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Pinna GD, Dacosto E, Maestri R, Crotti P, Montemartini S, Caporotondi A, Guazzotti G, Bruschi C. Postural changes in lung volumes in patients with heart failure and Cheyne-Stokes respiration: Relationship with sleep apnea severity. Sleep Med 2023; 101:154-161. [PMID: 36395720 DOI: 10.1016/j.sleep.2022.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND AIM It has been proposed that the increased severity of sleep apnea frequently observed in heart failure (HF) patients with Cheyne-Stokes respiration (CSR) when sleeping in the supine compared to the lateral position, may be caused by the concomitant reduction in functional residual capacity (FRC). We assessed positional changes in FRC in patients with CSR and investigated the relationship between these changes in the laboratory and corresponding changes in CSR severity during sleep. METHODS After a diagnostic polysomnography, 18 HF patients with dominant CSR and an apnea-hypopnea index (AHI)≥15 events/h underwent a standard pulmonary function test in the sitting position. Measurements were repeated in the supine, left lateral and right lateral. The latter two measurements were averaged to obtain a single lateral measurement. RESULTS The FRC in the seated position was 3.0 ± 0.5 L (85 ± 13% of predicted), decreased to 2.3 ± 0.3 L (-21 ± 8%, p < 0.0001) in the supine position, and increased to 2.8 ± 0.4 L (+21 ± 12%, p < 0.0001) from the supine to the lateral position (-5±8% vs seated, p = 0.013). During sleep, the AHI and the apnea index (AI) decreased from 47 ± 15 events/h to 26 ± 12 events/h (-46 ± 20%, p < 0.0001) and from 29 ± 21 events/h to 12 ± 10 events/h (-61 ± 40%, p < 0.001) from the supine to the lateral position. Changes in the AI were significantly correlated with corresponding changes in FRC (ρ = -0.55, p = 0.032). CONCLUSION In patients with HF and CSR, lying in the supine position causes a significant reduction in FRC in the context of a chronically reduced FRC. The negative correlation between postural changes in FRC and AI supports the hypothesis that the reduction in lung gas stores in the supine position may promote/exacerbate respiratory control instability.
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Affiliation(s)
- Gian Domenico Pinna
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy.
| | - Elena Dacosto
- Respiratory Physiopathology and Sleep Unit, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
| | - Roberto Maestri
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
| | - Paola Crotti
- Respiratory Physiopathology and Sleep Unit, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
| | - Silvia Montemartini
- Respiratory Physiopathology and Sleep Unit, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
| | - Angelo Caporotondi
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
| | - Giampaolo Guazzotti
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
| | - Claudio Bruschi
- Department of Pneumology, Istituti Clinici Scientifici Maugeri, Montescano Institute - IRCCS, Montescano, Italy
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Perioperative Management of Pulmonary Hypertension. a Review. ACTA ACUST UNITED AC 2021; 7:83-96. [PMID: 34722909 PMCID: PMC8519362 DOI: 10.2478/jccm-2021-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 01/31/2021] [Indexed: 12/18/2022]
Abstract
Pulmonary hypertension is a rare and progressive pathology defined by abnormally high pulmonary artery pressure mediated by a diverse range of aetiologies. It affects up to twenty-six individuals per one million patients currently living in the United Kingdom (UK), with a median life expectancy of 2.8 years in idiopathic pulmonary hypertension. The diagnosis of pulmonary hypertension is often delayed due to the presentation of non-specific symptoms, leading to a delay in referral to specialists services. The complexity of treatment necessitates a multidisciplinary approach, underpinned by a diverse disease aetiology from managing the underlying disease process to novel specialist treatments. This has led to the formation of dedicated specialist treatment centres within centralised UK cities. The article aimed to provide a concise overview of pulmonary hypertension’s clinical perioperative management, including key definitions, epidemiology, pathophysiology, and risk stratification.
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Orr JE, Ayappa I, Eckert DJ, Feldman JL, Jackson CL, Javaheri S, Khayat RN, Martin JL, Mehra R, Naughton MT, Randerath WJ, Sands SA, Somers VK, Badr MS. Research Priorities for Patients with Heart Failure and Central Sleep Apnea. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 203:e11-e24. [PMID: 33719931 PMCID: PMC7958519 DOI: 10.1164/rccm.202101-0190st] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Central sleep apnea (CSA) is common among patients with heart failure and has been strongly linked to adverse outcomes. However, progress toward improving outcomes for such patients has been limited. The purpose of this official statement from the American Thoracic Society is to identify key areas to prioritize for future research regarding CSA in heart failure. Methods: An international multidisciplinary group with expertise in sleep medicine, pulmonary medicine, heart failure, clinical research, and health outcomes was convened. The group met at the American Thoracic Society 2019 International Conference to determine research priority areas. A statement summarizing the findings of the group was subsequently authored using input from all members. Results: The workgroup identified 11 specific research priorities in several key areas: 1) control of breathing and pathophysiology leading to CSA, 2) variability across individuals and over time, 3) techniques to examine CSA pathogenesis and outcomes, 4) impact of device and pharmacological treatment, and 5) implementing CSA treatment for all individuals Conclusions: Advancing care for patients with CSA in the context of heart failure will require progress in the arenas of translational (basic through clinical), epidemiological, and patient-centered outcome research. Given the increasing prevalence of heart failure and its associated substantial burden to individuals, society, and the healthcare system, targeted research to improve knowledge of CSA pathogenesis and treatment is a priority.
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4
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Javaheri S, Brown LK, Khayat RN. Update on Apneas of Heart Failure With Reduced Ejection Fraction: Emphasis on the Physiology of Treatment. Chest 2020; 157:1637-1646. [DOI: 10.1016/j.chest.2019.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023] Open
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5
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Giannoni A, Gentile F, Navari A, Borrelli C, Mirizzi G, Catapano G, Vergaro G, Grotti F, Betta M, Piepoli MF, Francis DP, Passino C, Emdin M. Contribution of the Lung to the Genesis of Cheyne-Stokes Respiration in Heart Failure: Plant Gain Beyond Chemoreflex Gain and Circulation Time. J Am Heart Assoc 2019; 8:e012419. [PMID: 31237174 PMCID: PMC6662365 DOI: 10.1161/jaha.119.012419] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/22/2019] [Indexed: 01/26/2023]
Abstract
Background The contribution of the lung or the plant gain ( PG ; ie, change in blood gases per unit change in ventilation) to Cheyne-Stokes respiration ( CSR ) in heart failure has only been hypothesized by mathematical models, but never been directly evaluated. Methods and Results Twenty patients with systolic heart failure (age, 72.4±6.4 years; left ventricular ejection fraction, 31.5±5.8%), 10 with relevant CSR (24-hour apnea-hypopnea index [ AHI ] ≥10 events/h) and 10 without ( AHI <10 events/h) at 24-hour cardiorespiratory monitoring underwent evaluation of chemoreflex gain (CG) to hypoxia ([Formula: see text]) and hypercapnia ([Formula: see text]) by rebreathing technique, lung-to-finger circulation time, and PG assessment through a visual system. PG test was feasible and reproducible (intraclass correlation coefficient, 0.98; 95% CI , 0.91-0.99); the best-fitting curve to express the PG was a hyperbola ( R2≥0.98). Patients with CSR showed increased PG , [Formula: see text] (but not [Formula: see text]), and lung-to-finger circulation time, compared with patients without CSR (all P<0.05). PG was the only predictor of the daytime AHI ( R=0.56, P=0.01) and together with the [Formula: see text] also predicted the nighttime AHI ( R=0.81, P=0.0003) and the 24-hour AHI ( R=0.71, P=0.001). Lung-to-finger circulation time was the only predictor of CSR cycle length ( R=0.82, P=0.00006). Conclusions PG is a powerful contributor of CSR and should be evaluated together with the CG and circulation time to individualize treatments aimed at stabilizing breathing in heart failure.
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Affiliation(s)
- Alberto Giannoni
- Fondazione Toscana G. MonasterioPisaItaly
- Institute of Life SciencesScuola Superiore Sant'AnnaPisaItaly
| | | | | | | | | | | | - Giuseppe Vergaro
- Fondazione Toscana G. MonasterioPisaItaly
- Institute of Life SciencesScuola Superiore Sant'AnnaPisaItaly
| | | | | | | | - Darrel P. Francis
- International Center for Circulatory HealthNational Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Claudio Passino
- Fondazione Toscana G. MonasterioPisaItaly
- Institute of Life SciencesScuola Superiore Sant'AnnaPisaItaly
| | - Michele Emdin
- Fondazione Toscana G. MonasterioPisaItaly
- Institute of Life SciencesScuola Superiore Sant'AnnaPisaItaly
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6
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Najjar N, Staiano P, Louis M. Obstructive Sleep Apnea and Cardiovascular Disease in Women. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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7
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Javaheri S, Brown LK, Khayat R. Rebuttal to Naughton. J Clin Sleep Med 2018; 14:923-925. [PMID: 29852919 DOI: 10.5664/jcsm.7150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Shahrokh Javaheri
- Sleep Laboratory, Division of Sleep and Pulmonary Medicine, Bethesda North Hospital, Cincinnati, Ohio.,University of Cincinnati, Cincinnati, Ohio.,Ohio University Medical School, Columbus, Ohio
| | - 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.,University of New Mexico Sleep Disorders Center, Albuquerque, New Mexico.,Department of Electrical and Computer Engineering, University of New Mexico School of Engineering, Albuquerque, New Mexico
| | - Rami Khayat
- Division of Pulmonary Critical Care and Sleep, Ohio State University, Columbus, Ohio
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Kurmi OP, Li L, Davis KJ, Wang J, Bennett DA, Chan KH, Yang L, Chen Y, Guo Y, Bian Z, Chen J, Wei L, Jin D, Collins R, Peto R, Chen Z. Excess risk of major vascular diseases associated with airflow obstruction: a 9-year prospective study of 0.5 million Chinese adults. Int J Chron Obstruct Pulmon Dis 2018; 13:855-865. [PMID: 29563785 PMCID: PMC5846305 DOI: 10.2147/copd.s153641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background China has high COPD rates, even among never-regular smokers. Little is known about nonrespiratory disease risks, especially vascular morbidity and mortality after developing airflow obstruction (AFO) in Chinese adults. Objective We aimed to investigate the prospective association of prevalent AFO with major vascular morbidity and mortality. Materials and methods In 2004-2008, a nationwide prospective cohort study recruited 512,891 men and women aged 30-79 years from 10 diverse localities across China, tracking cause-specific mortality and coded episodes of hospitalization for 9 years. Cox regression yielded adjusted HRs for vascular diseases comparing individuals with spirometry-defined prevalent AFO at baseline to those without. Results Of 489,382 participants with no vascular disease at baseline, 6.8% had AFO, with prevalence rising steeply with age. Individuals with prevalent AFO had significantly increased vascular mortality (n=1,429, adjusted HR 1.29, 95% CI 1.21-1.36). There were also increased risks of hemorrhagic stroke (n=823, HR 1.18, 95% CI 1.09-1.27), major coronary events (n=635, HR 1.33, 95% CI 1.22-1.45), and heart failure (n=543, HR 2.19, 95% CI 1.98-2.41). For each outcome, the risk increased progressively with increasing COPD severity and persisted among never-regular smokers. Conclusion Among adult Chinese, AFO was associated with significantly increased risks of major vascular morbidity and mortality. COPD management should be integrated with vascular disease prevention and treatment programs to improve long-term prognosis.
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Affiliation(s)
- Om P Kurmi
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Liming Li
- Department of Epidemiology, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Kourtney J Davis
- Real World Evidence and Epidemiology, GlaxoSmithKline, Collegeville, PA, USA
| | - Jenny Wang
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Derrick A Bennett
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ka Hung Chan
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ling Yang
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yiping Chen
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yu Guo
- Chinese Academy of Medical Sciences, Beijing China
| | - Zheng Bian
- Chinese Academy of Medical Sciences, Beijing China
| | - Junshi Chen
- China National Center for Food Safety Risk Assessment, Beijing, China
| | - Liuping Wei
- NCDs Prevention and Control Department, Liuzhou CDC, Liuzhou, China
| | - Donghui Jin
- NCDs Prevention and Control Department, Hunan CDC, Changsha, China
| | - Rory Collins
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Peto
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zhengming Chen
- Clinical Trial Service and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Central Sleep Apnea with Cheyne-Stokes Breathing in Heart Failure – From Research to Clinical Practice and Beyond. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:327-351. [DOI: 10.1007/5584_2018_146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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10
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Impairment of pulmonary diffusion correlates with hypoxemic burden in central sleep apnea heart failure patients. Respir Physiol Neurobiol 2017; 243:7-12. [PMID: 28467884 DOI: 10.1016/j.resp.2017.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Central sleep apnea (CSA) and Cheyne-Stokes respiration (CSR) are highly prevalent in heart failure (HF) and are linked to increased mortality. Impaired pulmonary diffusion capacity [DLCO] and [KCO]) have been suggested to play a key role in CSA-CSR pathophysiology. This study investigated the relationship between HF, CSR, DLCO and KCO in well-characterized HF patients. METHODS This prospective study included HF patients with CSR, all patients underwent full overnight polysomnography (PSG) and lung function testing. RESULTS A total of 100 patients were included (age 70.7±9.7years, 95% male, body mass index 28.9±5.3kg/m2, left ventricular ejection fraction 33.5±7.7%, New York Heart Association class III 65%. DLCO and oxygenation were significantly correlated with hypoxemic burden (p<0.05). Mean oxygen saturation, oxygen desaturation, C-reactive protein level and pH were significantly associated with CSA-CSR severity (p<0.05). CONCLUSION The finding that lung diffusion capacity is significantly associated with hypoxemic burden in HF patients with CSA-CSR highlights the important of lung function in HF patients.
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11
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Positive airway pressure therapy in heart failure patients: Long-term effects on lung function. Respir Physiol Neurobiol 2017; 238:41-46. [PMID: 28126479 DOI: 10.1016/j.resp.2017.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/17/2017] [Accepted: 01/21/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE The prevalence of sleep-disordered breathing (SDB) in patients with heart failure (HF) is high. Positive airway pressure (PAP) is first-choice therapy, but recent data indicates that PAP therapy may increase mortality in HF patients with reduced ejection fraction (HF-REF) and predominant central sleep apnea (CSA). This study investigated long-term effects of PAP therapy on pulmonary function, including respiratory muscle strength. All patients underwent multichannel cardiorespiratory polysomnography (PSG) and comprehensive lung function testing at baseline and follow-up (mean 588±43days). RESULTS 350 patients (mean age 68±10.7years, 88% male) were included, inspiratory vital capacity, 3.3±0.9 vs 3.2±0.8L; forced expiratory volume in 1s, 2.5±0.7 vs 2.4±0.7L; lung diffusion capacity, 6.2±1.9 vs 5.9±1.8mmol/min/kPa; correction for hemoglobin, 1.1±0.02 vs 1.1±0.3mmol/min/kPa/L; and mouth occlusion pressure, 0.42±0.11 vs 0.4±0.12kPa. CONCLUSIONS PAP therapy had no negative nor positive impact on lung function, including respiratory muscle strength, in stable HF-REF patients with SDB, and is therefore safe from a respiratory perspective.
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Naughton MT, Kee K. Sleep apnoea in heart failure: To treat or not to treat? Respirology 2016; 22:217-229. [PMID: 27998040 DOI: 10.1111/resp.12964] [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] [Received: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/28/2023]
Abstract
Heart failure (HF) and sleep apnoea are common disorders which frequently coexist. Two main types of apnoea occur: one is obstructive which, through recurring episodes of snoring, hypoxaemia, large negative intra-thoracic pressures and arousals from sleep leading to downstream inflammatory and autonomic nervous system changes, is thought to be a causative factor to the development of systemic hypertension and HF. The other type of apnoea, Cheyne-Stokes respiration with central sleep apnoea (CSR-CSA), is characterized by an oscillatory pattern of ventilation with a prevailing hyperventilation-induced hypocapnia, often in the absence of significant hypoxaemia and snoring, and is thought to be a consequence of advanced HF-related low cardiac output, high sympathetic nervous system activation and pulmonary congestion. CSR-CSA may be a compensatory response to advanced HF. Rostral fluid shift during sleep may play an important role in the pathogenesis of both obstructive sleep apnoea (OSA) and CSA. Studies of positive airway pressure (PAP) treatment of OSA and CSA in HF have shown short-term improvements in cardiac and autonomic function; however, there is no evidence of improved survival. Loop gain may provide useful marker of continuous PAP (CPAP) responsiveness in patients with central apnoea. A greater understanding of the pathophysiology of the interaction between obstructive and central apnoea and the various types of HF, and the mechanisms of therapies, such as PAP, is required to develop new strategies to overcome the disabling symptoms, and perhaps improve the mortality, that accompany HF with sleep apnoea.
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Affiliation(s)
- Matthew T Naughton
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kirk Kee
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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13
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Orr JE, Malhotra A, Sands SA. Pathogenesis of central and complex sleep apnoea. Respirology 2016; 22:43-52. [PMID: 27797160 DOI: 10.1111/resp.12927] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 12/01/2022]
Abstract
Central sleep apnoea (CSA) - the temporary absence or diminution of ventilatory effort during sleep - is seen in a variety of forms including periodic breathing in infancy and healthy adults at altitude and Cheyne-Stokes respiration in heart failure. In most circumstances, the cyclic absence of effort is paradoxically a consequence of hypersensitive ventilatory chemoreflex responses to oppose changes in airflow, that is elevated loop gain, leading to overshoot/undershoot ventilatory oscillations. Considerable evidence illustrates overlap between CSA and obstructive sleep apnoea (OSA), including elevated loop gain in patients with OSA and the presence of pharyngeal narrowing during central apnoeas. Indeed, treatment of OSA, whether via continuous positive airway pressure (CPAP), tracheostomy or oral appliances, can reveal CSA, an occurrence referred to as complex sleep apnoea. Factors influencing loop gain include increased chemosensitivity (increased controller gain), reduced damping of blood gas levels (increased plant gain) and increased lung to chemoreceptor circulatory delay. Sleep-wake transitions and pharyngeal dilator muscle responses effectively raise the controller gain and therefore also contribute to total loop gain and overall instability. In some circumstances, for example apnoea of infancy and central congenital hypoventilation syndrome, central apnoeas are the consequence of ventilatory depression and defective ventilatory responses, that is low loop gain. The efficacy of available treatments for CSA can be explained in terms of their effects on loop gain, for example CPAP improves lung volume (plant gain), stimulants reduce the alveolar-inspired PCO2 difference and supplemental oxygen lowers chemosensitivity. Understanding the magnitude of loop gain and the mechanisms contributing to instability may facilitate personalized interventions for CSA.
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Affiliation(s)
- Jeremy E Orr
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, California, USA
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, California, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
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Abstract
Congestive heart failure (CHF) is among the most common causes of admission to hospitals in the United States, especially in those over age 65. Few data exist regarding the prevalence CHF of Cheyne-Stokes respiration (CSR) owing to congestive heart failure in the intensive care unit (ICU). Nevertheless, CSR is expected to be highly prevalent among those with CHF. Treatment should focus on the underlying mechanisms by which CHF increases loop gain and promotes unstable breathing. Few data are available to determine prevalence of CSR in the ICU, or how CSR might affect clinical management and weaning from mechanical ventilation.
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Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, Alfred Hospital and Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037, USA.
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15
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Epidemiology of central sleep apnoea in heart failure. Int J Cardiol 2016; 206 Suppl:S4-7. [DOI: 10.1016/j.ijcard.2016.02.125] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/27/2016] [Accepted: 02/21/2016] [Indexed: 11/19/2022]
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16
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Pathophysiology of central sleep apneas. Sleep Breath 2016; 20:467-82. [DOI: 10.1007/s11325-015-1290-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/10/2015] [Accepted: 11/23/2015] [Indexed: 11/26/2022]
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17
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Giannoni A, Raglianti V, Mirizzi G, Taddei C, Del Franco A, Iudice G, Bramanti F, Aimo A, Pasanisi E, Emdin M, Passino C. Influence of central apneas and chemoreflex activation on pulmonary artery pressure in chronic heart failure. Int J Cardiol 2016; 202:200-6. [DOI: 10.1016/j.ijcard.2015.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 08/16/2015] [Accepted: 09/06/2015] [Indexed: 10/23/2022]
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18
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Naughton MT. Respiratory sleep disorders in patients with congestive heart failure. J Thorac Dis 2015; 7:1298-310. [PMID: 26380758 DOI: 10.3978/j.issn.2072-1439.2015.07.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/15/2015] [Indexed: 11/14/2022]
Abstract
Respiratory sleep disorders (RSD) occur in about 40-50% of patients with symptomatic congestive heart failure (CHF). Obstructive sleep apnea (OSA) is considered a cause of CHF, whereas central sleep apnea (CSA) is considered a response to heart failure, perhaps even compensatory. In the setting of heart failure, continuous positive airway pressure (CPAP) has a definite role in treating OSA with improvements in cardiac parameters expected. However in CSA, CPAP is an adjunctive therapy to other standard therapies directed towards the heart failure (pharmacological, device and surgical options). Whether adaptive servo controlled ventilatory support, a variant of CPAP, is beneficial is yet to be proven. Supplemental oxygen therapy should be used with caution in heart failure, in particular, by avoiding hyperoxia as indicated by SpO2 values >95%.
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Affiliation(s)
- Matthew T Naughton
- 1 General Respiratory and Sleep Medicine, Department of Allergy, Immunology and Respiratory Medicine, 2 Department of Medicine, Monash University, The Alfred Hospital, Melbourne, VIC 3004, Australia
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19
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Abstract
Congestive heart failure (CHF) is among the most common causes of admission to hospitals in the United States, especially in those over age 65. Few data exist regarding the prevalence CHF of Cheyne-Stokes respiration (CSR) owing to congestive heart failure in the intensive care unit (ICU). Nevertheless, CSR is expected to be highly prevalent among those with CHF. Treatment should focus on the underlying mechanisms by which CHF increases loop gain and promotes unstable breathing. Few data are available to determine prevalence of CSR in the ICU, or how CSR might affect clinical management and weaning from mechanical ventilation.
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Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, Alfred Hospital and Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037, USA.
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Abstract
Heart failure (HF) is one of the most prevalent and costly diseases in the United States. Sleep apnea is now recognized as a common, yet underdiagnosed, comorbidity of HF. This article discusses the unique qualities that sleep apnea has when it occurs in HF and explains the underlying pathophysiology that illuminates why sleep apnea and HF frequently occur together. The authors provide an overview of the treatment options for sleep apnea in HF and discuss the relative efficacies of these treatments.
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Affiliation(s)
- David Rosen
- Pulmonary Medicine, Montefiore Medical Center, 111 E 210 Street, Bronx, NY 10467, USA.
| | - Francoise Joelle Roux
- Connecticut Multispecialty Group, Division of Pulmonary, Critical Care and Sleep Medicine, 85 Seymour Street, Suite 923, Hartford, CT 06106, USA
| | - Neomi Shah
- Pulmonary Medicine, Montefiore Medical Center, 111 E 210 Street, Bronx, NY 10467, USA
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Acetazolamide Attenuates Hunter-Cheyne-Stokes Breathing but Augments the Hypercapnic Ventilatory Response in Patients with Heart Failure. Ann Am Thorac Soc 2014; 11:80-6. [DOI: 10.1513/annalsats.201306-201oc] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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23
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Cui R, Yu S, Huang X, Zhang J, Tian C, Pu C. Papilloedema is an independent prognostic factor for POEMS syndrome. J Neurol 2013; 261:60-5. [DOI: 10.1007/s00415-013-7143-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/01/2013] [Accepted: 10/03/2013] [Indexed: 10/26/2022]
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Tanabe T, Rozycki HJ, Kanoh S, Rubin BK. Cardiac asthma: new insights into an old disease. Expert Rev Respir Med 2013; 6:705-14. [PMID: 23234454 DOI: 10.1586/ers.12.67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiac asthma has been defined as wheezing, coughing and orthopnea due to congestive heart failure. The clinical distinction between bronchial asthma and cardiac asthma can be straight forward, except in patients with chronic lung disease coexisting with left heart disease. Pulmonary edema and pulmonary vascular congestion have been thought to be the primary causes of cardiac asthma but most patients have a poor response to diuretics. There appears to be limited effectiveness of classical asthma medications like bronchodilators or corticosteroids in treating cardiac asthma. Evidence suggests that circulating inflammatory factors and tissue growth factors also lead to airway obstruction suggesting the possibility of developing novel therapies.
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Affiliation(s)
- Tsuyoshi Tanabe
- Department of Pediatrics, Virginia Commonwealth University School of Medicine and the Children's Hospital of Richmond at VCU, Richmond, VA, USA
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25
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Plataki M, Sands SA, Malhotra A. Clinical consequences of altered chemoreflex control. Respir Physiol Neurobiol 2013; 189:354-63. [PMID: 23681082 DOI: 10.1016/j.resp.2013.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/19/2013] [Accepted: 04/25/2013] [Indexed: 01/28/2023]
Abstract
Control of ventilation dictates various breathing patterns. The respiratory control system consists of a central pattern generator and several feedback mechanisms that act to maintain ventilation at optimal levels. The concept of loop gain has been employed to describe its stability and variability. Synthesizing all interactions under a general model that could account for every behavior has been challenging. Recent insight into the importance of these feedback systems may unveil therapeutic strategies for common ventilatory disturbances. In this review we will address the major mechanisms that have been proposed as mediators of some of the breathing patterns in health and disease that have raised controversies and discussion on ventilatory control over the years.
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Affiliation(s)
- Maria Plataki
- Department of Internal Medicine, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT, USA
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26
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Julian CG, Vargas E, Gonzales M, Dávila RD, Ladenburger A, Reardon L, Schoo C, Powers RW, Lee-Chiong T, Moore LG. Sleep-disordered breathing and oxidative stress in preclinical chronic mountain sickness (excessive erythrocytosis). Respir Physiol Neurobiol 2013; 186:188-96. [PMID: 23380170 DOI: 10.1016/j.resp.2013.01.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 01/21/2013] [Accepted: 01/22/2013] [Indexed: 11/26/2022]
Abstract
Chronic mountain sickness (CMS) is considered to be a loss of ventilatory acclimatization to high altitude (>2500m) resulting in marked arterial hypoxemia and polycythemia. This case-control study explores the possibility that sleep-disordered breathing (SDB) and associated oxidative stress contribute to the etiology of CMS. Nocturnal respiratory and [Formula: see text] patterns were measured using standard polysomnography techniques and compared between male high-altitude residents (aged 18-25) with preclinical CMS (excessive erythrocytosis (EE), n=20) and controls (n=19). Measures of oxidative stress and antioxidant status included isoprostanes (8-iso-PGF2alpha), superoxide dismutase and ascorbic acid. EE cases had a greater apnea-hypopnea index, a higher frequency of apneas (central and obstructive) and hypopneas during REM sleep, and lower nocturnal [Formula: see text] compared to controls. 8-iso-PGF2alpha was greater in EE than controls, negatively associated with nocturnal [Formula: see text] , and positively associated with hemoglobin concentration. Mild sleep-disordered breathing and oxidative stress are evident in preclinical CMS, suggesting that the resolution of nocturnal hypoxemia or antioxidant treatment may prevent disease progression.
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Affiliation(s)
- Colleen Glyde Julian
- Altitude Research Center, Department of Emergency Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA.
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Edwards BA, Sands SA, Berger PJ. Postnatal maturation of breathing stability and loop gain: the role of carotid chemoreceptor development. Respir Physiol Neurobiol 2012; 185:144-55. [PMID: 22705011 DOI: 10.1016/j.resp.2012.06.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 05/16/2012] [Accepted: 06/01/2012] [Indexed: 11/17/2022]
Abstract
Any general model of respiratory control must explain a puzzling array of breathing patterns that are observed during the course of a lifetime. Particular challenges are to understand why periodic breathing is rarely seen in the first few days after birth, reaches a peak at 2-4 weeks postnatal age, and disappears by 6 months, why it is prevalent in preterm infants, and why it reappears in adults at altitude or with heart failure. In this review we use the concept of loop gain to obtain quantitative insight into the genesis of unstable breathing patterns with a particular focus on how changes in carotid body function could underlie the age-related dependence of periodic breathing.
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Affiliation(s)
- Bradley A Edwards
- Division of Sleep Medicine, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA.
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Jungquist CR, Karan S, Perlis ML. Risk Factors for Opioid-Induced Excessive Respiratory Depression. Pain Manag Nurs 2011; 12:180-7. [DOI: 10.1016/j.pmn.2010.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 01/24/2010] [Accepted: 02/01/2010] [Indexed: 10/19/2022]
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American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression. Pain Manag Nurs 2011; 12:118-145.e10. [DOI: 10.1016/j.pmn.2011.06.008] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/21/2022]
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Abstract
Heart failure (HF) is a highly prevalent disease that leads to significant morbidity and mortality. There is increasing evidence that the symptoms of HF are exacerbated by its deleterious effects on lung function. HF appears to cause airway obstruction acutely and leads to impaired gas diffusing capacity and pulmonary hypertension in the longer term. It is postulated that this is the result of recurrent episodes of elevated pulmonary capillary pressure leading to pulmonary oedema and pulmonary capillary stress fracture, which produces lung fibrosis. It is likely that impaired lung function impairs the functional status of HF patients and makes them more prone to central sleep apnoea.
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Affiliation(s)
- Kirk Kee
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Victoria, Australia
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31
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Kee K, Sands SA, Edwards BA, Berger PJ, Naughton MT. Positive Airway Pressure in Congestive Heart Failure. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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MISE K, CAPKUN V, JURCEV-SAVICEVIC A, SUNDOV Z, BRADARIC A, MLADINOV S. The influence of gastroesophageal reflux in the lung: A case-control study. Respirology 2010; 15:837-42. [DOI: 10.1111/j.1440-1843.2010.01777.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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33
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Current World Literature. Curr Opin Pulm Med 2009; 15:638-44. [DOI: 10.1097/mcp.0b013e3283328a80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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34
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Heart failure and sleep-disordered breathing: mechanisms, consequences and treatment. Curr Opin Pulm Med 2009; 15:565-70. [DOI: 10.1097/mcp.0b013e3283319a87] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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35
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Current world literature. Curr Opin Anaesthesiol 2009; 22:447-56. [PMID: 19417565 DOI: 10.1097/aco.0b013e32832cbfed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.
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Lorenzi-Filho G, Genta PR. A New Straw in the Genesis of Cheyne-Stokes Respiration. Chest 2008; 134:7-9. [DOI: 10.1378/chest.08-0119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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