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Read N, Jennings C, Hare A. Obstructive sleep apnoea-hypopnoea syndrome. Emerg Top Life Sci 2023; 7:467-476. [PMID: 38130167 DOI: 10.1042/etls20180939] [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: 05/31/2023] [Revised: 10/25/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023]
Abstract
Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a common disorder characterised by repetitive episodes of the complete or partial collapse of the pharyngeal airway during sleep. This results in cessation (apnoea) or reduction (hypopnoea) of airflow, leading to oxygen desaturation and sleep fragmentation. An individual's disposition to develop OSAHS depends on the collapsibility of a segment of the upper airway. The degree of collapsibility can be quantified by the balance between occluding or extraluminal pressures of the surrounding tissues. Patients can experience snoring, unrefreshing sleep, witnessed apnoeas, waking with a choking sensation and excessive daytime sleepiness. OSAHS has a broad range of consequences, including cardiovascular, metabolic, and neurocognitive sequelae. Treatment options include lifestyle measures, in particular weight loss, and strategies to maintain upper airway patency overnight, including continuous positive airway pressure, mandibular advancement devices and positional modifiers.
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Affiliation(s)
- Nicola Read
- Royal Brompton Hospital, Kings Health Partnership, London, U.K
| | - Callum Jennings
- Royal Brompton Hospital, Kings Health Partnership, London, U.K
| | - Alanna Hare
- Royal Brompton Hospital, Kings Health Partnership, London, U.K
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2
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Gałgańska H, Jarmuszkiewicz W, Gałgański Ł. Carbon dioxide and MAPK signalling: towards therapy for inflammation. Cell Commun Signal 2023; 21:280. [PMID: 37817178 PMCID: PMC10566067 DOI: 10.1186/s12964-023-01306-x] [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: 06/13/2023] [Accepted: 09/05/2023] [Indexed: 10/12/2023] Open
Abstract
Inflammation, although necessary to fight infections, becomes a threat when it exceeds the capability of the immune system to control it. In addition, inflammation is a cause and/or symptom of many different disorders, including metabolic, neurodegenerative, autoimmune and cardiovascular diseases. Comorbidities and advanced age are typical predictors of more severe cases of seasonal viral infection, with COVID-19 a clear example. The primary importance of mitogen-activated protein kinases (MAPKs) in the course of COVID-19 is evident in the mechanisms by which cells are infected with SARS-CoV-2; the cytokine storm that profoundly worsens a patient's condition; the pathogenesis of diseases, such as diabetes, obesity, and hypertension, that contribute to a worsened prognosis; and post-COVID-19 complications, such as brain fog and thrombosis. An increasing number of reports have revealed that MAPKs are regulated by carbon dioxide (CO2); hence, we reviewed the literature to identify associations between CO2 and MAPKs and possible therapeutic benefits resulting from the elevation of CO2 levels. CO2 regulates key processes leading to and resulting from inflammation, and the therapeutic effects of CO2 (or bicarbonate, HCO3-) have been documented in all of the abovementioned comorbidities and complications of COVID-19 in which MAPKs play roles. The overlapping MAPK and CO2 signalling pathways in the contexts of allergy, apoptosis and cell survival, pulmonary oedema (alveolar fluid resorption), and mechanical ventilation-induced responses in lungs and related to mitochondria are also discussed. Video Abstract.
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Affiliation(s)
- Hanna Gałgańska
- Faculty of Biology, Molecular Biology Techniques Laboratory, Adam Mickiewicz University in Poznan, Uniwersytetu Poznanskiego 6, 61-614, Poznan, Poland
| | - Wieslawa Jarmuszkiewicz
- Faculty of Biology, Department of Bioenergetics, Adam Mickiewicz University in Poznan, Institute of Molecular Biology and Biotechnology, Uniwersytetu Poznanskiego 6, 61-614, Poznan, Poland
| | - Łukasz Gałgański
- Faculty of Biology, Department of Bioenergetics, Adam Mickiewicz University in Poznan, Institute of Molecular Biology and Biotechnology, Uniwersytetu Poznanskiego 6, 61-614, Poznan, Poland.
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Vijayakrishnan Nair V, Kish BR, Chong PL, Yang HCS, Wu YC, Tong Y, Schwichtenberg AJ. Neurofluid coupling during sleep and wake states. Sleep Med 2023; 110:44-53. [PMID: 37536211 PMCID: PMC11022242 DOI: 10.1016/j.sleep.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND In clinical populations, the movement of cerebrospinal fluid (CSF) during sleep is a growing area of research with potential mechanistic connections in both neurodegenerative (e.g., Alzheimer's Disease) and neurodevelopmental disorders. However, we know relatively little about the processes that influence CSF movement. To inform clinical intervention targets this study assesses the coupling between (a) real-time CSF movement, (b) neuronal-driven movement, and (c) non-neuronal systemic physiology driven movement. METHODS This study included eight young, healthy volunteers, with concurrently acquired neurofluid dynamics using functional Magnetic Resonance Imaging (MRI), neural activity using Electroencephalography (EEG), and non-neuronal systemic physiology with peripheral functional Near-Infrared Spectroscopy (fNIRS). Neuronal and non-neuronal drivers were assessed temporally; wherein, EEG measured slow wave activity that preceded CSF movement was considered neuronally driven. Similarly, slow wave oscillations (assessed via fNIRS) that coupled with CSF movement were considered non-neuronal systemic physiology driven. RESULTS AND CONCLUSIONS Our results document neural contributions to CSF movement were only present during light NREM sleep but low-frequency non-neuronal oscillations were strongly coupled with CSF movement in all assessed states - awake, NREM-1, NREM-2. The clinical/research implications of these findings are two-fold. First, neuronal-driven oscillations contribute to CSF movement outside of deep sleep (NREM-3); therefore, interventions aimed at increasing CSF movement may yield meaningful increases with the promotion of NREM sleep more generally - a focus on NREM S3 may not be needed. Second, non-neuronal systemic oscillations contribute across wake and sleep stages; therefore, interventions may increase CSF movement by manipulating systemic physiology.
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Affiliation(s)
| | - Brianna R Kish
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Pearlynne Lh Chong
- Department of Human Development and Family Science, College of Health and Human Sciences, Purdue University, West Lafayette, IN, 47907, USA
| | - Ho-Ching Shawn Yang
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Yu-Chien Wu
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, 46202, USA; Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Yunjie Tong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA.
| | - A J Schwichtenberg
- Department of Human Development and Family Science, College of Health and Human Sciences, Purdue University, West Lafayette, IN, 47907, USA.
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Alzaabi Y, Khandoker AH. Effect of depression on phase coherence between respiratory sinus arrhythmia and respiration during sleep in patients with obstructive sleep apnea. Front Physiol 2023; 14:1181750. [PMID: 37841315 PMCID: PMC10572546 DOI: 10.3389/fphys.2023.1181750] [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: 03/07/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction: A high prevalence of major depressive disorder (MDD) among Obstructive Sleep Apnea (OSA) patients has been observed in both community and clinical populations. Due to the overlapping symptoms between both disorders, depression is usually misdiagnosed when correlated with OSA. Phase coherence between respiratory sinus arrhythmia (RSA) and respiration (λ RSA-RESP) has been proposed as an alternative measure for assessing vagal activity. Therefore, this study aims to investigate if there is any difference in λ RSA-RESP in OSA patients with and without MDD. Methods: Electrocardiograms (ECG) and breathing signals using overnight polysomnography were collected from 40 OSA subjects with MDD (OSAD+), 40 OSA subjects without MDD (OSAD-), and 38 control subjects (Controls) without MDD and OSA. The interbeat intervals (RRI) and respiratory movement were extracted from 5-min segments of ECG signals with a single apneic event during non-rapid eye movement (NREM) [353 segments] and rapid eye movement (REM) sleep stages [298 segments]. RR intervals (RRI) and respiration were resampled at 10 Hz, and the band passed filtered (0.10-0.4 Hz) before the Hilbert transform was used to extract instantaneous phases of the RSA and respiration. Subsequently, the λ RSA-RESP between RSA and Respiration and Heart Rate Variability (HRV) features were computed. Results: Our results showed that λ RSA-RESP was significantly increased in the OSAD+ group compared to OSAD- group during NREM and REM sleep. This increase was accompanied by a decrease in the low frequency (LF) component of HRV. Discussion: We report that the phase synchronization index between RSA and respiratory movement could provide a useful measure for evaluating depression in OSA patients. Our findings suggest that depression has lowered sympathetic activity when accompanied by OSA, allowing for stronger synchronization between RSA and respiration.
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Affiliation(s)
- Yahya Alzaabi
- Healthcare Engineering Innovation Center (HEIC), Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
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Osman A, Gu C, Kim DE, Duan D, Barron B, Pham LV, Polotsky VY, Jun JC. Ketogenic diet acutely improves gas exchange and sleep apnoea in obesity hypoventilation syndrome: A non-randomized crossover study. Respirology 2023; 28:784-793. [PMID: 37246156 DOI: 10.1111/resp.14526] [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: 01/08/2023] [Accepted: 05/17/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Obesity hypoventilation syndrome (OHS) causes hypercapnia which is often refractory to current therapies. We examine whether hypercapnia in OHS can be improved by a ketogenic dietary intervention. METHODS We conducted a single-arm crossover clinical trial to examine the impact of a ketogenic diet on CO2 levels in patients with OHS. Patients were instructed to adhere to 1 week of regular diet, 2 weeks of ketogenic diet, followed by 1 week of regular diet in an ambulatory setting. Adherence was assessed with capillary ketone levels and continuous glucose monitors. At weekly visits, we measured blood gases, calorimetry, body composition, metabolic profiles, and sleep studies. Outcomes were assessed with linear mixed models. RESULTS A total of 20 subjects completed the study. Blood ketones increased from 0.14 ± 0.08 during regular diet to 1.99 ± 1.11 mmol/L (p < 0.001) after 2 weeks of ketogenic diet. Ketogenic diet decreased venous CO2 by 3.0 mm Hg (p = 0.008), bicarbonate by 1.8 mmol/L (p = 0.001), and weight by 3.4 kg (p < 0.001). Sleep apnoea severity and nocturnal oxygen levels significantly improved. Ketogenic diet lowered respiratory quotient, fat mass, body water, glucose, insulin, triglycerides, leptin, and insulin-like growth factor 1. Rebound hypercapnia was observed after resuming regular diet. CO2 lowering was dependent on baseline hypercapnia, and associated with circulating ketone levels and respiratory quotient. The ketogenic diet was well tolerated. CONCLUSION This study demonstrates for the first time that a ketogenic diet may be useful for control of hypercapnia and sleep apnoea in patients with obesity hypoventilation syndrome.
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Affiliation(s)
- Adam Osman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chenjuan Gu
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - David E Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daisy Duan
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bobbie Barron
- Institute for Clinical and Translational Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Luu V Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan C Jun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Bird JD, Sands SA, Alex RM, Shing CLH, Shafer BM, Jendzjowsky NG, Wilson RJA, Day TA, Foster GE. Sex-related Differences in Loop Gain during High-Altitude Sleep-disordered Breathing. Ann Am Thorac Soc 2023; 20:1192-1200. [PMID: 37000675 PMCID: PMC10405604 DOI: 10.1513/annalsats.202211-918oc] [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: 11/07/2022] [Accepted: 03/31/2023] [Indexed: 04/01/2023] Open
Abstract
Rationale: Central sleep apnea (CSA) is pervasive during sleep at high altitude, disproportionately impacting men and associated with increased peripheral chemosensitivity. Objectives: We aimed to assess whether biological sex affects loop gain (LGn) and CSA severity during sleep over 9-10 days of acclimatization to 3,800 m. We hypothesized that CSA severity would worsen with acclimatization in men but not in women because of greater increases in LGn in men. Methods: Sleep studies were collected from 20 (12 male) healthy participants at low altitude (1,130 m, baseline) and after ascent to (nights 2/3, acute) and residence at high altitude (nights 9/10, prolonged). CSA severity was quantified as the respiratory event index (REI) as a surrogate of the apnea-hypopnea index. LGn, a measure of ventilatory control instability, was quantified using a ventilatory control model fit to nasal flow. Linear mixed models evaluated effects of time at altitude and sex on respiratory event index and LGn. Data are presented as contrast means with 95% confidence intervals. Results: REI was comparable between men and women at acute altitude (4.1 [-9.3, 17.5] events/h; P = 0.54) but significantly greater in men at prolonged altitude (23.7 [10.3, 37.1] events/h; P = 0.0008). Men had greater LGn than did women for acute (0.08 [0.001, 0.15]; P = 0.047) and prolonged (0.17 [0.10, 0.25]; P < 0.0001) altitude. The change in REI per change in LGn was significantly greater in men than in women (107 ± 46 events/h/LGn; P = 0.02). Conclusions: The LGn response to high altitude differed between sexes and contributed to worsening of CSA over time in men but not in women. This sex difference in acclimatization appears to protect females from high altitude-related CSA. These data provide fundamental sex-specific physiological insight into high-altitude acclimatization in healthy individuals and may help to inform sex differences in sleep-disordered breathing pathogenesis in patients with cardiorespiratory disease.
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Affiliation(s)
- Jordan D. Bird
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Scott A. Sands
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raichel M. Alex
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Conan L. H. Shing
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Brooke M. Shafer
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Nicholas G. Jendzjowsky
- Respiratory Medicine and Exercise Physiology, The Lundquist Institute for Biomedical Innovation, Harbor University of California Los Angeles Medical Center, West Carson, California; and
| | - Richard J. A. Wilson
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute and Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Trevor A. Day
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Glen E. Foster
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
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Perger E, Bertoli S, Lombardi C. Pharmacotherapy for obstructive sleep apnea: targeting specific pathophysiological traits. Expert Rev Respir Med 2023; 17:663-673. [PMID: 37646222 DOI: 10.1080/17476348.2023.2241353] [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: 02/16/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The pathophysiology of obstructive sleep apnea (OSA) is multi-factorial and complex. Varying OSA's pathophysiological traits have been identified, including pharyngeal collapsibility, upper airway muscle reactivity, arousal threshold, and regulation of the ventilatory drive. Being CPAP of difficult tolerance and other interventions reserved to specific subpopulations new pharmacological treatments for OSA might be resolutive. AREAS COVERED Several existing and newly developed pharmacological drugs can impact one or more endotypes and could therefore be proposed as treatment options for sleep disordered breathing. With this review we will explore different pathophysiological traits as new targets for OSA therapy. This review will summarize the most promising pharmacological treatment for OSA accordingly with their mechanisms of action on upper airway collapsibility, muscle responsiveness, arousal threshold, and loop gain. EXPERT OPINION Only understanding the pathophysiological traits causing OSA in each patient and placing the disease in the framework of patient comorbidities, we will be able to evolve interventions toward OSA. The development of new drug's combinations will permit different approaches and different choices beside conventional treatments. In the next future, we hope that sleep specialists will select the treatment for a specific patient on the base of its pathophysiology, defining a precision medicine for OSA.
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Affiliation(s)
- Elisa Perger
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Simona Bertoli
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
- Lab of Nutrition and Obesity Research, Istituto Auxologico Italiano, IRCCS, Milan, Carolina
| | - Carolina Lombardi
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
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Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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Doufas AG, Tian L, Kutscher S, Finnsson E, Ágústsson JS, Chung BI, Panousis P. The effect of hyperoxia on ventilation during recovery from general anesthesia: A randomized pilot study for a parallel randomized controlled trial. J Clin Anesth 2022; 83:110982. [PMID: 36265267 DOI: 10.1016/j.jclinane.2022.110982] [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: 07/26/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE While supplemental O2 inhalation corrects hypoxemia, its effect on post-anesthesia ventilation remains unknown. This pilot trial tested the hypothesis that hyperoxia increases the time spent with a transcutaneous PCO2 (TcPCO2) > 45 mmHg, compared with standard O2 supplementation. DESIGN Single-blinded, parallel two-arm randomized pilot trial. SETTING University hospital. PATIENTS 20 patients undergoing robotic-assisted laparoscopic nephrectomy. MEASUREMENTS After institutional approval and informed consent, patients were randomized to receive O2 titrated to arterial saturation (SpO2): 90-94% (Conservative O2, N =10), or to SpO2 > 96% (Liberal O2, N = 10) for up to 90 min after anesthesia. Continuous TcPCO2, respiratory inductance plethysmography (RIP), and SpO2, were recorded. We calculated the percentage of time at TcPCO2 > 45 mmHg for each patient and compared the two groups using analysis of covariance, adjusting for sex, age, and body mass index. We also estimated the sample size required to detect the between-group difference observed in this pilot trial. RIP signals were used to calculate apnea/hypopnea index (AHI), which was then compared between two groups. MAIN RESULTS The mean percentage of time with a TcPCO2 > 45 mmHg was 80.6% for the Conservative O2 (N=9) and 61.2% for the Liberal O2 (N=10) group [between-group difference of 19.4% (95% CI: -18.7% to 57.6%), P = 0.140]. With an observed effect size of 0.73, we estimated that 30 participants per group are required, to demonstrate this difference with a power of 80% at a two-sided alpha of 5%. Means SpO2 were 94.5% and 99.9% for the Conservative O2 and the Liberal O2 groups, respectively. AHI was significantly higher in the Conservative O2, compared with the Liberal O2 group (median AHI: 16 vs. 3; P = 0.0014). CONCLUSIONS Hyperoxia in the post-anesthesia period reduced the time spent at TcPCO2 > 45 mmHg and significantly decreased AHI, while mean SpO2 ranged inside the a priori defined limits. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04723433.
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Affiliation(s)
- Anthony G Doufas
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States of America; Center for Sleep and Circadian Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Scott Kutscher
- Department of Psychiatry and Behavioral Sciences, and Center for Sleep Sciences and Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | | | | | - Benjamin I Chung
- Department of Urology, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Periklis Panousis
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
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Musselwhite MN, Shen TY, Rose MJ, Iceman KE, Poliacek I, Pitts T, Bolser DC. THE INFLUENCE OF CO 2 ON SPATIOTEMPORAL FEATURES OF MECHANICALLY INDUCED COUGH IN ANESTHETIZED CATS. Respir Physiol Neurobiol 2022; 307:103964. [PMID: 36174962 DOI: 10.1016/j.resp.2022.103964] [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: 12/08/2021] [Revised: 08/10/2022] [Accepted: 09/19/2022] [Indexed: 11/27/2022]
Abstract
Effective cough requires a significant increase in lung volume used to produce the shear forces on the airway to clear aspirated material. This increase in tidal volume during cough, along with an increase in tidal frequency during bouts of paroxysmal cough produces profound hyperventilation and thus reduces arterial CO2. While there are several reports in the literature regarding the effects of hypercapnia, hyperoxia, and hypoxia on cough, there is little research quantifying the effects of hypocapnia on the cough reflex. We hypothesized that decreased CO2 would enhance coughing. In 12 spontaneously breathing adult male cats, we compared bouts of prolonged mechanically stimulated cough, in which cough induced hyperventilation (CHV) was allowed to occur, with isocapnic cough trials where we maintained eupneic end-tidal CO2 by adding CO2 to the inspired gas. Isocapnia slightly increased cough number and decreased esophageal pressures with no change in EMG magnitudes or phase durations. The cough-to-eupnea transition was also analyzed between CHV, isocapnia, and a third group of animals that were mechanically hyperventilated to apnea. The transition to eupnea was highly sensitive to added CO2, and CHV apneas were much shorter than those produced by mechanical hyperventilation. We suggest that the cough pattern generator is relatively insensitive to CHV. In the immediate post-cough period, the appearance of breathing while CO2 is very low suggests a transient reduction in apneic threshold following a paroxysmal cough bout.
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Affiliation(s)
- M Nicholas Musselwhite
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida. 1333 Center Dr, Gainesville, Florida, 32603, United States of America.
| | - Tabitha Y Shen
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida. 1333 Center Dr, Gainesville, Florida, 32603, United States of America
| | - Melanie J Rose
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida. 1333 Center Dr, Gainesville, Florida, 32603, United States of America
| | - Kimberly E Iceman
- Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, College of Medicine, University of Louisville. 511 S Floyd St, MDR 616, Louisville, Kentucky, 40202, United States of America
| | - Ivan Poliacek
- Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Institute of Medical Biophysics. Malá hora 4A, 036 01 Martin-Záturčie, Slovakia
| | - Teresa Pitts
- Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, College of Medicine, University of Louisville. 511 S Floyd St, MDR 616, Louisville, Kentucky, 40202, United States of America.
| | - Donald C Bolser
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida. 1333 Center Dr, Gainesville, Florida, 32603, United States of America
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Hypoventilation and sleep hypercapnia in a case of congenital variant-like Rett syndrome. Ital J Pediatr 2022; 48:167. [PMID: 36071486 PMCID: PMC9450235 DOI: 10.1186/s13052-022-01359-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 08/30/2022] [Indexed: 11/18/2022] Open
Abstract
Background Breathing disturbances are often a primary clinical concern especially during wakefulness of the classic form of Rett syndrome, but data for atypical forms are lacking. Case presentation We report the case of a 20-month-old female affected by Rett syndrome with congenital variant-like onset, characterized by severe hypotonia and neurodevelopment impairment. She presented hypoventilation, persistent periodic breathing, and sustained desaturation during sleep, without obstructive or mixed events. Pulse oximetry and capnography during wakefulness were strictly normal. To the best of our knowledge, this is the first case of a patient affected by a congenital variant of Rett syndrome presenting sleep hypercapnia. Hypotonia may play a major role in the genesis of hypoventilation and hypoxemia in our patient. Non-invasive ventilation led to quality-of-life improvements. Conclusions Thus, we suggest screening patients with congenital-like Rett syndrome through transcutaneous bedtime carbon dioxide and oxygen monitoring. Moreover, assisted control mode was a breakthrough to achieve adequate ventilation in our case.
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Nokes B, Cooper J, Cao M. Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology. Expert Rev Respir Med 2022; 16:917-929. [PMID: 35949101 DOI: 10.1080/17476348.2022.2112669] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.
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Affiliation(s)
- Brandon Nokes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, USA.,Section of Sleep Medicine, Veterans Affairs (VA) San Diego Healthcare System, La Jolla, CA, USA
| | - Jessica Cooper
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Michelle Cao
- Division of Pulmonary, Allergy, Critical Care Medicine & Division of Sleep Medicine, Stanford University, Palo Alto, CA, USA
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13
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Heiniger G, Walbaum S, Sartori C, Lovis A, Sazzini M, Wellman A, Heinzer R. Altitude-Induced Sleep Apnea Is Highly Dependent on Ethnic Background (Sherpa Vs. Tamang). High Alt Med Biol 2022; 23:165-172. [PMID: 35708530 DOI: 10.1089/ham.2022.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Heiniger, Grégory, Simon Walbaum, Claudio Sartori, Alban Lovis, Marco Sazzini, Andrew Wellman, and Raphael Heinzer. Altitude-Induced Sleep Apnea Is Highly Dependent on Ethnic Background (Sherpa Vs. Tamang). High Alt Med Biol. 23:165-172, 2022. Rationale: High altitude-induced hypocapnic alkalosis generates central sleep apnea (CSA). In Nepal, two ethnic groups live at medium-to-high altitude: Tamangs originate from low-altitude Tibeto-Burman populations, whereas Sherpas descend from high-altitude Tibetans. Objective: To compare apnea severity at low and high altitude between Sherpas and Tamangs. Methods: Polygraphy recordings, including airflow and oxygen saturation, were performed in Nepal at "low" (2,030 m) and "high" (4,380 m) altitudes. Resting ventilation (V̇E) and mixed-exhaled CO2 (FECO2) were also measured at the same altitudes. Differences in apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and % of nocturnal periodic breathing (NPB) at the two altitudes were compared between ethnicities. Measurements and Main Results: Twenty Sherpas and 20 Tamangs were included (males, median [interquartile range] age: 24.5 [21.5-27.8] years vs. 26.0 [21.5-39.8] years, body mass index: 23.9 [22.1-26.1] kg/m2 vs. 25.21 [20.6-27.6] kg/m2). Compared with Tamangs, Sherpas showed a lower increase in AHI (+7.5 [2.6-17.2]/h vs. +31.5 [18.2-57.3]/h, p < 0.001), ODI (+13.8 [5.5-28.2]/h vs. +42.0 [22.6-77.6]/h, p < 0.001), and NPB proportion (+0.9 [0-3.5]% vs. +12.8 [3.1-27.4]%, p < 0.001) from low to high altitude. Resting V̇E was higher in Sherpas versus Tamangs at both low (8.45 [6.89-10.70] l/min vs. 6.3 [4.9-8.3] l/min, p = 0.005) and high (9.7 [8.5-11] l/min vs. 8.74 [7.39-9.73] l/min, p = 0.020) altitudes, whereas the mean ± standard deviation FECO2 decrease between low and high altitude was greater in Tamangs versus Sherpas (-0.50% ± 0.44% vs. -0.80% ± 0.33%, p < 0.023). Conclusion: Overall, altitude-adapted Sherpas showed a 3.2-times smaller increase in sleep-disordered breathing between low and high altitude compared with Tamangs, and higher ventilation and a smaller drop in FECO2 at high altitude. These data suggest that genetic differences in breathing control can be protective against CSA.
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Affiliation(s)
- Grégory Heiniger
- Center for Investigation and Research in Sleep, University Hospital of Lausanne, Lausanne, Switzerland
| | - Simon Walbaum
- Department of Internal Medicine and University Hospital of Lausanne, Lausanne, Switzerland
| | - Claudio Sartori
- Department of Internal Medicine and University Hospital of Lausanne, Lausanne, Switzerland
| | - Alban Lovis
- Department of Pulmonary, University Hospital of Lausanne, Lausanne, Switzerland
| | - Marco Sazzini
- Interdepartmental Centre Alma Mater Research Institute on Global Challenges and Climate Change, University of Bologna, Bologna, Italy.,Department of Biological, Geological and Environmental Sciences (BiGeA), Laboratory of Molecular Anthropology and Centre for Genome Biology, University of Bologna, Bologna, Italy
| | - Andrew Wellman
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Raphael Heinzer
- Center for Investigation and Research in Sleep, University Hospital of Lausanne, Lausanne, Switzerland
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14
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Hedner J, Stenlöf K, Zou D, Hoff E, Hansen C, Kuhn K, Lennartz P, Grote L. A Randomized Controlled Trial Exploring Safety and Tolerability of Sulthiame in Sleep Apnea. Am J Respir Crit Care Med 2022; 205:1461-1469. [PMID: 35202553 DOI: 10.1164/rccm.202109-2043oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONAL Current therapies in obstructive sleep apnea (OSA) are limited by insufficient efficacy, compliance or tolerability. An effective pharmacological treatment in OSA is warranted. Carbonic anhydrase (CA) inhibition has been shown to ameliorate OSA. OBJECTIVE To explore safety and tolerability of the CA inhibitor sulthiame (STM) in OSA. METHODS A four week double-blind, randomized, placebo-controlled dose guiding trial in patients with moderate/severe OSA not tolerating positive airway pressure treatment. MEASUREMENTS AND RESULTS Intermittent paresthesia was reported by 79, 67 and 18% of patients receiving 400 mg STM (N=34), 200 mg STM (N=12) or placebo (N=22), respectively. Dyspnea was reported only after 400 mg STM (18%). Six patients in the higher dose group withdrew due to an adverse event. There were no serious adverse events. STM reduced the apnea-hypopnea index (AHI) from 55.3 to 33.1 events/h ( 41.0%) in the 400 mg group and from 61.2 to 40.7 events/h ( 32.1%) after 200 mg (p<0.001, respectively). Corresponding placebo values were 53.9 and 50.9 events/h ( 5.4 %). The AHI reduction threshold of ≥50% was reached in 40% after 400 mg, 25% after 200 mg and 5% following placebo. Mean overnight oxygen saturation improved by 1.1% after 400 mg and 200 mg (p<0.001 and p=0.034, respectively). Patient related outcomes were unchanged. CONCLUSIONS STM showed a satisfactory safety profile in moderate/severe OSA. STM reduced OSA by more than 20 events/h, one of the strongest reductions reported in a drug trial in OSA. Larger scale clinical studies of STM in OSA are justified. Clinical trial registration available at https://www.clinicaltrialsregister.eu/https://www.clinicaltrialsregister.eu/, ID: 2017-004767-13.
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Affiliation(s)
- Jan Hedner
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden;
| | - Kaj Stenlöf
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden
| | - Ding Zou
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden
| | - Erik Hoff
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden
| | | | - Katrin Kuhn
- Desitin Arzneimittel GmbH, 60840, Hamburg, Germany
| | | | - Ludger Grote
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden.,Sahlgrenska University Hospital, 56749, Sleep Laboratory, Pulmonary Medicine, Goteborg, Sweden
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15
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Abstract
Central apnea syndrome is a disorder with protean manifestations and concomitant conditions. It can occur as a distinct clinical entity or as part of another clinical syndrome. The pathogenesis of central sleep apnea (CSA) varies depending on the clinical condition. Sleep-related withdrawal of the ventilatory drive to breathe is the common denominator among all cases of central apnea, whereas hypocapnia is the final common pathway leading to apnea in the majority of central apnea. Medical conditions most closely associated with CSA include heart failure, stroke, spinal cord injury, and opioid use, among others. Nocturnal polysomnography is the standard diagnostic method, including measurement of sleep and respiration. The latter includes detection of flow, measurement of oxyhemoglobin saturation and detection of respiratory effort. Management strategy incorporates clinical presentation, associated conditions, and the polysomnographic findings in an individualized manner. The pathophysiologic heterogeneity may explain the protean clinical manifestations and the lack of a single effective therapy for all patients. While research has enhanced our understanding of the pathogenesis of central apnea, treatment options are extrapolated from treatment of obstructive sleep apnea. Co-morbid conditions and concomitant obstructive sleep apnea influence therapeutic approach significantly. Therapeutic options include positive pressure therapy, pharmacologic therapy, and supplemental Oxygen. Continuous positive airway pressure (CPAP) is the initial standard of care, although the utility of other modes of positive pressure therapy, as well as pharmacotherapy and device-based therapies, are currently being investigated.
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Affiliation(s)
- Geoffrey Ginter
- Department of Internal Medicine, University Health Center and John D. Dingell VA Medical Center, Wayne State University School of Medicine, Detroit, MI, United States
| | - M Safwan Badr
- Department of Internal Medicine, University Health Center and John D. Dingell VA Medical Center, Wayne State University School of Medicine, Detroit, MI, United States.
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16
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Lévy P, Naughton MT, Tamisier R, Cowie MR, Bradley TD. Sleep Apnoea and Heart Failure. Eur Respir J 2021; 59:13993003.01640-2021. [PMID: 34949696 DOI: 10.1183/13993003.01640-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022]
Abstract
Heart Failure (HF) and Sleep-Disordered-Breathing (SDB) are two common conditions that frequently overlap and have been studied extensively in the past three decades. Obstructive Sleep Apnea (OSA) may result in myocardial damage, due to intermittent hypoxia increased sympathetic activity and transmural pressures, low-grade vascular inflammation and oxidative stress. On the other hand, central sleep apnoea and Cheyne-Stokes respiration (CSA-CSR) occurs in HF, irrespective of ejection fraction either reduced (HFrEF), preserved (HFpEF) or mildly reduced (HFmrEF). The pathophysiology of CSA-CSR relies on several mechanisms leading to hyperventilation, breathing cessation and periodic breathing. Pharyngeal collapse may result at least in part from fluid accumulation in the neck, owing to daytime fluid retention and overnight rostral fluid shift from the legs. Although both OSA and CSA-CSR occur in HF, the symptoms are less suggestive than in typical (non-HF related) OSA. Overnight monitoring is mandatory for a proper diagnosis, with accurate measurement and scoring of central and obstructive events, since the management will be different depending on whether the sleep apnea in HF is predominantly OSA or CSA-CSR. SDB in HF are associated with worse prognosis, including higher mortality than in patients with HF but without SDB. However, there is currently no evidence that treating SDB improves clinically important outcomes in patients with HF, such as cardiovascular morbidity and mortality.
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Affiliation(s)
- Patrick Lévy
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France .,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Matt T Naughton
- Alfred Hospital, Department of Respiratory Medicine and Monash University, Melbourne, Australia.,All authors contributed equally to the manuscript
| | - Renaud Tamisier
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France.,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Martin R Cowie
- Royal Brompton Hospital and Faculty of Lifesciences & Medicine, King"s College London, London, UK.,All authors contributed equally to the manuscript
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Centre for Sleep Medicine and Circadian Biology of the University of Toronto and Department of Medicine of the University Health Network Toronto General Hospital, Canada.,All authors contributed equally to the manuscript
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17
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Bird JD, Kalker A, Rimke AN, Chan JS, Chan G, Saran G, Jendzjowsky NG, Wilson RJA, Brutsaert TD, Sherpa MT, Day TA. Severity of central sleep apnea does not affect sleeping oxygen saturation during ascent to high altitude. J Appl Physiol (1985) 2021; 131:1432-1443. [PMID: 34435507 DOI: 10.1152/japplphysiol.00363.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Central sleep apnea (CSA) is characterized by periodic breathing (PB) during sleep, defined as intermittent periods of apnea/hypopnea and hyperventilation, with associated acute fluctuations in oxyhemoglobin saturation (SO2). CSA has an incidence of ∼50% in heart failure patients but is universal at high altitude (HA; ≥2,500 m), increasing in severity with further ascent and/or time at altitude. However, whether PB is adaptive, maladaptive, or neutral with respect to sleeping SO2 at altitude is unclear. We hypothesized that PB severity would improve mean sleeping SO2 during acclimatization to HA due to relative, intermittent hyperventilation subsequent to each apnea. We utilized portable sleep monitors to assess the incidence and severity of CSA via apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), and peripheral oxygen saturation ([Formula: see text]) during sleep during two ascent profiles to HA in native lowlanders: 1) rapid ascent to and residence at 3,800 m for 9 days/nights (n = 21) and 2) incremental ascent to 5,160 m over 10 days/nights (n = 21). In both ascent models, severity of AHI and ODI increased and mean sleeping [Formula: see text] decreased, as expected. However, during sleep on the last night/highest altitude of both ascent profiles, neither AHI nor ODI were correlated with mean sleeping [Formula: see text]. In addition, mean sleeping [Formula: see text] was not significantly different between high and low CSA. These data suggest that CSA is neither adaptive nor maladaptive with regard to mean oxygen saturation during sleep, owing to the relative hyperventilation between apneas, likely correcting transient apnea-mediated oxygen desaturation and maintaining mean oxygenation.NEW & NOTEWORTHY Central sleep apnea (CSA) is universal during ascent to high altitude, with intermittent and transient fluctuations in oxygen saturation, but the consequences on mean sleeping blood oxygenation are unclear. We assessed indices of CSA and mean sleeping peripheral oxygen saturation ([Formula: see text]) during ascent to high altitude using two ascent profiles: rapid ascent and residence at 3,800 m and incremental ascent to 5,160 m. The severity of CSA was not correlated with mean sleeping [Formula: see text] with ascent.
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Affiliation(s)
- Jordan D Bird
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Anne Kalker
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada.,Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander N Rimke
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Jason S Chan
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Garrick Chan
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Gurkarn Saran
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Nicholas G Jendzjowsky
- Respiratory Medicine and Exercise Physiology, The Lundquist Institute for Biomedical Innovation, Harbor UCLA Medical Center, West Carson, California
| | - Richard J A Wilson
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Thomas D Brutsaert
- Department of Exercise Science, School of Education, Syracuse University, Syracuse, New York
| | | | - Trevor A Day
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
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18
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Voulgaris A, Bonsignore MR, Schiza S, Marrone O, Steiropoulos P. Is kidney a new organ target in patients with obstructive sleep apnea? Research priorities in a rapidly evolving field. Sleep Med 2021; 86:56-67. [PMID: 34474225 DOI: 10.1016/j.sleep.2021.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/15/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
The bidirectional relationship between sleep disordered breathing and chronic kidney disease (CKD) has recently gained a lot of interest. Several lines of evidence suggest the high prevalence of coexistent obstructive sleep apnea (OSA) in patients with CKD and end-stage renal disease (ESRD). In addition, OSA seems to result in loss of kidney function in some patients, especially in those with cardio-metabolic comorbidities. Treatment of CKD/ESRD and OSA can alter the natural history of each other; still better phenotyping with selection of appropriate treatment approaches is urgently needed. The aim of this narrative review is to provide an update of recent studies on epidemiological associations, pathophysiological interactions, and management of patients with OSA and CKD or ESRD.
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Affiliation(s)
- Athanasios Voulgaris
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria R Bonsignore
- Institute of Biomedicine and Molecular Immunology, CNR, Palermo, Italy; Sleep Disordered Breathing and Chronic Respiratory Failure Clinic, PROMISE Department, University of Palermo, and IRIB, National Research Council (CNR), Palermo, Italy
| | - Sophia Schiza
- Sleep Disorders Center, Department of Respiratory Medicine, Medical School, University of Crete, Heraklion, Greece
| | - Oreste Marrone
- Institute of Biomedicine and Molecular Immunology, CNR, Palermo, Italy
| | - Paschalis Steiropoulos
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece.
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19
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Prowting J, Maresh S, Vaughan S, Kruppe E, Alsabri B, Badr MS, Sankari A. Mirtazapine reduces susceptibility to hypocapnic central sleep apnea in males with sleep-disordered breathing: a pilot study. J Appl Physiol (1985) 2021; 131:414-423. [PMID: 34080920 PMCID: PMC8325612 DOI: 10.1152/japplphysiol.00838.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Studies in humans and animal models with spinal cord injury (SCI) have demonstrated that medications targeting serotonin receptors may decrease the susceptibility to central sleep-disordered breathing (SDB). We hypothesized that mirtazapine would decrease the propensity to develop hypocapnic central sleep apnea (CSA) during sleep. We performed a single-blind pilot study on a total of 10 men with SDB (7 with chronic SCI and 3 noninjured) aged 52.0 ± 11.2 yr. Participants were randomly assigned to either mirtazapine (15 mg at bedtime) or a placebo for at least 1 wk, followed by a 7-day washout period before crossing over to the other intervention. Split-night studies included polysomnography and induction of hypocapnic CSA using a noninvasive ventilation (NIV) protocol. The primary outcome was CO2 reserve, defined as the difference between eupneic and end of NIV end-tidal CO2 ([Formula: see text]) preceding induced hypocapneic CSA. Secondary outcomes included controller gain (CG), other ventilatory parameters, and SDB severity. CG was defined as the ratio of change in minute ventilation (V̇e) between control and hypopnea to the change in CO2 during sleep. CO2 reserve was significantly widened on mirtazapine than placebo (-3.8 ± 1.2 vs. -2.0 ± 1.5 mmHg; P = 0.015). CG was significantly decreased on mirtazapine compared with placebo [2.2 ± 0.7 vs. 3.5 ± 1.9 L/(mmHg × min); P = 0.023]. There were no significant differences for other ventilatory parameters assessed or SDB severity between mirtazapine and placebo trials. These findings suggest that the administration of mirtazapine can decrease the susceptibility to central apnea by reducing chemosensitivity and increasing CO2 reserve; however, considering the lack of changes in apnea-hypopnea index (AHI), further research is required to understand the significance of this finding.NEW & NOTEWORTHY To our knowledge, this research study is novel as it is the first study in humans assessing the effect of mirtazapine on CO2 reserve and chemosensitivity in individuals with severe sleep-disordered breathing. This is also the first study to determine the potential therapeutic effects of mirtazapine on sleep parameters in individuals with a spinal cord injury.
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Affiliation(s)
- Joel Prowting
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan
| | - Scott Maresh
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan
| | - Sarah Vaughan
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan
| | - Elizabeth Kruppe
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan
| | - Bander Alsabri
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan
| | - M. Safwan Badr
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan
| | - Abdulghani Sankari
- 1Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan,2Wayne State University School of Medicine, Detroit, Michigan,3Ascension Providence Hospital, Southfield, Michigan
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20
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Brown LK. Acetazolamide for central sleep apnea: teaching an old drug new tricks? J Clin Sleep Med 2021; 17:1153-1155. [PMID: 33792537 DOI: 10.5664/jcsm.9306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.,Program in Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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21
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Ghirardo S, Amaddeo A, Griffon L, Khirani S, Fauroux B. Central apnea and periodic breathing in children with underlying conditions. J Sleep Res 2021; 30:e13388. [PMID: 34075643 PMCID: PMC9286345 DOI: 10.1111/jsr.13388] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 12/21/2022]
Abstract
Central sleep apneas and periodic breathing are poorly described in childhood. The aim of the study was to describe the prevalence and characteristics of central sleep apnea and periodic breathing in children with associated medical conditions, and the therapeutic management. We retrospectively reviewed all poly(somno)graphies with a central apnea index ≥ 5 events per hr in children aged > 1 month performed in a paediatric sleep laboratory over a 6‐year period. Clinical data and follow‐up poly(somno)graphies were gathered. Ninety‐five out of 2,981 patients (3%) presented central sleep apnea: 40% were < 1 year, 41% aged 1–6 years, and 19% aged ≥ 6 years. Chiari malformation was the most common diagnosis (13%). Mean central apnea index was 20 ± 30 events per hr (range 5–177). Fifty‐eight (61%) children had an exclusive central pattern with < 5 obstructive events per hr. Periodic breathing was present in 79 (83%) patients, with a mean percentage of time with periodic breathing of 9 ± 16%. Among periodic breathing episodes, 40% appeared after a sigh, 8% after an obstructive event, 6% after breathing instability and 2% after bradypnea. The highest clinical apnea index and percentage of time with periodic breathing were observed in children with encephalopathy and/or epilepsy (68 ± 63 events per hr and 30 ± 34%). Clinical apnea index did not differ according to age, while periodic breathing duration was longer in children > 1 year old. Watchful waiting was performed in 22 (23%) patients with spontaneous improvement in 20. Other treatments (upper airway or neurosurgery, nocturnal oxygen therapy, continuous positive airway pressure, non‐invasive ventilation) were effective in selected patients. Central sleep apnea is rare in children and comprises heterogeneous conditions. Sleep studies are essential for the diagnosis, characterization and management of central sleep apnea.
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Affiliation(s)
- Sergio Ghirardo
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, Paris, France.,University of Trieste Department of Medicine, Surgery and Health Sciences, Trieste, Italy
| | - Alessandro Amaddeo
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, Paris, France.,Equipe d'Accueil EA VIFASOM, Université de Paris, Paris, France
| | - Lucie Griffon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, Paris, France.,Equipe d'Accueil EA VIFASOM, Université de Paris, Paris, France
| | - Sonia Khirani
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, Paris, France.,Equipe d'Accueil EA VIFASOM, Université de Paris, Paris, France.,ASV Santé, Gennevilliers, France
| | - Brigitte Fauroux
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, Paris, France.,Equipe d'Accueil EA VIFASOM, Université de Paris, Paris, France
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22
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Doufas AG, Weingarten TN. Pharmacologically Induced Ventilatory Depression in the Postoperative Patient: A Sleep-Wake State-Dependent Perspective. Anesth Analg 2021; 132:1274-1286. [PMID: 33857969 DOI: 10.1213/ane.0000000000005370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pharmacologically induced ventilatory depression (PIVD) is a common postoperative complication with a spectrum of severity ranging from mild hypoventilation to severe ventilatory depression, potentially leading to anoxic brain injury and death. Recent studies, using continuous monitoring technologies, have revealed alarming rates of previously undetected severe episodes of postoperative ventilatory depression, rendering the recognition of such episodes by the standard intermittent assessment practice, quite problematic. This imprecise description of the epidemiologic landscape of PIVD has thus stymied efforts to understand better its pathophysiology and quantify relevant risk factors for this postoperative complication. The residual effects of various perianesthetic agents on ventilatory control, as well as the multiple interactions of these drugs with patient-related factors and phenotypes, make postoperative recovery of ventilation after surgery and anesthesia a highly complex physiological event. The sleep-wake, state-dependent variation in the control of ventilation seems to play a central role in the mechanisms potentially enhancing the risk for PIVD. Herein, we discuss emerging evidence regarding the epidemiology, risk factors, and potential mechanisms of PIVD.
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Affiliation(s)
- Anthony G Doufas
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota
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McKeown P, O’Connor-Reina C, Plaza G. Breathing Re-Education and Phenotypes of Sleep Apnea: A Review. J Clin Med 2021; 10:jcm10030471. [PMID: 33530621 PMCID: PMC7865730 DOI: 10.3390/jcm10030471] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
Four phenotypes of obstructive sleep apnea hypopnea syndrome (OSAHS) have been identified. Only one of these is anatomical. As such, anatomically based treatments for OSAHS may not fully resolve the condition. Equally, compliance and uptake of gold-standard treatments is inadequate. This has led to interest in novel therapies that provide the basis for personalized treatment protocols. This review examines each of the four phenotypes of OSAHS and explores how these could be targeted using breathing re-education from three dimensions of functional breathing: biochemical, biomechanical and resonant frequency. Breathing re-education and myofunctional therapy may be helpful for patients across all four phenotypes of OSAHS. More research is urgently needed to investigate the therapeutic benefits of restoring nasal breathing and functional breathing patterns across all three dimensions in order to provide a treatment approach that is tailored to the individual patient.
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Affiliation(s)
- Patrick McKeown
- Buteyko Clinic International, Loughwell, Moycullen, Co., H91 H4C1 Galway, Ireland;
| | - Carlos O’Connor-Reina
- Otorhinolaryngology Department, Hospital Quironsalud Marbella, 29603 Marbella, Spain;
- Otorhinolaryngology Department, Hospital Quironsalud Campo de Gibraltar, 11379 Palmones, Spain
| | - Guillermo Plaza
- Otorhinolaryngology Department, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain
- Otorhinolaryngology Department, Hospital Sanitas la Zarzuela, 28023 Madrid, Spain
- Correspondence:
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Testelmans D, Schoovaerts K, Belge C, Verleden SE, Vos R, Verleden GM, Buyse B. Sleep-disordered breathing after lung transplantation: An observational cohort study. Am J Transplant 2021; 21:281-290. [PMID: 32519458 DOI: 10.1111/ajt.16130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 01/25/2023]
Abstract
Data concerning sleep-disordered breathing (SDB) after lung transplantation (LTX) are scarce. This study aims to analyze prevalence, associated factors, and impact on survival of moderate to severe SDB in a large cohort of consecutive LTX patients (n = 219). Patients underwent a diagnostic polysomnography 1 year after LTX. Moderate to severe SDB was present in 57.5% of patients, with the highest prevalence in chronic obstructive pulmonary disease/emphysema (71.1%) and pulmonary fibrosis (65.1%). SDB patients were older, mostly male, and had higher body mass index and neck circumference. Nocturnal diastolic and 24-hour blood pressures were higher in SDB patients. In 45 patients, polysomnography was also performed pre-LTX. Compared to pre-LTX, mean apnea/hypopnea index (AHI) increased significantly after LTX. A significant correlation was seen between lung function parameters and AHI, suggesting a role of decreased caudal traction on the pharynx. Presence of SDB had no impact on mortality or prevalence of chronic lung allograft dysfunction. However, survival was better in continuous positive airway pressure (CPAP) compliant SDB patients compared to SDB patients without CPAP treatment. These findings may be pertinent for systematic screening of SDB after LTX.
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Affiliation(s)
- Dries Testelmans
- Clinical Department of Respiratory Diseases, UZ Leuven - BREATHE, department CHROMETA, KU Leuven, Leuven, Belgium
| | - Kathleen Schoovaerts
- Clinical Department of Respiratory Diseases, UZ Leuven - BREATHE, department CHROMETA, KU Leuven, Leuven, Belgium
| | - Catharina Belge
- Clinical Department of Respiratory Diseases, UZ Leuven - BREATHE, department CHROMETA, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Laboratory of Respiratory diseases and Thoracic Surgery (BREATHE) Department CHROMETA, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Clinical Department of Respiratory Diseases, UZ Leuven - BREATHE, department CHROMETA, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Clinical Department of Respiratory Diseases, UZ Leuven - BREATHE, department CHROMETA, KU Leuven, Leuven, Belgium
| | - Bertien Buyse
- Clinical Department of Respiratory Diseases, UZ Leuven - BREATHE, department CHROMETA, KU Leuven, Leuven, Belgium
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Abstract
Individuals with spinal cord injury (SCI) are at increased risk of respiratory complications during wake and sleep. Sleep-disordered breathing (SDB) is commonly associated with SCI and requires an individualized approach to its management. Respiratory control plays a key role in the pathogenesis of SDB in cervical SCI. Noninvasive ventilation plays an important role in the management of respiratory complications in individuals with SCI acutely and in chronic phases. Positive airway pressure treatment may be effective in eliminating SDB and improving sleepiness symptoms, but adherence to treatment is poor and effect on long-term outcomes is questionable.
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Affiliation(s)
- Asil Daoud
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Samran Haider
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Abdulghani Sankari
- Department of Medicine, John D. Dingell VA Medical Center, Wayne State University, Detroit Medical Center, 3990 John R St, Detroit, MI 48201, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University, 3990 John R, 3-Hudson, Detroit, MI 48201, USA; Ascension Providence Hospital, Southfield, MI, USA.
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26
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Maresh S, Prowting J, Vaughan S, Kruppe E, Alsabri B, Yarandi H, Badr MS, Sankari A. Buspirone decreases susceptibility to hypocapnic central sleep apnea in chronic SCI patients. J Appl Physiol (1985) 2020; 129:675-682. [PMID: 32816639 DOI: 10.1152/japplphysiol.00435.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Spinal cord injury (SCI) is a risk factor for central sleep apnea (CSA). Previous studies in animal models with SCI have demonstrated a promising recovery in respiratory and phrenic nerve activity post-injury induced by the systemic and local administration of serotonin receptor agonists such as Buspirone and Trazodone. Human trials must be performed to determine whether individuals with SCI respond similarly. We hypothesized that Buspirone and Trazodone would decrease the propensity to hypocapnic CSA during sleep. We studied eight males with chronic SCI and sleep-disordered breathing (SDB) [age: 48.8 ± 14.2 yr; apnea-hypopnea index (AHI): 44.9 ± 23.1] in a single-blind crossover design. For 13 days, participants were randomly assigned either Buspirone (7.5-15 mg twice daily), Trazodone (100 mg), or a placebo followed by a 14-day washout period before crossing over to the other interventions. Study nights included polysomnography and induction of CSA using a noninvasive ventilation protocol. We assessed indexes of SDB, CO2 reserve, apneic threshold (AT), controller gain (CG), plant gain (PG), and ventilatory parameters. CO2 reserve was significantly widened on Buspirone (-3.6 ± 0.9 mmHg) compared with both Trazodone (-2.5 ± 1.0 mmHg, P = 0.009) and placebo (-1.8 ± 1.5 mmHg, P < 0.001) but not on Trazodone vs. placebo (P = 0.061). CG was significantly decreased on Buspirone compared with placebo (1.8 ± 0.4 vs. 4.0 ± 2.0 L/(mmHg·min), P = 0.025) but not on Trazodone compared with placebo (2.5 ± 1.1 vs. 4.0 ± 2.0 L/(mmHg·min); P = 0.065). There were no significant differences for PG, AT, or any SDB indexes (AHI, obstructive apnea index, central apnea index, oxygen desaturation index). The administration of Buspirone decreased the susceptibility to induced hypocapnic central apnea by reducing chemosensitivity and increasing CO2 reserve in chronic SCI patients.NEW & NOTEWORTHY This research study is novel as it is the first study in a humans that we are aware of that demonstrates the ability of Buspirone to increase CO2 reserve and hence decrease susceptibility to hypocapnic central apnea in patients with spinal cord injury.
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Affiliation(s)
- Scott Maresh
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan
| | - Joel Prowting
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan
| | - Sarah Vaughan
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan
| | | | - Bander Alsabri
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan
| | - Hossein Yarandi
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan
| | - M Safwan Badr
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan
| | - Abdulghani Sankari
- Sleep Research Laboratory, John D. Dingell Veterans Affairs Medical Center, Wayne State University, Detroit, Michigan.,Ascension Providence Hospital, Southfield, Michigan
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27
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Pinna GD, La Rovere MT, Robbi E, Tavazzi L, Maestri R. CARDIAC chronotropic effects of sleep-disordered breathing in patients with heart failure. J Sleep Res 2020; 30:e13160. [PMID: 32791565 DOI: 10.1111/jsr.13160] [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: 05/04/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
It is still not known whether the oscillation in heart rate (HR) induced by sleep-disordered breathing (SDB) in patients with heart failure entails significant chronotropic effects. We hypothesised that since cyclical changes in ventilation and arterial blood gases during SDB affect HR through multiple and complexly interacting mechanisms characterised by large inter-subject variability, chronotropic effects may change from patient to patient. A total of 42 patients with moderate-to-severe chronic heart failure with systolic dysfunction underwent an in-hospital sleep study. Chronotropic effects of SDB were quantified by comparing the distribution of instantaneous HR during SDB with that during periods without SDB (noSDB) within the same night in each patient. Based on distribution changes from noSDB to SDB, 12, nine, 11, and 10 patients showed a significant tachycardic, bradycardic, tachycardic and bradycardic, and neither significant tachycardic nor significant bradycardic effect, respectively. Tachycardic and bradycardic effects were primarily due to an increase in the rate rather than in the magnitude of cyclical HR elevations and reductions, and were more prevalent and severe in patients with dominant obstructive and central events, respectively. The apnea-hypopnea index did not differ between groups. Conversely, the time spent with an oxygen saturation of <90% was greater in the tachycardic and tachycardic-bradycardic groups compared to the bradycardic group. These findings indicate that HR distribution changes induced by SDB can vary from patient to patient revealing four distinct and well-characterised chronotropic effects. These effects are related to the degree of hypoxic burden brought about by SDB and are affected by the type of sleep apnea (central/obstructive).
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Affiliation(s)
- Gian Domenico Pinna
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| | - Maria Teresa La Rovere
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| | - Elena Robbi
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy.,Sleep Laboratory, Department of Pneumology, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Roberto Maestri
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
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28
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Cross-sectional study of loop gain abnormalities in childhood obstructive sleep apnea syndrome. Sleep Med 2020; 69:172-178. [DOI: 10.1016/j.sleep.2020.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 11/22/2022]
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29
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Lin CH, Lurie RC, Lyons OD. Sleep Apnea and Chronic Kidney Disease. Chest 2020; 157:673-685. [DOI: 10.1016/j.chest.2019.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/20/2019] [Accepted: 09/01/2019] [Indexed: 12/20/2022] Open
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30
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Kouri I, Kolla BP, Morgenthaler TI, Mansukhani MP. Frequency and outcomes of primary central sleep apnea in a population-based study. Sleep Med 2019; 68:177-183. [PMID: 32044555 PMCID: PMC9272740 DOI: 10.1016/j.sleep.2019.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Primary central sleep apnea (PCSA) is believed to be rare and data regarding its prevalence and long-term outcomes are sparse. We used the Rochester Epidemiology Project (REP) resources to identify all Olmsted County, Minnesota, residents with an incident diagnosis of PCSA and their clinical outcomes. METHODS We searched the REP database for all residents with polysomnography (PSG)-confirmed diagnoses of central sleep apnea (CSA) between 2007 and 2015. From these, we reviewed the PSGs and medical records to find those who had PCSA based upon accepted diagnostic criteria. Data based on detailed review of the medical records, including all clinical notes and tests were recorded for analysis. RESULTS Of 650 patients identified with CSA, 25 (3.8%; 23 male) had PCSA, which was severe in most patients (n = 16, 64%). Of those, 23 (92%) patients were prescribed and 18/23 (78.2%) adherent to positive airway pressure therapy. Median duration of follow-up was 4.4 years (IQR:4.2). Four (16%) patients were subsequently diagnosed with cardiac arrhythmias, one (4%) with unstable angina, two (8%) with heart failure, five (20%) with mild cognitive impairment (MCI)/dementia and two (8%) with depression. Six (25%) patients died (median time to death = 5 years; IQR:4.8), three of whom had Lewy body dementia. CONCLUSIONS In this population-based study, PCSA was rare and when present, was severe in a majority of patients. The mortality rate was high. Most frequently observed disorders during follow-up were mild cognitive impairment (MCI)/dementia followed by cardiac arrhythmias; it is possible that these entities were present and not recognized prior to the diagnosis of PCSA.
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Affiliation(s)
- Ioanna Kouri
- Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bhanu Prakash Kolla
- Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Timothy I Morgenthaler
- Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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31
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Loop Gain in Heart Failure with Reduced Ejection Fraction and Periodic Breathing Is Associated with Sleep Stage and Arousals. Ann Am Thorac Soc 2019; 16:1591-1595. [DOI: 10.1513/annalsats.201903-224rl] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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32
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de la Motte T, Schwab M, Schultze T, Witte OW, Rupprecht S. An 82-Year-Old Man With Sleep-Onset Insomnia, Breathing Arrest, and Heart Failure. Chest 2019; 156:e95-e98. [PMID: 31699235 DOI: 10.1016/j.chest.2019.05.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/15/2019] [Accepted: 05/27/2019] [Indexed: 11/17/2022] Open
Abstract
CASE PRESENTATION An 82-year-old man presented with 6 months of difficulties of falling asleep. He described a feeling of fading breath culminating in breathing arrest when he becomes drowsy. These recurrent events prevented him from falling asleep. Symptoms would only appear when he went to sleep but not during wakefulness. Medical history comprised several episodes of acute decompensated heart failure due to supraventricular tachyarrhythmia with need for hospitalization during the last 2 years. He additionally had two-vessel coronary artery disease with myocardial infarction, pulmonary hypertension, chronic atrial fibrillation, peripheral arterial disease, and chronic kidney disease (stage 3). Medication included diuretics, sodium bicarbonate, angiotensin II receptor antagonist, beta-blocker, statin, clopidogrel, and phenprocoumon without sedatives or analgesics.
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Affiliation(s)
- Torben de la Motte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Matthias Schwab
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Torsten Schultze
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sven Rupprecht
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Interdisciplinary Centre for Sleep and Ventilatory Medicine, Jena University Hospital, Jena, Germany; Research Programme "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany.
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Targeting Endotypic Traits with Medications for the Pharmacological Treatment of Obstructive Sleep Apnea. A Review of the Current Literature. J Clin Med 2019; 8:jcm8111846. [PMID: 31684047 PMCID: PMC6912255 DOI: 10.3390/jcm8111846] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition with few therapeutic options. To date there is no approved pharmacotherapy for this disorder, but several attempts have been made in the past and are currently ongoing to find one. The recent identification of multiple endotypes underlying this disorder has oriented the pharmacological research towards tailored therapies targeting specific pathophysiological traits that contribute differently to cause OSA in each patient. In this review we retrospectively analyze the literature on OSA pharmacotherapy dividing the medications tested on the basis of the four main endotypes: anatomy, upper airway muscle activity, arousal threshold and ventilatory instability (loop gain). We show how recently introduced drugs for weight loss that modify upper airway anatomy may play an important role in the management of OSA in the near future, and promising results have been obtained with drugs that increase upper airway muscle activity during sleep and reduce loop gain. The lack of a medication that can effectively increase the arousal threshold makes this strategy less encouraging, although recent studies have shown that the use of certain sedatives do not worsen OSA severity and could actually improve patients' sleep quality.
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Voulgaris A, Marrone O, Bonsignore MR, Steiropoulos P. Chronic kidney disease in patients with obstructive sleep apnea. A narrative review. Sleep Med Rev 2019; 47:74-89. [PMID: 31376590 DOI: 10.1016/j.smrv.2019.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
Abstract
Prevalence of both chronic kidney disease (CKD) and obstructive sleep apnea (OSA) is continuously increasing. Moreover, the prevalence of OSA increases as kidney function declines and is higher among patients with end-stage renal disease (ESRD). In addition, OSA is recognized as a potential nontraditional risk factor for development and progression of CKD. Continuous positive airway pressure (CPAP) plays a pivotal role in the management of OSA, eliminating patients' symptoms and improving their quality of life. Recent studies suggested that CPAP treatment may have beneficial effects on kidney function among patients with OSA. This narrative review summarizes the existing knowledge on the association between CKD and OSA, with emphasis on the epidemiology, the pathophysiology of the development of CKD in OSA and vice versa, as well as the effect of CPAP on renal function.
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Affiliation(s)
- Athanasios Voulgaris
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Pneumonology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Oreste Marrone
- Institute of Biomedicine and Molecular Immunology, CNR, Palermo, Italy
| | - Maria R Bonsignore
- Institute of Biomedicine and Molecular Immunology, CNR, Palermo, Italy; Pulmonary Division, University Hospital AOUP Paolo Giaccone, PROMISE Department, University of Palermo, Palermo, Italy
| | - Paschalis Steiropoulos
- MSc Programme in Sleep Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece; Department of Pneumonology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece.
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35
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Benarroch EE. Control of the cardiovascular and respiratory systems during sleep. Auton Neurosci 2019; 218:54-63. [DOI: 10.1016/j.autneu.2019.01.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 01/01/2023]
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36
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Sleep Disordered Breathing at High Altitude in Adults and Its Interaction with Cardiovascular Homeostasis. CURRENT SLEEP MEDICINE REPORTS 2019. [DOI: 10.1007/s40675-019-00138-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Purpose The purpose of this review is to discuss the pathogenesis, clinical manifestations, diagnosis and treatment, including areas of controversy and uncertainty. Recent Findings Central apnea may be due to hypoventilation or to hypocapnia following hyperventilation. The occurrence of central apnea initiates a cascade of events that perpetuates breathing instability, recurrent central apnea and upper airway narrowing. In fact, breathing instability and upper airway narrowing are key elements of central and obstructive apnea. Clinically, central apnea is noted in association with obstructive sleep apnea, heart failure, atrial fibrillation, cerebrovascular accidents tetraplegia, and chronic opioid use.Management strategy for central apnea aim to eliminate abnormal respiratory events, stabilize sleep and alleviate the underlying clinical condition. Positive pressure therapy (PAP) remains a standard therapy for central as well as obstructive apnea. Other treatment options include adaptive-servo ventilation (ASV), supplemental oxygen, phrenic nerve stimulation, and pharmacologic therapy. However, ASV is contraindicated in patients with central sleep apnea who had heart failure with reduced ejection fraction, owing to increased mortality in this population. Summary There are several therapeutic options for central apnea. Randomized controlled studies are needed to ascertain the long-term effectiveness of individual, or combination, treatment modalities in different types of central apnea.
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Affiliation(s)
- M Safwan Badr
- Department of Internal Medicine, Division of pulmonary, critical; care and sleep medicine
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38
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Arterial oxygen saturation during Cheyne-Stokes respiration in heart failure patients: does measurement site matter? Sleep Med 2019; 55:6-13. [DOI: 10.1016/j.sleep.2018.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/30/2018] [Accepted: 10/15/2018] [Indexed: 11/17/2022]
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Furian M, Lichtblau M, Aeschbacher SS, Estebesova B, Emilov B, Sheraliev U, Marazhapov NH, Mademilov M, Osmonov B, Bisang M, Ulrich S, Latshang TD, Ulrich S, Sooronbaev TM, Bloch KE. Effect of Dexamethasone on Nocturnal Oxygenation in Lowlanders With Chronic Obstructive Pulmonary Disease Traveling to 3100 Meters: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e190067. [PMID: 30794302 PMCID: PMC6484579 DOI: 10.1001/jamanetworkopen.2019.0067] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE During mountain travel, patients with chronic obstructive pulmonary disease (COPD) are at risk of experiencing severe hypoxemia, in particular, during sleep. OBJECTIVE To evaluate whether preventive dexamethasone treatment improves nocturnal oxygenation in lowlanders with COPD at 3100 m. DESIGN, SETTING, AND PARTICIPANTS A randomized, placebo-controlled, double-blind, parallel trial was performed from May 1 to August 31, 2015, in 118 patients with COPD (forced expiratory volume in the first second of expiration [FEV1] >50% predicted, pulse oximetry at 760 m ≥92%) who were living at altitudes below 800 m. The study was conducted at a university hospital (760 m) and high-altitude clinic (3100 m) in Tuja-Ashu, Kyrgyz Republic. Patients underwent baseline evaluation at 760 m, were taken by bus to the clinic at 3100 m, and remained at the clinic for 2 days and nights. Participants were randomized 1:1 to receive either dexamethasone, 4 mg, orally twice daily or placebo starting 24 hours before ascent and while staying at 3100 m. Data analysis was performed from September 1, 2015, to December 31, 2016. INTERVENTIONS Dexamethasone, 4 mg, orally twice daily (dexamethasone total daily dose, 8 mg) or placebo starting 24 hours before ascent and while staying at 3100 m. MAIN OUTCOMES AND MEASURES Difference in altitude-induced change in nocturnal mean oxygen saturation measured by pulse oximetry (Spo2) during night 1 at 3100 m between patients receiving dexamethasone and those receiving placebo was the primary outcome and was analyzed according to the intention-to-treat principle. Other outcomes were apnea/hypopnea index (AHI) (mean number of apneas/hypopneas per hour of time in bed), subjective sleep quality measured by a visual analog scale (range, 0 [extremely bad] to 100 [excellent]), and clinical evaluations. RESULTS Among the 118 patients included, 18 (15.3%) were women; the median (interquartile range [IQR]) age was 58 (52-63) years; and FEV1 was 91% predicted (IQR, 73%-103%). In 58 patients receiving placebo, median nocturnal Spo2 at 760 m was 92% (IQR, 91%-93%) and AHI was 20.5 events/h (IQR, 12.3-48.1); during night 1 at 3100 m, Spo2 was 84% (IQR, 83%-85%) and AHI was 39.4 events/h (IQR, 19.3-66.2) (P < .001 both comparisons vs 760 m). In 60 patients receiving dexamethasone, Spo2 at 760 m was 92% (IQR, 91%-93%) and AHI was 25.9 events/h (IQR, 16.3-37.1); during night 1 at 3100 m, Spo2 was 86% (IQR, 84%-88%) (P < .001 vs 760 m) and AHI was 24.7 events/h (IQR, 13.2-33.7) (P = .99 vs 760 m). Altitude-induced decreases in Spo2 during night 1 were mitigated by dexamethasone vs placebo by a mean of 3% (95% CI, 2%-3%), and increases in AHI were reduced by 18.7 events/h (95% CI, 12.0-25.3). Similar effects were observed during night 2. Subjective sleep quality was improved with dexamethasone during night 2 by 12% (95% CI, 0%-23%). Sixteen (27.6%) patients using dexamethasone had asymptomatic hyperglycemia. CONCLUSIONS AND RELEVANCE In lowlanders in Central Asia with COPD traveling to a high altitude, preventive dexamethasone treatment improved nocturnal oxygen saturation, sleep apnea, and subjective sleep quality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02450994.
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Affiliation(s)
- Michael Furian
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | - Bermet Estebesova
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Berik Emilov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Ulan Sheraliev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Nuriddin H. Marazhapov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Maamed Mademilov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Batyr Osmonov
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Maya Bisang
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Stefanie Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Tsogyal D. Latshang
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Talant M. Sooronbaev
- Department of Respiratory Medicine, National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyz Republic
| | - Konrad E. Bloch
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
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Deacon-Diaz N, Malhotra A. Inherent vs. Induced Loop Gain Abnormalities in Obstructive Sleep Apnea. Front Neurol 2018; 9:896. [PMID: 30450076 PMCID: PMC6224344 DOI: 10.3389/fneur.2018.00896] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/02/2018] [Indexed: 12/11/2022] Open
Abstract
Unstable ventilatory chemoreflex control, quantified as loop gain, is recognized as one of four key pathophysiological traits that contribute to cause obstructive sleep apnea (OSA). Novel treatments aimed at reducing loop gain are being investigated, with the intention that future OSA treatment may be tailored to the individual's specific cause of apnea. However, few studies have evaluated loop gain in OSA and non-OSA controls and those that have provide little evidence to support an inherent abnormality in either overall chemical loop gain in OSA patients vs. non-OSA controls, or its components (controller and plant gain). However, intermittent hypoxia may induce high controller gain through neuroplastic changes to chemoreflex control, and may also decrease plant gain via oxidative stress induced inflammation and reduced lung function. The inherent difficulties and limitations with loop gain measurements are discussed and areas where further research are required are highlighted, as only by understanding the mechanisms underlying OSA are new therapeutic approaches likely to emerge in OSA.
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Affiliation(s)
- Naomi Deacon-Diaz
- Department of Medicine, Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA, United States
| | - Atul Malhotra
- Department of Medicine, Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA, United States
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41
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Benarroch EE. Brainstem integration of arousal, sleep, cardiovascular, and respiratory control. Neurology 2018; 91:958-966. [PMID: 30355703 DOI: 10.1212/wnl.0000000000006537] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Pinna GD, Robbi E, Terzaghi M, Corbellini D, La Rovere MT, Maestri R. Temporal relationship between arousals and Cheyne-Stokes respiration with central sleep apnea in heart failure patients. Clin Neurophysiol 2018; 129:1955-1963. [DOI: 10.1016/j.clinph.2018.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/11/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
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Sheikhbahaei S, Gourine AV, Smith JC. Respiratory rhythm irregularity after carotid body denervation in rats. Respir Physiol Neurobiol 2017; 246:92-97. [PMID: 28782663 PMCID: PMC5637156 DOI: 10.1016/j.resp.2017.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/09/2017] [Accepted: 08/01/2017] [Indexed: 12/13/2022]
Abstract
Respiratory activity is controlled by inputs from the peripheral and central chemoreceptors. Since overactivity of the carotid bodies, the main peripheral chemoreceptors, is linked to the pathophysiology of disparate metabolic and cardiovascular diseases, carotid body denervation (CBD) has been proposed as a potential treatment. However, long-term effects of CBD on the respiratory rhythm and regularity of breathing remain unknown. Here, we show that five weeks after bilateral CBD in rats, the respiratory rhythm was slower and less regular. Ten weeks after bilateral CBD, the respiratory frequency was not different from the sham-operated group, but the regularity of the respiratory rhythm was still reduced. Increased frequency of randomly occurring apneas is likely to be responsible for the irregular breathing pattern after CBD. These results should be taken into consideration since any treatment that reduces the stability of the respiratory rhythm might exacerbate the cardio-respiratory instability and worsen the cardiovascular outcomes.
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Affiliation(s)
- Shahriar Sheikhbahaei
- Cellular and Systems Neurobiology Section, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA; Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology, and Pharmacology, University College London, London WC1E 6BT, UK.
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology, and Pharmacology, University College London, London WC1E 6BT, UK
| | - Jeffrey C Smith
- Cellular and Systems Neurobiology Section, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
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Bascom AT, Sankari A, Badr MS. Spinal cord injury is associated with enhanced peripheral chemoreflex sensitivity. Physiol Rep 2017; 4:4/17/e12948. [PMID: 27597767 PMCID: PMC5027355 DOI: 10.14814/phy2.12948] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/07/2016] [Indexed: 11/24/2022] Open
Abstract
Sleep‐disordered breathing (SDB) is prevalent in individuals with chronic spinal cord injury (SCI), but the exact mechanism is unknown. The aim of this study was to investigate whether peripheral chemoreceptors activity is enhanced in individuals with chronic SCI compared to abled‐bodied control subjects using CO2 and O2 chemical tests. In protocol (1) 30 subjects (8 cervical [cSCI], 7 thoracic [tSCI] and 15 able‐bodied [AB]) were studied to determine the ventilatory response to hyperoxia during wakefulness in the supine position. In protocol (2) 24 subjects (6 cSCI, 6 tSCI, and 12 AB subjects) were studied to determine the ventilatory response to a single breath of CO2 (SBCO2). The chemoreflex response to SBCO2 was calculated as ∆VE/∆CO2 (L/min/mmHg). The ventilatory response to hyperoxia was defined as the % change in VT following acute hyperoxia compared to preceding baseline. During hyperoxia SCI subjects had a significant decrease in VT and VE (63.4 ± 21.7% and 63.1 ± 23.0% baseline, respectively, P < 0.05) compared to AB (VT: 87.1 ± 14.3% and VE: 91.38 ± 15.1% baseline, respectively, P < 0.05). There was no significant difference between cSCI and tSCI in the VT or VE during hyperoxia (P = NS). There was no significant correlation between AHI and VE% baseline (r = −0.28) in SCI and AB (n = 30). SCI participants had a greater ventilatory response to an SBCO2 than AB (0.78 ± 0.42 L/min/mmHg vs. 0.26 ± 0.10 L/min/mmHg, respectively, P < 0.05). Peripheral ventilatory chemoresponsiveness is elevated in individuals with chronic SCI compared to able‐bodied individuals.
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Affiliation(s)
- Amy T Bascom
- John D. Dingell VA Medical Center, Detroit, Michigan Department of Medicine, Wayne State University, Detroit, Michigan
| | - Abdulghani Sankari
- John D. Dingell VA Medical Center, Detroit, Michigan Department of Medicine, Wayne State University, Detroit, Michigan Cardiovascular Research Institute, Wayne State University, Detroit, Michigan
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Detroit, Michigan Department of Medicine, Wayne State University, Detroit, Michigan
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45
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Santin JM. How important is the CO 2 chemoreflex for the control of breathing? Environmental and evolutionary considerations. Comp Biochem Physiol A Mol Integr Physiol 2017; 215:6-19. [PMID: 28966145 DOI: 10.1016/j.cbpa.2017.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/19/2017] [Accepted: 09/19/2017] [Indexed: 12/27/2022]
Abstract
Haldane and Priestley (1905) discovered that the ventilatory control system is highly sensitive to CO2. This "CO2 chemoreflex" has been interpreted to dominate control of resting arterial PCO2/pH (PaCO2/pHa) by monitoring PaCO2/pHa and altering ventilation through negative feedback. However, PaCO2/pHa varies little in mammals as ventilation tightly couples to metabolic demands, which may minimize chemoreflex control of PaCO2. The purpose of this synthesis is to (1) interpret data from experimental models with meager CO2 chemoreflexes to infer their role in ventilatory control of steady-state PaCO2, and (2) identify physiological causes of respiratory acidosis occurring normally across vertebrate classes. Interestingly, multiple rodent and amphibian models with minimal/absent CO2 chemoreflexes exhibit normal ventilation, gas exchange, and PaCO2/pHa. The chemoreflex, therefore, plays at most a minor role in ventilatory control at rest; however, the chemoreflex may be critical for recovering PaCO2 following acute respiratory acidosis induced by breath-holding and activity in many ectothermic vertebrates. An apparently small role for CO2 feedback in the genesis of normal breathing contradicts the prevailing view that central CO2/pH chemoreceptors increased in importance throughout vertebrate evolution. Since the CO2 chemoreflex contributes minimally to resting ventilation, these CO2 chemoreceptors may have instead decreased importance throughout tetrapod evolution, particularly with the onset and refinement of neural innovations that improved the matching of ventilation to tissue metabolic demands. This distinct and elusive "metabolic ventilatory drive" likely underlies steady-state PaCO2 in air-breathers. Uncovering the mechanisms and evolution of the metabolic ventilatory drive presents a challenge to clinically-oriented and comparative respiratory physiologists alike.
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Abstract
Central sleep apnea and Cheyne-Stokes respiration are commonly observed breathing patterns during sleep in patients with congestive heart failure. Common risk factors are male gender, older age, presence of atrial fibrillation, and daytime hypocapnia. Proposed mechanisms include augmented peripheral and central chemoreceptor sensitivity, which increase ventilator instability during both wakefulness and sleep; diminished cerebrovascular reactivity and increased circulation time, which impair the normal buffering of Paco2 and hydrogen ions and delay the detection of changes in Paco2 during sleep; and rostral fluid shifts that predispose to hypocapnia.
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Chowdhuri S, Badr MS. Control of Ventilation in Health and Disease. Chest 2016; 151:917-929. [PMID: 28007622 DOI: 10.1016/j.chest.2016.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/02/2016] [Accepted: 12/05/2016] [Indexed: 11/29/2022] Open
Abstract
Control of ventilation occurs at different levels of the respiratory system through a negative feedback system that allows precise regulation of levels of arterial carbon dioxide and oxygen. Mechanisms for ventilatory instability leading to sleep-disordered breathing include changes in the genesis of respiratory rhythm and chemoresponsiveness to hypoxia and hypercapnia, cerebrovascular reactivity, abnormal chest wall and airway reflexes, and sleep state oscillations. One can potentially stabilize breathing during sleep and treat sleep-disordered breathing by identifying one or more of these pathophysiological mechanisms. This review describes the current concepts in ventilatory control that pertain to breathing instability during wakefulness and sleep, delineates potential avenues for alternative therapies to stabilize breathing during sleep, and proposes recommendations for future research.
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Affiliation(s)
- Susmita Chowdhuri
- John D. Dingell VA Medical Center, Wayne State University, Detroit MI; Department of Medicine, Wayne State University, Detroit MI.
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Wayne State University, Detroit MI; Department of Medicine, Wayne State University, Detroit MI
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Treatment of Obstructive Sleep Apnea. Prospects for Personalized Combined Modality Therapy. Ann Am Thorac Soc 2016; 13:101-8. [PMID: 26569377 DOI: 10.1513/annalsats.201508-537fr] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a common sleep disorder with serious associated morbidities. Although several treatment options are currently available, variable efficacy and adherence result in many patients either not being treated or receiving inadequate treatment long term. Personalized treatment based on relevant patient characteristics may improve adherence to treatment and long-term clinical outcomes. Four key traits of upper airway anatomy and neuromuscular control interact to varying degrees within individuals to cause OSA. These are: (1) the pharyngeal critical closing pressure, (2) the stability of ventilator chemoreflex feedback control (loop gain), (3) the negative intraesophageal pressure that triggers arousal (arousal threshold), and (4) the level of stimulus required to activated upper airway dilator muscles (upper airway recruitment threshold). Simplified diagnostic methods are being developed to assess these pathophysiological traits, potentially allowing prediction of which treatment would best suit each patient. In contrast to current practice of using various treatment modes alone, model predictions and pilot clinical trials show improved outcomes by combining several treatments targeted to each patient's pathophysiology profile. These developments could theoretically improve efficacy and adherence to treatment and in turn reduce the social and economic health burden of OSA and the associated life-threatening morbidities. This article reviews OSA pathophysiology and identifies currently available and investigational treatments that may be combined in the future to optimize therapy based on individual profiles of key patient pathophysiological traits.
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Abstract
Sleep is an essential function of life and serves a crucial role in the promotion of health and performance. Poor sleep quality and sleep disorders have been a recurrent finding in patients with chronic kidney disease (CKD). Sleep disorders such as obstructive sleep apnea (OSA) can contribute to hypertension, diabetes, cardiovascular disease, and worsen obesity, all of which are implicated in the etiology of CKD, but CKD itself may lead to OSA. Relationships between CKD/end-stage renal disease (ESRD) and OSA have been the subject of numerous investigations, but central sleep apnea (CSA) also is highly prevalent in CKD/ESRD but remains poorly understood, underdiagnosed, and undertreated in these patients. Emerging literature has implicated CSA as another contributor to morbidity and mortality in CKD/ESRD, and several studies have suggested that CSA treatment is beneficial in improving these outcomes. Patients with CKD/ESRD co-existing with congestive heart failure are particularly prone to CSA, and studies focused on managing CSA in congestive heart failure patients have provided important information concerning how best to manage CSA in kidney disease as well. Adaptive servo-ventilation ultimately may represent the treatment of choice in these patients, although a stepped approach using a variety of therapeutic modalities is recommended.
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Affiliation(s)
- Sushma M Dharia
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Lee K Brown
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
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Mateika JH, Komnenov D. Intermittent hypoxia initiated plasticity in humans: A multipronged therapeutic approach to treat sleep apnea and overlapping co-morbidities. Exp Neurol 2016; 287:113-129. [PMID: 27170208 DOI: 10.1016/j.expneurol.2016.05.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/18/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
Over the past three decades exposure to intermittent hypoxia (IH) has generally been considered a stimulus associated with a number of detrimental outcomes. However, there is sufficient evidence to link IH to many beneficial outcomes but they have largely been ignored, particularly in the field of sleep medicine in the United States. Recent reviews have postulated that this apparent contradiction is related to the severity and duration of exposure to IH; mild forms of IH initiate beneficial outcomes while severe forms of IH are coupled to detrimental consequences. In the present review we explore the role that IH has in initiating respiratory plasticity and the potential this form of plasticity has to mitigate obstructive sleep apnea (OSA) in humans. In taking this approach, we address the possibility that IH could serve as an adjunct therapy coupled with continuous positive airway pressure (CPAP) to treat OSA. Our working hypothesis is that exposure to mild IH leads to respiratory plasticity that manifests in increased stability of the upper airway, which could ultimately reduce the CPAP required to treat OSA. In turn, this reduction could increase CPAP compliance and extend the length of treatment each night, which might improve the magnitude of outcome measures. Improved treatment compliance coupled with the direct effect that IH has on numerous overlapping conditions (i.e. asthma, chronic obstructive pulmonary disease, spinal cord injury) may well lead to substantial improvements that exceed outcomes following treatment with CPAP alone. Overall, this review will consider evidence from the published literature which suggests that IH could serve as an effective multipronged therapeutic approach to treat sleep apnea and its overlapping co-morbidities.
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Affiliation(s)
- Jason H Mateika
- John D. Dingell Veterans Affairs Medical Center, Detroit, MI 48201, United States; Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201, United States; Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI 48201, United States.
| | - Dragana Komnenov
- John D. Dingell Veterans Affairs Medical Center, Detroit, MI 48201, United States; Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201, United States
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