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Javaheri S, Randerath WJ, Badr MS, Javaheri S. Medication-Induced Central Sleep Apnea: A Unifying Concept. Sleep 2024:zsae038. [PMID: 38334297 DOI: 10.1093/sleep/zsae038] [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: 12/06/2023] [Indexed: 02/10/2024] Open
Abstract
Medication-induced central sleep apnea (CSA) is one of the 8 categories of causes of CSA but in the absence of awareness and careful history may be misclassified as primary CSA. While opioids are a well-known cause of respiratory depression and CSA, non-opioids medications including sodium oxybate, baclofen, valproic acid, gabapentin and ticagrelor are less well-recognized. Opioids-induced respiratory depression and CSA are mediated primarily by µ-opioid receptors, which are abundant in the pontomedullary centers involved in breathing. The non-opioid medications, sodium oxybate, baclofen, valproic acid and gabapentin, act upon brainstem gamma-aminobutyric acid (GABA) receptors, which co-colonize with µ-opioid receptors and mediate CSA. The pattern of ataxic breathing associated with these medications is like that induced by opioids on polysomnogram. Finally, ticagrelor also causes periodic breathing and CSA by increasing central chemosensitivity and ventilatory response to carbon dioxide. Given the potential consequences of CSA and the association between some of these medications with mortality, it is critical to recognize these adverse drug reactions, particularly because discontinuation of the offending agents has been shown to eliminate CSA.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, Adjunct Professor of Medicine, Division of Cardiology, The Ohio State University, Columbus, Ohio, and Emeritus Professor of Medicine, Division of Pulmonary and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio , USA
| | - W J Randerath
- Professor and Head Physician, Institute of Pneumology, University of Cologne, Bethanien Hospital, Solingen, Germany, USA
| | - M Safwan Badr
- Professor and Chair, Department of Internal Medicine, Wayne State University School of Medicine Detroit, Staff Physician, John D. Dingell VA Medical Center, MI, USA
| | - Sogol Javaheri
- Assistant Professor of Sleep Medicine, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Javaheri S, Badr MS. Central sleep apnea: pathophysiologic classification. Sleep 2023; 46:6584630. [PMID: 35551411 PMCID: PMC9995798 DOI: 10.1093/sleep/zsac113] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Central sleep apnea is not a single disorder; it can present as an isolated disorder or as a part of other clinical syndromes. In some conditions, such as heart failure, central apneic events are due to transient inhibition of ventilatory motor output during sleep, owing to the overlapping influences of sleep and hypocapnia. Specifically, the sleep state is associated with removal of wakefulness drive to breathe; thus, rendering ventilatory motor output dependent on the metabolic ventilatory control system, principally PaCO2. Accordingly, central apnea occurs when PaCO2 is reduced below the "apneic threshold". Our understanding of the pathophysiology of central sleep apnea has evolved appreciably over the past decade; accordingly, in disorders such as heart failure, central apnea is viewed as a form of breathing instability, manifesting as recurrent cycles of apnea/hypopnea, alternating with hyperpnea. In other words, ventilatory control operates as a negative-feedback closed-loop system to maintain homeostasis of blood gas tensions within a relatively narrow physiologic range, principally PaCO2. Therefore, many authors have adopted the engineering concept of "loop gain" (LG) as a measure of ventilatory instability and susceptibility to central apnea. Increased LG promotes breathing instabilities in a number of medical disorders. In some other conditions, such as with use of opioids, central apnea occurs due to inhibition of rhythm generation within the brainstem. This review will address the pathogenesis, pathophysiologic classification, and the multitude of clinical conditions that are associated with central apnea, and highlight areas of uncertainty.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, USA.,Division of Pulmonary Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Cardiology, Department of Medicine, Ohio State University, Columbus, OH, USA
| | - M Safwan Badr
- Department of Internal Medicine, Liborio Tranchida, MD, Endowed Professor of Medicine, Wayne State University School of Medicine, University Health Center, Detroit, MI, USA
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Rosen CL. Sleep-Disordered Breathing (SDB) in Pediatric Populations. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Revol B, Jullian-Desayes I, Guichard K, Micoulaud-Franchi JA, Tamisier R, Philip P, Joyeux-Faure M, Pépin JL. Valproic acid and sleep apnoea: A disproportionality signal from the WHO pharmacovigilance database. Respirology 2020; 25:336-338. [PMID: 32000295 DOI: 10.1111/resp.13771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/18/2019] [Accepted: 12/10/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Bruno Revol
- HP2 Inserm U1042, Université Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, CHU Grenoble Alpes, Grenoble, France.,Centre Régional de Pharmacovigilance, CHU Grenoble Alpes, Grenoble, France
| | - Ingrid Jullian-Desayes
- HP2 Inserm U1042, Université Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, CHU Grenoble Alpes, Grenoble, France
| | - Kelly Guichard
- Clinique du Sommeil, CHU de Bordeaux, Bordeaux, France.,SANPSY, Université de Bordeaux, Bordeaux, France.,SANPSY USR 3413, CNRS, Bordeaux, France
| | - Jean-Arthur Micoulaud-Franchi
- Clinique du Sommeil, CHU de Bordeaux, Bordeaux, France.,SANPSY, Université de Bordeaux, Bordeaux, France.,SANPSY USR 3413, CNRS, Bordeaux, France
| | - Renaud Tamisier
- HP2 Inserm U1042, Université Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, CHU Grenoble Alpes, Grenoble, France
| | - Pierre Philip
- Clinique du Sommeil, CHU de Bordeaux, Bordeaux, France.,SANPSY, Université de Bordeaux, Bordeaux, France.,SANPSY USR 3413, CNRS, Bordeaux, France
| | - Marie Joyeux-Faure
- HP2 Inserm U1042, Université Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Louis Pépin
- HP2 Inserm U1042, Université Grenoble Alpes, Grenoble, France.,Laboratoire EFCR, CHU Grenoble Alpes, Grenoble, France
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