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Javaheri S, Randerath WJ, Safwan Badr M, Javaheri S. Medication-induced central sleep apnea: a unifying concept. Sleep 2024; 47:zsae038. [PMID: 38334297 DOI: 10.1093/sleep/zsae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/17/2024] [Indexed: 02/10/2024] Open
Abstract
Medication-induced central sleep apnea (CSA) is one of the eight categories of causes of CSA but in the absence of awareness and careful history may be misclassified as primary CSA. While opioids are a well-known cause of respiratory depression and CSA, non-opioid medications including sodium oxybate, baclofen, valproic acid, gabapentin, and ticagrelor are less well-recognized. Opioids-induced respiratory depression and CSA are mediated primarily by µ-opioid receptors, which are abundant in the pontomedullary centers involved in breathing. The non-opioid medications, sodium oxybate, baclofen, valproic acid, and gabapentin, act upon brainstem gamma-aminobutyric acid (GABA) receptors, which co-colonize with µ-opioid receptors and mediate CSA. The pattern of ataxic breathing associated with these medications is like that induced by opioids on polysomnogram. Finally, ticagrelor also causes periodic breathing and CSA by increasing central chemosensitivity and ventilatory response to carbon dioxide. Given the potential consequences of CSA and the association between some of these medications with mortality, it is critical to recognize these adverse drug reactions, particularly because discontinuation of the offending agents has been shown to eliminate CSA.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, USA
- Adjunct Professor of Medicine, Division of Cardiology, The Ohio State University, Columbus, Ohio, USA
- Emeritus Professor of Medicine, Division of Pulmonary and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Winfried J Randerath
- Professor and Head Physician, Institute of Pneumology, University of Cologne, Bethanien Hospital, Solingen, Germany
| | - M Safwan Badr
- Professor and Chair, Department of Internal Medicine, Wayne State University School of Medicine Detroit, Staff Physician, John D. Dingell VA Medical Center, MI, USA
| | - Sogol Javaheri
- Assistant Professor of Sleep Medicine, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Testelmans D, Kalkanis A, Papadopoulos D, Demolder S, Buyse B. Central sleep apnea: emphasizing recognition and differentiation. Expert Rev Respir Med 2024; 18:309-320. [PMID: 38878064 DOI: 10.1080/17476348.2024.2369256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/13/2024] [Indexed: 06/19/2024]
Abstract
INTRODUCTION Central sleep apnea (CSA) is a sleep-related breathing disorder in which the effort to breathe is intermittently diminished or absent. CSA is a common disorder among patients with different cardiovascular disorders, including heart failure. In addition, a growing number of medications have been shown to induce CSA and CSA can emerge after initiation of treatment for obstructive sleep apnea. Accumulating evidence shows that CSA is a heterogeneous disorder with individual differences in clinical and biological characteristics and/or underlying pathophysiological mechanisms. AREAS COVERED This narrative review offers an overview of the diagnostic aspects and classification of CSA, with an emphasis on heart failure patients, patients with CSA due to a medication and treatment-emergent CSA. The importance of evaluation of prognostic biomarkers in patients with different types of CSA is discussed. This narrative review synthesizes literature on CSA sourced from the PubMed database up to February 2024. EXPERT OPINION CSA presents a remarkably diverse disorder, with treatment modalities exhibiting potentially varied efficacy across its various phenotypes. This highlights the imperative for tailored management strategies that are rooted in phenotype classification.
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Affiliation(s)
- Dries Testelmans
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Alexandros Kalkanis
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Dimitrios Papadopoulos
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Saartje Demolder
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Bertien Buyse
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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Javaheri S, Rapoport DM, Schwartz AR. Distinguishing central from obstructive hypopneas on a clinical polysomnogram. J Clin Sleep Med 2023; 19:823-834. [PMID: 36661093 PMCID: PMC10071374 DOI: 10.5664/jcsm.10420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 01/21/2023]
Abstract
Among sleep-related disordered breathing events, hypopneas are the most frequent. Like obstructive and central apneas, hypopneas may be obstructive or central (reduced drive) in origin. Nevertheless, unlike apneas, categorizing hypopneas as either "obstructive" or "central" is often difficult or ambiguous. It has been suggested that hypopneas could be categorized as obstructive when associated with snoring, inspiratory flow limitation, or paradoxical thoraco-abdominal excursions. This approach, however, has not been extensively tested and misclassification of hypopneas is unavoidable. Yet, much rides on the accurate distinction of these events to guide therapy with medical devices or pharmacological therapy in each patient. Additionally, accurate hypopnea classification is critical for design of clinical trials, because therapeutic responses differ depending on the subtype of hypopnea. Correctly classifying hypopneas can also allay concerns about obtaining coverage for therapies that specifically target either central or obstructive sleep-disordered breathing events. The present paper expands on the current criteria for differentiating obstructive from central hypopneas and provides illustrative tracings that can help classify these events. CITATION Javaheri S, Rapoport DM, Schwartz AR. Distinguishing central from obstructive hypopneas on a clinical polysomnogram. J Clin Sleep Med. 2023;19(4):823-834.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep, Bethesda North Hospital, Cincinnati, Ohio
| | - David M. Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alan R. Schwartz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Javaheri S, Badr MS. Central sleep apnea: pathophysiologic classification. Sleep 2023; 46:6584630. [PMID: 35551411 PMCID: PMC9995798 DOI: 10.1093/sleep/zsac113] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Central sleep apnea is not a single disorder; it can present as an isolated disorder or as a part of other clinical syndromes. In some conditions, such as heart failure, central apneic events are due to transient inhibition of ventilatory motor output during sleep, owing to the overlapping influences of sleep and hypocapnia. Specifically, the sleep state is associated with removal of wakefulness drive to breathe; thus, rendering ventilatory motor output dependent on the metabolic ventilatory control system, principally PaCO2. Accordingly, central apnea occurs when PaCO2 is reduced below the "apneic threshold". Our understanding of the pathophysiology of central sleep apnea has evolved appreciably over the past decade; accordingly, in disorders such as heart failure, central apnea is viewed as a form of breathing instability, manifesting as recurrent cycles of apnea/hypopnea, alternating with hyperpnea. In other words, ventilatory control operates as a negative-feedback closed-loop system to maintain homeostasis of blood gas tensions within a relatively narrow physiologic range, principally PaCO2. Therefore, many authors have adopted the engineering concept of "loop gain" (LG) as a measure of ventilatory instability and susceptibility to central apnea. Increased LG promotes breathing instabilities in a number of medical disorders. In some other conditions, such as with use of opioids, central apnea occurs due to inhibition of rhythm generation within the brainstem. This review will address the pathogenesis, pathophysiologic classification, and the multitude of clinical conditions that are associated with central apnea, and highlight areas of uncertainty.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, USA.,Division of Pulmonary Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Cardiology, Department of Medicine, Ohio State University, Columbus, OH, USA
| | - M Safwan Badr
- Department of Internal Medicine, Liborio Tranchida, MD, Endowed Professor of Medicine, Wayne State University School of Medicine, University Health Center, Detroit, MI, USA
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Eckert DJ, Yaggi HK. Opioid Use Disorder, Sleep Deficiency, and Ventilatory Control: Bidirectional Mechanisms and Therapeutic Targets. Am J Respir Crit Care Med 2022; 206:937-949. [PMID: 35649170 PMCID: PMC9801989 DOI: 10.1164/rccm.202108-2014ci] [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: 08/31/2021] [Accepted: 05/31/2022] [Indexed: 01/07/2023] Open
Abstract
Opioid use continues to rise globally. So too do the associated adverse consequences. Opioid use disorder (OUD) is a chronic and relapsing brain disease characterized by loss of control over opioid use and impairments in cognitive function, mood, pain perception, and autonomic activity. Sleep deficiency, a term that encompasses insufficient or disrupted sleep due to multiple potential causes, including sleep disorders, circadian disruption, and poor sleep quality or structure due to other medical conditions and pain, is present in 75% of patients with OUD. Sleep deficiency accompanies OUD across the spectrum of this addiction. The focus of this concise clinical review is to highlight the bidirectional mechanisms between OUD and sleep deficiency and the potential to target sleep deficiency with therapeutic interventions to promote long-term, healthy recovery among patients in OUD treatment. In addition, current knowledge on the effects of opioids on sleep quality, sleep architecture, sleep-disordered breathing, sleep apnea endotypes, ventilatory control, and implications for therapy and clinical practice are highlighted. Finally, an actionable research agenda is provided to evaluate the basic mechanisms of the relationship between sleep deficiency and OUD and the potential for behavioral, pharmacologic, and positive airway pressure treatments targeting sleep deficiency to improve OUD treatment outcomes.
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Affiliation(s)
- Danny J. Eckert
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| | - H. Klar Yaggi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
- Clinical Epidemiology Research Center, Veterans Administration Connecticut Healthcare System, West Haven, Connecticut
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Javaheri S, Cao M. Chronic Opioid Use and Sleep Disorders. Sleep Med Clin 2022; 17:433-444. [PMID: 36150805 DOI: 10.1016/j.jsmc.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Opioid medications are considered a significant component in the multidisciplinary management of chronic pain. In the past two decades, the use of opioid medications has dramatically risen in part because of an increased awareness by health care providers to treat chronic pain more effectively. In addition, patients are encouraged to seek treatment. The release of a sentinel joint statement in 1997 by the American Academy of Pain Medicine and the American Pain Society in a national effort to increase awareness and support the treatment of chronic pain has undoubtedly contributed to the opioid crisis.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, 10535 Montgomery Road, Suite 200, Cincinnati, OH 45242, USA; Division of Medicine, The Ohio State University, 181 Taylor Avenue, Columbus, OH 43203, USA.
| | - Michelle Cao
- Division of Pulmonary, Allergy, Critical Care Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3143, Stanford, CA 94305, USA; Division of Sleep Medicine, Stanford University School of Medicine, 450 Broadway Street, Redwood City, CA 94063, USA
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Langstengel J, Yaggi HK. Sleep Deficiency and Opioid Use Disorder: Trajectory, Mechanisms, and Interventions. Clin Chest Med 2022; 43:e1-e14. [PMID: 35659031 PMCID: PMC10018646 DOI: 10.1016/j.ccm.2022.05.001] [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] [Indexed: 11/03/2022]
Abstract
Opioid use disorder (OUD) is a chronic and relapsing brain disease characterized by loss of control over opioid use and impairments in cognitive function, mood, pain perception, and autonomic activity. Sleep deficiency, a term that encompasses insufficient or disrupted sleep due to multiple potential causes, including sleep disorders (eg, insomnia, sleep apnea), circadian disruption (eg, delayed sleep phase and social jet lag), and poor sleep quality (eg, sleep fragmentation, impaired sleep architecture), is present in greater than 75% of patients with OUD. This article focuses on highlighting bidirectional mechanisms between OUD and sleep deficiency and points toward promising therapeutic targets.
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Affiliation(s)
- Jennifer Langstengel
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA
| | - H Klar Yaggi
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT, USA.
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Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med 2022; 18:647-652. [PMID: 34672945 PMCID: PMC8805010 DOI: 10.5664/jcsm.9730] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 02/03/2023]
Abstract
Opioids are widely prescribed for pain management, and it is estimated that 40% of adults in the United States use prescription opioids every year. Opioid misuse leads to high mortality, with respiratory depression as the main cause of death. Animal and human studies indicate that opioid use may lead to sleep-disordered breathing. Opioids affect control of breathing and impair upper airway function, causing central apneas, upper airway obstruction, and hypoxemia during sleep. The presence of obstructive sleep apnea (OSA) increases the risk of opioid-induced respiratory depression. However, even if the relationship between opioids and central sleep apnea is firmly established, the question of whether opioids can aggravate OSA remains unanswered. While several reports have shown a high prevalence of OSA and nocturnal hypoxemia in patients receiving a high dose of opioids, other studies did not find a correlation between opioid use and obstructive events. These differences can be attributed to considerable interindividual variability, divergent effects of opioids on different phenotypic traits of OSA, and wide-ranging methodology. This review will discuss mechanistic insights into the effects of opioids on the upper airway and hypoglossal motor activity and the association of opioid use and obstructive sleep apnea. CITATION Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.
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Affiliation(s)
- Carla Freire
- Johns Hopkins Sleep Disorders Center, Baltimore, Maryland
- Otolaryngology Department, University of São Paulo, Sao Paulo, Brazil
| | - Luiz U. Sennes
- Otolaryngology Department, University of São Paulo, Sao Paulo, Brazil
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At the intersection of sleep deficiency and opioid use: mechanisms and therapeutic opportunities. Transl Res 2021; 234:58-73. [PMID: 33711513 PMCID: PMC8217216 DOI: 10.1016/j.trsl.2021.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/17/2021] [Accepted: 03/06/2021] [Indexed: 12/18/2022]
Abstract
Due to the ongoing opioid epidemic, innovative scientific perspectives and approaches are urgently needed to reduce the unprecedented personal and societal burdens of nonmedical and recreational opioid use. One promising opportunity is to focus on the relationship between sleep deficiency and opioid use. In this review, we examine empirical evidence: (1) at the interface of sleep deficiency and opioid use, including hypothesized bidirectional associations between sleep efficiency and opioid abstinence; (2) as to whether normalization of sleep deficiency might directly or indirectly improve opioid abstinence (and vice versa); and (3) regarding mechanisms that could link improvements in sleep to opioid abstinence. Based on available data, we identify candidate sleep-restorative therapeutic approaches that should be examined in rigorous clinical trials.
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Associations between obstructive sleep apnea and prescribed opioids among veterans. Pain 2021; 161:2035-2040. [PMID: 32358418 DOI: 10.1097/j.pain.0000000000001906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Sleep disruption caused by obstructive sleep apnea (OSA) may be associated with hyperalgesia and may contribute to poor pain control and use of prescription opioids. However, the relationship between OSA and opioid prescription is not well described. We examine this association using cross-sectional data from a national cohort of veterans from recent wars enrolled from October 1, 2001 to October 7, 2014. The primary outcome was the relative risk ratio (RRR) of receiving opioid prescriptions for acute (<90 days/year) and chronic (≥90 days/year) durations compared with no opioid prescriptions. The primary exposure was a diagnosis of OSA. We used multinomial logistic regression to control for factors that may affect diagnosis of OSA or receipt of opioid prescriptions. Of the 1,149,874 patients (mean age 38.0 ± 9.6 years) assessed, 88.1% had no opioid prescriptions, 9.4% had acute prescriptions, and 2.5% had chronic prescriptions. Ten percent had a diagnosis of OSA. Patients with OSA were more likely to be older, male, nonwhite, obese, current or former smokers, have higher pain intensity, and have medical and psychiatric comorbidities. Controlling for these differences, patients with OSA were more likely to receive acute (RRR 2.02 [95% confidence interval 1.98-2.06]) or chronic (RRR 2.15 [2.09-2.22]) opioids. Further dividing opioid categories by high vs low dosage did not yield substantially different results. Obstructive sleep apnea is associated with a two-fold likelihood of being prescribed opioids for pain. Clinicians should consider incorporating OSA treatment into multimodal pain management strategies; OSA as a target for pain management should be further studied.
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Predictive Performance of Oximetry to Detect Sleep Apnea in Patients Taking Opioids. Anesth Analg 2021; 133:500-506. [PMID: 33950884 DOI: 10.1213/ane.0000000000005545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Long-term use of opioids for treatment of chronic pain is associated with significant risks including worsening unrecognized or untreated sleep apnea that may increase morbidity and mortality. Overnight oximetry has been validated for predicting sleep apnea in surgical and sleep clinic patients. The objective of the study was to assess the predictive accuracy of oxygen desaturation index (ODI 4%) from home overnight oximetry when compared to apnea hypopnea index (AHI) from polysomnography for predicting sleep apnea in patients taking opioids for chronic pain. METHODS This was a planned post hoc analysis of a prospective cohort study conducted at 5 pain clinics. Patient characteristics and daily morphine milligram equivalent (MME) dose were recorded. All consented patients underwent home overnight oximetry (PULSOX-300i, Konica Minolta Sensing, Inc, Osaka, Japan) and in-laboratory polysomnography. The predictive performance of ODI 4% from oximetry was assessed against AHI from polysomnography. RESULTS Among 332 consented patients, 181 with polysomnography and overnight oximetry data were analyzed. The mean age and body mass index of 181 patients were 52 ± 13 years and 29 ± 6 kg/m2, respectively, with 40% men. The area under the receiver operating curve for ODI to predict moderate-to-severe sleep apnea (AHI ≥15 events/h) and severe sleep apnea (AHI ≥30 events/h) was 0.82 (95% confidence interval [CI], 0.75-0.88) and 0.87 (95% CI, 0.80-0.94). ODI ≥5 events/h had a sensitivity of 85% (95% CI, 74-92) and specificity of 57% (95% CI, 52-61) to predict moderate-to-severe sleep apnea. ODI ≥15 events/h had a sensitivity of 71% (95% CI, 55-83) and specificity of 88% (95% CI, 84-91) to predict severe sleep apnea. CONCLUSIONS Overnight home oximetry has a high predictive performance in predicting moderate-to-severe and severe sleep apnea in patients on opioids for chronic pain. It is a useful additional tool for health care providers for the screening of sleep apnea in this high-risk group.
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Paboeuf C, Priou P, Meslier N, Roulaud F, Trzepizur W, Gagnadoux F. Ticagrelor-Associated Shift From Obstructive to Central Sleep Apnea: A Case Report. J Clin Sleep Med 2020; 15:1179-1182. [PMID: 31482841 DOI: 10.5664/jcsm.7818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
None Ticagrelor, a P2Y12 receptor antagonist, is used in combination with aspirin in patients with coronary artery disease. Recent reports suggest that ticagrelor might induce central sleep apnea (CSA) by increasing chemosensitivity to hypercapnia. We herein describe the case of a patient with positive airway pressure (PAP)-treated obstructive sleep apnea (OSA), in whom PAP-telemonitoring revealed the emergence of CSA and Cheyne-Stokes respiration (CSR) after initiation of ticagrelor for an acute coronary syndrome with preserved left ventricular ejection fraction. Ticagrelor-associated shift from OSA to CSA was confirmed by respiratory polygraphy after PAP withdrawal, and was associated with an increased chemosensitivity to hypercapnia. Ticagrelor discontinuation was associated with the recurrence of pure OSA and the normalization of hypercapnic ventilatory response. A transient recurrence of CSA and CSR was identified by PAP-telemonitoring after accidental reintroduction of the drug. Further studies are required to determine the mechanisms, incidence, and consequences of ticagrelor-associated CSA. CITATION Paboeuf C, Priou P, Meslier N, Roulaud F, Trzepizur W, Gagnadoux F. Ticagrelor-associated shift from obstructive to central sleep apnea: a case report. J Clin Sleep Med. 2019;15(8):1179-1182.
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Affiliation(s)
- Caroline Paboeuf
- Département de Pneumologie, Centre Hospitalier Universitaire, Angers, France
| | - Pascaline Priou
- Département de Pneumologie, Centre Hospitalier Universitaire, Angers, France Inserm UMR 1063, Université d'Angers, Angers, France
| | - Nicole Meslier
- Département de Pneumologie, Centre Hospitalier Universitaire, Angers, France Inserm UMR 1063, Université d'Angers, Angers, France
| | - Frédéric Roulaud
- Service de Cardiologie, Centre Hospitalier Universitaire, Angers, France
| | - Wojciech Trzepizur
- Département de Pneumologie, Centre Hospitalier Universitaire, Angers, France; Inserm UMR 1063, Université d'Angers, Angers, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalier Universitaire, Angers, France; Inserm UMR 1063, Université d'Angers, Angers, France
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Selvanathan J, Peng PWH, Wong J, Ryan CM, Chung F. Sleep-disordered breathing in patients on opioids for chronic pain. Reg Anesth Pain Med 2020; 45:826-830. [PMID: 32928994 DOI: 10.1136/rapm-2020-101540] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/23/2020] [Accepted: 07/02/2020] [Indexed: 11/03/2022]
Abstract
The past two decades has seen a substantial rise in the use of opioids for chronic pain, along with opioid-related mortality and adverse effects. A contributor to opioid-associated mortality is the high prevalence of moderate/severe sleep-disordered breathing, including central sleep apnea and obstructive sleep apnea, in patients with chronic pain. Although evidence-based treatments are available for sleep-disordered breathing, patients are not frequently assessed for sleep-disordered breathing in pain clinics. To aid healthcare providers in this area of clinical uncertainty, we present evidence on the interaction between opioids and sleep-disordered breathing, and the prevalence and predictive factors for sleep-disordered breathing in patients on opioids for chronic pain. We provide recommendations on how to evaluate patients on opioids for risk of moderate/severe sleep-disordered breathing in clinical care, which could lead to earlier use of therapeutic interventions for opioid-associated sleep-disordered breathing, such as opioid cessation or positive airway pressure therapy. This would improve quality of life and well-being of patients with chronic pain.
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Affiliation(s)
- Janannii Selvanathan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Philip W H Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada .,Institute of Medical Science, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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14
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Postoperative outcomes in patients with treatment-emergent central sleep apnea: a case series. J Anesth 2020; 34:841-848. [DOI: 10.1007/s00540-020-02828-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/13/2020] [Indexed: 11/26/2022]
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Chung F, Wong J, Bellingham G, Lebovic G, Singh M, Waseem R, Peng P, George CFP, Furlan A, Bhatia A, Clarke H, Juurlink DN, Mamdani MM, Horner R, Orser BA, Ryan CM. Predictive factors for sleep apnoea in patients on opioids for chronic pain. BMJ Open Respir Res 2019; 6:e000523. [PMID: 31908788 PMCID: PMC6936992 DOI: 10.1136/bmjresp-2019-000523] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 12/26/2022] Open
Abstract
Background The risk of death is elevated in patients taking opioids for chronic non-cancer pain. Respiratory depression is the main cause of death due to opioids and sleep apnoea is an important associated risk factor. Methods In chronic pain clinics, we assessed the STOP-Bang questionnaire (a screening tool for sleep apnoea; Snoring, Tiredness, Observed apnoea, high blood Pressure, Body mass index, age, neck circumference and male gender), Epworth Sleepiness Scale, thyromental distance, Mallampati classification, daytime oxyhaemoglobin saturation (SpO2) and calculated daily morphine milligram equivalent (MME) approximations for each participant, and performed an inlaboratory polysomnogram. The primary objective was to determine the predictive factors for sleep apnoea in patients on chronic opioid therapy using multivariable logistic regression models. Results Of 332 consented participants, 204 underwent polysomnography, and 120 (58.8%) had sleep apnoea (AHI ≥5) (72% obstructive, 20% central and 8% indeterminate sleep apnoea), with a high prevalence of moderate (23.3%) and severe (30.8%) sleep apnoea. The STOP-Bang questionnaire and SpO2 are predictive factors for sleep apnoea (AHI ≥15) in patients on opioids for chronic pain. For each one-unit increase in the STOP-Bang score, the odds of moderate-to-severe sleep apnoea (AHI ≥15) increased by 70%, and for each 1% SpO2 decrease the odds increased by 33%. For each 10 mg MME increase, the odds of Central Apnoea Index ≥5 increased by 3%, and for each 1% SpO2 decrease the odds increased by 45%. Conclusion In patients on opioids for chronic pain, the STOP-Bang questionnaire and daytime SpO2 are predictive factors for sleep apnoea, and MME and daytime SpO2 are predictive factors for Central Apnoea Index ≥5. Trial registration number NCT02513836
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Affiliation(s)
- Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, Women's College Hospital, University of Toronto, Toronto, On, Canada
| | - Geoff Bellingham
- Department of Anesthesia and Perioperative Medicine, St. Joseph's Health Care, Western University, London, Ontario, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, St Michael's Hospital, Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, On, Canada
| | - Mandeep Singh
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rida Waseem
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Philip Peng
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Charles F P George
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Andrea Furlan
- Toronto Rehabilitation Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, On, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad M Mamdani
- Applied Health Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,Applied Health Research Center, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Richard Horner
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Beverley A Orser
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Medicine, Sunnybrook Research Institute, University of Toronto, Toronto, On, Canada
| | - Clodagh M Ryan
- Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, Toronto, On, Canada.,Department of Medicine, University of Toronto, Toronto, On, Canada
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16
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Szereda-Przestaszewska M, Kaczyńska K. Pharmacologically evoked apnoeas. Receptors and nervous pathways involved. Life Sci 2018; 217:237-242. [PMID: 30553870 DOI: 10.1016/j.lfs.2018.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/05/2018] [Accepted: 12/12/2018] [Indexed: 01/07/2023]
Abstract
This review analyses the knowledge about the incidence of transient apnoeic spells, induced by substances which activate vagal chemically sensitive afferents. It considers the specificity and expression of appropriate receptors, and relevant research on pontomedullary circuits contributing to a cessation of respiration. Insight is gained into an excitatory drive of 5-HT1A serotonin receptors in overcoming opioid-induced respiratory inhibition.
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Affiliation(s)
- Małgorzata Szereda-Przestaszewska
- Department of Respiration Physiology, Mossakowski Medical Research Centre Polish Academy of Sciences, A. Pawińskiego 5, 02-106 Warsaw, Poland
| | - Katarzyna Kaczyńska
- Department of Respiration Physiology, Mossakowski Medical Research Centre Polish Academy of Sciences, A. Pawińskiego 5, 02-106 Warsaw, Poland.
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17
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Abstract
Chronic use of opioids negatively affects sleep on 2 levels: sleep architecture and breathing. Patients suffer from a variety of daytime sequelae. There may be a bidirectional relationship between poor sleep quality, sleep-disordered breathing, and daytime function. Opioids are a potential cause of incident depression. The best therapeutic option is withdrawal of opioids, which proves difficult. Positive airway pressure devices are considered first-line treatment for sleep-related breathing disorders. New generation positive pressure servo ventilators are increasingly popular as a treatment option for opioid-induced sleep-disordered breathing. Treatments to improve sleep quality, sleep-related breathing disorders, and quality of life in patients who use opioids chronically are discussed.
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Affiliation(s)
- Michelle Cao
- Division of Sleep Medicine, Stanford University School of Medicine, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Shahrokh Javaheri
- Bethesda North Hospital, University of Cincinnati College of Medicine, 10535 Montgomery Road, Suite 200, Cincinnati, OH 45242, USA; Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University, 181 Taylor Avenue, Columbus, OH 43203, USA.
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