airflow from transpulmonary pressure changes clearly highlighted periods of acute and prolonged upper airway obstruction, including within the first few breaths following sleep onset in patients with OSA. This novel technique provides unique quantitative insights into the complex and dynamically changing interrelationships between breathing effort and achieved airflow during periods of obstructed breathing in sleep.NEW & NOTEWORTHY Ineffective breathing efforts with snoring and obstructive sleep apnea (OSA) are challenging to quantify. Measurements of esophageal or epiglottic pressure swings and diaphragm electromyography are useful, but units are problematic to interpret and compare between individuals and to measured ventilation. This paper derives a novel method that uses esophageal pressure and respiratory mechanics first principles to quantify breathing effort as "attempted" flow and volume in units directly comparable with measured airflow, volume, and ventilation.
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Affiliation(s)
- Laura K Gell
- Flinders Health and Medical Research Institute: Sleep Health (formerly Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
| | - Karen J Reynolds
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
| | - R Doug McEvoy
- Flinders Health and Medical Research Institute: Sleep Health (formerly Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Duc Phuc Nguyen
- Flinders Health and Medical Research Institute: Sleep Health (formerly Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
| | - Peter G Catcheside
- Flinders Health and Medical Research Institute: Sleep Health (formerly Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- The Medical Device Research Institute, College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
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Orr JE, Malhotra A, Gruenberg E, Marin T, Sands SA, Alex RM, Owens RL, Schmickl CN. Pathogenesis of sleep disordered breathing in the setting of opioid use: A multiple mediation analysis using physiology. Sleep 2024:zsae090. [PMID: 38605676 DOI: 10.1093/sleep/zsae090] [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: 11/03/2023] [Indexed: 04/13/2024] Open
Abstract
STUDY OBJECTIVES Opioid medications are commonly used and are known to impact both breathing and sleep, and are linked with adverse health outcomes including death. Clinical data indicate that chronic opioid use causes central sleep apnea, and might also worsen obstructive sleep apnea. The mechanisms by which opioids influence sleep-disordered breathing pathogenesis are not established. METHODS Patients who underwent clinically-indicated polysomnography confirming sleep-disordered breathing (SDB) (AHI≥5/hr) were included. Each patient using opioids was matched by sex, age, and BMI to three control individuals not using opioids. Physiology known to influence SDB pathogenesis were determined from validated polysomnography-based signal analysis. PSG and physiology paramters of interest were compared between opioid and control individuals, adjusted for covariates. Mediation analysis was used to evaluate the link between opioids, physiology, and polysomnographic metrics. RESULTS 178 individuals using opioids were matched to 534 controls (median [IQR] age 59 [50,65] years, BMI 33 [29,41] kg/m2, 57% female, daily morphine equivalent 30 [20,80] mg). Compared with controls, opioids were associated with increased central apneas (2.8 vs 1.7 events/hr; p=0.001) and worsened hypoxemia (5 vs 3% sleep with SpO2<88%; p=0.013), with similar overall AHI. Use of opioids was associated with higher loop gain, a lower respiratory rate and higher respiratory rate variability. Higher loop gain and increased respiratory rate variability mediated the effect of opioids on central apnea, but did not mediate the effect on hypoxemia. CONCLUSIONS Opioids have multi-level effects impacting SDB. Targeting these factors may help mitigate deleterious respiratory consequences of chronic opioid use.
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Affiliation(s)
- Jeremy E Orr
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, La Jolla, CA, USA
| | - Eli Gruenberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, La Jolla, CA, USA
| | - Traci Marin
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, La Jolla, CA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Raichel M Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, La Jolla, CA, USA
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, La Jolla, CA, USA
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10
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Cheng WJ, Finnsson E, Ágústsson JS, Sands SA, Hang LW. Endotypic traits of supine position and supine-predominant obstructive sleep apnoea in Asian patients. Eur Respir J 2024; 63:2301660. [PMID: 38212076 DOI: 10.1183/13993003.01660-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Over half of all cases of obstructive sleep apnoea (OSA) are classified as supine-related OSA; however, the pathological endotype during supine position is not fully understood. This study aims to investigate the endotypic traits of supine-predominant OSA and explore the variations in endotypic traits between the supine and lateral positions. METHODS We prospectively recruited 689 adult patients with OSA from a single sleep centre between April 2020 and December 2022. Endotypic traits, namely arousal threshold, collapsibility, loop gain and upper airway muscle compensation, were retrieved from polysomnographic signals. We identified spOSA by a supine to non-supine apnoea-hypopnoea index (AHI) ratio >2. We cross-sectionally compared demographic and endotypic traits between supine-predominant OSA and non-positional OSA and examined the associations between supine-predominant OSA and endotypic traits. Additionally, we compared the changes in endotypic traits between supine and lateral positions in patients with supine-predominant OSA and non-positional OSA. RESULTS In our study sample, 75.8% of patients were identified as having supine-predominant OSA. Compared to non-positional OSA, supine-predominant OSA was associated with low collapsibility (β= -3.46 %eupnoea, 95% CI -5.93- -1.00 %eupnoea) and reduced compensation (β= -6.79 %eupnoea, 95% CI -10.60- -2.99 %eupnoea). When transitioning from the lateral to supine position, patients with supine-predominant OSA had a substantial decrease in compensation compared to those with non-positional OSA (-11.98 versus -6.28 %eupnoea). CONCLUSIONS Supine-predominant OSA is the prevalent phenotype of OSA in Asian patients. Inadequate upper airway compensation appears to be a crucial underlying pathology in patients with supine-predominant OSA.
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Affiliation(s)
- Wan-Ju Cheng
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Miaoli, Taiwan
| | | | | | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Liang-Wen Hang
- College of Medicine, China Medical University, Taichung, Taiwan
- Sleep Medicine Center, Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung, Taiwan
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11
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Brooker EJ, Landry SA, Mann D, Prguda E, McLeay SC, Drummond SPA, Edwards BA. The obstructive sleep apnoea endotypes are similar in elderly trauma-exposed veterans with and without diagnosed PTSD. Sleep Med 2024; 115:48-54. [PMID: 38330695 DOI: 10.1016/j.sleep.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Approximately 60% of veterans living with posttraumatic stress disorder (PTSD) experience obstructive sleep apnoea (OSA). Why OSA is so prevalent in individuals with PTSD remains unknown, though PTSD may influence the underlying endotypes known to cause OSA. We examined whether these endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) differ between those with comorbid OSA and PTSD relative to their counterparts with OSA-only. METHODS Using the ventilatory flow pattern from diagnostic polysomnography, the OSA endotypes were measured in a retrospective cohort of 21 OSA patients with PTSD and 27 OSA-only patients. All participants were trauma exposed elderly male Australian Vietnam War veterans with mild-to-severe OSA (median Apnoea-Hypopnea index: 20.2 vs. 23.6 events/h). Age and BMI were similar between groups (70.7 vs. 71.7 years, and 28.4 vs. 28.4 kg/m2). RESULTS There were no significant differences in the OSA endotype traits between PTSD + OSA and OSA-only patients for upper airway collapsibility (76.68 [71.53-83.56] vs. 78.35 [72.81-83.82] %Veupnea, median [IQR]), muscle compensation (4.27 [0.34-9.18] vs. 5.41 [1.83-7.21] %Veupnea), loop gain (0.56(0.17) vs. 0.60(0.14)), and arousal threshold (135.76 [126.59-147.54] vs. 146.95 [128.64-151.28] %Veupnea). CONCLUSION The OSA endotypes in veterans with PTSD were similar to their trauma exposed OSA-only counterparts. PTSD appears to exert little influence on the OSA endotypes beyond the effect that age and trauma exposure may have. The aetiology of increased prevalence of OSA in PTSD remains unclear. Further work examining OSA endotypes using larger and more diverse samples is needed before robust conclusions can be made.
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Affiliation(s)
- Elliot J Brooker
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, 3800, Australia
| | - Shane A Landry
- Biomedicine Discovery Institute, Department of Physiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Dwayne Mann
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Emina Prguda
- Gallipoli Medical Research Foundation, Brisbane, Queensland, 4120, Australia; The University of Queensland, Brisbane, Queensland, 4006, Australia
| | - Sarah C McLeay
- Gallipoli Medical Research Foundation, Brisbane, Queensland, 4120, Australia
| | - Sean P A Drummond
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, 3800, Australia
| | - Bradley A Edwards
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, 3800, Australia; Biomedicine Discovery Institute, Department of Physiology, Monash University, Clayton, Victoria, 3800, Australia.
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12
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Hoff E, Strassberger C, Zou D, Grote L, Stenlöf K, Hedner J. Modification of Endotypic Traits in OSA by the Carbonic Anhydrase Inhibitor Sulthiame. Chest 2024; 165:704-715. [PMID: 37776971 DOI: 10.1016/j.chest.2023.09.022] [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: 04/14/2023] [Revised: 08/29/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND The carbonic anhydrase inhibitor sulthiame reduces OSA severity, increases overnight oxygenation, and improves sleep quality. Insights into how sulthiame modulates OSA pathophysiologic features (endotypic traits) adds to our understanding of the breathing disorder itself, as well as the effects of carbonic anhydrases in respiratory regulation. RESEARCH QUESTION How does sulthiame treatment modify endotypic traits in OSA? STUDY DESIGN AND METHODS Per-protocol tertiary analysis of a randomized controlled trial with the inclusion criteria as follow: BMI, ≥ 20 to ≤ 35 kg/m2; age, 18-75 years; apnea-hypopnea index (AHI) ≥ 15 events/h; Epworth sleepiness scale score, ≥ 6; as well as nonacceptance or nontolerance of positive airway pressure treatment. Patients were randomized to receive placebo (n = 22), sulthiame 200 mg (n = 12), or sulthiame 400 mg (n = 24) during 4 weeks of treatment. Polysomnography was applied twice at baseline and follow-up. Endotypic traits were determined from polysomnography tracings (PUPBeta). Sulthiame plasma concentration was analyzed. Differences from baseline to follow-up (Δs) were analyzed with the analysis of covariance or Kruskal-Wallis H test and Pearson (r) or Spearman correlations (rs). RESULTS Sulthiame (200-mg and 400-mg groups) consistently reduced loop gain (response to a 1-cycle/min disturbance, LG1; mean, -0.16 [95% CI, -0.18 to -0.13]; P < .05) in addition to increased ventilation at lowest decile of ventilatory drive (Vmin; median, +12 [95% CI, 4-20]; P < .05) and median ventilation at eupneic ventilatory drive (Vpassive; median, +4 [95% CI, 0-5]; P < .05). ΔLG1 correlated with ΔAHI percentage (200 mg: r = 0.65; P < .05). Vmin and Vpassive correlated with ΔAHI (all sulthiame: rs = -0.59 and rs = -0.65; P < .05 for all). The reduction of LG1 was seen already in the lower sulthiame concentration range, whereas changes in Vmin peaked in the higher range. INTERPRETATION The effect of sulthiame in OSA may be explained by a reduction of ventilatory instability (LG1) as well as upper airway collapsibility (Vmin and Vpassive). TRIAL REGISTRY European Union Drug Regulating Authorities Clinical Trials Database; No.: EudraCT 2017-004767-13; URL: https://www.clinicaltrialsregister.eu.
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Affiliation(s)
- Erik Hoff
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Department of Infectious Diseases, Södra Älvsborgs Hospital, Borås, Sweden.
| | - Christian Strassberger
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ding Zou
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ludger Grote
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Centre for Sleep Medicine, Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kaj Stenlöf
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Jan Hedner
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Centre for Sleep Medicine, Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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13
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Sands SA, Collet J, Gell LK, Calianese N, Hess LB, Vena D, Azarbarzin A, Bertisch SM, Landry S, Thomson L, Joosten SA, Hamilton GS, Edwards BA. Combination pharmacological therapy targeting multiple mechanisms of sleep apnoea: a randomised controlled cross-over trial. Thorax 2024; 79:259-268. [PMID: 38286618 DOI: 10.1136/thorax-2023-220184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/23/2023] [Indexed: 01/31/2024]
Abstract
RATIONALE Acetazolamide and atomoxetine-plus-oxybutynin ('AtoOxy') can improve obstructive sleep apnoea (OSA) by stabilising ventilatory control and improving dilator muscle responsiveness respectively. Given the different pathophysiological mechanisms targeted by each intervention, we tested whether AtoOxy-plus-acetazolamide would be more efficacious than AtoOxy alone. METHODS In a multicentre randomised crossover trial, 19 patients with moderate-to-severe OSA received AtoOxy (80/5 mg), acetazolamide (500 mg), combined AtoOxy-plus-acetazolamide or placebo at bedtime for three nights (half doses on first night) with a 4-day washout between conditions. Outcomes were assessed at baseline and night 3 of each treatment period. Mixed model analysis compared the reduction in Apnoea-Hypopnoea Index (AHI) from baseline between AtoOxy-plus-acetazolamide and AtoOxy (primary outcome). Secondary outcomes included hypoxic burden and arousal index. RESULTS Although AtoOxy lowered AHI by 49 (33, 62)%baseline (estimate (95% CI)) vs placebo, and acetazolamide lowered AHI by+34 (14, 50)%baseline vs placebo, AtoOxy-plus-acetazolamide was not superior to AtoOxy alone (difference: -2 (-18, 11)%baseline, primary outcome p=0.8). Likewise, the hypoxic burden was lowered with AtoOxy (+58 (37, 71)%baseline) and acetazolamide (+37 (5, 58)%baseline), but no added benefit versus AtoOxy occurred when combined (difference: -13 (-5, 39)%baseline). Arousal index was also modestly reduced with each intervention (11%baseline-16%baseline). Mechanistic analyses revealed that similar traits (ie, higher baseline compensation, lower loop gain) were associated with both AtoOxy and acetazolamide efficacy. CONCLUSIONS While AtoOxy halved AHI, and acetazolamide lowered AHI by a third, the combination of these leading experimental interventions provided no greater efficacy than AtoOxy alone. Failure of acetazolamide to further increase efficacy suggests overlapping physiological mechanisms. TRIAL REGISTRATION NUMBER NCT03892772.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne M Bertisch
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shane Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Luke Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
- School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
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14
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Korkalainen H, Kainulainen S, Islind AS, Óskarsdóttir M, Strassberger C, Nikkonen S, Töyräs J, Kulkas A, Grote L, Hedner J, Sund R, Hrubos-Strom H, Saavedra JM, Ólafsdóttir KA, Ágústsson JS, Terrill PI, McNicholas WT, Arnardóttir ES, Leppänen T. Review and perspective on sleep-disordered breathing research and translation to clinics. Sleep Med Rev 2024; 73:101874. [PMID: 38091850 DOI: 10.1016/j.smrv.2023.101874] [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: 04/06/2023] [Revised: 09/18/2023] [Accepted: 11/09/2023] [Indexed: 01/23/2024]
Abstract
Sleep-disordered breathing, ranging from habitual snoring to severe obstructive sleep apnea, is a prevalent public health issue. Despite rising interest in sleep and awareness of sleep disorders, sleep research and diagnostic practices still rely on outdated metrics and laborious methods reducing the diagnostic capacity and preventing timely diagnosis and treatment. Consequently, a significant portion of individuals affected by sleep-disordered breathing remain undiagnosed or are misdiagnosed. Taking advantage of state-of-the-art scientific, technological, and computational advances could be an effective way to optimize the diagnostic and treatment pathways. We discuss state-of-the-art multidisciplinary research, review the shortcomings in the current practices of SDB diagnosis and management in adult populations, and provide possible future directions. We critically review the opportunities for modern data analysis methods and machine learning to combine multimodal information, provide a perspective on the pitfalls of big data analysis, and discuss approaches for developing analysis strategies that overcome current limitations. We argue that large-scale and multidisciplinary collaborative efforts based on clinical, scientific, and technical knowledge and rigorous clinical validation and implementation of the outcomes in practice are needed to move the research of sleep-disordered breathing forward, thus increasing the quality of diagnostics and treatment.
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Affiliation(s)
- Henri Korkalainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland.
| | - Samu Kainulainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Anna Sigridur Islind
- Department of Computer Science, Reykjavik University, Reykjavik, Iceland; Reykjavik University Sleep Institute, Reykjavik University, Reykjavik, Iceland
| | - María Óskarsdóttir
- Department of Computer Science, Reykjavik University, Reykjavik, Iceland
| | - Christian Strassberger
- Centre for Sleep and Wake Disorders, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Sami Nikkonen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Juha Töyräs
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Australia; Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Antti Kulkas
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neurophysiology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Ludger Grote
- Centre for Sleep and Wake Disorders, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden; Sleep Disorders Centre, Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Hedner
- Centre for Sleep and Wake Disorders, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden; Sleep Disorders Centre, Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Reijo Sund
- School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Harald Hrubos-Strom
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Ear, Nose and Throat Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Jose M Saavedra
- Reykjavik University Sleep Institute, Reykjavik University, Reykjavik, Iceland; Physical Activity, Physical Education, Sport and Health (PAPESH) Research Group, Department of Sports Science, Reykjavik University, Reykjavik, Iceland
| | | | | | - Philip I Terrill
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Australia
| | - Walter T McNicholas
- School of Medicine, University College Dublin, and Department of Respiratory and Sleep Medicine, St Vincent's Hospital Group, Dublin Ireland
| | - Erna Sif Arnardóttir
- Reykjavik University Sleep Institute, Reykjavik University, Reykjavik, Iceland; Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Timo Leppänen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland; School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Australia
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15
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Qin H, Fietze I, Mazzotti DR, Steenbergen N, Kraemer JF, Glos M, Wessel N, Song L, Penzel T, Zhang X. Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring. J Sleep Res 2024; 33:e14020. [PMID: 37709966 DOI: 10.1111/jsr.14020] [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: 02/07/2023] [Revised: 07/23/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023]
Abstract
Obstructive sleep apnea is a highly prevalent sleep-related breathing disorder, resulting in a disturbed breathing pattern, changes in blood gases, abnormal autonomic regulation, metabolic fluctuation, poor neurocognitive performance, and increased cardiovascular risk. With broad inter-individual differences recognised in risk factors, clinical symptoms, gene expression, physiological characteristics, and health outcomes, various obstructive sleep apnea subtypes have been identified. Therapeutic efficacy and its impact on outcomes, particularly for cardiovascular consequences, may also vary depending on these features in obstructive sleep apnea. A number of interventions such as positive airway pressure therapies, oral appliance, surgical treatment, and pharmaceutical options are available in clinical practice. Selecting an effective obstructive sleep apnea treatment and therapy is a challenging medical decision due to obstructive sleep apnea heterogeneity and numerous treatment modalities. Thus, an objective marker for clinical evaluation is warranted to estimate the treatment response in patients with obstructive sleep apnea. Currently, while the Apnea-Hypopnea Index is used for severity assessment of obstructive sleep apnea and still considered a major guide to diagnosis and managements of obstructive sleep apnea, the Apnea-Hypopnea Index is not a robust marker of symptoms, function, or outcome improvement. Abnormal cardiac autonomic modulation can provide additional insight to better understand obstructive sleep apnea phenotyping. Heart rate variability is a reliable neurocardiac tool to assess altered autonomic function and can also provide cardiovascular information in obstructive sleep apnea. Beyond the Apnea-Hypopnea Index, this review aims to discuss the role of heart rate variability as an indicator and predictor of therapeutic efficacy to different modalities in order to optimise tailored treatment for obstructive sleep apnea.
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Affiliation(s)
- Hua Qin
- Department of Otolaryngology, Head and Neck Surgery, State Key Laboratory of Respiratory Disease, The Key Laboratory of Advanced Interdisciplinary Studies Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ingo Fietze
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
- The Fourth People's Hospital of Guangyuan, Guangyuan, China
| | - Diego R Mazzotti
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Jan F Kraemer
- Department of Physics, Humboldt-Universität zu Berlin, Berlin, Germany
- Information Processing and Analytics Group, School of Library and Information Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Glos
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Niels Wessel
- Department of Physics, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Medicine, Medical School Berlin, Berlin, Germany
| | - Lijun Song
- Department of Otolaryngology, Head and Neck Surgery, State Key Laboratory of Respiratory Disease, The Key Laboratory of Advanced Interdisciplinary Studies Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Xiaowen Zhang
- Department of Otolaryngology, Head and Neck Surgery, State Key Laboratory of Respiratory Disease, The Key Laboratory of Advanced Interdisciplinary Studies Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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16
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Cheng WJ, Finnsson E, Ágústsson JS, Sands SA, Hang LW. Continuous positive airway pressure and adherence in patients with different endotypes of obstructive sleep apnea. J Sleep Res 2024; 33:e13999. [PMID: 37452710 PMCID: PMC10788376 DOI: 10.1111/jsr.13999] [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: 03/09/2023] [Revised: 05/26/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Determining the endotypes of obstructive sleep apnea (OSA) has potential implications for precision interventions. Here we assessed whether continuous positive airway pressure (CPAP) treatment outcomes differ across endotypic subgroups. We conducted a retrospective analysis of data obtained from 225 patients with moderate-to-severe OSA from a single sleep centre. Polysomnographic and CPAP titration study data were collected between May 2020 and January 2022. One-month CPAP treatment adherence was followed. Obstructive sleep apnea endotypes, namely arousal threshold, collapsibility, loop gain, and upper airway gain were estimated from polysomnography and dichotomised as high versus low. We examined associations between endotypic subgroups and (1) optimal CPAP titration pressure, (2) CPAP-related improvements in sleep architecture (proportions of slow-wave and rapid eye movement (REM) sleep), and (3) CPAP adherence. We observed that patients with high collapsibility required a higher CPAP pressure than those with low collapsibility (∆ = 0.4 cmH2 O, 95% confidence interval [CI] = 0.3-1.7). A larger increase in slow-wave sleep and in REM sleep proportions after CPAP treatment were observed in patients with a high arousal threshold, high collapsibility, high loop gain, or high upper airway gain than in those with low levels of endotypes. High loop gain and high collapsibility were independently associated with longer CPAP use hours per night (∆ = 0.6 h, 95% CI = 0.2-1.5 and ∆ = 0.3 h, 95% CI = 0.03-1.5, respectively). In conclusion, different endotypic subgroups of OSA exhibit a difference in outcomes of CPAP treatment. Knowledge of endotypes may help clinicians to understand which patients are expected to benefit most from CPAP therapy prior to its administration.
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Affiliation(s)
- Wan-Ju Cheng
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, 35 Keyan Road, Miaoli, Taiwan
| | | | | | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Liang-Wen Hang
- School of Nursing & Graduate Institute of Nursing, China Medical University, Taichung, Taiwan
- Sleep Medicine Center, Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung, Taiwan
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17
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Abu K, Khraiche ML, Amatoury J. Obstructive sleep apnea diagnosis and beyond using portable monitors. Sleep Med 2024; 113:260-274. [PMID: 38070375 DOI: 10.1016/j.sleep.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/03/2023] [Accepted: 11/21/2023] [Indexed: 01/07/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic sleep and breathing disorder with significant health complications, including cardiovascular disease and neurocognitive impairments. To ensure timely treatment, there is a need for a portable, accurate and rapid method of diagnosing OSA. This review examines the use of various physiological signals used in the detection of respiratory events and evaluates their effectiveness in portable monitors (PM) relative to gold standard polysomnography. The primary objective is to explore the relationship between these physiological parameters and OSA, their application in calculating the apnea hypopnea index (AHI), the standard metric for OSA diagnosis, and the derivation of non-AHI metrics that offer additional diagnostic value. It is found that increasing the number of parameters in PMs does not necessarily improve OSA detection. Several factors can cause performance variations among different PMs, even if they extract similar signals. The review also highlights the potential of PMs to be used beyond OSA diagnosis. These devices possess parameters that can be utilized to obtain endotypic and other non-AHI metrics, enabling improved characterization of the disorder and personalized treatment strategies. Advancements in PM technology, coupled with thorough evaluation and validation of these devices, have the potential to revolutionize OSA diagnosis, personalized treatment, and ultimately improve health outcomes for patients with OSA. By identifying the key factors influencing performance and exploring the application of PMs beyond OSA diagnosis, this review aims to contribute to the ongoing development and utilization of portable, efficient, and effective diagnostic tools for OSA.
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Affiliation(s)
- Kareem Abu
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon; Neural Engineering and Nanobiosensors Group, American University of Beirut, Beirut, Lebanon; Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon
| | - Massoud L Khraiche
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon; Neural Engineering and Nanobiosensors Group, American University of Beirut, Beirut, Lebanon
| | - Jason Amatoury
- Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon; Sleep and Upper Airway Research Group (SUARG), American University of Beirut, Beirut, Lebanon.
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Edwards BA, O'Driscoll DM, Brooker EJ, Landry SA. A deep dive into the physiological differences responsible for obstructive sleep apnea between races. Sleep 2023; 46:zsad186. [PMID: 37429581 DOI: 10.1093/sleep/zsad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Bradley A Edwards
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Denise M O'Driscoll
- Department of Respiratory and Sleep Medicine, Eastern Health, Melbourne, VIC, Australia
- Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Elliot J Brooker
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC, Australia
| | - Shane A Landry
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
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19
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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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20
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Sweetman A, Osman A, Lack L, Crawford M, Wallace D. Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions. Curr Opin Pulm Med 2023; 29:567-573. [PMID: 37642477 DOI: 10.1097/mcp.0000000000001007] [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: 08/31/2023]
Abstract
PURPOSE OF REVIEW Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions. RECENT FINDINGS People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches. SUMMARY It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.
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Affiliation(s)
- Alexander Sweetman
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Amal Osman
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Leon Lack
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Megan Crawford
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Douglas Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
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21
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Labarca G, Vena D, Hu WH, Esmaeili N, Gell L, Yang HC, Wang TY, Messineo L, Taranto-Montemurro L, Sofer T, Barr RG, Stone KL, White DP, Wellman A, Sands S, Redline S, Azarbarzin A. Sleep Apnea Physiological Burdens and Cardiovascular Morbidity and Mortality. Am J Respir Crit Care Med 2023; 208:802-813. [PMID: 37418748 PMCID: PMC10563185 DOI: 10.1164/rccm.202209-1808oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 07/07/2023] [Indexed: 07/09/2023] Open
Abstract
Rationale: Obstructive sleep apnea is characterized by frequent reductions in ventilation, leading to oxygen desaturations and/or arousals. Objectives: In this study, association of hypoxic burden with incident cardiovascular disease (CVD) was examined and compared with that of "ventilatory burden" and "arousal burden." Finally, we assessed the extent to which the ventilatory burden, visceral obesity, and lung function explain variations in hypoxic burden. Methods: Hypoxic, ventilatory, and arousal burdens were measured from baseline polysomnograms in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Osteoporotic Fractures in Men (MrOS) studies. Ventilatory burden was defined as event-specific area under ventilation signal (mean normalized, area under the mean), and arousal burden was defined as the normalized cumulative duration of all arousals. The adjusted hazard ratios for incident CVD and mortality were calculated. Exploratory analyses quantified contributions to hypoxic burden of ventilatory burden, baseline oxygen saturation as measured by pulse oximetry, visceral obesity, and spirometry parameters. Measurements and Main Results: Hypoxic and ventilatory burdens were significantly associated with incident CVD (adjusted hazard ratio [95% confidence interval] per 1 SD increase in hypoxic burden: MESA, 1.45 [1.14, 1.84]; MrOS, 1.13 [1.02, 1.26]; ventilatory burden: MESA, 1.38 [1.11, 1.72]; MrOS, 1.12 [1.01, 1.25]), whereas arousal burden was not. Similar associations with mortality were also observed. Finally, 78% of variation in hypoxic burden was explained by ventilatory burden, whereas other factors explained only <2% of variation. Conclusions: Hypoxic and ventilatory burden predicted CVD morbidity and mortality in two population-based studies. Hypoxic burden is minimally affected by measures of adiposity and captures the risk attributable to ventilatory burden of obstructive sleep apnea rather than a tendency to desaturate.
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Affiliation(s)
- Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wen-Hsin Hu
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Neda Esmaeili
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hyung Chae Yang
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, South Korea
| | - Tsai-Yu Wang
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tamar Sofer
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert G. Barr
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; and
| | - Katie L. Stone
- Research Institute, California Pacific Medical Center, San Francisco, California
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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22
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Aishah A, Tong BKY, Osman AM, Pitcher G, Donegan M, Kwan BCH, Brown E, Altree TJ, Adams R, Mukherjee S, Eckert DJ. Stepwise Add-On and Endotype-informed Targeted Combination Therapy to Treat Obstructive Sleep Apnea: A Proof-of-Concept Study. Ann Am Thorac Soc 2023; 20:1316-1325. [PMID: 37159953 DOI: 10.1513/annalsats.202210-892oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale: Oral appliance therapy (OAT) is an effective treatment for many people with obstructive sleep apnea (OSA). However, OSA pathogenesis is heterogeneous, and, in ∼50% of cases, OAT does not fully control OSA. Objectives: This study aimed to control OSA in individuals with an incomplete response to OAT alone by using additional targeted therapies informed by OSA endotype characterization. Methods: Twenty-three people with OSA (apnea-hypopnea index [AHI], 41 ± 19 events/h) not fully resolved (AHI, >10 events/h) with OAT alone were prospectively recruited. OSA endotypes were characterized pretherapy during a detailed physiology study night. Initially, an expiratory positive airway pressure (EPAP) valve and supine avoidance device therapy were added to target the impaired anatomical endotype. Those with residual OSA (AHI, >10 events/h) then received one or more nonanatomical interventions based on endotype characterization. This included O2 (4 L/min) to reduce high loop gain (unstable respiratory control) and 80/5 mg atomoxetine-oxybutynin to increase pharyngeal muscle activity. Finally, if required, OAT was combined with EPAP and continuous positive airway pressure (CPAP) therapy. Results: Twenty participants completed the study. OSA was successfully controlled (AHI, <10 events/h) with combination therapy in all but one participant (17 of 20 without CPAP). OAT plus EPAP and supine avoidance therapy treated OSA in 10 (50%) participants. OSA was controlled in five (25%) participants with the addition of O2 therapy, one with atomoxetine-oxybutynin, and one required O2 plus atomoxetine-oxybutynin. Two participants required CPAP for their OSA, and another was CPAP intolerant. Conclusions: These novel prospective findings highlight the potential of precision medicine to inform targeted combination therapy to treat OSA. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001995268).
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Affiliation(s)
- Atqiya Aishah
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Benjamin K Y Tong
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Amal M Osman
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Geoffrey Pitcher
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Michelle Donegan
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Benjamin C H Kwan
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Elizabeth Brown
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Thomas J Altree
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Robert Adams
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Sutapa Mukherjee
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Danny J Eckert
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
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23
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Cheng WJ, Finnsson E, Arnardóttir E, Ágústsson JS, Sands SA, Hang LW. Relationship between Symptom Profiles and Endotypes among Patients with Obstructive Sleep Apnea: A Latent Class Analysis. Ann Am Thorac Soc 2023; 20:1337-1344. [PMID: 37321164 PMCID: PMC10502883 DOI: 10.1513/annalsats.202212-1054oc] [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: 12/26/2022] [Accepted: 06/15/2023] [Indexed: 06/17/2023] Open
Abstract
Rationale: Obstructive sleep apnea (OSA) is a heterogeneous syndrome with various endotypic traits and symptoms. A link among symptoms, endotypes, and disease prognosis has been proposed but remains unsupported by empirical data. Objectives: To link symptom profiles and endotypes by clustering endotypic traits estimated using polysomnographic signals. Methods: We recruited 509 patients with moderate to severe OSA from a single sleep center. Polysomnographic data were collected between May 2020 and January 2022. Endotypic traits, namely arousal threshold, upper airway collapsibility, loop gain, and upper airway muscle compensation, were retrieved using polysomnographic signals during non-rapid eye movement periods. We used latent class analysis to group participants into endotype clusters. Demographic and polysomnographic parameter differences were compared between clusters, and associations between endotype clusters and symptom profiles were examined using logistic regression analyses. Results: Three endotype clusters were identified, characterized by high collapsibility/loop gain, low arousal threshold, and low compensation, respectively. Patients in each cluster exhibited similar demographic characteristics, but those in the high collapsibility/loop gain cluster had the highest proportion of obesity and severe oxygen desaturation observed in polysomnographic studies. The low compensation cluster was characterized by fewer sleepy symptoms and exhibited a lower rate of diabetes mellitus. Compared with the excessively sleepy group, disturbed sleep symptoms were associated with the low arousal threshold cluster (odds ratio, 1.89; 95% confidence interval, 1.16-3.10). Excessively sleepy symptoms were associated with the high collapsibility/loop gain cluster (odds ratio, 2.16; 95% confidence interval, 1.39-3.37) compared with the minimally symptomatic group. Conclusions: Three pathological endotype clusters were identified among patients with moderate to severe OSA, each exhibiting distinct polysomnographic characteristics and clinical symptom profiles.
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Affiliation(s)
- Wan-Ju Cheng
- Department of Psychiatry and
- Department of Public Health and
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Miaoli, Taiwan
| | | | | | | | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Liang-Wen Hang
- Sleep Medicine Center, Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Nursing & Graduate Institute of Nursing, China Medical University, Taichung, Taiwan
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24
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McNicholas WT, Korkalainen H. Translation of obstructive sleep apnea pathophysiology and phenotypes to personalized treatment: a narrative review. Front Neurol 2023; 14:1239016. [PMID: 37693751 PMCID: PMC10483231 DOI: 10.3389/fneur.2023.1239016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Obstructive Sleep Apnea (OSA) arises due to periodic blockage of the upper airway (UA) during sleep, as negative pressure generated during inspiration overcomes the force exerted by the UA dilator muscles to maintain patency. This imbalance is primarily seen in individuals with a narrowed UA, attributable to factors such as inherent craniofacial anatomy, neck fat accumulation, and rostral fluid shifts in the supine posture. Sleep-induced attenuation of UA dilating muscle responsiveness, respiratory instability, and high loop gain further exacerbate UA obstruction. The widespread comorbidity profile of OSA, encompassing cardiovascular, metabolic, and neuropsychiatric domains, suggests complex bidirectional relationships with conditions like heart failure, stroke, and metabolic syndrome. Recent advances have delineated distinct OSA phenotypes beyond mere obstruction frequency, showing links with specific symptomatic manifestations. It is vital to bridge the gap between measurable patient characteristics, phenotypes, and underlying pathophysiological traits to enhance our understanding of OSA and its interplay with related outcomes. This knowledge could stimulate the development of tailored therapies targeting specific phenotypic and pathophysiological endotypes. This review aims to elucidate the multifaceted pathophysiology of OSA, focusing on the relationships between UA anatomy, functional traits, clinical manifestations, and comorbidities. The ultimate objective is to pave the way for a more personalized treatment paradigm in OSA, offering alternatives to continuous positive airway pressure therapy for selected patients and thereby optimizing treatment efficacy and adherence. There is an urgent need for personalized treatment strategies in the ever-evolving field of sleep medicine, as we progress from a 'one-size-fits-all' to a 'tailored-therapy' approach.
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Affiliation(s)
- Walter T. McNicholas
- School of Medicine and the Conway Research Institute, University College Dublin, Dublin, Ireland
- Department of Respiratory and Sleep Medicine, St. Vincent’s Hospital Group, Dublin, Ireland
| | - Henri Korkalainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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25
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Tolbert TM, Schoenholz RL, Parekh A, Berkalieva A, Osorio RS, Ayappa I, Rapoport DM. Night-to-night reliability and agreement of obstructive sleep apnea pathophysiologic mechanisms estimated with phenotyping using polysomnography in cognitively normal elderly participants. Sleep 2023; 46:zsad058. [PMID: 36881682 PMCID: PMC10848222 DOI: 10.1093/sleep/zsad058] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/12/2023] [Indexed: 03/09/2023] Open
Abstract
STUDY OBJECTIVES Phenotyping using polysomnography (PUP) is an algorithmic method to quantify physiologic mechanisms underlying obstructive sleep apnea (OSA): loop gain (LG1), arousal threshold (ArTH), and upper airway collapsibility (Vpassive) and muscular compensation (Vcomp). The consecutive-night test-retest reliability and agreement of PUP-derived estimates are unknown. From a cohort of elderly (age ≥55 years), largely non-sleepy, community-dwelling volunteers who underwent in-lab polysomnography (PSG) on 2 consecutive nights, we determined the test-retest reliability and agreement of PUP-estimated physiologic factors. METHODS Participants who had an apnea-hypopnea index (AHI3A) of at least 15 events per hour on the first night were included. PUP analyses were performed on each of the two PSGs from each participant. Physiologic factor estimates were derived from NREM sleep and compared across nights using intraclass correlation coefficients for reliability and smallest real differences (SRD) for agreement. RESULTS Two PSGs from each of 43 participants (86 total) were analyzed. A first-night effect was evident with increased sleep time and stability and decreased OSA severity on the second night. LG1, ArTH, and Vpassive demonstrated good reliability (ICC > 0.80). Vcomp had modest reliability (ICC = 0.67). For all physiologic factors, SRD values were approximately 20% or more of the observed ranges, suggesting limited agreement of longitudinal measurements for a given individual. CONCLUSIONS For NREM sleep in cognitively normal elderly individuals with OSA, PUP-estimated LG1, ArTH, and Vpassive demonstrated consistent relative ranking of individuals (good reliability) on short-term repeat measurement. For all physiologic factors, longitudinal measurements demonstrated substantial intraindividual variability across nights (limited agreement).
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Affiliation(s)
- Thomas M Tolbert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reagan L Schoenholz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ankit Parekh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asem Berkalieva
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York, NY, USA
| | - Ricardo S Osorio
- Department of Psychiatry, NYU Grossman School of Medicine, Healthy Brain Aging and Sleep Center, New York, NY, USA
| | - Indu Ayappa
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M Rapoport
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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26
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Keenan BT, Magalang UJ, Schwab RJ. Night-to-night reliability and agreement of physiological endotypes: two steps forward, one step back. Sleep 2023; 46:zsad116. [PMID: 37074871 PMCID: PMC10424163 DOI: 10.1093/sleep/zsad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 04/20/2023] Open
Affiliation(s)
- Brendan T Keenan
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ulysses J Magalang
- Division of Pulmonary, Critical Care and Sleep Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Richard J Schwab
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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27
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Kaczmarski P, Sochal M, Strzelecki D, Białasiewicz P, Gabryelska A. Influence of glutamatergic and GABAergic neurotransmission on obstructive sleep apnea. Front Neurosci 2023; 17:1213971. [PMID: 37521710 PMCID: PMC10372424 DOI: 10.3389/fnins.2023.1213971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
Glutamate and γ-aminobutyric acid (GABA) are the two main neurotransmitters in the human brain. The balance between their excitatory and inhibitory functions is crucial for maintaining the brain's physiological functions. Disturbance of glutamatergic or GABAergic neurotransmission leads to serious health problems including neurodegeneration, affective and sleep disorders. Both GABA and glutamate are involved in the control of the sleep-wake cycle. The disturbances in their function may cause sleep and sleep-related disorders. Obstructive sleep apnea (OSA) is the most common sleep respiratory disorder and is characterized by repetitive collapse of the upper airway resulting in intermittent hypoxia and sleep fragmentation. The complex pathophysiology of OSA is the basis of the development of numerous comorbid diseases. There is emerging evidence that GABA and glutamate disturbances may be involved in the pathogenesis of OSA, as well as its comorbidities. Additionally, the GABA/glutamate targeted pharmacotherapy may also influence the course of OSA, which is important in the implementation of wildly used drugs including benzodiazepines, anesthetics, and gabapentinoids. In this review, we summarize current knowledge on the influence of disturbances in glutamatergic and GABAergic neurotransmission on obstructive sleep apnea.
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Affiliation(s)
- Piotr Kaczmarski
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Marcin Sochal
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Dominik Strzelecki
- Department of Affective and Psychotic Disorders, Medical University of Łódź, Łódź, Poland
| | - Piotr Białasiewicz
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Agata Gabryelska
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
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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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Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med 2023; 19:1183-1190. [PMID: 36805833 PMCID: PMC10315604 DOI: 10.5664/jcsm.10528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
STUDY OBJECTIVES The potential sedative effect of dronabinol and the high expression of cannabinoid receptors on the hypoglossal motor nuclei makes this agent a good candidate for obstructive sleep apnea (OSA) pharmacotherapy to be tested with atomoxetine, a noradrenergic reuptake inhibitor that reduced OSA severity in combination with oxybutynin. Here we tested the effect of atomoxetine 80 mg plus dronabinol (Ato-Dro) at 2 different doses (5 and 10 mg) vs. baseline and atomoxetine alone in a 2-center, open-label, dose-escalating trial. The primary outcome was the effect of Ato-Dro vs. baseline on OSA severity (apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation). Safety of the combination and self-reported outcomes were also assessed. METHODS Fifteen patients with OSA received progressively increasing Ato-Dro doses (dose escalation was performed every week, starting from Ato-Dro 40-2.5 mg, then 80-5 mg and finally 80-10 mg). A clinical, in-lab polysomnography was performed at baseline, on Ato-Dro 80-5 and Ato-Dro 80-10 mg. RESULTS Ato-Dro 80-10 mg did not significantly reduce apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation, and hypoxic burden and yielded limited clinical benefit vs. baseline and atomoxetine alone. However, Ato-Dro 80-5 mg did improve OSA severity (Δapnea-hypopnea index = 8.3[0.3, 16.3] events/h; mean [confidence interval]; Δhypoxic burden = 37.7[12.5, 62.7] %min/h) and multiple self-reported outcomes vs. baseline and/or atomoxetine alone. Ato-Dro administration was characterized by several potentially harmful side effects and treatment discontinuation in 1/3 of cases. CONCLUSIONS Ato-Dro 80-5 mg might be useful to reduce OSA severity and lead to self-reported improvement in those who could tolerate the combination. However, given the numerous side effects and the exploratory nature of this open-label study, our results warrant further validation in larger trials. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Study for Efficacy and Dose Escalation of AD313 + Atomoxetine (SEED) (SEED); URL: https://clinicaltrials.gov/ct2/show/NCT05101122; Identifier: NCT05101122. CITATION Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med. 2023;19(7):1183-1190.
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Affiliation(s)
- Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Daniel Norman
- Santa Monica Clinical Trials, Los Angeles, California
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Corser B, Eves E, Warren-McCormick J, Rucosky G. Effects of atomoxetine plus a hypnotic on obstructive sleep apnea severity in patients with a moderately collapsible pharyngeal airway. J Clin Sleep Med 2023; 19:1035-1042. [PMID: 36734173 PMCID: PMC10235724 DOI: 10.5664/jcsm.10464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVES Pharmacotherapy for obstructive sleep apnea (OSA) regained consideration after the discovery that atomoxetine and oxybutynin greatly reduced OSA severity. However, atomoxetine and oxybutynin reduced the arousal threshold and may therefore be poorly tolerated in patients with OSA and disturbed sleep. As a result, we tested the combination of atomoxetine plus 2 hypnotics in patients with OSA. The effects of atomoxetine plus: (1) trazodone (Ato-Trazo) and (2) lemborexant vs placebo on apnea-hypopnea index, hypoxic burden, arousal threshold, and total sleep time were assessed. Drug safety was also ascertained, together with the effect of the combinations on other OSA traits, self-reported sleep quality, and next-day alertness. METHODS Following a baseline study, 15 patients with mild-to-severe OSA with moderate upper airway collapsibility were administered Ato-Trazo, atomoxetine and lemborexant, and matching placebo according to a double-blind, randomized, crossover design. Apnea-hypopnea index and other objective outcomes were calculated from 3 clinical, in-laboratory polysomnograms. RESULTS Ato-Trazo significantly reduced apnea-hypopnea index from a median [interquartile range] of 18.2 [11.8 to 31.3] on placebo to 7.4 [5.4 to 16.1] events/h, P = .024, and hypoxic burden from 46.3 [25.1 to 88.3] on placebo to 18.7 [14.9 to 43.5], P = .003. This effect was likely driven by an increase in polysomnography-estimated pharyngeal muscle activity during the events (P = .029). Atomoxetine and lemborexant had smaller statistically insignificant effects. Contrary to atomoxetine and oxybutynin, Ato-Trazo and atomoxetine and lemborexant did not reduce the arousal threshold. Both combinations had no effect on total sleep time but worsened self-reported sleep quality. CONCLUSIONS Ato-Trazo has the potential to become a useful drug combination, however, longer trials are needed to determine the best dosage and the subgroup of patients who may benefit most from this combination. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Crossover Trial of AD182 and AD504 in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT04645524; Identifier: NCT04645524. CITATION Corser B, Eves E, Warren-McCormick J, Rucosky G. Effects of atomoxetine plus a hypnotic on obstructive sleep apnea severity in patients with a moderately collapsible pharyngeal airway. J Clin Sleep Med. 2023;19(6):1035-1042.
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Affiliation(s)
| | - Erica Eves
- Sleep Management Institute, Cincinnati, Ohio
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31
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Sands SA, Edwards BA. Pro: can physiological risk factors for obstructive sleep apnea be determined by analysis of data obtained from routine polysomnography? Sleep 2023; 46:zsac310. [PMID: 36715219 PMCID: PMC10171624 DOI: 10.1093/sleep/zsac310] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
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32
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Zitting KM, Lockyer BJ, Azarbarzin A, Sands SA, Wang W, Wellman A, Quan SF. Association of cortical arousals with sleep-disordered breathing events. J Clin Sleep Med 2023; 19:899-912. [PMID: 36708264 PMCID: PMC10152355 DOI: 10.5664/jcsm.10492] [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: 05/13/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVES The American Academy of Sleep Medicine recommends scoring hypopneas in adults when there is a ≥ 3% oxygen desaturation or when the event is associated with an arousal. However, there is no rule regarding the duration of the interval between the event termination and the associated arousal. The purpose of this study is to explore the timing between arousals and sleep-disordered breathing (SDB) events. METHODS We analyzed cortical arousals (> 1.6 million) and SDB events (> 350,000 apneas and > 1.9 million hypopneas) from 11,400 manually scored polysomnography recordings. Only arousals that started within ±30 seconds from the end of SDB events were included. We used the 2 local minimums on either side of the arousal distribution as the start/end times for the distribution and to define which arousals are associated with SDB events. Finally, we calculated arousal probability near the end of SDB events. RESULTS Cortical arousals with start times that fell within the 2 minimums were considered to be associated with SDB events. Using this definition, we found that 90% of apnea-associated arousals started no earlier than 4 seconds before and no later than 9 seconds after the end of apneas. Similarly, 90% of hypopnea-associated arousals started no earlier than 6 seconds before and no later than 14 seconds after the end of hypopneas, with the peak of the distribution coinciding with event end time. Arousal probability was highest during the first 10 seconds after the end of the event and was higher for longer events. CONCLUSIONS Our results suggest that 90% of SDB-associated arousals start no earlier than 6 seconds before and no later than 14 seconds after the end of the respiratory events. CITATION Zitting K-M, Lockyer BJ, Azarbarzin A, et al. Association of cortical arousals with sleep-disordered breathing events. J Clin Sleep Med. 2023;19(5):899-912.
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Affiliation(s)
- Kirsi-Marja Zitting
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Brandon J. Lockyer
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Wei Wang
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Stuart F. Quan
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
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Strassberger C, Hedner J, Sands SA, Tolbert TM, Taranto-Montemurro L, Marciniak A, Zou D, Grote L. Night-to-Night Variability of Polysomnography-Derived Physiologic Endotypic Traits in Patients With Moderate to Severe OSA. Chest 2023; 163:1266-1278. [PMID: 36610664 PMCID: PMC10206510 DOI: 10.1016/j.chest.2022.12.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Emerging data suggest that determination of physiologic endotypic traits (eg, loop gain) may enable precision medicine in OSA. RESEARCH QUESTION Does a single-night assessment of polysomnography-derived endotypic traits provide reliable estimates in moderate to severe OSA? STUDY DESIGN AND METHODS Two consecutive in-lab polysomnography tests from a clinical trial (n = 67; male, 69%; mean ± SD age, 61 ± 10 years; apnea-hypopnea index [AHI] 53 ± 22 events/h) were used for the reliability analysis. Endotypic traits, reflecting upper airway collapsibility (ventilation at eupneic drive [Vpassive]), upper airway dilator muscle tone (ventilation at the arousal threshold [Vactive]), loop gain (stability of ventilatory control, LG1), and arousal threshold (ArTh) were determined. Reliability was expressed as an intraclass correlation coefficient (ICC). Minimal detectable differences (MDDs) were computed to provide an estimate of maximum spontaneous variability. Further assessment across four repeated polysomnography tests was performed in a subcohort (n = 22). RESULTS Reliability of endotypic traits between the two consecutive nights was moderate to good (ICC: Vpassive = 0.82, Vactive = 0.76, LG1 = 0.72, ArTh = 0.83). Variability in AHI, but not in body position or in sleep stages, was associated with fluctuations in Vpassive and Vactive (r = -0.49 and r = -0.41, respectively; P < .001 for both). MDDs for single-night assessments were: Vpassive = 22, Vactive = 34, LG1 = 0.17, and ArTh = 21. Multiple assessments (mean of two nights, n = 22) further reduced MDDs by approximately 20% to 30%. INTERPRETATION Endotypic trait analysis using a single standard polysomnography shows acceptable reliability and reproducibility in patients with moderate to severe OSA. The reported MDDs of endotypic traits may facilitate the quantification of relevant changes and may guide future evaluation of interventions in OSA.
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Affiliation(s)
- Christian Strassberger
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Hedner
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Sleep Medicine, Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Scott A Sands
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas M Tolbert
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Luigi Taranto-Montemurro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Albert Marciniak
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ding Zou
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ludger Grote
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Sleep Medicine, Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ni YN, Holzer RC, Thomas RJ. Acute and long-term effects of acetazolamide in presumed high loop gain sleep apnea. Sleep Med 2023; 107:137-148. [PMID: 37178545 DOI: 10.1016/j.sleep.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The acute effect during positive pressure titration and long term efficacy of acetazolamide (AZT) in high loop gain sleep apnea (HLGSA) is inadequately assessed. We predicted that AZT may improve HLGSA in both conditions. METHODS A retrospective analysis of polysomnograms from patients with presumed HLGSA and residual respiratory instability administered AZT (125 or 250 mg) about 3 h into an initially drug-free positive pressure titration. A responder was defined as ≥ 50% reduction of the apnea hypopnea index(AHI 3% or arousal) before and after AZT. A multivariable logistic regression model estimated responder predictors. Long term efficacy of AZT was assessed by comparing both auto-machine (aREIFLOW) and manually scored respiratory events (sREIFLOW) extracted from the ventilator, prior to and after 3 months of AZT, in a subset. RESULTS Of the 231 participants (median age of 61[51-68] years) and 184 (80%) males in the acute effect testing: 77 and 154 patients were given 125 mg and 250 mg AZT. Compared to PAP alone, PAP plus AZT was associated with a lower breathing related arousal index (8 [3-16] vs. 5 [2-10], p < 0.001), and AHI3% (19 [7-37] vs. 11 [5-21], p < 0.001); 98 patients were responders. The non-rapid eye movement sleep (NREM) AHI3% (OR 1.031, 95%CI [1.016-1.046], p < 0.001) was a strong predictor for responder status with AZT exposure. In the 109 participants with 3-month data, both aREIFLOW and sREIFLOWwere significantly reduced after AZT. CONCLUSIONS AZT acutely and chronically reduced residual sleep apnea in presumed HLGSA; NREM AHI3% is a response predictor. AZT was well tolerated and beneficial for at least 3 months.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Rena C Holzer
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Brennan HL, Kirby SD. The role of artificial intelligence in the treatment of obstructive sleep apnea. J Otolaryngol Head Neck Surg 2023; 52:7. [PMID: 36747273 PMCID: PMC9903572 DOI: 10.1186/s40463-023-00621-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The first-line and most common treatment for obstructive sleep apnea is nasal continuous positive airway pressure, which serves as a pneumatic splint to stabilize the upper airway and is effective when used with appropriate adherence. Continuous positive airway pressure compliance rates remain significantly low despite machine improvements and compliance intervention. Other treatment options include oral appliances, myofunctional therapy, and surgery. The aim of this project is to elucidate the role of artificial intelligence within improving the treatment of obstructive sleep apnea. METHODS Related publications between 1999 and 2022 were reviewed from PubMed and Embase databases utilizing search terms "artificial intelligence," "machine learning," "obstructive sleep apnea," and "treatment." Both authors independently screened the results by title/abstract then by full text review. 126 non-duplicate articles were screened, 38 articles were included after title and abstract screen and 30 articles were included after full text review. The inclusion criteria are outline in the PICO framework and involved studies focused on artificial intelligence application in guiding and evaluating obstructive sleep apnea treatment. Non-English articles were excluded. RESULTS The role of artificial intelligence in the treatment of OSA was categorized into the following sections: Predicting treatment outcomes of various treatment options, Improving/Evaluating treatment, and Personalizing treatment with improving understanding of underlying mechanisms of OSA. CONCLUSIONS Artificial intelligence has the capacity to improve the treatment of OSA through predicting outcomes of treatment options, evaluating the treatment the patient is currently utilizing and increasing understanding of the mechanisms that contribute to OSA disease process and physiology. Implementing AI in guiding treatment decisions allows patients to connect with treatment methods that would be most effective on an individual basis.
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Affiliation(s)
- Hannah L. Brennan
- grid.25055.370000 0000 9130 6822Faculty of Medicine, Memorial University of Newfoundland and Labrador, 98 Pearltown Rd, St. John’s, NL A1G 1P3 Canada
| | - Simon D. Kirby
- grid.25055.370000 0000 9130 6822Faculty of Medicine, Memorial University of Newfoundland and Labrador, 98 Pearltown Rd, St. John’s, NL A1G 1P3 Canada
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Hajipour M, Baumann B, Azarbarzin A, Allen AH, Liu Y, Fels S, Goodfellow S, Singh A, Jen R, Ayas NT. Association of alternative polysomnographic features with patient outcomes in obstructive sleep apnea: a systematic review. J Clin Sleep Med 2023; 19:225-242. [PMID: 36106591 PMCID: PMC9892740 DOI: 10.5664/jcsm.10298] [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: 05/30/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVES Polysomnograms (PSGs) collect a plethora of physiologic signals across the night. However, few of these PSG data are incorporated into standard reports, and hence, ultimately, under-utilized in clinical decision making. Recently, there has been substantial interest regarding novel alternative PSG metrics that may help to predict obstructive sleep apnea (OSA)-related outcomes better than standard PSG metrics such as the apnea-hypopnea index. We systematically review the recent literature for studies that examined the use of alternative PSG metrics in the context of OSA and their association with health outcomes. METHODS We systematically searched EMBASE, MEDLINE, and the Cochrane Database of Systematic Reviews for studies published between 2000 and 2022 for those that reported alternative metrics derived from PSG in adults and related them to OSA-related outcomes. RESULTS Of the 186 initial studies identified by the original search, data from 31 studies were ultimately included in the final analysis. Numerous metrics were identified that were significantly related to a broad range of outcomes. We categorized the outcomes into 2 main subgroups: (1) cardiovascular/metabolic outcomes and mortality and (2) cognitive function- and vigilance-related outcomes. Four general categories of alternative metrics were identified based on signals analyzed: autonomic/hemodynamic metrics, electroencephalographic metrics, oximetric metrics, and respiratory event-related metrics. CONCLUSIONS We have summarized the current landscape of literature for alternative PSG metrics relating to risk prediction in OSA. Although promising, further prospective observational studies are needed to verify findings from other cohorts, and to assess the clinical utility of these metrics. CITATION Hajipour M, Baumann B, Azarbarzin A, et al. Association of alternative polysomnographic features with patient outcomes in obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2023;19(2):225-242.
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Affiliation(s)
- Mohammadreza Hajipour
- Department of Experimental Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Brett Baumann
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - A.J. Hirsch Allen
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Yu Liu
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Department of Pharmacology, Shanxi Medical University, Taiyuan, China
| | - Sidney Fels
- Department of Electrical and Computer Engineering, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sebastian Goodfellow
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amrit Singh
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Rachel Jen
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Najib T. Ayas
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Jeong HG, Kim T, Hong JE, Kim HJ, Yun SY, Kim S, Yoo J, Lee SH, Thomas RJ, Yun CH. Automated deep neural network analysis of lateral cephalogram data can aid in detecting obstructive sleep apnea. J Clin Sleep Med 2023; 19:327-337. [PMID: 36271597 PMCID: PMC9892734 DOI: 10.5664/jcsm.10258] [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: 02/16/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVES Information on obstructive sleep apnea (OSA) is often latently detected in diagnostic tests conducted for other purposes, providing opportunities for maximizing value. This study aimed to develop a convolutional neural network (CNN) to identify the risk of OSA using lateral cephalograms. METHODS The lateral cephalograms of 5,648 individuals (mean age, 49.0 ± 15.8 years; men, 62.3%) with or without OSA were collected and divided into training, validation, and internal test datasets in a 5:2:3 ratio. A separate external test dataset (n = 378) was used. A densely connected CNN was trained to diagnose OSA using a cephalogram. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC). Gradient-weighted class activation mapping (Grad-CAM) was used to evaluate the region of focus, and the relationships between the model outputs, anthropometric characteristics, and OSA severity were evaluated. RESULTS The AUROC of the model for the presence of OSA was 0.82 (95% confidence interval, 0.80-0.84) and 0.73 (95% confidence interval, 0.65-0.81) in the internal and external test datasets, respectively. Grad-CAM demonstrated that the model focused on the area of the tongue base and oropharynx in the cephalogram. Sigmoid output values were positively correlated with OSA severity, body mass index, and neck and waist circumference. CONCLUSIONS Deep learning may help develop a model that classifies OSA using a cephalogram, which may be clinically useful in the appropriate context. The definition of ground truth was the main limitation of this study. CITATION Jeong H-G, Kim T, Hong JE, et al. Automated deep neural network analysis of lateral cephalogram data can aid in detecting obstructive sleep apnea. J Clin Sleep Med. 2023;19(2):327-337.
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Affiliation(s)
- Han-Gil Jeong
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji Eun Hong
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyun Ji Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - So-Yeon Yun
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Sejoong Kim
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Division of Nephrology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jun Yoo
- Department of Otorhinolaryngology–Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Seung Hoon Lee
- Department of Otorhinolaryngology–Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Robert Joseph Thomas
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Chang-Ho Yun
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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Liu Y, Abdul Ghafoor A, Hajipour M, Ayas N. Role of precision medicine in obstructive sleep apnoea. BMJ MEDICINE 2023; 2:e000218. [PMID: 36936264 PMCID: PMC9951383 DOI: 10.1136/bmjmed-2022-000218] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/14/2022] [Indexed: 01/07/2023]
Abstract
Obstructive sleep apnoea is a substantial clinical and public health problem because it contributes to harmful effects on quality of life, daytime symptoms, road traffic incidents, and cardiometabolic disease. Increasingly, obstructive sleep apnoea is recognised as a heterogeneous disease, and patients have varied susceptibility to long term complications and different responses to treatment. This narrative review summarises the current knowledge of precision medicine in obstructive sleep apnoea, particularly the role of symptom clusters, polysomnogram phenotypes, physiological endotypes, and circulating biomarkers in defining subtypes. In the near future, the prognostic accuracy of these measures in predicting long term complications in obstructive sleep apnoea will likely be improved, together with better matching of treatments to disease subtypes.
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Affiliation(s)
- Yu Liu
- Department of Pharmacology, Shanxi Medical University, Taiyuan, Shanxi, China
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Ali Abdul Ghafoor
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Mohammadreza Hajipour
- Division of Experimental Medicine, Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Najib Ayas
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
- Leon Judah Blackmore Sleep Disorders Program, UBC Hospital, Vancouver, BC, Canada
- Canadian Sleep and Circadian Network, Montréal, QC, Canada
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Guo J, Xiao Y. New Metrics from Polysomnography: Precision Medicine for OSA Interventions. Nat Sci Sleep 2023; 15:69-77. [PMID: 36923968 PMCID: PMC10010122 DOI: 10.2147/nss.s400048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a highly preventable disease accompanied by multiple comorbid conditions. Despite the well-established cardiovascular and neurocognitive sequelae with OSA, the optimal metric for assessing the OSA severity and response to therapy remains controversial. Although overnight polysomnography (PSG) is the golden standard for OSA diagnosis, the abundant information is not fully exploited. With the development of deep learning and the era of big data, new metrics derived from PSG have been validated in some OSA consequences and personalized treatment. In this review, these metrics are introduced based on the pathophysiological mechanisms of OSA and new technologies. Emphasis is laid on the advantages and the prognostic value against apnea-hypopnea index. New classification criteria should be established based on these metrics and other clinical characters for precision medicine.
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Affiliation(s)
- Junwei Guo
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yi Xiao
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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Sensorimotor Cortical Activity during Respiratory Arousals in Obstructive Sleep Apnea. Int J Mol Sci 2022; 24:ijms24010047. [PMID: 36613490 PMCID: PMC9820672 DOI: 10.3390/ijms24010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Intensity of respiratory cortical arousals (RCA) is a pathophysiologic trait in obstructive sleep apnea (OSA) patients. We investigated the brain oscillatory features related to respiratory arousals in moderate and severe OSA. Raw electroencephalography (EEG) data recorded during polysomnography (PSG) of 102 OSA patients (32 females, mean age 51.6 ± 12 years) were retrospectively analyzed. Among all patients, 47 had moderate (respiratory distress index, RDI = 15−30/h) and 55 had severe (RDI > 30/h) OSA. Twenty RCA per sleep stage in each patient were randomly selected and a total of 10131 RCAs were analyzed. EEG signals obtained during, five seconds before and after the occurrence of each arousal were analyzed. The entropy (approximate (ApEn) and spectral (SpEn)) during each sleep stage (N1, N2 and REM) and area under the curve (AUC) of the EEG signal during the RCA was computed. Severe OSA compared to moderate OSA patients showed a significant decrease (p < 0.0001) in the AUC of the EEG signal during the RCA. Similarly, a significant decrease in spectral entropy, both before and after the RCA was observed, was observed in severe OSA patients when compared to moderate OSA patients. Contrarily, the approximate entropy showed an inverse pattern. The highest increase in approximate entropy was found in sleep stage N1. In conclusion, the dynamic range of sensorimotor cortical activity during respiratory arousals is sleep-stage specific, dependent on the frequency of respiratory events and uncoupled from autonomic activation. These findings could be useful for differential diagnosis of severe OSA from moderate OSA.
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Messineo L, Taranto-Montemurro L, Calianese N, Gell LK, Azarbarzin A, Labarca G, Vena D, Yang HC, Wang TY, Wellman A, Sands SA. Atomoxetine and fesoterodine combination improves obstructive sleep apnoea severity in patients with milder upper airway collapsibility. Respirology 2022; 27:975-982. [PMID: 35811347 PMCID: PMC10041976 DOI: 10.1111/resp.14326] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/23/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE The combination of the noradrenergic atomoxetine plus the anti-muscarinic oxybutynin acutely increased genioglossus activity and reduced obstructive sleep apnoea (OSA) severity. However, oxybutynin has shorter half-life than atomoxetine and side effects that might discourage long-term usage. Accordingly, we aimed to test the combination of atomoxetine and fesoterodine (Ato-Feso), a newer anti-muscarinic with extended release formulation, on OSA severity and endotypes. METHODS Twelve subjects with OSA underwent a randomized, double-blind, crossover trial comparing one night of atomoxetine plus fesoterodine (80-4 mg) to placebo. Parameters of OSA severity (e.g., apnoea-hypopnoea index [AHI], nadir oxygen desaturation and hypoxic burden) were calculated from two clinical, in-lab polysomnographic studies. OSA endotypes (including collapsibility per VMIN and arousal threshold) were derived from validated algorithms. RESULTS Compared to placebo, Ato-Feso did not reduce the AHI (34.2 ± 19.1 vs. 30.1 ± 28.2 events/h, p = 0.493), but reduced the apnoea index (12.9 [28.8] vs. 1.8 [9.1] events/h, median [interquartile range], p = 0.027) and increased nadir desaturation (76.8 [8.0] vs. 82.2 [8.8] %, p = 0.003); a non-significant trend for improved hypoxic burden was observed (52.4 [50.5] vs. 29.7 [78.9] %min/h, p = 0.093). Ato-Feso lowered collapsibility (raised VMIN ; 43.7 [29.8-55.7] vs. 56.8 [43.8-69.8] %VEUPNOEA , mean [CI], p = 0.002), but reduced the arousal threshold (129.3 [120.1-138.6] vs. 116.7 [107.5-126] %VEUPNOEA , p = 0.038). In post hoc analysis, 6/6 patients with milder collapsibility (VMIN > 43%) exhibited OSA resolution (drop in AHI > 50% and residual AHI < 10 events/h) and improved hypoxaemia. CONCLUSION While inefficacious in unselected patients, Ato-Feso administered for one night suppressed OSA in patients with milder collapsibility. Ato-Feso may hold some promise as an alternative OSA treatment in certain subgroups of individuals.
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Affiliation(s)
- Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Dan Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Hyung Chae Yang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Tsai-Yu Wang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
- Department of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
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Parrino L, Halasz P, Szucs A, Thomas RJ, Azzi N, Rausa F, Pizzarotti S, Zilioli A, Misirocchi F, Mutti C. Sleep medicine: Practice, challenges and new frontiers. Front Neurol 2022; 13:966659. [PMID: 36313516 PMCID: PMC9616008 DOI: 10.3389/fneur.2022.966659] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Sleep medicine is an ambitious cross-disciplinary challenge, requiring the mutual integration between complementary specialists in order to build a solid framework. Although knowledge in the sleep field is growing impressively thanks to technical and brain imaging support and through detailed clinic-epidemiologic observations, several topics are still dominated by outdated paradigms. In this review we explore the main novelties and gaps in the field of sleep medicine, assess the commonest sleep disturbances, provide advices for routine clinical practice and offer alternative insights and perspectives on the future of sleep research.
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Affiliation(s)
- Liborio Parrino
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- *Correspondence: Liborio Parrino
| | - Peter Halasz
- Szentagothai János School of Ph.D Studies, Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Anna Szucs
- Department of Behavioral Sciences, National Institute of Clinical Neurosciences, Semmelweis University, Budapest, Hungary
| | - Robert J. Thomas
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Nicoletta Azzi
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
| | - Francesco Rausa
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Silvia Pizzarotti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
| | - Alessandro Zilioli
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Francesco Misirocchi
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
| | - Carlotta Mutti
- Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
- Department of Medicine and Surgery, Unit of Neurology, University of Parma, Parma, Italy
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Wong AM, Landry SA, Joosten SA, Thomson LDJ, Turton A, Stonehouse J, Mansfield DR, Burgess G, Hays A, Sands SA, Andara C, Beatty CJ, Hamilton GS, Edwards BA. Examining the impact of multilevel upper airway surgery on the obstructive sleep apnoea endotypes and their utility in predicting surgical outcomes. Respirology 2022; 27:890-899. [PMID: 35598093 PMCID: PMC9542009 DOI: 10.1111/resp.14280] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial-down or clinical polysomnographic (PSG) methods. METHODS We prospectively studied 23 OSA patients before and ≥3 months after multilevel upper airway surgery. Participants underwent clinical and research PSG to measure OSA severity (apnoea-hypopnoea index [AHI]) and endotypes (measured in supine non-rapid eye movement [NREM]). Values are presented as mean ± SD or median (interquartile range). RESULTS Surgery reduced the AHITotal (38.7 [23.4 to 79.2] vs. 22.0 [13.3 to 53.5] events/h; p = 0.009). There were no significant changes in OSA endotypes, however, large but variable improvements in collapsibility were observed (CPAP dial-down method: ∆1.9 ± 4.9 L/min, p = 0.09, n = 21; PSG method: ∆3.4 [-2.8 to 49.0]%Veupnoea , p = 0.06, n = 20). Improvement in collapsibility strongly correlated with improvement in AHI (%∆AHISupineNREM vs. ∆collapsibility: p < 0.005; R2 = 0.46-0.48). None of the baseline OSA endotypes predicted response to surgery. CONCLUSION Surgery unpredictably alters upper airway collapsibility but does not alter the non-anatomical endotypes. There are no baseline predictors of response to surgery.
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Affiliation(s)
- Ai-Ming Wong
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane A Landry
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Anthony Turton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Jeremy Stonehouse
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Darren R Mansfield
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Glen Burgess
- Department of Ear, Nose and Throat, Monash Health, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew Hays
- Department of Ear, Nose and Throat, Monash Health, Melbourne, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Christopher Andara
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria
| | - Caroline J Beatty
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
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Magalang UJ, Grant BJB. Understanding stability of obstructive sleep apnea endotypes: a step forward. Sleep 2022; 45:6648763. [DOI: 10.1093/sleep/zsac174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ulysses J Magalang
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Brydon J B Grant
- Division of Pulmonary, Critical Care, and Sleep Medicine and Department of Epidemiology and Environmental Health, University at Buffalo , Buffalo, NY , USA
- Public Health Graduate Studies, Baha’i Institute for Higher Education , Iran
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The Association between Idiopathic Pulmonary Fibrosis and Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11175008. [PMID: 36078938 PMCID: PMC9457448 DOI: 10.3390/jcm11175008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/25/2022] Open
Abstract
The prevalence of obstructive sleep apnea (OSA) has greatly increased in recent years. Recent data suggest that severe and moderate forms of OSA affect between 6 and 17% of adults in the general population. Many papers are reporting the significantly increased prevalence of OSA in patients suffering from fibrotic diseases, including idiopathic pulmonary fibrosis (IPF). Therefore, we performed a systematic review and meta-analysis regarding the dependency between IPF and OSA. Due to the lack of papers focusing on IPF among OSA patients, we focused on the prevalence of OSA among IPF patients. In the search strategy, a total of 684 abstracts were identified, 496 after the removal of duplicates. After the screening of titles and abstracts, 31 studies were qualified for further full-text analysis for eligibility criteria. The final analysis was performed on 614 IPF patients from 18 studies, which met inclusion criteria. There were 469 (76.38%) IPF patients with OSA and 145 (23.62%) without. The mean age varied from 60.9 ± 8.1 up to 70.3 ± 7.9. The obtained prevalence was 76.4 (95% CI: 72.9–79.7) and 75.7 (95% CI: 70.1–80.9) for fixed and random effects, respectively. The median prevalence of OSA among non-IPF patients for all the ethnics groups included in this study was 16,4% (IQR: 3.4%–26.8%). The study provides strong evidence for the increased prevalence of OSA in IPF patients when comparing with the general OSA prevalence.
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The Role of Inflammation, Hypoxia, and Opioid Receptor Expression in Pain Modulation in Patients Suffering from Obstructive Sleep Apnea. Int J Mol Sci 2022; 23:ijms23169080. [PMID: 36012341 PMCID: PMC9409023 DOI: 10.3390/ijms23169080] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 12/18/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a relatively common disease in the general population. Besides its interaction with many comorbidities, it can also interact with potentially painful conditions and modulate its course. The association between OSA and pain modulation has recently been a topic of concern for many scientists. The mechanism underlying OSA-related pain connection has been linked with different pathophysiological changes in OSA and various pain mechanisms. Furthermore, it may cause both chronic and acute pain aggravation as well as potentially influencing the antinociceptive mechanism. Characteristic changes in OSA such as nocturnal hypoxemia, sleep fragmentation, and systemic inflammation are considered to have a curtailing impact on pain perception. Hypoxemia in OSA has been proven to have a significant impact on increased expression of proinflammatory cytokines influencing the hyperalgesic priming of nociceptors. Moreover, hypoxia markers by themselves are hypothesized to modulate intracellular signal transduction in neurons and have an impact on nociceptive sensitization. Pain management in patients with OSA may create problems arousing from alterations in neuropeptide systems and overexpression of opioid receptors in hypoxia conditions, leading to intensification of side effects, e.g., respiratory depression and increased opioid sensitivity for analgesic effects. In this paper, we summarize the current knowledge regarding pain and pain treatment in OSA with a focus on molecular mechanisms leading to nociceptive modulation.
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Thomson LDJ, Landry SA, Joosten SA, Mann D, Wong A, Cheung T, Adam M, Beatty C, Hamilton GS, Edwards BA. A single dose of noradrenergic/serotonergic reuptake inhibitors combined with an antimuscarinic does not improve obstructive sleep apnoea severity. Physiol Rep 2022; 10:e15440. [PMID: 36029192 PMCID: PMC9419156 DOI: 10.14814/phy2.15440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023] Open
Abstract
Previous trials have demonstrated that the combination of noradrenergic reuptake inhibitors with an antimuscarinic can substantially reduce the apnoea-hypopnoea index (AHI) and improve airway collapsibility in patients with obstructive sleep apnoea (OSA). However, some studies have shown that when administered individually, neither noradrenergic or serotonergic agents have been effective at alleviating OSA. This raises the possibility that serotonergic agents (like noradrenergic agents) may also need to be delivered in combination to be efficacious. Therefore, we investigated the effect of an antimuscarinic (oxybutynin) on OSA severity when administered with either duloxetine or milnacipran, two dual noradrenergic/serotonergic reuptake inhibiters. A randomized, double-blind, 4 way cross-over, placebo-controlled trial in ten OSA patients was performed. Patients received each drug condition separately across four overnight in-lab polysomnography (PSG) studies ~1-week apart. The primary outcome measure was the AHI. In addition, the four key OSA endotypes (collapsibility, muscle compensation, arousal threshold, loop gain) were measured non-invasively from the PSGs using validated techniques. There was no significant effect of either drug combinations on reducing the total AHI or improving any of the key OSA endotypes. However, duloxetine+oxybutynin did significantly increase the fraction of hypopnoeas to apnoeas (FHypopnoea ) compared to placebo (p = 0.02; d = 0.54). In addition, duloxetine+oxybutynin reduced time in REM sleep (p = 0.009; d = 1.03) which was positively associated with a reduction in the total AHI (R2 = 0.62; p = 0.02). Neither drug combination significantly improved OSA severity or modified the key OSA endotypes when administered as a single dose to unselected OSA patients.
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Affiliation(s)
- Luke D. J. Thomson
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Shane A. Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Simon A. Joosten
- School of Clinical SciencesMonash UniversityMelbourneVictoriaAustralia
- Monash Lung, Sleep, Allergy and ImmunologyMonash HealthMelbourneVictoriaAustralia
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Dwayne L. Mann
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- School of Information Technology and Electrical EngineeringThe University of QueenslandBrisbaneQueenslandAustralia
| | - Ai‐Ming Wong
- Monash Lung, Sleep, Allergy and ImmunologyMonash HealthMelbourneVictoriaAustralia
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Tim Cheung
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Mulki Adam
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
| | - Caroline J. Beatty
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Garun S. Hamilton
- School of Clinical SciencesMonash UniversityMelbourneVictoriaAustralia
- Monash Lung, Sleep, Allergy and ImmunologyMonash HealthMelbourneVictoriaAustralia
- Monash Partners – EpworthMelbourneVictoriaAustralia
| | - Bradley A. Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
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Gell LK, Vena D, Alex RM, Azarbarzin A, Calianese N, Hess LB, Taranto-Montemurro L, White DP, Wellman A, Sands SA. Neural ventilatory drive decline as a predominant mechanism of obstructive sleep apnoea events. Thorax 2022; 77:707-716. [PMID: 35064045 PMCID: PMC10039972 DOI: 10.1136/thoraxjnl-2021-217756] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/18/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In the classic model of obstructive sleep apnoea (OSA), respiratory events occur with sleep-related dilator muscle hypotonia, precipitating increased neural ventilatory 'drive'. By contrast, a drive-dependent model has been proposed, whereby falling drive promotes dilator muscle hypotonia to precipitate respiratory events. Here we determine the extent to which the classic versus drive-dependent models of OSA are best supported by direct physiological measurements. METHODS In 50 OSA patients (5-91 events/hour), we recorded ventilation ('flow', oronasal mask and pneumotach) and ventilatory drive (calibrated intraoesophageal diaphragm electromyography, EMG) overnight. Flow and drive during events were ensemble averaged; patients were classified as drive dependent if flow fell/rose simultaneously with drive. Overnight effects of lower drive on flow, genioglossus muscle activity (EMGgg) and event risk were quantified (mixed models). RESULTS On average, ventilatory drive fell (rather than rose) during events (-20 (-42 to 3)%baseline, median (IQR)) and was strongly correlated with flow (R=0.78 (0.24 to 0.94)). Most patients (30/50, 60%) were classified as exhibiting drive-dependent event pathophysiology. Lower drive during sleep was associated with lower flow (-17 (-20 to -14)%/drive) and EMGgg (-3.5 (-3.8 to -3.3)%max/drive) and greater event risk (OR: 2.2 (1.8 to 2.5) per drive reduction of 100%eupnoea); associations were concentrated in patients with drive-dependent OSA (ie, flow: -37 (-40 to -34)%/drive, OR: 6.8 (5.3 to 8.7)). Oesophageal pressure-without tidal volume correction-falsely suggested rising drive during events (classic model). CONCLUSIONS In contrast to the prevailing view, patients with OSA predominantly exhibit drive-dependent event pathophysiology, whereby flow is lowest at nadir drive, and lower drive raises event risk. Preventing ventilatory drive decline is therefore considered a target for OSA intervention.
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Affiliation(s)
- Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Raichel M Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Uygun DS, Basheer R. Circuits and components of delta wave regulation. Brain Res Bull 2022; 188:223-232. [PMID: 35738502 DOI: 10.1016/j.brainresbull.2022.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/07/2022] [Accepted: 06/14/2022] [Indexed: 11/02/2022]
Abstract
Sleep is vital and the deepest stages of sleep occur within Non-rapid-eye-movement sleep (NREM), defined by high electroencephalographic power in the delta (~0.5-4Hz) wave frequency range. Delta waves are thought to facilitate a myriad of physical and mental health functions. This review aims to comprehensively cover the historical and recent advances in the understanding of the mechanisms orchestrating NREM delta waves. We discuss a complete neurocircuit - focusing on one leg of the circuit at a time - and delve deeply into the molecular mechanistic components that contribute to NREM delta wave regulation. We also discuss the relatively localized nature in which these mechanisms have been defined, and how likely they might generalize across distinct sensory and higher order modalities in the brain.
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Affiliation(s)
- David S Uygun
- VA Boston Healthcare System and Harvard Medical School, Dept. of Psychiatry, West Roxbury, MA; 02132.
| | - Radhika Basheer
- VA Boston Healthcare System and Harvard Medical School, Dept. of Psychiatry, West Roxbury, MA; 02132.
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50
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Vena D, Taranto-Montemurro L, Azarbarzin A, Op de Beeck S, Marques M, Vanderveken OM, Edwards BA, Gell L, Calianese N, Hess LB, Radmand R, Hamilton GS, Joosten SA, Verbraecken J, Braem M, White DP, Redline S, Sands SA, Wellman A. Clinical polysomnographic methods for estimating pharyngeal collapsibility in obstructive sleep apnea. Sleep 2022; 45:zsac050. [PMID: 35238379 PMCID: PMC9189952 DOI: 10.1093/sleep/zsac050] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea has major health consequences but is challenging to treat. For many therapies, efficacy is determined by the severity of underlying pharyngeal collapsibility, yet there is no accepted clinical means to measure it. Here, we provide insight into which polysomnographic surrogate measures of collapsibility are valid, applicable across the population, and predictive of therapeutic outcomes. METHODS Seven promising polysomnography-derived surrogate collapsibility candidates were evaluated: Vpassive (flow at eupneic ventilatory drive), Vmin (ventilation at nadir drive), event depth (depth of the average respiratory event), oxygen desaturation slope and mean oxygen desaturation (events-related averages), Fhypopneas (fraction of events scored as hypopneas), and apnea index. Evaluation included (1) validation by comparison to physiological gold-standard collapsibility values (critical closing pressure, Pcrit), (2) capacity to detect increased collapsibility with older age, male sex, and obesity in a large community-based cohort (Multi-Ethnic Study of Atherosclerosis, MESA), and (3) prediction of treatment efficacy (oral appliances and pharmacological pharyngeal muscle stimulation using atomoxetine-plus-oxybutynin). RESULTS Pcrit was significantly correlated with Vmin (r = -0.54), event depth (r = 0.49), Vpassive (r = -0.38), Fhypopneas (r = -0.46), and apnea index (r = -0.46; all p < .01) but not others. All measures detected greater collapsibility with male sex, age, and obesity, except Fhypopneas and apnea index which were not associated with obesity. Fhypopneas and apnea index were associated with oral appliance and atomoxetine-plus-oxybutynin efficacy (both p < .05). CONCLUSIONS Among several candidates, event depth, Fhypopneas, and apnea index were identified as preferred pharyngeal collapsibility surrogates for use in the clinical arena.
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Affiliation(s)
- Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Laboratório do sono, Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Laura Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Radmand
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Johan Verbraecken
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Marc Braem
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Division of Special Care Dentistry, Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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