Computational simulation of human upper airway collapse using a pressure-/state-dependent model of genioglossal muscle contraction under laminar flow conditions

Tissue-specified reconstruction modeling of the head and neck structure and its application in simulating airway obstruction

Background and objective

Three-dimensional (3D) reconstruction of head and neck tissues has extensive clinical applications, but due to the complexity and variability of tissue structure, there is still a lack of a complete scheme to reconstruct the head and neck tissues. This study aims to establish a tissue-specified multi-directional cross-sectional image sequence construction method to capture diverse tissue contour information.

Methods

The image sequences that are most conducive to acquiring the boundary contours of the target tissue are constructed from 3D MRI images of the head and neck in a non-traditional way based on the characteristics of each target tissue, and an effective registration strategy is used to integrate the boundaries of the target tissue segmented from multiple image sequences. The NURBS (Non-Uniform Rational B-Splines) surface modeling method is used to construct the 3D structure of the head and neck based on the segmented tissue boundaries, and then the constructed structure is used to build a fluid-structure interaction model to simulate airway collapse.

Results

The multi-directional cross-sectional image sequences of head and neck tissues were reconstructed, which successfully supplemented the missing boundary information in unidirectional image sequences commonly used in anatomical reconstructions. The boundaries of the tongue and soft palate were obtained from three corresponding sequential images respectively, and nonlinear registration methods were developed to match the intersections of the target tissue boundaries segmented from different image sequences. The complete 3D head and neck structure, including the surrounding tissues of the upper airway, was accurately reconstructed, and then directly converted into a finite element model through a meshing procedure. The head and neck numerical models successfully simulate airway collapse in both the obstructive sleep apnea patient and the normal subject, providing detailed information on soft tissue deformation and predicting the values of the airway critical closing pressure.

Conclusions

A complete 3D reconstruction scheme from multi-directional image sequence construction to nonlinear boundary registration and NURBS surface generation is established. The constructed model can accurately reflect the characteristics of real anatomical structure, and can be directly used for complex numerical simulations of upper airway collapse.

Comparison of treatments for equine laryngeal hemiplegia using computational fluid dynamic analysis in an equine head model

Introduction

Computational fluid dynamics (CFD) is gaining momentum as a useful mechanism for analyzing obstructive disorders and surgeries in humans and warrants further development for application in equine surgery. While advancements in procedures continue, much remains unknown about the specific impact that different surgeries have on obstructive airway disorders. The objective of this study was to apply CFD analysis to an equine head inhalation model replicating recurrent laryngeal neuropathy (RLN) and four surgical procedures. CFD was hypothesized to corroborate the order of the different trials based on impedance and to provide an impedance value numerically similar to the experimental results. In addition, it was hypothesized that CFD would offer insights into the changes in airflow associated with each procedure on a finite scale.

Methods

An equine cadaver head underwent airflow testing and computed tomographic (CT) scans to replicate the disease state (RLN) and four surgical procedures: laryngoplasty, combined laryngoplasty and corniculectomy, corniculectomy, and partial arytenoidectomy. Pressure measurements at the pharynx and trachea were recorded, along with airflow data, for each trial.

Results and discussion

The CFD and experimental models showed that partial arytenoidectomy had the lowest impedance in this case. While this procedure did have the largest rima glottidis area, the remaining procedural order was not dictated by the rima glottidis area. Recurrent laryngeal neuropathy and combined laryngoplasty with corniculectomy models showed negative pressure concentration on the luminal surface of the left arytenoid cartilage, which indicated a greater collapsing force on the tissue in this region. Narrowing within the caudal larynx at the level of the saccule showed increased negative pressure and higher velocity in the procedures with greater impedance, while partial arytenoidectomy exhibited more uniform pressure and velocity. Although this specific experimental head model contradicted previous flow studies, the CFD model reflected the experimental findings for the procedure with the least impedance and provided some insights into why these discrepancies occurred in this particular case.

Influence of natural hyoid bone position and surgical repositioning on upper airway patency: a computational finite element modeling study

The hyoid bone's inferior baseline position in obstructive sleep apnea (OSA) has led to surgical hyoid repositioning (SHR) treatment, yet outcomes vary widely. The influence of baseline hyoid position (BHP; phenotype) and SHR on upper airway (UA) function remains unclear. We aimed to investigate their impact on the UA using computational modeling. A validated finite element model of the rabbit UA was advanced and used to simulate changes in BHP and SHR, alone and in combination. The hyoid was displaced in cranial, caudal, anterior, anterior-cranial, and anterior-caudal directions from 1 to 4 mm. Model outcomes included UA collapsibility, measured using closing pressure (Pclose), cross-sectional area (CSA), and soft tissue mechanics (displacement, stress, and strain). Graded BHP increments increased Pclose for all directions and up to 29%-43% at 4 mm (relative to the original BHP). Anterior-based SHR decreased Pclose (approximately -115% at 4 mm) and increased ΔCSA (approximately +35% at 4 mm). Cranial SHR decreased ΔPclose (-29%), minimally affecting CSA. Caudal SHR increased ΔPclose (+27%) and decreased ΔCSA (-7%). Anterior-cranial and anterior-caudal SHR produced the highest stresses and strains. SHR effects on UA outcomes were dependent on BHP, with more caudal BHPs leading to less effective surgeries. In conclusion, BHP (phenotype) and SHR both alter UA outcomes, with effects dependent on hyoid displacement direction and magnitude. BHP influences the effectiveness of SHR in reducing UA collapsibility. These findings provide further insights into the hyoid's role in UA patency and suggest that considering the hyoid's baseline position and surgical repositioning direction/increment may help improve hyoid surgeries for OSA treatment.NEW & NOTEWORTHY Using computational modeling, this study directly shows that any shift from the healthy natural hyoid bone position increases upper airway collapsibility. Surgical hyoid repositioning alters upper airway outcomes in a direction- and magnitude-dependent manner, with its effects influenced by the natural hyoid position. Accounting for both the natural hyoid position and individually prescribed surgical repositioning may enhance upper airway stability and improve outcomes in obstructive sleep apnea (OSA) treatment.

Mechanical mechanism to induce inspiratory flow limitation in obstructive sleep apnea patients revealed from in-vitro studies

Inspiratory flow limitation means that when the flowrate reaches a certain value, it no longer increases, or even decreases, which is called negative effort dependence flow limitation, even if the inspiration effort is increased. This occurs often in obstructive sleep apnea patients, but its mechanism remains unclear. To reveal the mechanism of inspiratory flow limitation, we constructed a unique partially collapsible in-vitro upper airway model of obstructive sleep apnea patients to observe the change of airway resistance with inspiratory driving pressure. The important findings demonstrate that with the increase of inspiratory effort, the driving pressure increases faster than the airway resistance in the early stages, and then the reverse occurs as the airway becomes narrower. The airway collapse caused by the transmural pressure can lead to a rapid increase in downstream resistance with the increase of inspiratory effort, which is the key reason causing the flow reduction and the formation of typical negative effort dependence flow limitation. The mechanical mechanism revealed in this study will lead to fully new insights into the study and treatment of obstructive sleep apnea.

Sealing mechanism study of laryngeal mask airways via 3D modelling and finite element analysis

Proper sealing of laryngeal mask airways (LMAs) is critical for airway management in clinical use. Understanding the sealing mechanism can significantly help front-line anaesthetists to reduce the incidence of adverse events. However, anaesthetists, who may not have the most substantial engineering backgrounds, lack intuitive ways to develop an understanding of the LMA sealing mechanism effectively. The paper aims to study the LMA-pharynx sealing mechanisms from the perspective of front-line anaesthetists. We use a computer-aided 3D modelling technique to visualise the LMA—pharynx interactions, which helps anaesthetists identify the critical areas of complications. Furthermore, we conduct a quantitative pressure distribution analysis of the LMA-pharynx contacting surface using the finite element analysis technique, which helps further understand the sealing mechanics in those areas. We present two cases studies based on one male volunteer, aged 50, inserted with a ProSeal LMA. In the first case, a relatively low cuff pressure (CP) was applied to simulate the clinical circumstances in which complications related to air leakage are most likely to happen; in the second case, we increase the CP to a relatively high value to simulate the scenarios with an increased risk of complications related to high mucosal pressure. The experiments suggest the follows: (1) Sore throat complications related to high mucosal pressure is most likely to occur in the hypopharynx with a high CP setting, particularly in the areas where the cricoid cartilage presses the mucosa. (2) The narrow hyoid bone super horn width likely causes LMA insertion difficulties. (3) Insufficient CP will significantly increase the risk of air leakage in the oropharynx. A complete sealing pressure line in the contacting surface will be formed with sufficient CP, thereby preventing the air leakage into the oral.

The Biomechanical Mechanism of Upper Airway Collapse in OSAHS Patients Using Clinical Monitoring Data during Natural Sleep

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common sleep disorder characterized by repeated pharyngeal collapse with partial or complete obstruction of the upper airway. This study investigates the biomechanics of upper airway collapse of OSASH patients during natural sleep. Computerized tomography (CT) scans and data obtained from a device installed on OSASH patients, which is comprised of micro pressure sensors and temperature sensors, are used to develop a pseudo three-dimensional (3D) finite element (FE) model of the upper airway. With consideration of the gravity effect on the soft palate while patients are in a supine position, a fluid–solid coupling analysis is performed using the FE model for the two respiratory modes, eupnea and apnea. The results of this study show that the FE simulations can provide a satisfactory representation of a patient’s actual respiratory physiological processes during natural sleep. The one-way valve effect of the soft palate is one of the important mechanical factors causing upper airway collapse. The monitoring data and FE simulation results obtained in this study provide a comprehensive understanding of the occurrence of OSAHS and a theoretical basis for the individualized treatment of patients. The study demonstrates that biomechanical simulation is a powerful supplementation to clinical monitoring and evaluation.

Predicting critical closing pressure in children with obstructive sleep apnea using fluid-structure interaction

Surgical treatment of obstructive sleep apnea (OSA) in children requires knowledge of upper airway dynamics, including the closing pressure (Pcrit), a measure of airway collapsibility. We applied a flow-structure interaction (FSI) computational model to estimate Pcrit in patient-specific upper airway models obtained from magnetic resonance imaging (MRI) scans. We sought to examine the agreement between measured and estimated Pcrit from FSI models in children with Down syndrome. We hypothesized that the estimated Pcrit would accurately reflect measured Pcrit during sleep and therefore reflect the severity of OSA as measured by the obstructive apnea-hypopnea index (AHI). All participants (n = 41) underwent polysomnography and sedated sleep MRI scans. We used Bland-Altman plots to examine the agreement between measured and estimated Pcrit. We determined associations between estimated Pcrit and OSA severity, as measured by AHI, using regression models. The agreement between passive and estimated Pcrit showed a fixed bias of -1.31 [confidence interval (CI) = -2.78, 0.15] and a nonsignificant proportional bias. A weaker agreement with active Pcrit was observed. A model including AHI, gender, an interaction term for AHI, and gender and neck circumference explained the largest variation (R2 = 0.61) in the relationship between AHI and estimated Pcrit (P < 0.0001). Overlap between the areas of the airway with the lowest stiffness, and areas of collapse on dynamic MRI, was 77.4 ± 30% for the nasopharyngeal region and 78.6 ± 33% for the retroglossal region. The agreement between measured and estimated Pcrit and the significant association with AHI supports the validity of Pcrit estimates from the FSI model.NEW & NOTEWORTHY We present a noninvasive method for estimating critical closing pressure (Pcrit) using fluid-structure interaction (FSI) simulations and magnetic resonance imaging (MRI) scans in patients with obstructive sleep apnea (OSA). We used patient-specific stiffness measures in our FSI model to account for any individual variability in the elasticity of soft tissues surrounding the upper airway. We validated this model by measuring the degree of agreement between measured and estimated Pcrit.

Estimation of the hyperelastic parameters of fresh human oropharyngeal soft tissues using indentation testing

Patient-specific finite element (FE) modeling of the upper airway is an effective tool for accurate assessment of obstructive sleep apnea (OSA) syndrome. It is also useful for planning minimally invasive surgical procedures under severe OSA conditions. A major requirement of FE modeling is having reliable data characterizing the biomechanical properties of the upper airway tissues, particularly oropharyngeal soft tissue. While some data characterizing this tissue's linear elastic regime is available, reliable data characterizing its hyperelasticity is scarce. The aim of the current study is to estimate the hyperelastic mechanical properties of the oropharyngeal soft tissues, including the palatine tonsil, soft palate, uvula, and tongue base. Fresh tissue specimens of human oropharyngeal tissue were acquired from 13 OSA patients who underwent standard surgical procedures. Indentation testing was performed on the specimens to obtain their force-displacement data. To determine the specimens' hyperelastic parameters using these data, an inverse FE framework was utilized. In this work, the hyperelastic parameters corresponding to the commonly used Yeoh and 2nd order Ogden models were obtained. Both models captured the experimental force-displacement data of the tissue specimens reasonably accurately with mean errors of 11.65% or smaller. This study has provided estimates of the hyperelastic parameters of all upper airway soft tissues using fresh human tissue specimens for the first time.

Modeling the upper airway: A precursor to personalized surgical interventions for the treatment of sleep apnea

An accurate benchtop model was developed to mimic the different forms of human upper airway collapse in adult sleep apnea patients. This was done via modeling the airway through digital imaging. Airway representative models were then produced in two steps via a customized pneumatic extrusion 3D printing system. This allowed the pressure of collapse and planes of collapse to be manipulated to accurately represent those seen in sleep apnea patients. The pressure flow relationships of the collapsible airways were then studied by inserting the collapsible airways into a module that allowed the chamber pressure (P_c ) around the airways to be increased in order to cause collapse. Airways collapsed at physiologically relevant pressures (5.32-9.58 cmH₂ O). Nickel and iron magnetic polymers were then printed into the airway in order to investigate the altering of the airway collapse. The introduction of the nickel and iron magnetic polymers increased the pressure of collapse substantially (7.38-17.51 cmH₂ O). Finally, the force produced by the interaction of the magnetic polymer and the magnetic module was studied by measuring a sample of the magnetic airways. The peak force in (48.59-163.34 cN) and the distance over which the forces initially registered (6.8-9.7 mm) were measured using a force transducer. This data set may be used to inform future treatment of sleep apnea, specifically the production of an implantable polymer for surgical intervention.

Outcome predictors for non-resective pharyngoplasty alone or as a part of multilevel surgery, in obstructive sleep apnea-hypopnea syndrome

PURPOSE

Non-resective pharyngoplasty techniques have been shown to be effective to treat oropharyngeal collapse in patients affected by obstructive sleep apnea-hypopnea syndrome (OSAHS). The aim of our study is to evaluate outcome predictors in a cohort of patients affected by OSAHS and treated with non-resective pharyngoplasty, including variation of pharyngeal measures at the end of the surgical procedure.

METHODS

A cohort of patients affected by OSAHS, with palatal or lateral pharyngeal wall collapse, who underwent non-resective pharyngoplasty, were enrolled between 2014 and 2017. Surgical procedures encompassed non-resective pharyngoplasty by expansion sphincter pharyngoplasty (ESP) or barbed antero-lateral pharyngoplasty with barbed reposition pharyngoplasty (BRP) or barbed suspension pharyngoplasty (BSP) techniques, eventually associated with nasal surgery. Pharyngeal measures were recorded intraoperatively and their variation at the end of the procedure was considered. Surgical success was evaluated at least 6 months after surgery with respiratory polygraphy and ESS questionnaire. Outcome predictors were examined by multivariable logistic regression and ROC curve analysis.

RESULTS

Seventy patients met the study inclusion criteria. ESP, BRP, and BSP in a uni-/multilevel setting led to significant improvement of all respiratory polygraphic parameters and daily sleepiness (p < 0.0001). Outcome analysis showed that greater variation of antero-posterior pharyngeal measure was associated with success (p = 0.01), with an optimal cutoff value of 8.5 mm; low AHI_pre, high ESS_pre, and antero-lateral pharyngoplasty with barbed sutures were associated with a higher rate of cure (p < 0.05).

CONCLUSIONS

Non-resective pharyngoplasty is effective in treating OSAHS patients affected by palatal or lateral pharyngeal wall collapse, and intraoperative variation of antero-posterior width may be a useful tool to predict surgical success.

Threshold of the upper airway cross-section for hypopnea onset during sleep and its identification under waking condition

Background

There is currently no method that can predict whether or under what condition hypopnea, even obstructive sleep apnea (OSA), will occur during sleep for individuals based on credible parameters measured under waking condition. We propose a threshold concept based on the narrowest cross-sectional area of the upper airway (CSA-UA) and aim to prove our hypothesis on the threshold of the area for hypopnea onset (TAHO), which can be used as an indicator of hypopnea onset during sleep and measured while awake.

Methods

We performed magnetic resonance imaging for 20 OSA patients to observe CSA-UA changes during fluid accumulation in the neck caused by elevating their legs, and identified TAHO by capturing the sudden enlargement in CSA-UA. Correlation analyses between TAHO and the body mass index (BMI), and between the reduction in CSA-UA and the increase in the neck circumference (NC) with fluid accumulation were performed. Logistic regression analysis was performed for identifying OSA patients based on the behaviors of their CSA-UA changes during leg raising. Shape changes of airway cross-section were also investigated.

Results

Four CSA-UA change patterns after fluid redistribution were identified. Six patients had similar CSA-UA variation behaviors observed in healthy subjects. From the other three change patterns involving 14 patients, a threshold value of CSA-UA 0.63 ± 0.21 cm² was identified for normal breathing. Data showed a positive correlation between TAHO and BMI (r = 0.681, p = 0.0007), and a negative correlation between the reduction in CSA-UA and the increase in NC (r = − 0.513, p = 0.051) with fluid accumulation. A sigmoid function for the probability of being a OSA patient p = 1/[1 + exp. (4.836 + 3.850 t-8.4 h)] was obtained to effectively separate OSA patients from normal subjects. The upper airway narrowing occurred in anteroposterior, lateral, or both directions, suggesting different tendencies of upper airway collapse in patients. Three types of shape changes in the cross-section of the upper airway, which had different effects on airway resistance, were measured.

Conclusions

Our findings prove TAHO hypothesis. The threshold measured while awake for normal breathing can be used clinically as the indicator of hypopnea onset during sleep, and therefore to identify OSA patients under waking condition and design effective personalized treatments for OSA patients. Both shape and size changes in the cross-section of the upper airway affect airway resistance significantly. Shape change in the cross-section of the upper airway can provide key clinical information on the collapse patterns of the upper airway for individuals.

Direct visualizations of air flow in the human upper airway using in-vitro models

A better understanding of airflow characteristics in the upper airway (UA) is crucial in investigating obstructive sleep apnea (OSA), particle sedimentation, drug delivery, and many biomedical problems. Direct visualization of air flow patterns in in-vitro models with realistic anatomical structures is a big challenge. In this study, we constructed unique half-side transparent physical models of normal UA based on realistic anatomical structures. A smoke-wire method was developed to visualize the air flow in UA models directly. The results revealed that the airflow through the pharynx was laminar but not turbulent under normal inspiration, which suggested that compared with turbulent models, a laminar model should be more suitable in numerical simulations. The flow predicted numerically using the laminar model was consistent with the observations in the physical models. The comparison of the velocity fields predicted numerically using the half-side and complete models confirmed that it was reasonable to investigate the flow behaviors in UA using the half-side model. Using the laminar model, we simulated the flow and evaluated the effects of UA narrowing caused by rostral fluid shift on pharyngeal resistance. The results suggested that fluid shift could play an important role in the formation of hypopnea or OSA during sleep.

The Finite Element Simulation of the Upper Airway of Patients with Moderate and Severe Obstructive Sleep Apnea Hypopnea Syndrome

Objectives

To investigate the snoring modes of patients with Obstructive Sleep Apnea Hypopnea Syndrome and to discover the main sources of snoring in soft tissue vibrations.

Methods

A three-dimensional finite element model was developed with SolidEdge to simulate the human upper airway. The inherent modal simulation was conducted to obtain the frequencies and the corresponding shapes of the soft tissue vibrations. The respiration process was simulated with the fluid-solid interaction method through ANSYS.

Results

The first 6 orders of modal vibration were 12 Hz, 18 Hz, 21 Hz, 22 Hz, 36 Hz, and 39 Hz. Frequencies of modes 1, 2, 4, and 5 were from tongue vibrations. Frequencies of modes 3 and 6 were from soft palate vibrations. Steady pressure distribution and air distribution lines in the upper airway were shown clearly in the fluid-solid interaction simulation results.

Conclusions

We were able to observe the vibrations of soft tissue and the modeled airflow by applying the finite element methods. Future studies could focus on improving the soft tissues vibration compliances by adjusting the model parameters. Additionally, more attention should be paid to vibrational components below 20 Hz when performing an acoustic analysis of human snore sounds due to the presence of these frequencies in this model.

In vivo measurements of human neck skin elasticity using MRI and finite element modeling

PURPOSE

The assessment of mechanical properties of the human skin is very important in investigating the mechanism of obstructive sleep apnea, a common disorder characterized by repetitive collapse and obstruction of the upper airway during sleep. In this study, a unique method, combining magnetic resonance imaging (MRI) and finite element modeling (FEM), was developed to obtain the value of the in vivo elastic modulus of the neck skin.

MEHTHOD

A total of 22 subjects, 16 males and six females, were recruited to participate in the MRI studies. The changes in the airway and the neck size resulting from fluid shift from the lower body to the neck were measured based on the MR images. A two-dimensional plane strain FE model was built to simulate such changes in the neck cross-section for each subject.

RESULTS

Solving an inverse problem using FEM by matching the measured data, we obtained the in vivo elastic modulus of the neck skin to be 1.78 ± 1.73 MPa. Results showed that the elastic modulus tended to increase with age and body mass index for these subjects. A sensitivity analysis of the muscle and fat mechanical parameters was also performed to test their effects on the predicted skin elasticity.

CONCLUSION

The unique method developed in this study for measuring the in vivo elastic modulus of the neck skin is quite effective, and the skin elasticity value obtained using this method is credible.

Development and validation of a computational finite element model of the rabbit upper airway: simulations of mandibular advancement and tracheal displacement

The mechanisms leading to upper airway (UA) collapse during sleep are complex and poorly understood. We previously developed an anesthetized rabbit model for studying UA physiology. On the basis of this body of physiological data, we aimed to develop and validate a two-dimensional (2D) computational finite element model (FEM) of the passive rabbit UA and peripharyngeal tissues. Model geometry was reconstructed from a midsagittal computed tomographic image of a representative New Zealand White rabbit, which included major soft (tongue, soft palate, constrictor muscles), cartilaginous (epiglottis, thyroid cartilage), and bony pharyngeal tissues (mandible, hard palate, hyoid bone). Other UA muscles were modeled as linear elastic connections. Initial boundary and contact definitions were defined from anatomy and material properties derived from the literature. Model parameters were optimized to physiological data sets associated with mandibular advancement (MA) and caudal tracheal displacement (TD), including hyoid displacement, which featured with both applied loads. The model was then validated against independent data sets involving combined MA and TD. Model outputs included UA lumen geometry, peripharyngeal tissue displacement, and stress and strain distributions. Simulated MA and TD resulted in UA enlargement and nonuniform increases in tissue displacement, and stress and strain. Model predictions closely agreed with experimental data for individually applied MA, TD, and their combination. We have developed and validated an FEM of the rabbit UA that predicts UA geometry and peripharyngeal tissue mechanical changes associated with interventions known to improve UA patency. The model has the potential to advance our understanding of UA physiology and peripharyngeal tissue mechanics.

Tailored treatment strategies for obstructive sleep apnea

Obstructive sleep apnea (OSA) is characterized by repetitive collapse of the upper airway (UA) during sleep and is associated with chronic intermittent hypoxemia, catecholamine surges, and sleep disrupt. Multiple pathophysiological risk factors have been identified and contribute to OSA, including anatomical abnormalities (elevated UA mechanical load), compromised UA dilators, increased loop gain (unstable respiratory control), and decreased arousal threshold. These factors may contribute to the pathophysiology of sleep apnea in different individuals and recent evidence suggests that treatment may be targeted towards underlying pathophysiological mechanism. In some cases, combination therapy may be required to treat the condition.

A Method for Accurate Reconstructions of the Upper Airway Using Magnetic Resonance Images

Objective

The purpose of this study is to provide an optimized method to reconstruct the structure of the upper airway (UA) based on magnetic resonance imaging (MRI) that can faithfully show the anatomical structure with a smooth surface without artificial modifications.

Methods

MRI was performed on the head and neck of a healthy young male participant in the axial, coronal and sagittal planes to acquire images of the UA. The level set method was used to segment the boundary of the UA. The boundaries in the three scanning planes were registered according to the positions of crossing points and anatomical characteristics using a Matlab program. Finally, the three-dimensional (3D) NURBS (Non-Uniform Rational B-Splines) surface of the UA was constructed using the registered boundaries in all three different planes.

Results

A smooth 3D structure of the UA was constructed, which captured the anatomical features from the three anatomical planes, particularly the location of the anterior wall of the nasopharynx. The volume and area of every cross section of the UA can be calculated from the constructed 3D model of UA.

Conclusions

A complete scheme of reconstruction of the UA was proposed, which can be used to measure and evaluate the 3D upper airway accurately.

Future of Sleep-Disordered Breathing Therapy Using a Mechanistic Approach

Sleep disordered breathing (SDB) is highly prevalent among patients with cardiovascular disease (CVD), and the relationship between SDB and CVD may be bidirectional. However, SDB remains underdiagnosed and undertreated. One of the major barriers identified by cardiologists is lack of satisfaction with SDB therapy. This situation could be the result of the discordance between treatment and the pathophysiological characteristics of SDB. This condition is caused by multiple pathophysiological mechanisms, which could be classified into upper airway anatomic compromise, pharyngeal dilator muscle dysfunction, and ventilatory control instability. However, the effective treatment of SDB remains limited, and positive airway pressure therapy is still the mainstay of the treatment. Therefore, we review the pathophysiological characteristics of SDB in this article, and we propose to provide individualized treatment of SDB based on the underlying mechanism. This approach requires further study but could potentially improve adherence and success of therapy.

Development of a computational biomechanical model of the human upper-airway soft-tissues toward simulating obstructive sleep apnea

Numerous challenges are faced in investigations aimed at developing a better understanding of the pathophysiology of obstructive sleep apnea (OSA). The anatomy of the tongue and other upper-airway tissues, and the ability to model their behavior, are central to such investigations. We present details of the construction and development of a soft-tissue model of the human upper airway, with the ultimate goal of simulating obstructive sleep apnea. The steps taken to produce a representative anatomical geometry, of which the associated muscle histology is also captured, are documented. An overview of the mathematical models used to describe tissue behavior, both at a macro- and microscopic level, is given. A neurological model, which mimics the proprioceptive capabilities of the body, is described as it is applies to control of the active dynamics of the tongue. A simplified scenario, which allows for the manipulation of several environmental influences, is presented. It is demonstrated that the response of the genioglossus is qualitatively similar to that determined through experimental techniques. Furthermore, insights into the stress distribution developed within the tongue are discussed. It is shown that changes in almost any aspect of the breathing or physiological conditions invoke a significant change in the response of the airway dilators. The results of this study provide further evidence of the importance of modeling and simulation techniques as an aid in understanding the complex behavior of the human body.

Implementation and validation of a 1D fluid model for collapsible channels

A 1D fluid model is implemented for the purpose of fluid-structure interaction (FSI) simulations in complex and completely collapsible geometries, particularly targeting the case of obstructive sleep apnea (OSA). The fluid mechanics are solved separately from any solid mechanics, making possible the use of a highly complex and/or black-box solver for the solid mechanics. The fluid model is temporally discretized with a second-order scheme and spatially discretized with an asymmetrical fourth-order scheme that is robust in highly uneven geometries. A completely collapsing and reopening geometry is handled smoothly using a modified area function. The numerical implementation is tested with two driven-geometry cases: (1) an inviscid analytical solution and (2) a completely closing geometry with viscous flow. Three-dimensional fluid simulations in static geometries are performed to examine the assumptions of the 1D model, and with a well-defined pressure-recovery constant the 1D model agrees well with 3D models. The model is very fast computationally, is robust, and is recommended for OSA simulations where the bulk flow pressure is primarily of interest.

The biomechanics of the human tongue

The human tongue is composed mainly of skeletal muscle tissue and has a complex architecture. Its anatomy is characterised by interweaving yet distinct muscle groups. It is a significant contributor to the phenomenon of obstructive sleep apnoea syndrome. A realistic model of the tongue and computational simulations are important in areas such as linguistics and speech therapy. The aim of this work is to report on the construction of a geometric and constitutive model of the human tongue and to demonstrate its use in computational simulations for obstructive sleep apnoea syndrome research. The geometry of the tongue and each muscle group of the tongue, including muscle fibre orientations, are captured from the Visible Human Project dataset. The fully linear muscle model is based on the Hill three-element model that represents the constituent parts of muscle fibres. The mechanics of the model are limited to quasi-static, small-strain, linear-elastic behaviour. The main focus of this work is on the material directionality and muscle activation. The transversely isotropic behaviour of the muscle tissue is accounted for, as well as the influence of muscle activation. The behaviour of the model is illustrated in a number of benchmark tests and for the case of a subject in the supine position.

Noninvasive estimation of pharyngeal airway resistance and compliance in children based on volume-gated dynamic MRI and computational fluid dynamics

Computational fluid dynamics (CFD) analysis was used to model the effect of collapsing airway geometry on internal pressure and velocity in the pharyngeal airway of three sedated children with obstructive sleep apnea syndrome (OSAS) and three control subjects. Model geometry was reconstructed from volume-gated magnetic resonance images during normal tidal breathing at 10 increments of tidal volume through the respiratory cycle. Each geometry was meshed with an unstructured grid and solved using a low-Reynolds number k-ω turbulence model driven by flow data averaged over 12 consecutive breathing cycles. Combining gated imaging with CFD modeling created a dynamic three-dimensional view of airway anatomy and mechanics, including the evolution of airway collapse and flow resistance and estimates of the local effective compliance. The upper airways of subjects with OSAS were generally much more compliant during tidal breathing. Compliance curves (pressure vs. cross-section area), derived for different locations along the airway, quantified local differences along the pharynx and between OSAS subjects. In one subject, the distal oropharynx was more compliant than the nasopharynx (1.028 vs. 0.450 mm(2)/Pa) and had a lower theoretical limiting flow rate, confirming the distal oropharynx as the flow-limiting segment of the airway in this subject. Another subject had a more compliant nasopharynx (0.053 mm(2)/Pa) during inspiration and apparent stiffening of the distal oropharynx (C = 0.0058 mm(2)/Pa), and the theoretical limiting flow rate indicated the nasopharynx as the flow-limiting segment. This new method may help to differentiate anatomical and functional factors in airway collapse.

Onset of airflow limitation in a collapsible tube model: impact of surrounding pressure, longitudinal strain, and wall folding geometry

We studied the impact of wall strain and surrounding pressure on the onset of airflow limitation in a thin-walled “floppy” tube model. A vacuum source-generated steady-state (baseline) airflow (0–350 ml/s) through a thin-walled latex tube (length 80 mm, wall thickness 0.23 mm) enclosed within a rigid, sealed, air-filled, cylindrical chamber while upstream minus downstream pressure, chamber pressure (Pc), and lumen geometry [in-line digital camera; segmentation (Amira 5.2.2) and analysis (Rhinoceros 4) software] were monitored. Longitudinal strain (S; 0–62.5%) and Pc (0–20 cmH2O) combinations were imposed, and Pc associated with onset of 1) reduced airflow and 2) fully developed airflow limitation recorded. At any strain, increasing Pc resulted in a decrease in airflow. Across all baseline airflow, threshold pressure was 1–7 cmH2O for S < 25%, 6–8 cmH2O at S = 25% and 37.5%, and 5–7 cmH2O at S = 50% and 62.5%. Pc associated with fully developed airflow limitation was 4–6 cmH2O for S < 25%, >20 cmH2O at S = 25% (i.e., no flow limitation), 18 cmH2O at S = 37.5%, and 8–12 cmH2O at S = 50% and 62.5%. Lumen area decreased with increasing Pc but was 1) larger at S = 25% and 2) characterized by bifold narrowing at S < 25% and trifold narrowing at S ≥ 25%. In conclusion, tube function was modulated by Pc vs. S interactions, with S = 25% producing trifold lumen narrowing, maximal patency, and no airflow limitation. Findings may have implications for understanding peripharyngeal tissue pressure and pharyngeal wall strain effects on passive pharyngeal airway function in humans.

An integrative model of respiratory and cardiovascular control in sleep-disordered breathing

While many physiological control models exist in the literature, none thus far has focused on characterizing the interactions among the respiratory, cardiovascular and sleep-wake regulation systems that occur in sleep-disordered breathing. The model introduced in this study integrates the autonomic control of the cardiovascular system, chemoreflex and state-related control of respiration, including respiratory and upper airway mechanics, along with a model of circadian and sleep-wake regulation. The integrative model provides realistic predictions of the physiological responses under a variety of conditions including: the sleep-wake cycle, hypoxia-induced periodic breathing, Cheyne-Stokes respiration in chronic heart failure, and obstructive sleep apnoea (OSA). It can be used to investigate the effects of a variety of interventions, such as isocapnic and hypercapnic and/or hypoxic gas administration, the Valsalva and Mueller maneuvers, and the application of continuous positive airway pressure on OSA subjects. By being able to delineate the influences of the various interacting physiological mechanisms, the model is useful in providing a more lucid understanding of the complex dynamics that characterize state-cardiorespiratory control in the different forms of sleep-disordered breathing.

Modeling upper airway collapse by a finite element model with regional tissue properties

This study presents a new computational system for modeling the upper airway in rats that combines tagged magnetic resonance imaging (MRI) with tissue material properties to predict three-dimensional (3D) airway motion. The model is capable of predicting airway wall and tissue deformation under airway pressure loading up to airway collapse. The model demonstrates that oropharynx collapse pressure depends primarily on ventral wall (tongue muscle) elastic modulus and airway architecture. An iterative approach that involves substituting alternative possible tissue elastic moduli was used to improve model precision. The proposed 3D model accounts for stress-strain relationships in the complex upper airway that should present new opportunities for understanding pathogenesis of airway collapse, improving diagnosis and developing treatments.

Potential therapeutic targets in obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is a disease of ever-increasing importance due to its association with multiple impairments and rising prevalence in an increasingly susceptible demographic. The syndrome is linked with loud snoring, disrupted sleep and observed apnoeas. Serious co-morbidities associated with OSA appear to be reversed by continuous positive airway pressure (CPAP) treatment; however, CPAP is variably tolerated leaving many patients untreated and emphasising the need for alternative treatments. Virtually all OSA patients have airways that are anatomically vulnerable to collapse, but numerous pathophysiological factors underlie when and how OSA is manifested. This review describes how the complexity of OSA requires multiple treatment approaches that are individually targeted. This approach may take the form of more specific diagnoses in terms of the mechanisms underlying OSA as well as rational pharmacological treatment directed toward such disparate ends as arousal threshold and ventilatory control/chemosensitivity, and mechanical treatment in the form of surgery and augmentation of lung volumes.

Investigation of obstructive sleep apnea using nonlinear mode interactions in nonstationary snore signals

Acoustic studies on snoring sounds have recently drawn attention as a potential alternative to polysomnography in the diagnosis of obstructive sleep apnea (OSA). This paper investigates the feasibility of using nonlinear coupling between frequency modes in snore signals via wavelet bicoherence (WBC) analysis for screening of OSA. Two novel markers (PF1 and PSF), which are frequency modes with high nonlinear coupling strength in their respective WBC spectrum, are proposed to differentiate between apneic and benign snores in same- or both-gender snorers. Snoring sounds were recorded from 40 subjects (30 apneic and 10 benign) by a hanging microphone, and subsequently preprocessed within a wavelet transform domain. Forty inspiratory snores (30 as training and 10 as test data) from each subject were examined. Results demonstrate that nonlinear mode interactions in apneic snores are less self-coupled and usually occupy higher and wider frequency ranges than that of benign snores. PF1 and PSF are indicative of apneic and benign snores (p < 0.0001), with optimal thresholds of PF1 = 285 Hz and PSF = 492 Hz (for both genders combined), as well as sensitivity and specificity values between 85.0 and 90.7%, respectively, outperforming the conventional diagnostic indicator (spectral peak frequency, PF = 243-275 Hz, sensitivity = 77.7-79.7%, specificity = 72.0-78.0%, p < 0.0001). Relationships between apnea-hypopnea index and the proposed markers could likely take the functional form of exponential or power. Perspectives on nonlinear dynamics analysis of snore signals are promising for further research and development of a reliable and inexpensive diagnostic tool for OSA.

Upper airway length may be associated with the severity of obstructive sleep apnea syndrome

OBJECTIVES

The exact pathophysiology leading to pharyngeal collapse in obstructive sleep apnea syndrome (OSAS) remains incompletely understood. Prior research has shown that normal men have a longer pharyngeal airway than women, and it has been hypothesized that this difference may play a role in the gender-related differences in OSAS. In the current study, we sought to study the potential relationship between the length of the collapsible pharyngeal segment, the upper airway length (UAL), and the severity of OSAS.

STUDY DESIGN

The hospital records were searched for all patients who had had polysomnography and also had had a computed tomography of the neck. A total of 24 such patients were identified who participated (15 men and nine women).

MEASUREMENTS AND RESULTS

The UAL, the distance between the lower posterior part of the hard palate bone to the upper posterior part of the hyoid bone, was measured for all participants in the midsagittal plane. A correlation coefficient (Pearson r) of 0.406 was found between Respiratory Disturbance Index (RDI) and UAL (p = 0.049). When UAL was normalized to body height, a correlation coefficient (r) of 0.423 was found (p = 0.039). A gender-related difference in UAL was also found. Men with OSAS were found to have longer UAL even when normalized to body height (p = 0.003, unpaired t test) as compared with OSAS women.

CONCLUSION

This study provides potential clinical relevance to prior studies in normal subjects, by demonstrating that men with OSAS have longer UAL than women with OSAS, independent of body size. In addition, the significant correlation between UAL and OSAS severity suggests that UAL may play a role in the pathophysiology of OSAS. These findings are consistent with our predictions from computational modeling studies.

Pathophysiology of adult obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive narrowing or collapse of the pharyngeal airway during sleep. The disorder is associated with major comorbidities including excessive daytime sleepiness and increased risk of cardiovascular disease. The underlying pathophysiology is multifactorial and may vary considerably between individuals. Important risk factors include obesity, male sex, and aging. However, the physiological mechanisms underlying these risk factors are not clearly understood. This brief review summarizes the current understanding of OSA pathophysiology in adults and highlights the potential mechanisms underlying the principal risk factors. In addition, some of the pathophysiological characteristics associated with OSA that may modulate disease severity are illustrated. Finally, the potential for novel treatment strategies, based on an improved understanding of the underlying pathophysiology, is also discussed with the ultimate aim of stimulating research ideas in areas where knowledge is lacking.

Simulation of Turbulent Airflow Using a CT Based Upper Airway Model of a Racehorse

Computational model for airflow through the upper airway of a horse was developed. Previous flow models for human airway do not hold true for horses due to significant differences in anatomy and the high Reynolds number of flow in the equine airway. Moreover, models that simulate the entire respiratory cycle and emphasize on pressures inside the airway in relation to various anatomical diseases are lacking. The geometry of the airway was created by reconstructing images obtained from computed tomography scans of a thoroughbred racehorse. Different geometries for inhalation and exhalation were used for the model based on the difference in the nasopharynx size during the two phases of respiration. The Reynolds averaged Navier–Stokes equations were solved for the isothermal flow with the standard k-ϵ model for turbulence. Transient pressure boundary conditions for the entire breathing cycle were obtained from past experimental studies on live horses. The flow equations were solved in a commercial finite volume solver. The flow rates, computed based on the applied pressure conditions, were compared to experimentally measured flow rates for model validation. Detailed analysis of velocity, pressure, and turbulence characteristics of the flow was done. Velocity magnitudes at various slices during inhalation were found to be higher than corresponding velocity magnitudes during exhalation. The front and middle parts of the nasopharynx were found to have minimum intraluminal pressure in the airway during inhalation. During exhalation, the pressures in the soft palate were higher compared to those in the larynx, epiglottis, and nasopharynx. Turbulent kinetic energy was found to be maximum at the entry to the airway and gradually decreased as the flow moved inside the airway. However, turbulent kinetic energy increased in regions of the airway with abrupt change in area. Based on the analysis of pressure distribution at different sections of the airway, it was concluded that the front part of the nasopharynx requires maximum muscular activity to support it during inhalation. During exhalation, the soft palate is susceptible to displacements due to presence of high pressures. These can serve as critical information for diagnosis and treatment planning of diseases known to affect the soft palate and nasopharynx in horses, and can potentially be useful for human beings.

Flow-induced oscillation of collapsed tubes and airway structures

The self-excited oscillation of airway structures and flexible tubes in response to flow is reviewed. The structures range from tiny airways deep in the lung causing wheezing at the end of a forced expiration, to the pursed lips of a brass musical instrument player. Other airway structures that vibrate include the vocal cords (and their avian equivalent, the syrinx) and the soft palate of a snorer. These biological cases are compared with experiments on and theories for the self-excited oscillation of flexible tubes conveying a flow on the laboratory bench, with particular reference to those observations dealing with the situation where the inertia of the tube wall is dominant. In each case an attempt is made to summarise the current state of understanding. Finally, some outstanding challenges are identified.

Analysis of the interplay between neurochemical control of respiration and upper airway mechanics producing upper airway obstruction during sleep in humans

Increased loop gain (a function of both controller gain and plant gain), which results in instability in feedback control, is of major importance in producing recurrent central apnoeas during sleep but its role in causing obstructive apnoeas is not clear. The purpose of this study was to investigate the role of loop gain in producing obstructive sleep apnoeas. Owing to the complexity of factors that may operate to produce obstruction during sleep, we used a mathematical model to sort them out. The model used was based on our previous model of neurochemical control of breathing, which included the effects of chemical stimuli and changes in alertness on respiratory pattern generator activity. To this we added a model of the upper airways that contained a narrowed section which behaved as a compressible elastic tube and was tethered during inspiration by the contraction of the upper airway dilator muscles. These muscles in the model, as in life, responded to changes in hypoxia, hypercapnia and alertness in a manner similar to the action of the chest wall muscles, opposing the compressive action caused by the negative intraluminal pressure generated during inspiration which was magnified by the Bernoulli Effect. As the velocity of inspiratory airflow increased, with sufficiently large increase in airflow velocity, obstruction occurred. Changes in breathing after sleep onset were simulated. The simulations showed that increases in controller gain caused the more rapid onset of obstructive apnoeas. Apnoea episodes were terminated by arousal. With a constant controller gain, as stiffness decreased, obstructed breaths appeared and periods of obstruction recurred longer after sleep onset before disappearing. Decreased controller gain produced, for example, by breathing oxygen eliminated the obstructive apnoeas resulting from moderate reductions in constricted segment stiffness. This became less effective as stiffness was reduced more. Contraction of the upper airway muscles with hypercapnia and hypoxia could prevent obstructed apnoeas with moderate but not with severe reductions in stiffness. Increases in controller gain, as might occur with hypoxia, converted obstructive to central apnoeas. Breathing CO2 eliminated apnoeas when the activity of the upper airway muscles was considered to change as a function of CO2 to some exponent. Low arousal thresholds and increased upper airway resistance are two factors that promoted the occurrence and persistence of obstructive sleep apnoeas.

Use of computational modeling to predict responses to upper airway surgery in obstructive sleep apnea

OBJECTIVES

Despite the well-recognized consequences of obstructive sleep apnea (OSA), its treatment remains unsatisfactory. Therapeutic strategies are complicated by often poor adherence in the case of continuous positive airway pressure or the highly variable efficacy in the case of many upper airway surgeries. Computational models of the upper airway using finite element analysis to simulate the effects of various anatomic and physiologic manipulations on pharyngeal mechanics could be helpful in predicting surgical success.

STUDY DESIGN

Computational and physiologic study.

METHODS

Using representative OSA magnetic resonance images and experimentally measured upper airway dilator muscle activities, we developed a working two-dimensional and a partial three-dimensional model of the upper airway.

RESULTS

As predicted from experimental measurements, the OSA model airway has a closing pressure of -2 cm H2O. Manipulations such as palatal stiffening, palatal resection, and tongue stiffening all have demonstrable effects on pharyngeal mechanics. We have also developed a partial three-dimensional OSA model in which we simulate the mechanics of the pharyngeal airway in the mid-sagittal and parasagittal slices, spanning more than 1 inch in thickness. Using this model, we have observed important effects of tongue and palatal stiffening on anteroposterior collapse of the pharyngeal airway.

CONCLUSIONS

Our data suggest that computational modeling is feasible and can be used to generate hypotheses for subsequent clinical trials regarding anatomic manipulations in OSA. We further believe that the goal of individualizing OSA therapy on the basis of underlying mechanisms could be facilitated by computational modeling.

Upper airway imaging in obstructive sleep apnea

PURPOSE OF REVIEW

Obstructive sleep apnea continues to be a significant public health problem. A variety of imaging modalities have been used recently to gain insight into the pathogenesis of this disease, as well as to identify therapeutic options.

RECENT FINDINGS

Data from more recent imaging studies have highlighted key findings regarding the anatomic sites of collapse and local tissue factors promoting upper airway compromise. The role of genetics, aging, gender and ethnicity in the development of sleep apnea and the identification of predictors for successful treatment outcomes for sleep-disordered breathing are also reviewed.

SUMMARY

As our understanding of obstructive sleep apnea evolves, newer imaging techniques and computerized models may be able to further enhance our understanding of the pathogenesis and treatment of this disease.

Computational fluid dynamics modeling of the upper airway of children with obstructive sleep apnea syndrome in steady flow

Computational fluid dynamic (CFD) analysis was used to model the effect of airway geometry on internal pressure in the upper airway of three children with obstructive sleep apnea syndrome (OSAS), and three controls. Model geometry was reconstructed from magnetic resonance images obtained during quiet tidal breathing, meshed with an unstructured grid, and solved at normative peak resting flow. The unsteady Reynolds-averaged Navier-Stokes equations were solved with steady flow boundary conditions in inspiration and expiration, using a two-equation low-Reynolds number turbulence model. Model results were validated using an in-vitro scale model, unsteady flow simulation, and reported nasal resistance measurements in children. Pharynx pressure drop strongly correlated to airway area restriction. Inspiratory pressure drop was primarily proportional to the square of flow, consistent with pressure losses due to convective acceleration caused by area restriction. On inspiration, in OSAS pressure drop occurred primarily between the choanae and the region where the adenoids overlap the tonsils (overlap region) due to airway narrowing, rather than in the nasal passages; in controls the majority of pressure drop was in the nasal passages. On expiration, in OSAS the majority of pressure drop occurred between the oropharynx (posterior to the tongue) and overlap region, and local minimum pressure in the overlap region was near atmospheric due to pressure recovery in the anterior nasopharynx. The results suggest that pharyngeal airway shape in children with OSAS significantly affects internal pressure distribution compared to nasal resistance. The model may also help explain regional dynamic airway narrowing during expiration.

The impact of anatomic manipulations on pharyngeal collapse: results from a computational model of the normal human upper airway

Obstructive sleep apnea (OSA) is a common disease with important neurocognitive and cardiovascular sequelae. Existing therapies are unsatisfactory, leading investigators to seek alternative forms of anatomic manipulation to influence pharyngeal mechanics. We have developed a two-dimensional computational model of the normal human upper airway based on signal averaging of MRI. Using the finite element method, we can perform various anatomic perturbations on the structure in order to assess the impact of these manipulations on pharyngeal mechanics and collapse. By design, the normal sleeping upper airway model collapses at -13 cm H2O. This closing pressure becomes more negative (ie, less collapsible) when we perform mandibular advancement (-21 cm H2O), palatal resection (-18 cm H2O), or palatal stiffening (-17 cm H2O). Where clinical data are available in the literature, the results of our model correspond reasonably well. Furthermore, our model provides information regarding the site of obstruction and provides hypotheses for clinical studies that can be undertaken in the future (eg, combination therapies). We believe that, in the future, finite element modeling will provide a useful tool to help advance our understanding of OSA and its response to various therapies.