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An act of balance: Interaction of central and peripheral chemosensitivity with inflammatory and anti-inflammatory factors in obstructive sleep apnoea. Respir Physiol Neurobiol 2019; 266:73-81. [DOI: 10.1016/j.resp.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023]
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Nasal function and CPAP compliance. Auris Nasus Larynx 2018; 46:548-558. [PMID: 30538069 DOI: 10.1016/j.anl.2018.11.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/21/2018] [Accepted: 11/14/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Continuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination. METHODS In total, 711 adult patients with initial diagnosis of OSA and an apnea-hypopnea index of ≥20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1year), treatment continuation rate at 2 months and 1year, and nasal treatments for all patients. RESULTS CPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1year. Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of ≥0.35Pa/cm3/s were independent predictors of surgical treatment. CONCLUSION Long-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.
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Affiliation(s)
- Cynthia M. Beall
- Department of Anthropology, Case Western Reserve University, Cleveland, Ohio 44106-7125; e-mail:
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Beall CM, Strohl KP, Blangero J, Williams-Blangero S, Almasy LA, Decker MJ, Worthman CM, Goldstein MC, Vargas E, Villena M, Soria R, Alarcon AM, Gonzales C. Ventilation and hypoxic ventilatory response of Tibetan and Aymara high altitude natives. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 1997. [PMID: 9453694 DOI: 10.1002/(sici)1096-8644(199712)104:4%3c427::aid-ajpa1%3e3.0.co;2-p] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Newcomers acclimatizing to high altitude and adult male Tibetan high altitude natives have increased ventilation relative to sea level natives at sea level. However, Andean and Rocky Mountain high altitude natives have an intermediate level of ventilation lower than that of newcomers and Tibetan high altitude natives although generally higher than that of sea level natives at sea level. Because the reason for the relative hypoventilation of some high altitude native populations was unknown, a study was designed to describe ventilation from adolescence through old age in samples of Tibetan and Andean high altitude natives and to estimate the relative genetic and environmental influences. This paper compares resting ventilation and hypoxic ventilatory response (HVR) of 320 Tibetans 9-82 years of age and 542 Bolivian Aymara 13-94 years of age, native residents at 3,800-4,065 m. Tibetan resting ventilation was roughly 1.5 times higher and Tibetan HVR was roughly double that of Aymara. Greater duration of hypoxia (older age) was not an important source of variation in resting ventilation or HVR in either sample. That is, contrary to previous studies, neither sample acquired hypoventilation in the age ranges under study. Within populations, greater severity of hypoxia (lower percent of oxygen saturation of arterial hemoglobin) was associated with slightly higher resting ventilation among Tibetans and lower resting ventilation and HVR among Aymara women, although the associations accounted for just 2-7% of the variation. Between populations, the Tibetan sample was more hypoxic and had higher resting ventilation and HVR. Other systematic environmental contrasts did not appear to elevate Tibetan or depress Aymara ventilation. There was more intrapopulation genetic variation in these traits in the Tibetan than the Aymara sample. Thirty-five percent of the Tibetan, but none of the Aymara, resting ventilation variance was due to genetic differences among individuals. Thirty-one percent of the Tibetan HVR, but just 21% of the Aymara, HVR variance was due to genetic differences among individuals. Thus there is greater potential for evolutionary change in these traits in the Tibetans. Presently, there are two different ventilation phenotypes among high altitude natives as compared with sea level populations at sea level: lifelong sustained high resting ventilation and a moderate HVR among Tibetans in contrast with a slightly elevated resting ventilation and a low HVR among Aymara.
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Affiliation(s)
- C M Beall
- Case Western Reserve University, Cleveland, Ohio 44106-7125, USA.
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Beall CM, Strohl KP, Blangero J, Williams-Blangero S, Almasy LA, Decker MJ, Worthman CM, Goldstein MC, Vargas E, Villena M, Soria R, Alarcon AM, Gonzales C. Ventilation and hypoxic ventilatory response of Tibetan and Aymara high altitude natives. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 1997; 104:427-47. [PMID: 9453694 DOI: 10.1002/(sici)1096-8644(199712)104:4<427::aid-ajpa1>3.0.co;2-p] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Newcomers acclimatizing to high altitude and adult male Tibetan high altitude natives have increased ventilation relative to sea level natives at sea level. However, Andean and Rocky Mountain high altitude natives have an intermediate level of ventilation lower than that of newcomers and Tibetan high altitude natives although generally higher than that of sea level natives at sea level. Because the reason for the relative hypoventilation of some high altitude native populations was unknown, a study was designed to describe ventilation from adolescence through old age in samples of Tibetan and Andean high altitude natives and to estimate the relative genetic and environmental influences. This paper compares resting ventilation and hypoxic ventilatory response (HVR) of 320 Tibetans 9-82 years of age and 542 Bolivian Aymara 13-94 years of age, native residents at 3,800-4,065 m. Tibetan resting ventilation was roughly 1.5 times higher and Tibetan HVR was roughly double that of Aymara. Greater duration of hypoxia (older age) was not an important source of variation in resting ventilation or HVR in either sample. That is, contrary to previous studies, neither sample acquired hypoventilation in the age ranges under study. Within populations, greater severity of hypoxia (lower percent of oxygen saturation of arterial hemoglobin) was associated with slightly higher resting ventilation among Tibetans and lower resting ventilation and HVR among Aymara women, although the associations accounted for just 2-7% of the variation. Between populations, the Tibetan sample was more hypoxic and had higher resting ventilation and HVR. Other systematic environmental contrasts did not appear to elevate Tibetan or depress Aymara ventilation. There was more intrapopulation genetic variation in these traits in the Tibetan than the Aymara sample. Thirty-five percent of the Tibetan, but none of the Aymara, resting ventilation variance was due to genetic differences among individuals. Thirty-one percent of the Tibetan HVR, but just 21% of the Aymara, HVR variance was due to genetic differences among individuals. Thus there is greater potential for evolutionary change in these traits in the Tibetans. Presently, there are two different ventilation phenotypes among high altitude natives as compared with sea level populations at sea level: lifelong sustained high resting ventilation and a moderate HVR among Tibetans in contrast with a slightly elevated resting ventilation and a low HVR among Aymara.
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Affiliation(s)
- C M Beall
- Case Western Reserve University, Cleveland, Ohio 44106-7125, USA.
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Stanley G, Verotta D, Craft N, Siegel RA, Schwartz JB. Age effects on interrelationships between lung volume and heart rate during standing. THE AMERICAN JOURNAL OF PHYSIOLOGY 1997; 273:H2128-34. [PMID: 9374744 DOI: 10.1152/ajpheart.1997.273.5.h2128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To determine the effects of aging and posture on the relationship between respiration and heart rate (HR), we collected 5 min of lung volume and R-R interval data from 7 young (27 +/- 3 yr, mean +/- SD) and 10 old (69 +/- 6 yr) healthy humans during spontaneous breathing while they were supine (SU) and standing (ST). Lung volume and HR power spectra and transfer functions between lung volume and HR were estimated. Age and position effects and age-position interactions were determined by analysis of variance for repeated measures. Older subjects had a lower and more variable respiration rate (P < 0.03, P < 0.04), but both age groups exhibited decreased rate of respiration and increased tidal volume with ST (P < 0.05, P < 0.005). ST decreased lung volume-to-HR transfer function magnitude in both groups (P < 0.07). The more marked age-related differences were in phase angle. Both SU and ST phase angles were greater in older subjects (P < 0.003). ST decreased phase angle in young but increased phase angle in older subjects (P < 0.001). In conclusion, respiration, and respiration-HR interrelationships are altered by aging, with increased time delays between lung volume and HR and altered relationships with ST.
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Affiliation(s)
- G Stanley
- Department of Mechanical Engineering, University of California, Berkeley 94720, USA
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Abstract
The study of ventilatory periodicities is relevant to the problem of obstructive sleep apnea. Apneas occur at the nadirs of periodicities during sleep. Periodicities can be caused by chemical instability, related to unstable action of the closed loop feedback system for the chemical regulation of breathing. Such instability occurs when overall loop gain is greater than or equal to unity and the phase lag around the loop is 180 degrees. Periodic breathing during hypoxia and in patients with congestive heart failure is likely to be explained by this mechanism. Periodic breathing can also be the result of state instability. Here ventilation declines at sleep onset and the resultant changes in blood gases trigger an arousal, i.e., sudden transition to a lighter stage of sleep. With arousal, ventilation increases. Thus, periodic breathing is secondary to these changes in sleep state. These processes, chemical instability and state instability, can interact and produce complex patterns of oscillation in ventilation.
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Affiliation(s)
- A I Pack
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia
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Gold AR, Schwartz AR, Wise RA, Smith PL. Pulmonary function and respiratory chemosensitivity in moderately obese patients with sleep apnea. Chest 1993; 103:1325-9. [PMID: 8486005 DOI: 10.1378/chest.103.5.1325] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
To determine whether moderately obese, normocapnic, sleep apnea patients are distinguished from normal obese individuals by differences in waking pulmonary function and respiratory chemosensitivity, we compared the waking pulmonary function, hypercapnic, and hypoxic ventilatory responses of 35 nonhypercapnic sleep apnea patients (32 men and 3 women) with those of 17 age-, sex-, weight-, and obesity-matched nonapneic control subjects (16 men and 1 woman). The waking ventilatory response to hypercapnia was lower among sleep apnea patients (mean +/- SD, 2.05 +/- 1.29 L/min/mm Hg) than control subjects (3.02 +/- 2.05 L/min/mm Hg, p < 0.05). Patients with sleep apnea demonstrated a higher waking PaCO2 (40.4 +/- 2.9 vs 37.0 +/- 2.7 mm Hg, p < 0.001), and a lower waking PaO2 (81.4 +/- 11.7 vs 89.7 +/- 10.4 mm Hg, p < 0.03). The waking hypoxic ventilatory response, however, was not significantly different between the groups. Moreover, control subjects had a higher total lung capacity than sleep apnea patients (6.99 +/- 1.12 L and 6.27 +/- 1.09 L, respectively, p < 0.05). The lower hypercapnic ventilatory response, higher waking PaCO2, and lower total lung capacity in the sleep apnea patients resemble the pattern observed in patients with pickwickian syndrome. This suggests that disturbances in pulmonary function and ventilatory control in moderately obese sleep apnea patients are intermediate along a continuum from normal obesity to the pickwickian syndrome.
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Affiliation(s)
- A R Gold
- Department of Medicine, Johns Hopkins Sleep Disorders Center, Francis Scott Key Medical Center, Johns Hopkins School of Medicine, Baltimore
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Schwartz AR, Gold AR, Schubert N, Stryzak A, Wise RA, Permutt S, Smith PL. Effect of weight loss on upper airway collapsibility in obstructive sleep apnea. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1991; 144:494-8. [PMID: 1892285 DOI: 10.1164/ajrccm/144.3_pt_1.494] [Citation(s) in RCA: 270] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previous investigators have demonstrated in patients with obstructive sleep apnea that weight reduction results in a decrease in apnea severity. Although the mechanism for this decrease is not clear, we hypothesize that decreases in upper airway collapsibility account for decreases in apnea severity with weight loss. To determine whether weight loss causes decreases in collapsibility, we measured the upper airway critical pressure (Pcrit) before and after a 17.4 +/- 3.4% (mean +/- SD) reduction in body mass index in 13 patients with obstructive sleep apnea. Thirteen weight-stable control subjects matched for age, body mass index, gender (all men), and non-REM disordered breathing rate (DBR) also were studied before and after usual care intervention. During non-REM sleep, maximal inspiratory airflow was measured by varying the level of nasal pressure and Pcrit was determined by the level of nasal pressure below which maximal inspiratory airflow ceased. In the weight loss group, a significant decrease in DBR from 83.3 +/- 31.0 to 32.5 +/- 35.9 episodes/h and in Pcrit from 3.1 +/- 4.2 to -2.4 +/- 4.4 cm H2O (p less than 0.00001) was demonstrated. Moreover, decreases in Pcrit were associated with nearly complete elimination of apnea in each patient whose Pcrit fell below -4 cm H2O. In contrast, no significant change in DBR and a minimal reduction in Pcrit from 5.2 +/- 2.3 to 4.2 +/- 1.8 cm H2O (p = 0.031) was observed in the "usual care" group. We conclude that (1) weight loss is associated with decreases in upper airway collapsibility in obstructive sleep apnea, and that (2) the resolution of sleep apnea depends on the absolute level to which Pcrit falls.
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Affiliation(s)
- A R Schwartz
- Department of Medicine, Johns Hopkins Asthma and Allergy Center, Francis Scott Key Medical Center, Baltimore, Maryland 21224
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Fox AW, Monoson PK, Morgan CD. Speech dysfunction of obstructive sleep apnea. A discriminant analysis of its descriptors. Chest 1989; 96:589-95. [PMID: 2766817 DOI: 10.1378/chest.96.3.589] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We have previously demonstrated a relationship between abnormal speech and obstructive sleep apnea in a small subject sample. The present study was designed to replicate the previous one with a much larger population, analyze the perceptual characteristics of the speech quality, and determine the degree to which each of three descriptors of speech abnormality contributed to the perception of speech abnormality. Ten graduate students in speech pathology listened in two 1.5 hour sessions to 252 random speech samples presented on a master tape. There were 81 subjects comprised of 27 sleep apnea patients, 27 matched chronic obstructive pulmonary disease control patients, and 27 matched normal control subjects. Rating the speech along an equally-appearing interval scale from 1 to 7, the judges heard abnormal resonance, articulation or phonation in 74 percent of the sleep apnea subjects, 53 percent of the COPD subjects, and 7 percent of the normal subjects (significant difference by chi 2 test at the .01 level of confidence). Discriminant function equations based on these speech descriptors correctly identified 96.3 percent of the normal subjects and 63.0 percent of the sleep apnea subjects. Analysis of abnormal speech resonance, articulation and phonation may identify obstructive sleep apnea or may provide insight into its pathology.
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Affiliation(s)
- A W Fox
- University of Illinois College of Medicine, Peoria
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Abstract
We have developed a method of recording oxygen saturation over time using ambulatory equipment. A pulse oximeter was modified to be powered by battery, and values for oxygen saturation were recorded by an analog recorder. The unit is compact and functions for 30 hours between battery changes. The mean difference between oxygen saturation reported by the pulse oximeter and an IL 282 CO-oximeter was -1.12 percent, with a range of difference +/- 2.75 percent, indicating 95 percent confidence limits 5.5 percent either side of the mean. Continuous ambulatory recordings were obtained in 16 male subjects; six were healthy nonsnorers, five were healthy snorers, and five had sleep apnea. Of the average recording time, 19 +/- 5 hours, records contained 89 +/- 7 percent usable data. We conclude that ambulatory pulse oximetry is a feasible means of unsupervised long-term monitoring of oxygenation during daily activities.
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Affiliation(s)
- M J Decker
- Department of Medicine, Case Western Reserve University, Cleveland
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Abstract
Administration of epidural and intrathecal opioids may provide excellent postoperative analgesia, but a minority of patients will suffer dangerous respiratory depression. This review discusses the detection and measurement of respiratory depression and summarizes the relevant literature as it pertains to epidural and intrathecal opioid administration. The respiratory depressant effects and pharmacokinetics of spinal opioids are reviewed. The clinical implications and areas of future investigation are discussed.
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Affiliation(s)
- R C Etches
- Department of Anaesthesia, Toronto General Hospital, Ontario
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McGinty D, Beahm E, Stern N, Littner M, Sowers J, Reige W. Nocturnal hypotension in older men with sleep-related breathing disorders. Chest 1988; 94:305-11. [PMID: 3396408 DOI: 10.1378/chest.94.2.305] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Sleeping and awake blood pressures were related to sleep oxygenation and awake control of breathing in hypertensive and normotensive older men. During sleep, episodes of both hypertension and hypotension were observed, but hypotension was prominent. Five of 26 subjects exhibited episodes with a minimum mean arterial pressure of 60 mm Hg or less. These hypotensive episodes were associated with hemoglobin desaturation below 80 percent, secondary to sleep-related breathing disorders, and elevated supine nasopharyngeal airway resistance. Hypotensive subjects were habitual snorers. Waking hypertension was not associated with sleep-related breathing disorders in this older sample. In some older persons with sleep-related breathing disorders, sympathetic reflexes may be impaired, permitting hypotension and risk of circulatory failure. Epidemiologic evidence supports the hypothesis that this mechanism can explain the elevated incidence of cerebral infarction during sleep.
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Affiliation(s)
- D McGinty
- Veterans Administration Medical Center, Sepulveda
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Monoson PK, Fox AW. Preliminary observation of speech disorder in obstructive and mixed sleep apnea. Chest 1987; 92:670-5. [PMID: 3308347 DOI: 10.1378/chest.92.4.670] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clinical observation suggested that speech disorder seemed to be associated with sleep apnea. We recorded a standard speech sample from 39 matched subjects in three groups, 13 sleep apnea individuals, 13 subjects with COPD, and 13 subjects without sleep apnea or COPD. Three speech pathologists in a single blind listening task of the recorded samples judged whether or not speech disorder was present. Eight of the sleep apnea subjects were judged to have disordered speech compared to three of the COPD group and one of the non-sleep apnea, non-COPD (normal) group. These results were statistically significant. This supports a clinical impression that speech disorder is more common in sleep apnea than expected. There may be common anatomic and physiologic disturbances present between the two conditions, and perhaps disordered speech is a sign of sleep apnea.
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Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Changes in breathing and the pharynx after weight loss in obstructive sleep apnea. Chest 1987; 92:631-7. [PMID: 3652748 DOI: 10.1378/chest.92.4.631] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The effect of weight loss following dietary restriction on disordered breathing on the pharyngeal airway is controversial in patients with obstructive sleep apnea (OSA). We therefore prospectively studied eight patients before and after dietary-induced weight loss. Mean weight loss was 20.6 kg +/- 12.8 SD. After weight loss there were significant improvements in PO2 and PCO2 measured during wakefulness, and in the number of desaturation episodes per hour of sleep, average desaturation per episode, and number of movement arousals. The number of apneas and hypopneas significantly decreased in six of eight patients. There was a significant correlation between body mass index and number of disordered breathing events. Nasopharyngeal collapsibility and pulse flow resistance decreased in awake patients after weight loss. We conclude that moderate weight loss in obese patients with OSA improves oxygenation during both sleep and wakefulness, decreases the number of disordered breathing events in many patients, decreases the collapsibility of the nasopharyngeal airway.
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Affiliation(s)
- P M Suratt
- Pulmonary Division, University of Virginia School of Medicine, Charlottesville 22908
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Littner MR, Hanson WR. Listening to our patients takes on new meaning. Chest 1987; 92:584-5. [PMID: 3652744 DOI: 10.1378/chest.92.4.584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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