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Patrician A, Anholm JD, Ainslie PN. A narrative review of periodic breathing during sleep at high altitude: From acclimatizing lowlanders to adapted highlanders. J Physiol 2024. [PMID: 38534039 DOI: 10.1113/jp285427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/15/2024] [Indexed: 03/28/2024] Open
Abstract
Periodic breathing during sleep at high altitude is almost universal among sojourners. Here, in the context of acclimatization and adaptation, we provide a contemporary review on periodic breathing at high altitude, and explore whether this is an adaptive or maladaptive process. The mechanism(s), prevalence and role of periodic breathing in acclimatized lowlanders at high altitude are contrasted with the available data from adapted indigenous populations (e.g. Andean and Tibetan highlanders). It is concluded that (1) periodic breathing persists with acclimatization in lowlanders and the severity is proportional to sleeping altitude; (2) periodic breathing does not seem to coalesce with poor sleep quality such that, with acclimatization, there appears to be a lengthening of cycle length and minimal impact on the average sleeping oxygen saturation; and (3) high altitude adapted highlanders appear to demonstrate a blunting of periodic breathing, compared to lowlanders, comprising a feature that withstands the negative influences of chronic mountain sickness. These observations indicate that periodic breathing persists with high altitude acclimatization with no obvious negative consequences; however, periodic breathing is attenuated with high altitude adaptation and therefore potentially reflects an adaptive trait to this environment.
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Affiliation(s)
- Alexander Patrician
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - James D Anholm
- Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
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Derstine M, Jean D, Beidleman BA, Pichler Hefti J, Hillebrandt D, Horakova L, Kriemler S, Mateikaitė-Pipirienė K, Paal P, Rosier AJ, Andjelkovic M, Keyes LE. Acute Mountain Sickness and High Altitude Cerebral Edema in Women: A Scoping Review-UIAA Medical Commission Recommendations. High Alt Med Biol 2023; 24:259-267. [PMID: 37870579 DOI: 10.1089/ham.2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
Derstine, Mia, Dominique Jean, Beth A. Beidleman, Jacqueline Pichler Hefti, David Hillebrandt, Lenka Horakova, Susi Kriemler, Kasté Mateikaité-Pipiriené, Peter Paal, Alison Rosier, Marija Andjelkovic, and Linda E. Keyes. Acute mountain sickness and high altitude cerebral edema in women: A scoping review-UIAA Medical Commission recommendations. High Alt Med Biol. 24:259-267, 2023. Background: Acute mountain sickness (AMS) and high-altitude cerebral edema (HACE) are illnesses associated with rapid ascent to altitudes over 2,500 m in unacclimatized lowlanders. The aim of this scoping review is to summarize the current knowledge on sex differences in the epidemiology, pathophysiology, symptomatology, and treatment of AMS and HACE, especially in women. Methods and Results: The UIAA Medical Commission convened an international author team to review women's health issues at high altitude and to publish updated recommendations. Pertinent literature from PubMed and Cochrane was identified by keyword search combinations (including AMS, HACE, and high altitude), with additional publications found by hand search. The primary search focus was for articles assessing lowland women sojourning at high altitude. Results: The literature search yielded 7,165 articles, 37 of which were ultimately included. The majority of publications included did not find women at increased risk for AMS or HACE. There was extremely limited sex-specific data on risk factors or treatment. Conclusions: There is a limited amount of data on female-specific findings regarding AMS and HACE, with most publications addressing only prevalence or incidence with regard to sex. As such, general prevention and treatment strategies for AMS and HACE should be used regardless of sex.
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Affiliation(s)
- Mia Derstine
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
| | - Dominique Jean
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Paediatrics, Infectious Diseases and Altitude Medicine, Grenoble, France
| | - Beth A Beidleman
- US Army Research Institute of Environmental Medicine, Military Performance Division, Natick, Massachusetts, USA
| | | | - David Hillebrandt
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- General Medical Practitioner, Holsworthy, United Kingdom
| | - Lenka Horakova
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Susi Kriemler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Kastė Mateikaitė-Pipirienė
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Diaverum Clinics, Elektrėnai Division, Lithuania
| | - Peter Paal
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelesus Medical University, Salzburg, Austria
| | - Alison J Rosier
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
| | - Marija Andjelkovic
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Pharmacy, Singidunum University, Belgrade, Serbia
| | - Linda E Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
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Vignati C, Contini M, Salvioni E, Lombardi C, Caravita S, Bilo G, Swenson ER, Parati G, Agostoni P. Exercise in hypoxia: a model from laboratory to on-field studies. Eur J Prev Cardiol 2023; 30:ii40-ii46. [PMID: 37819224 DOI: 10.1093/eurjpc/zwad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/05/2023] [Accepted: 05/31/2023] [Indexed: 10/13/2023]
Abstract
Clinical outcome and quality of life of patients with chronic heart failure (HF) have greatly improved over the last two decades. These results and the availability of modern lifts allow many cardiac patients to spend leisure time at altitude. Heart failure per se does not impede a safe stay at altitude, but exercise at both simulated and real altitudes is associated with a reduction in performance, which is inversely proportional to HF severity. For example, in normal subjects, the reduction in functional capacity is ∼2% every 1000 m altitude increase, whereas it is 4 and 10% in HF patients with normal or slightly diminished exercise capacity and in HF patients with markedly diminished exercise capacity, respectively. Also, the on-field experience with HF patients at altitude confirms safety and shows overall similar data to that reported at simulated altitude. Even 'optimal' HF treatment in patients spending time at altitude or at hypoxic conditions is likely different from optimal treatment at sea level, particularly with regard to the selectivity of β-blockers. Furthermore, high altitude, both simulated and on-field, represents a stimulating model of hypoxia in HF patients and healthy subjects. Our data suggest that spending time at altitude (<3500 m) can be safe even for HF patients, provided that subjects are free from comorbidities that may directly interfere with the adaptation to altitude and are stable. However, HF patients experience a reduction of exercise capacity directly proportional to HF severity and altitude. Finally, HF patients should be tested for functional capacity and must undergo a specific 'hypoxic-tailored treatment' to avoid pharmacological interference with altitude adaptation mechanisms, particularly with regard to the selectivity of β-blockers.
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Affiliation(s)
- Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Via Parea, Milano 20138, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Parea, Milano 20138, Italy
| | - Mauro Contini
- Centro Cardiologico Monzino, IRCCS, Via Parea, Milano 20138, Italy
| | | | - Carolina Lombardi
- Sleep Medicine Center, Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Grzegorz Bilo
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Via Parea, Milano 20138, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Via Parea, Milano 20138, Italy
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Oeung B, Pham K, Olfert IM, De La Zerda DJ, Gaio E, Powell FL, Heinrich EC. The normal distribution of the hypoxic ventilatory response and methodological impacts: a meta-analysis and computational investigation. J Physiol 2023; 601:4423-4440. [PMID: 37589511 PMCID: PMC10543592 DOI: 10.1113/jp284767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Abstract
The hypoxic ventilatory response (HVR) is the increase in breathing in response to reduced arterial oxygen pressure. Over several decades, studies have revealed substantial population-level differences in the magnitude of the HVR as well as significant inter-individual variation. In particular, low HVRs occur frequently in Andean high-altitude native populations. However, our group conducted hundreds of HVR measures over several years and commonly observed low responses in sea-level populations as well. As a result, we aimed to determine the normal HVR distribution, whether low responses were common, and to what extent variation in study protocols influence these findings. We conducted a comprehensive search of the literature and examined the distributions of HVR values across 78 studies that utilized step-down/steady-state or progressive hypoxia methods in untreated, healthy human subjects. Several studies included multiple datasets across different populations or experimental conditions. In the final analysis, 72 datasets reported mean HVR values and 60 datasets provided raw HVR datasets. Of the 60 datasets reporting raw HVR values, 35 (58.3%) were at least moderately positively skewed (skew > 0.5), and 21 (35%) were significantly positively skewed (skew > 1), indicating that lower HVR values are common. The skewness of HVR distributions does not appear to be an artifact of methodology or the unit with which the HVR is reported. Further analysis demonstrated that the use of step-down hypoxia versus progressive hypoxia methods did not have a significant impact on average HVR values, but that isocapnic protocols produced higher HVRs than poikilocapnic protocols. This work provides a reference for expected HVR values and illustrates substantial inter-individual variation in this key reflex. Finally, the prevalence of low HVRs in the general population provides insight into our understanding of blunted HVRs in high-altitude adapted groups. KEY POINTS: The hypoxic ventilatory response (HVR) plays a crucial role in determining an individual's predisposition to hypoxia-related pathologies. There is notable variability in HVR sensitivity across individuals as well as significant population-level differences. We report that the normal distribution of the HVR is positively skewed, with a significant prevalence of low HVR values amongst the general healthy population. We also find no significant impact of the experimental protocol used to induce hypoxia, although HVR is greater with isocapnic versus poikilocapnic methods. These results provide insight into the normal distribution of the HVR, which could be useful in clinical decisions of diseases related to hypoxaemia. Additionally, the low HVR values found within the general population provide insight into the genetic adaptations found in populations residing in high altitudes.
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Affiliation(s)
- Britney Oeung
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA
| | - Kathy Pham
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA
| | - I. Mark Olfert
- West Virginia University School of Medicine, Department of Physiology & Pharmacology and Division of Exercise Physiology
| | | | - Eduardo Gaio
- School of Medicine, Deakin University, Geelong, Australia
| | - Frank L. Powell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, CA
| | - Erica C. Heinrich
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA
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Pezzuto B, Agostoni P. The Current Role of Cardiopulmonary Exercise Test in the Diagnosis and Management of Pulmonary Hypertension. J Clin Med 2023; 12:5465. [PMID: 37685532 PMCID: PMC10487723 DOI: 10.3390/jcm12175465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis if left untreated. Despite remarkable achievements in understanding disease pathophysiology, specific treatments, and therapeutic strategies, we are still far from a definitive cure for the disease, and numerous evidences have underlined the importance of early diagnosis and treatment to improve the prognosis. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity and evaluating the pathophysiological mechanisms underlying exercise limitation. As effort dyspnea is the earliest and one of the main clinical manifestations of PAH, CPET has been shown to provide valid support in early detection, differential diagnosis, and prognostic stratification of PAH patients, being a useful tool in both the first approach to patients and follow-up. The purpose of this review is to present the current applications of CPET in pulmonary hypertension and to propose possible future utilization to be further investigated.
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Affiliation(s)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Bird JD, Sands SA, Alex RM, Shing CLH, Shafer BM, Jendzjowsky NG, Wilson RJA, Day TA, Foster GE. Sex-related Differences in Loop Gain during High-Altitude Sleep-disordered Breathing. Ann Am Thorac Soc 2023; 20:1192-1200. [PMID: 37000675 PMCID: PMC10405604 DOI: 10.1513/annalsats.202211-918oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/31/2023] [Indexed: 04/01/2023] Open
Abstract
Rationale: Central sleep apnea (CSA) is pervasive during sleep at high altitude, disproportionately impacting men and associated with increased peripheral chemosensitivity. Objectives: We aimed to assess whether biological sex affects loop gain (LGn) and CSA severity during sleep over 9-10 days of acclimatization to 3,800 m. We hypothesized that CSA severity would worsen with acclimatization in men but not in women because of greater increases in LGn in men. Methods: Sleep studies were collected from 20 (12 male) healthy participants at low altitude (1,130 m, baseline) and after ascent to (nights 2/3, acute) and residence at high altitude (nights 9/10, prolonged). CSA severity was quantified as the respiratory event index (REI) as a surrogate of the apnea-hypopnea index. LGn, a measure of ventilatory control instability, was quantified using a ventilatory control model fit to nasal flow. Linear mixed models evaluated effects of time at altitude and sex on respiratory event index and LGn. Data are presented as contrast means with 95% confidence intervals. Results: REI was comparable between men and women at acute altitude (4.1 [-9.3, 17.5] events/h; P = 0.54) but significantly greater in men at prolonged altitude (23.7 [10.3, 37.1] events/h; P = 0.0008). Men had greater LGn than did women for acute (0.08 [0.001, 0.15]; P = 0.047) and prolonged (0.17 [0.10, 0.25]; P < 0.0001) altitude. The change in REI per change in LGn was significantly greater in men than in women (107 ± 46 events/h/LGn; P = 0.02). Conclusions: The LGn response to high altitude differed between sexes and contributed to worsening of CSA over time in men but not in women. This sex difference in acclimatization appears to protect females from high altitude-related CSA. These data provide fundamental sex-specific physiological insight into high-altitude acclimatization in healthy individuals and may help to inform sex differences in sleep-disordered breathing pathogenesis in patients with cardiorespiratory disease.
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Affiliation(s)
- Jordan D. Bird
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Scott A. Sands
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raichel M. Alex
- Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Conan L. H. Shing
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Brooke M. Shafer
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Nicholas G. Jendzjowsky
- Respiratory Medicine and Exercise Physiology, The Lundquist Institute for Biomedical Innovation, Harbor University of California Los Angeles Medical Center, West Carson, California; and
| | - Richard J. A. Wilson
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute and Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Trevor A. Day
- Faculty of Science and Technology, Department of Biology, Mount Royal University, Calgary, Alberta, Canada
| | - Glen E. Foster
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
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Ni YN, Holzer RC, Thomas RJ. Acute and long-term effects of acetazolamide in presumed high loop gain sleep apnea. Sleep Med 2023; 107:137-148. [PMID: 37178545 DOI: 10.1016/j.sleep.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The acute effect during positive pressure titration and long term efficacy of acetazolamide (AZT) in high loop gain sleep apnea (HLGSA) is inadequately assessed. We predicted that AZT may improve HLGSA in both conditions. METHODS A retrospective analysis of polysomnograms from patients with presumed HLGSA and residual respiratory instability administered AZT (125 or 250 mg) about 3 h into an initially drug-free positive pressure titration. A responder was defined as ≥ 50% reduction of the apnea hypopnea index(AHI 3% or arousal) before and after AZT. A multivariable logistic regression model estimated responder predictors. Long term efficacy of AZT was assessed by comparing both auto-machine (aREIFLOW) and manually scored respiratory events (sREIFLOW) extracted from the ventilator, prior to and after 3 months of AZT, in a subset. RESULTS Of the 231 participants (median age of 61[51-68] years) and 184 (80%) males in the acute effect testing: 77 and 154 patients were given 125 mg and 250 mg AZT. Compared to PAP alone, PAP plus AZT was associated with a lower breathing related arousal index (8 [3-16] vs. 5 [2-10], p < 0.001), and AHI3% (19 [7-37] vs. 11 [5-21], p < 0.001); 98 patients were responders. The non-rapid eye movement sleep (NREM) AHI3% (OR 1.031, 95%CI [1.016-1.046], p < 0.001) was a strong predictor for responder status with AZT exposure. In the 109 participants with 3-month data, both aREIFLOW and sREIFLOWwere significantly reduced after AZT. CONCLUSIONS AZT acutely and chronically reduced residual sleep apnea in presumed HLGSA; NREM AHI3% is a response predictor. AZT was well tolerated and beneficial for at least 3 months.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Rena C Holzer
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Pesta D, Heieis J, Hand O, Frings-Meuthen P, Marcus K, Clemen CS, Levine B, Sadek H, Hoffmann F, Limper U, Jordan J, Sies W, Tank J, Zange J, Rittweger J. Case Report: Muscle Wasting during Severe Sustained Hypoxia in Two Professional Mountaineers. Med Sci Sports Exerc 2023; 55:335-341. [PMID: 36730975 DOI: 10.1249/mss.0000000000003060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Chronic exposure to hypoxia can induce muscle wasting in unaccustomed individuals. Detailed assessment of the effects of hypoxia on muscle tissue adaptation in elite mountaineers has not been performed. This study aims to assess muscle volume after exposure to normobaric hypoxia. METHODS Two professional mountaineers (A and B) participated in a 35-d intervention of graded normobaric hypoxia with the aim of 14 d exposure to 8% oxygen corresponding to 7112-m altitude. Volume of the shank, thigh, and hip muscles was assessed by magnetic resonance imaging pre- and postintervention. Dietary intake and physical activity were monitored throughout the study from food images and accelerometry analysis, together with blood analysis and anthropometric measurements. RESULTS Hypoxia reduced total leg muscle volume by 3.3% ± 6.0% in A and by 9.4% ± 7.3% in B. A lost 288 g and B 642 g of muscle mass, whereas dietary intake only declined by ~23% in the last intervention week. Arterial oxygen saturation declined from 95% and 86% to 77% and 72% in A and B, respectively. In hypoxia, participants could not maintain their physical activity levels. Notably, muscle loss varied substantially across muscle groups amounting to 5.4% ± 3.0%, 8.3% ± 5.2%, and 4.1% ± 8.6% for hip, thigh, and shank muscles, respectively. CONCLUSIONS Our results indicate that hypoxia and resultant reductions in physical activity and caloric intake lead to substantial loss of muscle mass that was accentuated in proximal muscle as opposed to distal muscles. Surprisingly, thigh muscle wasting during this intervention is comparable with that observed during strict 56-d bed rest.
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Affiliation(s)
| | - Jule Heieis
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | - Olga Hand
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | - Petra Frings-Meuthen
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | - Katrin Marcus
- Medical Proteome Analysis, Center for Proteindiagnostics (PRODI), Ruhr-University Bochum, Bochum, GERMANY
| | | | | | - Hesham Sadek
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX
| | - Fabian Hoffmann
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | | | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | - Wolfram Sies
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
| | - Jochen Zange
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, GERMANY
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Arterial bicarbonate is associated with hypoxic burden and uncontrolled hypertension in obstructive sleep apnea - The ESADA cohort. Sleep Med 2023; 102:39-45. [PMID: 36599194 DOI: 10.1016/j.sleep.2022.11.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Blood bicarbonate concentration plays an important role for obstructive sleep apnea (OSA) patients to maintain acid-base balance. We investigated the association between arterial standard bicarbonate ([HCO3-]) and nocturnal hypoxia as well as comorbid hypertension in OSA. METHODS A cross-sectional analysis of 3329 patients in the European Sleep Apnea Database (ESADA) was performed. Arterial blood gas analysis and lung function test were performed in conjunction with polysomnographic sleep studies. The 4% oxygen desaturation index (ODI), mean and minimum oxygen saturation (SpO2), and percentage of time with SpO2 below 90% (T90%) were used to reflect nocturnal hypoxic burden. Arterial hypertension was defined as a physician diagnosis of hypertension with ongoing antihypertensive medication. Hypertensive patients with SBP/DBP below or above 140/90 mmHg were classified as controlled-, uncontrolled hypertension, respectively. RESULTS The [HCO3-] level was normal in most patients (average 24.0 ± 2.5 mmol/L). ODI, T90% increased whereas mean and minimum SpO2 decreased across [HCO3-] tertiles (ANOVA, p = 0.030, <0.001, <0.001, and <0.001, respectively). [HCO3-] was independently associated with ODI, mean SpO2, minimum SpO2, and T90% after adjusting for confounders (β value [95%CI]: 1.21 [0.88-1.54], -0.16 [-0.20 to -0.11], -0.51 [-0.64 to -0.37], 1.76 [1.48-2.04], respectively, all p < 0.001). 1 mmol/L elevation of [HCO3-] was associated with a 4% increased odds of uncontrolled hypertension (OR: 1.04 [1.01-1.08], p = 0.013). CONCLUSION We first demonstrated an independent association between [HCO3-] and nocturnal hypoxic burden as well as uncontrolled hypertension in OSA patients. Bicarbonate levels as an adjunctive measure provide insight into the pathophysiology of hypertension in OSA.
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Castiglioni P, Parati G, Faini A. Cepstral Analysis for Scoring the Quality of Electrocardiograms for Heart Rate Variability. Front Physiol 2022; 13:921210. [PMID: 35784895 PMCID: PMC9247307 DOI: 10.3389/fphys.2022.921210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
Mobile-health solutions based on heart rate variability often require electrocardiogram (ECG) recordings by inexperienced operators or real-time automatic analyses of long-term recordings by wearable devices in free-moving individuals. In this context, it is useful to associate a quality index with the ECG, scoring the adequacy of the recording for heart rate variability to identify noise or arrhythmias. Therefore, this work aims to propose and validate a computational method for assessing the adequacy of single-lead ECGs for heart rate variability analysis that may run in real time on wearable systems with low computational power. The method quantifies the ECG pseudo-periodic structure employing cepstral analysis. The cepstrum (spectrum of log-spectrum) is estimated on a running ECG window of 10 s before and after "liftering" (filtering in the cepstral domain) to remove slower noise components. The ECG periodicity generates a dominant peak in the liftered cepstrum at the "quefrency" of the mean cardiac interval. The Cepstral Quality Index (CQI) is the ratio between the cepstral-peak power and the total power of the unliftered cepstrum. Noises and arrhythmias reduce the relative power of the cepstral peak decreasing CQI. We analyzed a public dataset of 6072 single-lead ECGs manually classified in normal rhythm or inadequate for heart rate variability analysis because of noise or atrial fibrillation, and the CQI = 47% cut-off identified the inadequate recordings with 79% sensitivity and 85% specificity. We showed that the performance is independent of the lead considering a public dataset of 1,000 12-lead recordings with quality classified as "acceptable" or "unacceptable" by visual inspection. Thus, the cepstrum describes the ECG periodic structure effectively and concisely and CQI appears to be a robust score of the adequacy of ECG recording for heart rate variability analysis, evaluable in real-time on wearable devices.
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Affiliation(s)
| | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Ital
| | - Andrea Faini
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
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Riveros-Rivera A, Penzel T, Gunga HC, Opatz O, Paul F, Klug L, Boschmann M, Mähler A. Hypoxia Differentially Affects Healthy Men and Women During a Daytime Nap With a Dose-Response Relationship: a Randomized, Cross-Over Pilot Study. Front Physiol 2022; 13:899636. [PMID: 35685284 PMCID: PMC9171024 DOI: 10.3389/fphys.2022.899636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Context: The use of daytime napping as a countermeasure in sleep disturbances has been recommended but its physiological evaluation at high altitude is limited. Objective: To evaluate the neuroendocrine response to hypoxic stress during a daytime nap and its cognitive impact. Design, Subject, and Setting: Randomized, single-blind, three period cross-over pilot study conducted with 15 healthy lowlander subjects (8 women) with a mean (SD) age of 29(6) years (Clinicaltrials identifier: NCT04146857, https://clinicaltrials.gov/ct2/show/NCT04146857?cond=napping&draw=3&rank=12). Interventions: Volunteers underwent a polysomnography, hematological and cognitive evaluation around a 90 min midday nap, being allocated to a randomized sequence of three conditions: normobaric normoxia (NN), normobaric hypoxia at FiO2 14.7% (NH15) and 12.5% (NH13), with a washout period of 1 week between conditions. Results: Primary outcome was the interbeat period measured by the RR interval with electrocardiogram. Compared to normobaric normoxia, RR during napping was shortened by 57 and 206 ms under NH15 and NH13 conditions, respectively (p < 0.001). Sympathetic predominance was evident by heart rate variability analysis and increased epinephrine levels. Concomitantly, there were significant changes in endocrine parameters such as erythropoietin (∼6 UI/L) and cortisol (∼100 nmol/L) (NH13 vs. NN, p < 0.001). Cognitive evaluation revealed changes in the color-word Stroop test. Additionally, although sleep efficiency was preserved, polysomnography showed lesser deep sleep and REM sleep, and periodic breathing, predominantly in men. Conclusion: Although napping in simulated altitude does not appear to significantly affect cognitive performance, sex-dependent changes in cardiac autonomic modulation and respiratory pattern should be considered before napping is prescribed as a countermeasure.
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Affiliation(s)
- Alain Riveros-Rivera
- Center for Space Medicine and Extreme Environments Berlin, Institute of Physiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Physiological Sciences, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hanns-Christian Gunga
- Center for Space Medicine and Extreme Environments Berlin, Institute of Physiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Oliver Opatz
- Center for Space Medicine and Extreme Environments Berlin, Institute of Physiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, A Cooperation Between the Max-Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin Berlin, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Lars Klug
- Experimental and Clinical Research Center, A Cooperation Between the Max-Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin Berlin, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Michael Boschmann
- Experimental and Clinical Research Center, A Cooperation Between the Max-Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin Berlin, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Anja Mähler
- Experimental and Clinical Research Center, A Cooperation Between the Max-Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin Berlin, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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12
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Li T, Tan L, Furian M, Zhang Y, Luo L, Lei F, Xue X, He J, Tang X. Sex-Specific Difference in the Effect of Altitude on Sleep and Nocturnal Breathing in Young Healthy Volunteers. J Clin Med 2022; 11:jcm11102869. [PMID: 35628996 PMCID: PMC9143383 DOI: 10.3390/jcm11102869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/05/2022] [Accepted: 05/16/2022] [Indexed: 02/05/2023] Open
Abstract
Importance: To date, there is no established evidence of sex-specific differences in altitude-induced sleep-disordered breathing (SDB) during polysomnography-confirmed sleep. Objective: The aim of this study was to investigate whether differences in sex play a pivotal role in incidences of SDB and acute mountain sickness (AMS) when staying overnight at high altitude. Design: This was a prospective cohort study. Setting: Participants underwent overnight polysomnography (PSG) and clinical assessment in a sleep laboratory at 500 m and two consecutive days at 3270 m. Participants: The participants comprised 28 (18 women) healthy, young, low-altitude residents with a median (interquartile range) age of 26.0 (25.0, 28.0) years. Exposures: Altitude exposure. Main outcomes and Measures: The primary outcome was altitude-induced change in the PSG-confirmed apnea−hypopnea index (AHI) at 3270 m compared to 500 m between men and women. Secondary outcomes included sex differences in other parameters related to SDB, sleep structure, AMS, psychomotor vigilance test reaction time and parameters from arterial and venous blood analyses. Results: The median (interquartile range) AHIs at 500 m and 3270 m on night 1 and on night 2 were 6.5/h (3.6, 9.1), 23.7/h (16.2, 42.5) and 15.2/h (11.8, 20.9) in men, respectively, and 2.2/h (1.0, 5.5), 8.0/h (5.3, 17.0) and 7.1/h (4.9, 11.5) in women, respectively (p < 0.05 nights 1 and 2 at 3270 m vs. 500 m in men and women). The median difference (95% CI) of altitude-induced change in AHI (3270 m night 1 compared to 500 m) between men and women was 11.2/h (1.9 to 19.6) (p < 0.05). Over the time course of 2 days at 3270 m, 9 out of 18 (50%) women and 1 out of 10 (10%) men developed AMS (p < 0.05 women versus men). Conclusions and Relevance: This prospective cohort study showed that men were more susceptible to altitude-induced SDB but that they had a lower AMS incidence when staying for 2 days at 3270 m than women. These findings indicate that sex-related prevention and intervention strategies against SDB and AMS are highly warranted. Trial Registration: This trial was registered at the Chinese Clinical Trial Registry; No. ChiCTR1800020155.
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Affiliation(s)
- Taomei Li
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; (T.L.); (L.T.); (Y.Z.); (L.L.); (F.L.)
| | - Lu Tan
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; (T.L.); (L.T.); (Y.Z.); (L.L.); (F.L.)
| | - Michael Furian
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, 8091 Zurich, Switzerland;
| | - Yanyan Zhang
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; (T.L.); (L.T.); (Y.Z.); (L.L.); (F.L.)
| | - Lian Luo
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; (T.L.); (L.T.); (Y.Z.); (L.L.); (F.L.)
| | - Fei Lei
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; (T.L.); (L.T.); (Y.Z.); (L.L.); (F.L.)
| | - Xiaofang Xue
- Department of Cardiology, Diqing Tibetan Autonomous Prefectural People’s Hospital, Shangri-La 674400, China; (X.X.); (J.H.)
| | - Jiaming He
- Department of Cardiology, Diqing Tibetan Autonomous Prefectural People’s Hospital, Shangri-La 674400, China; (X.X.); (J.H.)
| | - Xiangdong Tang
- Sleep Medicine Center, Mental Health Center, Department of Respiratory and Critical Care Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; (T.L.); (L.T.); (Y.Z.); (L.L.); (F.L.)
- Correspondence: ; Tel.: +86-28-85422733; Fax: +86-28-85422632
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13
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Heart Rate Variability from Wearable Photoplethysmography Systems: Implications in Sleep Studies at High Altitude. SENSORS 2022; 22:s22082891. [PMID: 35458875 PMCID: PMC9028181 DOI: 10.3390/s22082891] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 02/04/2023]
Abstract
The interest in photoplethysmography (PPG) for sleep monitoring is increasing because PPG may allow assessing heart rate variability (HRV), which is particularly important in breathing disorders. Thus, we aimed to evaluate how PPG wearable systems measure HRV during sleep at high altitudes, where hypobaric hypoxia induces respiratory disturbances. We considered PPG and electrocardiographic recordings in 21 volunteers sleeping at 4554 m a.s.l. (as a model of sleep breathing disorder), and five alpine guides sleeping at sea level, 6000 m and 6800 m a.s.l. Power spectra, multiscale entropy, and self-similarity were calculated for PPG tachograms and electrocardiography R–R intervals (RRI). Results demonstrated that wearable PPG devices provide HRV measures even at extremely high altitudes. However, the comparison between PPG tachograms and RRI showed discrepancies in the faster spectral components and at the shorter scales of self-similarity and entropy. Furthermore, the changes in sleep HRV from sea level to extremely high altitudes quantified by RRI and PPG tachograms in the five alpine guides tended to be different at the faster frequencies and shorter scales. Discrepancies may be explained by modulations of pulse wave velocity and should be considered to interpret correctly autonomic alterations during sleep from HRV analysis.
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14
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Tan L, Furian M, Li T, Tang X. Effect of acetazolamide on obstructive sleep apnoea in highlanders: protocol for a randomised, placebo-controlled, double-blinded crossover trial. BMJ Open 2022; 12:e057113. [PMID: 35256446 PMCID: PMC8905944 DOI: 10.1136/bmjopen-2021-057113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is a highly prevalent disease that causing systemic hypertension. Furthermore, altitude-dependent hypobaric hypoxic condition and Tibetan ethnicity have been associated with systemic hypertension independent of OSA, therefore patients with OSA living at high altitude might be at profound risk to develop systemic hypertension. Acetazolamide has been shown to decrease blood pressure, improve arterial oxygenation and prevent high altitude periodic breathing in healthy volunteers ascending to high altitude and decrease blood pressure in patients with systemic hypertension at low altitude. However, the effect of acetazolamide on 24-hour blood pressure, sleep-disordered disturbance and daytime cognitive performance in patients with OSA permanently living at high altitude has not been studied. METHODS AND ANALYSIS This study protocol describes a randomised, placebo-controlled, double-blinded crossover trial. Highland residents of both sexes, aged 30-60 years, Tibetan ethnicity, living at an elevation of 3650 m and apnoea-hypopnoea index over 15/hour will be included. Participants will be randomly assigned to a 2×2 week treatment period starting with 750 mg/day acetazolamide followed by placebo treatment or vice versa, separated by a 1-week wash-out phase. Clinical assessments, 24-hour ambulatory blood pressure monitoring (ABPM), polysomnography (PSG), near-infrared spectroscopy, nocturnal fluid shift and cognitive performance will be assessed before and at the end of each treatment period. The primary outcome will be the difference in 24-hour mean blood pressure between acetazolamide therapy and placebo; secondary outcomes will be the difference in other 24-hour ABPM-derived parameters, PSG-derived parameters, cognitive performance and overnight change in different segments of fluid volume between acetazolamide therapy and placebo. Accounting for potential dropouts, 40 participants will be recruited. ETHICS AND DISSEMINATION The protocol was approved by the West China Hospital of Sichuan University Biomedical Research Ethics Committee. Recruitment will start in spring 2022. Dissemination of the results include presentations at conferences and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2100049304.
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Affiliation(s)
- Lu Tan
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Translational Neuroscience Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Michael Furian
- Sleep Disorders Center, Department of Respiratory Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Taomei Li
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Translational Neuroscience Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangdong Tang
- Sleep Medicine Center, Department of Respiratory and Critical Care Medicine, Translational Neuroscience Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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15
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Hedner J, Stenlöf K, Zou D, Hoff E, Hansen C, Kuhn K, Lennartz P, Grote L. A Randomized Controlled Trial Exploring Safety and Tolerability of Sulthiame in Sleep Apnea. Am J Respir Crit Care Med 2022; 205:1461-1469. [PMID: 35202553 DOI: 10.1164/rccm.202109-2043oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONAL Current therapies in obstructive sleep apnea (OSA) are limited by insufficient efficacy, compliance or tolerability. An effective pharmacological treatment in OSA is warranted. Carbonic anhydrase (CA) inhibition has been shown to ameliorate OSA. OBJECTIVE To explore safety and tolerability of the CA inhibitor sulthiame (STM) in OSA. METHODS A four week double-blind, randomized, placebo-controlled dose guiding trial in patients with moderate/severe OSA not tolerating positive airway pressure treatment. MEASUREMENTS AND RESULTS Intermittent paresthesia was reported by 79, 67 and 18% of patients receiving 400 mg STM (N=34), 200 mg STM (N=12) or placebo (N=22), respectively. Dyspnea was reported only after 400 mg STM (18%). Six patients in the higher dose group withdrew due to an adverse event. There were no serious adverse events. STM reduced the apnea-hypopnea index (AHI) from 55.3 to 33.1 events/h ( 41.0%) in the 400 mg group and from 61.2 to 40.7 events/h ( 32.1%) after 200 mg (p<0.001, respectively). Corresponding placebo values were 53.9 and 50.9 events/h ( 5.4 %). The AHI reduction threshold of ≥50% was reached in 40% after 400 mg, 25% after 200 mg and 5% following placebo. Mean overnight oxygen saturation improved by 1.1% after 400 mg and 200 mg (p<0.001 and p=0.034, respectively). Patient related outcomes were unchanged. CONCLUSIONS STM showed a satisfactory safety profile in moderate/severe OSA. STM reduced OSA by more than 20 events/h, one of the strongest reductions reported in a drug trial in OSA. Larger scale clinical studies of STM in OSA are justified. Clinical trial registration available at https://www.clinicaltrialsregister.eu/https://www.clinicaltrialsregister.eu/, ID: 2017-004767-13.
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Affiliation(s)
- Jan Hedner
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden;
| | - Kaj Stenlöf
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden
| | - Ding Zou
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden
| | - Erik Hoff
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden
| | | | - Katrin Kuhn
- Desitin Arzneimittel GmbH, 60840, Hamburg, Germany
| | | | - Ludger Grote
- University of Gothenburg Sahlgrenska Academy, 70712, Internal Medicine, Center for Sleep and Wake Disorders, Goteborg, Sweden.,Sahlgrenska University Hospital, 56749, Sleep Laboratory, Pulmonary Medicine, Goteborg, Sweden
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16
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Staab JE, Muza SR, Fulco CS, Andrew SP, Beidleman BA. Impact of 2 days of staging at 2500-4300 m on sleep quality and quantity following subsequent exposure to 4300 m. Physiol Rep 2021; 9:e15063. [PMID: 34713967 PMCID: PMC8554773 DOI: 10.14814/phy2.15063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/21/2022] Open
Abstract
The impact of 2 days of staging at 2500-4300 m on sleep quality and quantity following subsequent exposure to 4300 m was determined. Forty-eight unacclimatized men and women were randomly assigned to stage for 2 days at one of four altitudes (2500, 3000, 3500, or 4300 m) prior to assessment on the summit of Pikes Peak (4300 m) for 2 days. Volunteers slept for one night at sea level (SL), two nights at respective staging altitudes, and two nights at Pikes Peak. Each wore a pulse oximeter to measure sleep arterial oxygen saturation (sSpO2 , %) and number of desaturations (DeSHr, events/hr) and a wrist motion detector to estimate sleep awakenings (Awak, awakes/hr) and sleep efficiency (Eff, %). Acute mountain sickness (AMS) was assessed using the Environmental Symptoms Questionnaire and daytime SpO2 was assessed after AMS measurements. The mean of all variables for both staging days (STG) and Pikes Peak days (PP) was calculated. The sSpO2 and daytime SpO2 decreased (p < 0.05) from SL during STG in all groups in a dose-dependent manner. During STG, DeSHr were higher (p < 0.05), Eff was lower (p < 0.05), and AMS symptoms were higher (p < 0.05) in the 3500 and 4300 m groups compared to the 2500 and 3000 m groups while Awak did not differ (p > 0.05) between groups. At PP, the sSpO2 , DeSHr, Awak, and Eff were similar among all groups but the 2500 m group had greater AMS symptoms (p < 0.05) than the other groups. Two days of staging at 2500-4300 m induced a similar degree of sleep acclimatization during subsequent ascent to 4300 m but the 2500 m group was not protected against AMS at 4300 m.
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Affiliation(s)
- Janet E. Staab
- Military Performance DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Stephen R. Muza
- Strategic Scientific Management OfficeU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Charles S. Fulco
- Thermal and Mountain Medicine DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Sean P. Andrew
- Thermal and Mountain Medicine DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
| | - Beth A. Beidleman
- Biophysics and Biomedical Modeling DivisionU.S. Army Research Institute of Environmental MedicineNatickMassachusettsUSA
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17
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Gao D, Wang Y, Zhang R, Zhang Y. Efficacy of acetazolamide for the prophylaxis of acute mountain sickness: A systematic review, meta-analysis, and trial sequential analysis of randomized clinical trials. Ann Thorac Med 2021; 16:337-346. [PMID: 34820021 PMCID: PMC8588948 DOI: 10.4103/atm.atm_651_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute mountain sickness (AMS) is a benign and self-limiting syndrome, but can progress to life-threatening conditions if leave untreated. This study aimed to assess the efficacy of acetazolamide for the prophylaxis of AMS, and disclose factors that affect the treatment effect of acetazolamide. METHODS Randomized controlled trials comparing the use of acetazolamide versus placebo for the prevention of AMS were included. The incidence of AMS was our primary endpoint. Meta-regression analysis was conducted to explore factors that associated with acetazolamide efficacy. Trial sequential analyses were conducted to estimate the statistical power of the available data. RESULTS A total of 22 trials were included. Acetazolamide at 125, 250, and 375 mg/bid significantly reduced incidence of AMS compared to placebo. TAS indicated that the current evidence was adequate confirming the efficacy of acetazolamide at 125, 250, and 375 mg/bid in lowering incidence of AMS. There was no evidence of an association between efficacy and dose of acetazolamide, timing at start of acetazolamide treatment, mode of ascent, AMS assessment score, timing of AMS assessment, baseline altitude, and endpoint altitude. CONCLUSION Acetazolamide is effective prophylaxis for the prevention of AMS at 125, 250, and 375 mg/bid. Future investigation should focus on personal characteristics, disclosing the correlation between acetazolamide efficacy and body mass, height, degree of prior acclimatization, individual inborn susceptibility, and history of AMS.
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Affiliation(s)
- Daiquan Gao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Rujiang Zhang
- Department of Neurology, The People's Hospital of RuiLi, Yunnan, China
| | - Yunzhou Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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18
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Schmickl CN, Landry S, Orr JE, Nokes B, Edwards BA, Malhotra A, Owens RL. Effects of acetazolamide on control of breathing in sleep apnea patients: Mechanistic insights using meta-analyses and physiological model simulations. Physiol Rep 2021; 9:e15071. [PMID: 34699135 PMCID: PMC8547551 DOI: 10.14814/phy2.15071] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 11/24/2022] Open
Abstract
Obstructive and central sleep apnea affects ~1 billion people globally and may lead to serious cardiovascular and neurocognitive consequences, but treatment options are limited. High loop gain (ventilatory instability) is a major pathophysiological mechanism underlying both types of sleep apnea and can be lowered pharmacologically with acetazolamide, thereby improving sleep apnea severity. However, individual responses vary and are strongly correlated with the loop gain reduction achieved by acetazolamide. To aid with patient selection for long-term trials and clinical care, our goal was to understand better the factors that determine the change in loop gain following acetazolamide in human subjects with sleep apnea. Thus, we (i) performed several meta-analyses to clarify how acetazolamide affects ventilatory control and loop gain (including its primary components controller/plant gain), and based on these results, we (ii) performed physiological model simulations to assess how different baseline conditions affect the change in loop gain. Our results suggest that (i) acetazolamide primarily causes a left shift of the chemosensitivity line thus lowering plant gain without substantially affecting controller gain; and (ii) higher controller gain, higher paCO2 at eupneic ventilation, and lower CO2 production at baseline result in a more pronounced loop gain reduction with acetazolamide. In summary, the combination of mechanistic meta-analyses with model simulations provides a unified framework of acetazolamide's effects on ventilatory control and revealed physiological predictors of response, which are consistent with empirical observations of acetazolamide's effects in different sleep apnea subgroups. Prospective studies are needed to validate these predictors and assess their value for patient selection.
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Affiliation(s)
- Christopher N. Schmickl
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Shane Landry
- Department of PhysiologySleep and Circadian Medicine LaboratorySchool of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Jeremy E. Orr
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Brandon Nokes
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Bradley A. Edwards
- Department of PhysiologySleep and Circadian Medicine LaboratorySchool of Biomedical Sciences and Biomedical Discovery InstituteMonash UniversityMelbourneVictoriaAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneVictoriaAustralia
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep MedicineUniversity of California, San Diego (UCSD)La JollaCaliforniaUSA
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19
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Vignati C, Mapelli M, Nusca B, Bonomi A, Salvioni E, Mattavelli I, Sciomer S, Faini A, Parati G, Agostoni P. A Breathtaking Lift: Sex and Body Mass Index Differences in Cardiopulmonary Response in a Large Cohort of Unselected Subjects with Acute Exposure to High Altitude. High Alt Med Biol 2021; 22:379-385. [PMID: 34424758 PMCID: PMC8742268 DOI: 10.1089/ham.2021.0039] [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] [Indexed: 11/12/2022] Open
Abstract
Vignati, Carlo, Massimo Mapelli, Benedetta Nusca, Alice Bonomi, Elisabetta Salvioni, Irene Mattavelli, Susanna Sciomer, Andrea Faini, Gianfranco Parati, and Piergiuseppe Agostoni. A breathtaking lift: sex and body mass index differences in cardiopulmonary response in a large cohort of unselected subjects with acute exposure to high altitude. High Alt Med Biol 00:000-000, 2021. Background: Every year, thousands of people travel to high altitude and experience hypoxemia. At high altitude, the partial pressure of oxygen decreases. The aim of this observational study was to determine if there is a relationship between anthropometric features and basic cardiorespiratory variables, including oxygen saturation (SpO2), heart rate (HR), and blood pressure (BP), following acute exposure to high altitude. Materials and Methods: At the 3,466 m top of a cableway station, we installed an automated system for measuring peripheral SpO2, HR, BP, height, weight, and body mass index (BMI). Results: Between January and October 2020, out of 4,874 volunteers (age 39.9 ± 15.4 years, male 54.4%), 3,267 provided complete data (1,808 cases during winter and 1,459 during summer). SpO2 was 86.8% ± 6.8%. At multivariable analysis, SpO2 was significantly associated with age, sex, season, BMI, and HR but not with BP. We identified 391 (12%) subjects with SpO2 ≤80%: they were older, with a higher BMI and HR but without sex or BP differences. Finally, winter season was associated with greater frequency of SpO2 ≤80% (13.3% vs. 10.3%, p = 0.008). Conclusion: Our data show that high BMI, older age, and male sex were associated with greater degrees of hypoxemia following exposure to high altitude, particularly during the winter.
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Affiliation(s)
- Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | | | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | | | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, "Sapienza" Rome University, Rome, Italy
| | - Andrea Faini
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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Exercising in Hypoxia and Other Stimuli: Heart Rate Variability and Ventilatory Oscillations. Life (Basel) 2021; 11:life11070625. [PMID: 34203350 PMCID: PMC8306822 DOI: 10.3390/life11070625] [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: 06/01/2021] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 12/24/2022] Open
Abstract
Periodic breathing is a respiratory phenomenon frequently observed in patients with heart failure and in normal subjects sleeping at high altitude. However, until recently, periodic breathing has not been studied in wakefulness and during exercise. This review relates the latest findings describing this ventilatory disorder when a healthy subject is submitted to simultaneous physiological (exercise) and environmental (hypoxia, hyperoxia, hypercapnia) or pharmacological (acetazolamide) stimuli. Preliminary studies have unveiled fundamental physiological mechanisms related to the genesis of periodic breathing characterized by a shorter period than those observed in patients (11~12 vs. 30~60 s). A mathematical model of the respiratory system functioning under the aforementioned stressors corroborated these data and pointed out other parameters, such as dead space, later confirmed in further research protocols. Finally, a cardiorespiratory interdependence between ventilatory oscillations and heart rate variability in the low frequency band may partly explain the origin of the augmented sympathetic activation at exercise in hypoxia. These nonlinear instabilities highlight the intrinsic "homeodynamic" system that allows any living organism to adapt, to a certain extent, to permanent environmental and internal perturbations.
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21
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Venkat D, Dhillon K, Rowley JA. Effects of High Altitude on Sleep and Respiratory System. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00276-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Gao D, Wang Y, Zhang R, Zhang Y. Efficacy of Acetazolamide for the Prophylaxis of Acute Mountain Sickness: A Systematic Review, Meta-Analysis and Trial Sequential Analysis of Randomized Clinical Trials. Am J Med Sci 2021; 361:635-645. [PMID: 33587912 DOI: 10.1016/j.amjms.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute mountain sickness (AMS) is a benign and self-limiting syndrome but can progress to life-threatening conditions if leave untreated. This study aimed to assess the efficacy of acetazolamide for the prophylaxis of AMS and disclose potential factors that affect the treatment effect of acetazolamide. MATERIALS AND METHODS Randomized controlled trials comparing the use of acetazolamide versus placebo for the prevention of AMS were included. The incidence of AMS was the primary endpoint. Meta-regression analysis was conducted to explore potential factors associated with acetazolamide efficacy. Trial sequential analysis (TSA) was conducted to estimate the statistical power of the available data. RESULTS A total of 22 trials were included. Acetazolamide at 125, 250, and 375 mg/ twice daily (bid) significantly reduced incidence of AMS compared to placebo. TAS indicated that the current evidence was adequate confirming the efficacy of acetazolamide at 125, 250, and 375 mg/bid in lowering incidence of AMS. There was no evidence of an association between efficacy and dose of acetazolamide, timing at start of acetazolamide treatment, mode of ascent, AMS assessment score, timing of AMS assessment, baseline altitude, and endpoint altitude. CONCLUSION Acetazolamide is effective prophylaxis for the prevention of AMS in doses of 125, 250, and 375 mg/bid. Future investigations should focus on personal characteristics, disclosing the correlation between acetazolamide efficacy and body mass, height, degree of prior acclimatization, individual inborn susceptibility, and history of AMS.
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Affiliation(s)
- Daiquan Gao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Rujiang Zhang
- Department of Neurology, The People's Hospital of RuiLi, Yunnan, China
| | - Yunzhou Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China.
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23
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Effect of Carbohydrate-Electrolyte Solution Including Bicarbonate Ion Ad Libitum Ingestion on Urine Bicarbonate Retention during Mountain Trekking: A Randomized, Controlled Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041441. [PMID: 33557035 PMCID: PMC7913653 DOI: 10.3390/ijerph18041441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 11/16/2022]
Abstract
We investigated whether bicarbonate ion (HCO3−) in a carbohydrate-electrolyte solution (CE+HCO3) ingested during climbing to 3000 m on Mount Fuji could increase urine HCO3− retention. This study was a randomized, controlled pilot study. Sixteen healthy lowlander adults were divided into two groups (six males and two females for each): a tap water (TW) group (0 kcal with no energy) and a CE+HCO3 group. The allocation to TW or CE+HCO3 was double blind. The CE solution contains 10 kcal energy, including Na+ (115 mg), K+ (78 mg), HCO3− (51 mg) per 100 mL. After collecting baseline urine and measuring body weight, participants started climbing while energy expenditure (EE) and heart rate (HR) were recorded every min with a portable calorimeter. After reaching a hut at approximately 3000 m, we collected urine and measured body weight again. The HCO3− balance during climbing, measured by subtracting the amount of urine excreted from the amount of fluid ingested, was −0.37 ± 0.77 mmol in the CE+HCO3, which was significantly higher than in the TW (−2.23 ± 0.96 mmol, p < 0.001). These results indicate that CE containing HCO3− supplementation may increase the bicarbonate buffering system during mountain trekking up to ~3000 m, suggesting a useful solution, at least, in the population of the present study on Mount Fuji.
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Acetazolamide for OSA and Central Sleep Apnea: A Comprehensive Systematic Review and Meta-Analysis. Chest 2020; 158:2632-2645. [PMID: 32768459 DOI: 10.1016/j.chest.2020.06.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Therapy options for OSA and central sleep apnea (CSA) are limited, thus many patients remain untreated. Clinically, acetazolamide is sometimes used for CSA; however, given overlapping pathophysiologic properties of OSA and CSA, we hypothesized that acetazolamide is equally effective for both types. Prior reviews focused on specific subtypes of sleep apnea, study designs, and languages, thus including few studies (typically ≤3) limiting insights. RESEARCH QUESTION How efficacious is acetazolamide for sleep apnea, and is its effect modified by sleep apnea type or acetazolamide dose? STUDY DESIGN AND METHODS We queried MEDLINE, EMBASE, and ClinicalTrials.gov from inception until March 11, 2019. Any study in which adults with OSA/CSA received oral acetazolamide vs no acetazolamide (control) that reported sleep apnea-related outcomes was eligible, independent of study design or language. Two reviewers independently assessed eligibility and abstracted data. Primary outcomes were apnea-hypopnea index (AHI) and oxygen saturation nadir. Quality of evidence (QoE) was rated with the use of Grades of Recommendation Assessment, Development and Evaluation methods. RESULTS We included 28 studies (13 OSA/15 CSA; NSubjects,Acetazolamide = 542; NSubjects,Control = 553) that enabled meta-analyses for 24 outcomes. Acetazolamide doses ranged from 36 to 1000 mg/d and treatment duration from 1 to 90 d (median, 6 d). Overall, acetazolamide vs control lowered the AHI by -0.7 effect sizes (95% CI, -0.83 to -0.58; I2 = 0%; moderate QoE) that corresponded to a reduction of 37.7% (95% CI, -44.7 to -31.3) or 13.8/h (95% CI, -16.3 to -11.4; AHIControl = 36.5/h). The AHI reduction was similar in OSA vs CSA, but significantly greater with higher doses (at least up to 500 mg/d). Furthermore, acetazolamide improved oxygen saturation nadir by +4.4% (95% CI, 2.3 to 6.5; I2 = 63%; no evidence of effect modification; very low QoE) and several secondary outcomes that included sleep quality measures and BP (mostly low QoE). INTERPRETATION Short-term acetazolamide improved both OSA and CSA. Rigorous studies with long-term follow up are warranted to assess Acetazolamide's value for the chronic treatment of patients with sleep apnea. CLINICAL TRIAL REGISTRATION PROSPERO (CRD42019147504).
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Petkovic J, Jull J, Yoganathan M, Dewidar O, Baird S, Grimshaw JM, Johansson KA, Kristjansson E, McGowan J, Moher D, Petticrew M, Robberstad B, Shea B, Tugwell P, Volmink J, Wells GA, Whitehead M, Cuervo LG, White H, Taljaard M, Welch V. Reporting of health equity considerations in cluster and individually randomized trials. Trials 2020; 21:308. [PMID: 32245522 PMCID: PMC7118943 DOI: 10.1186/s13063-020-4223-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/02/2020] [Indexed: 01/12/2023] Open
Abstract
Background The randomized controlled trial (RCT) is considered the gold standard study design to inform decisions about the effectiveness of interventions. However, a common limitation is inadequate reporting of the applicability of the intervention and trial results for people who are “socially disadvantaged” and this can affect policy-makers’ decisions. We previously developed a framework for identifying health-equity-relevant trials, along with a reporting guideline for transparent reporting. In this study, we provide a descriptive assessment of health-equity considerations in 200 randomly sampled equity-relevant trials. Methods We developed a search strategy to identify health-equity-relevant trials published between 2013 and 2015. We randomly sorted the 4316 records identified by the search and screened studies until 100 individually randomized (RCTs) and 100 cluster randomized controlled trials (CRTs) were identified. We developed and pilot-tested a data extraction form based on our initial work, to inform the development of our reporting guideline for equity-relevant randomized trials. Results In total, 39 trials (20%) were conducted in a low- and middle-income country and 157 trials (79%) in a high-income country focused on socially disadvantaged populations (78% CRTs, 79% RCTs). Seventy-four trials (37%) reported a subgroup analysis across a population characteristic associated with disadvantage (25% CRT, 49% RCTs), with 19% of included studies reporting subgroup analyses across sex, 9% across race/ethnicity/culture, and 4% across socioeconomic status. No subgroup analyses were reported for place of residence, occupation, religion, education, or social capital. One hundred and forty-one trials (71%) discussed the applicability of their results to one or more socially disadvantaged populations (68% of CRT, 73% of RCT). Discussion In this set of trials, selected for their relevance to health equity, data that were disaggregated for socially disadvantaged populations were rarely reported. We found that even when the data are available, opportunities to analyze health-equity considerations are frequently missed. The recently published equity extension of the Consolidated Reporting Standards for Randomized Trials (CONSORT-Equity) may help improve delineation of hypotheses related to socially disadvantaged populations, and transparency and completeness of reporting of health-equity considerations in RCTs. This study can serve as a baseline assessment of the reporting of equity considerations.
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Affiliation(s)
- Jennifer Petkovic
- Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Janet Jull
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Manosila Yoganathan
- Infectious Diseases and Prevention Control Branch, Public Health Agency of Canada, Ottawa, ON, Canada
| | - Omar Dewidar
- Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Sarah Baird
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kjell Arne Johansson
- Bergen Centre for Ethics and Priority Setting (BCEPS) Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Elizabeth Kristjansson
- School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Jessie McGowan
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - David Moher
- Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark Petticrew
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Bjarne Robberstad
- Section for Ethics and Health Economics, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Beverley Shea
- Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tugwell
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Bruyère Research Institute, Ottawa, ON, Canada
| | - Jimmy Volmink
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - George A Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Luis Gabriel Cuervo
- Department of Health Systems and Services, Pan American Health Organization, Washington, DC, USA
| | | | - Monica Taljaard
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Vivian Welch
- Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada
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Torlasco C, Bilo G, Giuliano A, Soranna D, Ravaro S, Oliverio G, Faini A, Zambon A, Lombardi C, Parati G. Effects of acute exposure to moderate altitude on blood pressure and sleep breathing patterns. Int J Cardiol 2020; 301:173-179. [DOI: 10.1016/j.ijcard.2019.09.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/11/2019] [Accepted: 09/16/2019] [Indexed: 11/16/2022]
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27
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Faini A, Caravita S, Parati G, Castiglioni P. Alterations of Cardiovascular Complexity during Acute Exposure to High Altitude: A Multiscale Entropy Approach. ENTROPY 2019. [PMCID: PMC7514569 DOI: 10.3390/e21121224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Stays at high altitude induce alterations in cardiovascular control and are a model of specific pathological cardiovascular derangements at sea level. However, high-altitude alterations of the complex cardiovascular dynamics remain an almost unexplored issue. Therefore, our aim is to describe the altered cardiovascular complexity at high altitude with a multiscale entropy (MSE) approach. We recorded the beat-by-beat series of systolic and diastolic blood pressure and heart rate in 20 participants for 15 min twice, at sea level and after arrival at 4554 m a.s.l. We estimated Sample Entropy and MSE at scales of up to 64 beats, deriving average MSE values over the scales corresponding to the high-frequency (MSEHF) and low-frequency (MSELF) bands of heart-rate variability. We found a significant loss of complexity at heart-rate and blood-pressure scales complementary to each other, with the decrease with high altitude being concentrated at Sample Entropy and at MSEHF for heart rate and at MSELF for blood pressure. These changes can be ascribed to the acutely increased chemoreflex sensitivity in hypoxia that causes sympathetic activation and hyperventilation. Considering high altitude as a model of pathological states like heart failure, our results suggest new ways for monitoring treatments and rehabilitation protocols.
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Affiliation(s)
- Andrea Faini
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, S.Luca Hospital, 20149 Milan, Italy; (A.F.); (S.C.)
| | - Sergio Caravita
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, S.Luca Hospital, 20149 Milan, Italy; (A.F.); (S.C.)
- Department of Management, Information and Production Engineering, University of Bergamo, 24044 Dalmine, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, S.Luca Hospital, 20149 Milan, Italy; (A.F.); (S.C.)
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Correspondence:
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28
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Parati G, Agostoni P, Basnyat B, Bilo G, Brugger H, Coca A, Festi L, Giardini G, Lironcurti A, Luks AM, Maggiorini M, Modesti PA, Swenson ER, Williams B, Bärtsch P, Torlasco C. Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions: A joint statement by the European Society of Cardiology, the Council on Hypertension of the European Society of Cardiology, the European Society of Hypertension, the International Society of Mountain Medicine, the Italian Society of Hypertension and the Italian Society of Mountain Medicine. Eur Heart J 2019; 39:1546-1554. [PMID: 29340578 PMCID: PMC5930248 DOI: 10.1093/eurheartj/ehx720] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 12/15/2017] [Indexed: 01/22/2023] Open
Abstract
Adapted from Bärtsch and Gibbs2 Physiological response to hypoxia. Life-sustaining oxygen delivery, in spite of a reduction in the partial pressure of inhaled oxygen between 25% and 60% (respectively at 2500 m and 8000 m), is ensured by an increase in pulmonary ventilation, an increase in cardiac output by increasing heart rate, changes in vascular tone, as well as an increase in haemoglobin concentration. BP, blood pressure; HR, heart rate; PaCO2, partial pressure of arterial carbon dioxide. ![]()
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Affiliation(s)
- Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, Italy
| | - Piergiuseppe Agostoni
- Department of Cardiology, Heart Failure Unit, Centro Cardiologico Monzino, via Parea 4, 20138 Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, via Festa del Perdono 7, 20122 Milan, Italy
| | - Buddha Basnyat
- Nuffield Department of Clinical Medicine, Oxford University Clinical Research Unit-Nepal and Centre for Tropical Medicine and Global Health, University of Oxford, Old Road campus, Roosevelt Drive, Headington, Oxford OX3 7FZ, UK
| | - Grzegorz Bilo
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine at the EURAC Research, viale Druso 1, 39100 Bolzano, Italy.,Medical University, Christoph-Probst-Platz 1, Innrain 52 A - 6020 Innsbruck, Austria
| | - Antonio Coca
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Clínic (IDIBAPS), University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Luigi Festi
- Surgery Department, Ospedale di Circolo Fondazione Macchi, viale Luigi Borri, 57, 21100 Varese, Italy.,University of Insubria, via Ravasi 2, 21100 Varese, Italy
| | - Guido Giardini
- Department of Neurology, Neurophysiopathology Unit, Valle d'Aosta Regional Hospital, via Ginevra, 3, 11100 Aosta, Italy
| | - Alessandra Lironcurti
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy
| | - Andrew M Luks
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, 98195 WA, USA
| | - Marco Maggiorini
- Medical Intensive Care Unit, University Hospital, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Pietro A Modesti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134 Florence, Florence, Italy
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, 98195 WA, USA.,Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, 98108 WA, USA
| | - Bryan Williams
- University College London (UCL) and NIHR UCL Hospitals Biomedical Research Centre, NHS Foundation Trust, University College, Gower St, Bloomsbury, London WC1E 6BT, UK
| | - Peter Bärtsch
- Department of Internal Medicine, University Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Camilla Torlasco
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia, 20, 20149 Milan, Italy
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Teppema LJ, Boulet LM, Hackett HK, Dominelli PB, Cheyne WS, Dominelli GS, Swenson ER, Foster GE. Influence of methazolamide on the human control of breathing: A comparison to acetazolamide. Exp Physiol 2019; 105:293-301. [PMID: 31595565 DOI: 10.1113/ep088058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/04/2019] [Indexed: 01/15/2023]
Abstract
NEW FINDINGS What is the central question of this study? Acetazolamide and methazolamide both reduce hypoxic pulmonary vasoconstriction equally, but methazolamide does not impair skeletal muscle function. The effect of methazolamide on respiratory control in humans is not yet known. What is the main finding and its importance? Similar to acetazolamide after chronic oral administration, methazolamide causes a metabolic acidosis and shifts the ventilatory CO2 response curve leftwards without reducing O2 sensitivity. The change in ventilation over the change in log P O 2 provides a more accurate measure of hypoxic sensitivity than the change in ventilation over the change in arterial oxyhaemoglobin saturation. ABSTRACT Acetazolamide is used to prevent/treat acute mountain sickness and both central and obstructive sleep apnoea. Methazolamide, like acetazolamide, reduces hypoxic pulmonary vasoconstriction, but has fewer side-effects, including less impairment of skeletal muscle function. Given that the effects of methazolamide on respiratory control in humans are unknown, we compared the effects of oral methazolamide and acetazolamide on ventilatory control and determined the ventilation-log P O 2 relationship in humans. In a double-blind, placebo-controlled, randomized cross-over design, we studied the effects of acetazolamide (250 mg three times daily), methazolamide (100 mg twice daily) and placebo in 14 young male subjects who were exposed to 7 min of normoxic hypercapnia and to three levels of eucapnia and hypercapnic hypoxia. With placebo, methazolamide and acetazolamide, the CO2 sensitivities were 2.39 ± 1.29, 3.27 ± 1.82 and 2.62 ± 1.79 l min-1 mmHg-1 (n.s.) and estimated apnoeic thresholds 32 ± 3, 28 ± 3 and 26 ± 3 mmHg, respectively (P < 0.001, placebo versus methazolamide and acetazolamide). The relationship between ventilation ( V ̇ I ) and log P O 2 (using arterialized venous P O 2 in hypoxia) was linear, and neither agent influenced the relationship between hypoxic sensitivity ( Δ V ̇ I / Δ log P O 2 ) and arterial [H+ ]. Using Δ V ̇ I / Δ log P O 2 rather than Δ V ̇ I /Δ arterial oxyhaemoglobin saturation enables a more accurate estimation of oxygenation and ventilatory control in metabolic acidosis/alkalosis when right- or leftward shifts of the oxyhaemoglobin saturation curve occur. Given that acetazolamide and methazolamide have similar effects on ventilatory control, methazolamide might be preferred for indications requiring the use of a carbonic anhydrase inhibitor, avoiding some of the negative side-effects of acetazolamide.
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Affiliation(s)
- Luc J Teppema
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lindsey M Boulet
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Heather K Hackett
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Paolo B Dominelli
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - William S Cheyne
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Giulio S Dominelli
- Southern Medical Program, University of British Columbia, Kelowna, BC, Canada
| | - Erik R Swenson
- Division of Pulmonary & Critical Care Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - Glen E Foster
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
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30
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Sex differences in breathing. Comp Biochem Physiol A Mol Integr Physiol 2019; 238:110543. [PMID: 31445081 DOI: 10.1016/j.cbpa.2019.110543] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 01/15/2023]
Abstract
Breathing is a vital behavior that ensures both the adequate supply of oxygen and the elimination of CO2, and it is influenced by many factors. Despite that most of the studies in respiratory physiology rely heavily on male subjects, there is much evidence to suggest that sex is an important factor in the respiratory control system, including the susceptibility for some diseases. These different respiratory responses in males and females may be related to the actions of sex hormones, especially in adulthood. These hormones affect neuromodulatory systems that influence the central medullary rhythm/pontine pattern generator and integrator, sensory inputs to the integrator and motor output to the respiratory muscles. In this article, we will first review the sex dependence on the prevalence of some respiratory-related diseases. Then, we will discuss the role of sex and gonadal hormones in respiratory control under resting conditions and during respiratory challenges, such as hypoxia and hypercapnia, and whether hormonal fluctuations during the estrous/menstrual cycle affect breathing control. We will then discuss the role of the locus coeruleus, a sexually dimorphic CO2/pH-chemosensitive nucleus, on breathing regulation in males and females. Next, we will highlight the studies that exist regarding sex differences in respiratory control during development. Finally, the few existing studies regarding the influence of sex on breathing control in non-mammalian vertebrates will be discussed.
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Pramsohler S, Schilz R, Patzak A, Rausch L, Netzer NC. Periodic breathing in healthy young adults in normobaric hypoxia equivalent to 3500 m, 4500 m, and 5500 m altitude. Sleep Breath 2019; 23:703-709. [PMID: 30972693 PMCID: PMC6529391 DOI: 10.1007/s11325-019-01829-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/18/2019] [Accepted: 03/21/2019] [Indexed: 01/01/2023]
Abstract
Purpose The occurrence of periodic breathing (PB) at high altitude during sleep and the quality of sleep are individually different and influenced by multiple factors including sex. Although poor sleep quality at high altitude might not be directly linked to oxygen desaturations, the PB upsurge at high altitude leads to significant oscillations in oxygen saturation. Methods Thirty-three students were recruited. Participants were randomly assigned to three groups (A, B, C) sleeping one full night in a dormitory with normobaric hypoxia at a FIO2 of 14.29% (A), a FIO2 of 12.47% (B), or a FIO2 of 10.82% (C). Full polysomnography was performed in each participant. Results Mean total sleeping time decreased significantly with increasing hypoxia (p < 0.001). Respiratory events changed from central hypopneas to central apneas (CA) with increasing hypoxia: CA = 17.8%, 50.0%, 92.2% of AHI (37.96 events per hour (n/h), 68.55 n/h, 93.44 n/h). AHI (p = 0.014) and time duration of respiratory events (p = 0.003) were significantly different between sexes, both greater in men. REM sleep was reduced. Conclusions Men tend to be more prone to PB in normobaric hypoxia. Further research should implicate a longer acclimatization period around simulated 4500 m in order to find out if the exponential increase in PB between 4500 m and 5500 m could be shifted to lower hypoxic levels, i.e., higher altitudes.
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Affiliation(s)
- Stephan Pramsohler
- Dept. of Psychology and Sports Science, Hermann Buhl Institute for Hypoxia and Sleep Medicine Research, University of Innsbruck, Ghersburgstr. 9, 83043, Bad Aibling, Germany.
| | - Robert Schilz
- University Hospitals of Cleveland and Case University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Andreas Patzak
- Charité-Universitätsmedizin Berlin, Institute for Vegetative Physiology, Chariteplatz 1, 10117, Berlin, Germany
| | - Linda Rausch
- Dept. of Psychology and Sports Science, Hermann Buhl Institute for Hypoxia and Sleep Medicine Research, University of Innsbruck, Ghersburgstr. 9, 83043, Bad Aibling, Germany
- Dept. of Psychology and Sport Science, University Innsbruck, Fürstenweg 185, 6020, Innsbruck, Austria
| | - Nikolaus C Netzer
- Dept. of Psychology and Sports Science, Hermann Buhl Institute for Hypoxia and Sleep Medicine Research, University of Innsbruck, Ghersburgstr. 9, 83043, Bad Aibling, Germany
- Dept. of Psychology and Sport Science, University Innsbruck, Fürstenweg 185, 6020, Innsbruck, Austria
- Division of Sports Medicine and Rehabilitation, Department of Medicine, University Ulm, Leimgrubenweg 14, 89070, Ulm, Germany
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Caravita S, Faini A, Baratto C, Bilo G, Macarlupu JL, Lang M, Revera M, Lombardi C, Villafuerte FC, Agostoni P, Parati G. Upward Shift and Steepening of the Blood Pressure Response to Exercise in Hypertensive Subjects at High Altitude. J Am Heart Assoc 2018; 7:e008506. [PMID: 29886423 PMCID: PMC6220550 DOI: 10.1161/jaha.117.008506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/27/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute exposure to high-altitude hypobaric hypoxia induces a blood pressure rise in hypertensive humans, both at rest and during exercise. It is unclear whether this phenomenon reflects specific blood pressure hyperreactivity or rather an upward shift of blood pressure levels. We aimed at evaluating the extent and rate of blood pressure rise during exercise in hypertensive subjects acutely exposed to high altitude, and how these alterations can be counterbalanced by antihypertensive treatment. METHODS AND RESULTS Fifty-five subjects with mild hypertension, double-blindly randomized to placebo or to a fixed-dose combination of an angiotensin-receptor blocker (telmisartan 80 mg) and a calcium-channel blocker (nifedipine slow release 30 mg), performed a cardiopulmonary exercise test at sea level and after the first night's stay at 3260 m altitude. High-altitude exposure caused both an 8 mm Hg upward shift (P<0.01) and a 0.4 mm Hg/mL/kg per minute steepening (P<0.05) of the systolic blood pressure/oxygen consumption relationship during exercise, independent of treatment. Telmisartan/nifedipine did not modify blood pressure reactivity to exercise (blood pressure/oxygen consumption slope), but downward shifted (P<0.001) the relationship between systolic blood pressure and oxygen consumption by 26 mm Hg, both at sea level and at altitude. Muscle oxygen delivery was not influenced by altitude exposure but was higher on telmisartan/nifedipine than on placebo (P<0.01). CONCLUSIONS In hypertensive subjects exposed to high altitude, we observed a hypoxia-driven upward shift and steepening of the blood pressure response to exercise. The effect of the combination of telmisartan/nifedipine slow release outweighed these changes and was associated with better muscle oxygen delivery. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01830530.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Grzegorz Bilo
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Josè Luis Macarlupu
- Laboratorio de Fisiologia Comparada, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Morin Lang
- Department de Ciencias de la Rehabilitación y del Movimiento Humano, Universidad de Antofagasta, Chile
| | - Miriam Revera
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Carolina Lombardi
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francisco C Villafuerte
- Laboratorio de Fisiologia Comparada, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Dominelli PB, McNeil CJ, Vermeulen TD, Stuckless TJR, Brown CV, Dominelli GS, Swenson ER, Teppema LJ, Foster GE. Effect of acetazolamide and methazolamide on diaphragm and dorsiflexor fatigue: a randomized controlled trial. J Appl Physiol (1985) 2018; 125:770-779. [PMID: 29792554 DOI: 10.1152/japplphysiol.00256.2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Acetazolamide, a carbonic anhydrase (CA) inhibitor used clinically and to prevent acute mountain sickness, worsens skeletal muscle fatigue in animals and humans. In animals, methazolamide, a methylated analog of acetazolamide and an equally potent CA inhibitor, reportedly exacerbates fatigue less than acetazolamide. Accordingly, we sought to determine, in humans, if methazolamide would attenuate diaphragm and dorsiflexor fatigue compared with acetazolamide. Healthy men (dorsiflexor: n = 12; diaphragm: n = 7) performed fatiguing exercise on three occasions, after ingesting acetazolamide (250 mg three times a day) and then in random order, methazolamide (100 mg twice a day) or placebo for 48 h. For both muscles, subjects exercised at a fixed intensity until exhaustion on acetazolamide, with subsequent iso-time and -workload trials. Diaphragm exercise was performed using a threshold-loading device, while dorsiflexor exercise was isometric. Neuromuscular function was determined pre- and postexercise by potentiated transdiaphragmatic twitch pressure and dorsiflexor torque in response to stimulation of the phrenic and fibular nerve, respectively. Diaphragm contractility 3-10 min postexercise was impaired more for acetazolamide than methazolamide or placebo (82 ± 10, 87 ± 9, and 91 ± 8% of pre-exercise value; P < 0.05). Similarly, dorsiflexor fatigue was greater for acetazolamide than methazolamide (mean twitch torque of 61 ± 11 vs. 57 ± 13% of baseline, P < 0.05). In normoxia, methazolamide leads to less neuromuscular fatigue than acetazolamide, indicating a possible benefit for clinical use or in the prophylaxis of acute mountain sickness. NEW & NOTEWORTHY Acetazolamide, a carbonic anhydrase inhibitor, may worsen diaphragm and locomotor muscle fatigue after exercise; whereas, in animals, methazolamide does not impair diaphragm function. Compared with both methazolamide and the placebo, acetazolamide significantly compromised dorsiflexor function at rest and after exhaustive exercise. Similarly, diaphragm function was most compromised on acetazolamide followed by methazolamide and placebo. Methazolamide may be preferable over acetazolamide for clinical use and altitude illness prophylaxis to avoid skeletal muscle dysfunction.
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Affiliation(s)
- Paolo B Dominelli
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Chris J McNeil
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Tyler D Vermeulen
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Troy J R Stuckless
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Courtney V Brown
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
| | - Giulio S Dominelli
- Southern Medical Program, University of British Columbia, Kelowna, Canada
| | - Erik R Swenson
- Division of Pulmonary & Critical Care Medicine, VA Puget Sound Health Care System, University of Washington , Seattle, Washington
| | - Lucas J Teppema
- Department of Anesthesiology, Leiden University Medical Center , Leiden , The Netherlands
| | - Glen E Foster
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia , Kelowna , Canada
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Nieto Estrada VH, Molano Franco D, Medina RD, Gonzalez Garay AG, Martí‐Carvajal AJ, Arevalo‐Rodriguez I. Interventions for preventing high altitude illness: Part 1. Commonly-used classes of drugs. Cochrane Database Syst Rev 2017; 6:CD009761. [PMID: 28653390 PMCID: PMC6481751 DOI: 10.1002/14651858.cd009761.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND High altitude illness (HAI) is a term used to describe a group of cerebral and pulmonary syndromes that can occur during travel to elevations above 2500 metres (8202 feet). Acute hypoxia, acute mountain sickness (AMS), high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE) are reported as potential medical problems associated with high altitude. In this review, the first in a series of three about preventive strategies for HAI, we assess the effectiveness of six of the most recommended classes of pharmacological interventions. OBJECTIVES To assess the clinical effectiveness and adverse events of commonly-used pharmacological interventions for preventing acute HAI. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), LILACS and trial registries in January 2017. We adapted the MEDLINE strategy for searching the other databases. We used a combination of thesaurus-based and free-text terms to search. SELECTION CRITERIA We included randomized-controlled and cross-over trials conducted in any setting where commonly-used classes of drugs were used to prevent acute HAI. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 64 studies (78 references) and 4547 participants in this review, and classified 12 additional studies as ongoing. A further 12 studies await classification, as we were unable to obtain the full texts. Most of the studies were conducted in high altitude mountain areas, while the rest used low pressure (hypobaric) chambers to simulate altitude exposure. Twenty-four trials provided the intervention between three and five days prior to the ascent, and 23 trials, between one and two days beforehand. Most of the included studies reached a final altitude of between 4001 and 5000 metres above sea level. Risks of bias were unclear for several domains, and a considerable number of studies did not report adverse events of the evaluated interventions. We found 26 comparisons, 15 of them comparing commonly-used drugs versus placebo. We report results for the three most important comparisons: Acetazolamide versus placebo (28 parallel studies; 2345 participants)The risk of AMS was reduced with acetazolamide (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.56; I2 = 0%; 16 studies; 2301 participants; moderate quality of evidence). No events of HAPE were reported and only one event of HACE (RR 0.32, 95% CI 0.01 to 7.48; 6 parallel studies; 1126 participants; moderate quality of evidence). Few studies reported side effects for this comparison, and they showed an increase in the risk of paraesthesia with the intake of acetazolamide (RR 5.53, 95% CI 2.81 to 10.88, I2 = 60%; 5 studies, 789 participants; low quality of evidence). Budenoside versus placebo (2 parallel studies; 132 participants)Data on budenoside showed a reduction in the incidence of AMS compared with placebo (RR 0.37, 95% CI 0.23 to 0.61; I2 = 0%; 2 studies, 132 participants; low quality of evidence). Studies included did not report events of HAPE or HACE, and they did not find side effects (low quality of evidence). Dexamethasone versus placebo (7 parallel studies; 205 participants)For dexamethasone, the data did not show benefits at any dosage (RR 0.60, 95% CI 0.36 to 1.00; I2 = 39%; 4 trials, 176 participants; low quality of evidence). Included studies did not report events of HAPE or HACE, and we rated the evidence about adverse events as of very low quality. AUTHORS' CONCLUSIONS Our assessment of the most commonly-used pharmacological interventions suggests that acetazolamide is an effective pharmacological agent to prevent acute HAI in dosages of 250 to 750 mg/day. This information is based on evidence of moderate quality. Acetazolamide is associated with an increased risk of paraesthesia, although there are few reports about other adverse events from the available evidence. The clinical benefits and harms of other pharmacological interventions such as ibuprofen, budenoside and dexamethasone are unclear. Large multicentre studies are needed for most of the pharmacological agents evaluated in this review, to evaluate their effectiveness and safety.
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Affiliation(s)
- Víctor H Nieto Estrada
- Fundacion Universitaria Sanitas, Colombia ClinicDepartment of Critical CareCarrera 19 # 8‐32BogotaBogotaColombia11001
| | - Daniel Molano Franco
- Fundacion Universitaria de Ciencias de la Salud, Hospital de San JoséDepartment of Critical CareCarrera 19 # 8‐32BogotaBogotaColombia11001
| | - Roger David Medina
- Fundación Universitaria de Ciencias de la SaludDivision of ResearchCarrera 19 # 8‐32Bogotá D.C.Colombia
| | - Alejandro G Gonzalez Garay
- National Institute of PediatricsMethodology Research UnitInsurgentes Sur 3700 ‐ CCol. Insurgentes Cuicuilco, CoyoacanMexico CityDistrito FederalMexico04530
| | | | - Ingrid Arevalo‐Rodriguez
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoAv. Mariscal Sucre s/n y Av. Mariana de JesúsQuitoEcuador
- Hospital Universitario Ramon y Cajal (IRYCIS)Clinical Biostatistics UnitMadridSpain
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Caravita S, Faini A, Deboeck G, Bondue A, Naeije R, Parati G, Vachiéry JL. Pulmonary hypertension and ventilation during exercise: Role of the pre-capillary component. J Heart Lung Transplant 2016; 36:754-762. [PMID: 28131663 DOI: 10.1016/j.healun.2016.12.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/08/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Excessive exercise-induced hyperventilation and high prevalence of exercise oscillatory breathing (EOB) are present in patients with post-capillary pulmonary hypertension (PH) complicating left heart disease (LHD). Patients with pre-capillary PH have even higher hyperventilation but no EOB. We sought to determine the impact of a pre-capillary component of PH on ventilatory response to exercise in patients with PH and left heart disease. METHODS We retrospectively compared patients with idiopathic or heritable pulmonary arterial hypertension (PAH, n = 29), isolated post-capillary PH (IpcPH, n = 29), and combined post- and pre-capillary PH (CpcPH, n = 12). Diastolic pressure gradient (DPG = diastolic pulmonary artery pressure - pulmonary wedge pressure) was used to distinguish IpcPH (DPG <7 mm Hg) from CpcPH (DPG ≥7 mm Hg). RESULTS Pulmonary vascular resistance (PVR) was higher in PAH, intermediate in CpcPH, and low in IpcPH. All patients with CpcPH but 1 had PVR >3 Wood unit. Exercise-induced hyperventilation (high minute ventilation over carbon dioxide production, low end-tidal carbon dioxide) was marked in PAH, intermediate in CpcPH, and low in IpcPH (p < 0.001) and correlated with DPG and PVR. Prevalence of EOB decreased from IpcPH to CpcPH to PAH (p < 0.001). CONCLUSIONS Patients with CpcPH may have worse hemodynamics than patients with IpcPH and distinct alterations of ventilatory control, consistent with more exercise-induced hyperventilation and less EOB. This might be explained at least in part by the presence and extent of pulmonary vascular disease.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium; Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Gael Deboeck
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Robert Naeije
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy; Department of Health Sciences, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium.
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Role of acetazolamide and telmisartan/nifedipine-GITS combination in antagonizing the blood pressure rise induced by high altitude exposure. Int J Cardiol 2016; 225:324-326. [DOI: 10.1016/j.ijcard.2016.09.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/24/2016] [Indexed: 11/23/2022]
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Liu HM, Chiang IJ, Kuo KN, Liou CM, Chen C. The effect of acetazolamide on sleep apnea at high altitude: a systematic review and meta-analysis. Ther Adv Respir Dis 2016; 11:20-29. [PMID: 28043212 PMCID: PMC5941979 DOI: 10.1177/1753465816677006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Acetazolamide has been investigated for treating sleep apnea in newcomers
ascending to high altitude. This study aimed to assess the effect of
acetazolamide on sleep apnea at high altitude, determine the optimal
therapeutic dose, and compare its effectiveness in healthy trekkers and
obstructive sleep apnea (OSA) patients. Methods: PubMed, Embase, Scopus, Cochrane Library, and Airiti Library databases were
searched up to July 2015 for randomized controlled trials (RCTs) performed
above 2500 m in lowlanders and that used acetazolamide as intervention in
sleep studies. Studies including participants with medical conditions other
than OSA were excluded. Results: Eight studies of 190 adults were included. In healthy participants, the
pooled mean effect sizes of acetazolamide on Apnea–Hypopnea Index (AHI),
percentage of periodic breathing time, and nocturnal oxygenation were 34.66
[95% confidence interval (CI) 25.01–44.30] with low heterogeneity
(p = 0.7, I2 = 0%), 38.56%
(95% CI 18.92–58.19%) with low heterogeneity (p = 0.24,
I2 = 28%), and 4.75% (95% CI 1.35–8.15%)
with high heterogeneity (p < 0.01,
I2 = 87%), respectively. In OSA patients,
the pooled mean effect sizes of acetazolamide on AHI and nocturnal
oxygenation were 13.18 (95% CI 9.25–17.1) with low heterogeneity
(p = 0.33, I2 = 0%) and
1.85% (95% CI 1.08–2.62%) with low heterogeneity (P = 0.56,
I2 = 0%). Conclusions: Acetazolamide improves sleep apnea at high altitude by decreasing AHI and
percentage of periodic breathing time and increasing nocturnal oxygenation.
Acetazolamide is more beneficial in healthy participants than in OSA
patients, and a 250 mg daily dose may be as effective as higher daily doses
for healthy trekkers.
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Affiliation(s)
- Hsin-Ming Liu
- Graduate Institute of Medical Sciences, College
of Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Jen Chiang
- Graduate Institute of Data Science, Taipei
Medical University, Taipei, Taiwan
| | - Ken N. Kuo
- Cochrane Taiwan, Taipei Medical University and
Department of Orthopedic Surgery, National Taiwan University Hospital and
Children Hospital, Taipei, Taiwan
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Abstract
Awareness of the importance of sleep-related disorders in patients with cardiovascular diseases is growing. In particular, sleep-disordered breathing, short sleep time, and low sleep quality are frequently reported by patients with heart failure (HF). Sleep-disordered breathing, which includes obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is common in patients with HF and has been suggested to increase the morbidity and mortality in these patients. Both OSA and CSA are associated with increased sympathetic activation, vagal withdrawal, altered haemodynamic loading conditions, and hypoxaemia. Moreover, OSA is strongly associated with arterial hypertension, the most common risk factor for cardiac hypertrophy and failure. Intrathoracic pressure changes are also associated with OSA, contributing to haemodynamic alterations and potentially affecting overexpression of genes involved in ventricular remodelling. HF treatment can decrease the severity of both OSA and CSA. Indeed, furosemide and spironolactone administration, exercise training, cardiac resynchronization therapy, and eventually heart transplantation have shown a positive effect on OSA and CSA in patients with HF. At present, whether CSA should be treated and, if so, which is the optimal therapy is still debated. By contrast, more evidence is available on the beneficial effects of OSA treatment in patients with HF.
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Bilo G, Villafuerte FC, Faini A, Anza-Ramírez C, Revera M, Giuliano A, Caravita S, Gregorini F, Lombardi C, Salvioni E, Macarlupu JL, Ossoli D, Landaveri L, Lang M, Agostoni P, Sosa JM, Mancia G, Parati G. Ambulatory Blood Pressure in Untreated and Treated Hypertensive Patients at High Altitude. Hypertension 2015; 65:1266-72. [DOI: 10.1161/hypertensionaha.114.05003] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/27/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Grzegorz Bilo
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Francisco C. Villafuerte
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Andrea Faini
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Cecilia Anza-Ramírez
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Miriam Revera
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Andrea Giuliano
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Sergio Caravita
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Francesca Gregorini
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Carolina Lombardi
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Elisabetta Salvioni
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Jose Luis Macarlupu
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Deborah Ossoli
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Leah Landaveri
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Morin Lang
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Piergiuseppe Agostoni
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - José Manuel Sosa
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Giuseppe Mancia
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
| | - Gianfranco Parati
- From the Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Milan, Italy (G.B., A.F., M.R., A.G., S.C., F.G., C.L., D.O., G.M., G.P.); Laboratorio de Fisiologia Comparada, Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru (F.C.V., C.A.-R., J.L.M., L.L., J.M.S.); Department of Health Sciences, Università di Milano-Bicocca, Milan, Italy (S.C., G.M., G.P.); Heart Failure Unit, Centro Cardiologico Monzino, IRCCS,
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40
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Affiliation(s)
- Linda E. Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado
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