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Montazeri Ghahjaverestan N, Chavoshian S, Cao X, Bradley TD, Tarlo SM, Stanbrook M, Chapman KR, Yadollahi A. The Effect of Simulated Obstructive Apneas on Mechanical Characteristics of Lower Airways in Individuals with Asthma. Ann Biomed Eng 2024; 52:1617-1624. [PMID: 38433152 DOI: 10.1007/s10439-024-03475-3] [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: 11/07/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
Increased negative intrathoracic pressure that occurs during pharyngeal obstruction can increase thoracic fluid volume that may contribute to lower airway narrowing in individuals with obstructive sleep apnea (OSA) and asthma. Our previous study showed that fluid accumulation in the thorax induced by simulated OSA can increase total respiratory resistance. However, the effect of fluid shift on lower airway narrowing has not been investigated. To examine the effect of fluid accumulation in the thorax on the resistance of the lower airway. Non-asthma participants and individuals with (un)controlled asthma were recruited and underwent a single-day experiment. A catheter with six pressure sensors was inserted through the nose to continuously measure pressure at different sites of the airway, while a pneumotachograph was attached to a mouthpiece to record airflow. To simulate obstructive apneas, participants performed 25 Mueller maneuvers (MMs) while lying supine. Using the recordings of pressure sensor and airflow, total respiratory (RT), lower respiratory components (RL), and upper airway (RUA) resistances were calculated before and after MMs. Generalized estimation equation method was used to find the predictors of RL among variables including age, sex, body mass index, and the effect of MMs and asthma. Eighteen participants were included. Performing MMs significantly increased RT (2.23 ± 2.08 cmH2O/L/s, p = 0.003) and RL (1.52 ± 2.00 cmH2O/L/s, p = 0.023) in participants with asthma, while only RL was increased in non-asthma group (1.96 ± 1.73 cmH2O/L/s, p = 0.039). We found the model with age, and the effect of MMs and asthma severity generated the highest correlation (R2 = 0.69, p < 0.001). We provide evidence that fluid accumulation in the thorax caused by excessive intrathoracic pressure increases RL in both non-asthma and asthma groups. The changes in RL were related to age, having asthma and the effect of simulated OSA. This can explain the interrelationship between OSA and asthma.
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Affiliation(s)
- Nasim Montazeri Ghahjaverestan
- KITE, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Shaghayegh Chavoshian
- KITE, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Xiaoshu Cao
- KITE, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - T Douglas Bradley
- KITE, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Susan M Tarlo
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Matthew Stanbrook
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Kenneth R Chapman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Asthma & Airway Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Azadeh Yadollahi
- KITE, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.
- University Health Network Toronto Rehabilitation Institute, Room 12-106, 550 University Ave., Toronto, ON, M5G 2A2, Canada.
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B H S, G D, Sawal A, Balwir TP. Anatomical Basis of Obstructive Sleep Apnoea: A Review of Randomized Controlled Trials. Cureus 2023; 15:e44525. [PMID: 37789996 PMCID: PMC10544646 DOI: 10.7759/cureus.44525] [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: 12/20/2022] [Accepted: 09/01/2023] [Indexed: 10/05/2023] Open
Abstract
Repeated obstruction and closure of the upper airway, sporadic hypoxic episodes, and sympathetic activity are symptoms of obstructive sleep apnea (OSA). Obstructive sleep apnoea is due to a combination of altered upper airway structure and muscular function, a low arousal threshold and increased loop gain. Although recurrent upper airway (UA) collapse during sleep is the most frequent clinical hallmark of OSA, the exact cause of this collapse is unknown. Furthermore, while continuous positive airway pressure aids in the management of OSA, many patients find it intolerable. As a result, a better knowledge of the causes of OSA may result in more effective treatments. We did a review of randomized controlled trials that were done in this regard in the last 10 years and whose full-text version is available on the PubMed database. A total of 20 articles were finalized for review after applying our criteria. The articles have proposed different theories regarding the anatomical basis responsible for obstructive sleep apnoea. The theories proposed by different studies in the last decade include reduced genioglossus and hypoglossal nerve activity, the pharyngeal muscles' failure to keep the airway open or tighten it, tonsils and adenoid hypertrophy, an oversensitive ventilatory control system and low respiratory arousal threshold, mandibular position, pharyngeal muscles' high sympathetic drive, cephalometric alterations such as mandibular and hyoid bone position and the length of the soft palate, obesity, and neck fat and fluid re-distribution in the body, from the lower to the upper parts while reclining. Given the diverse etiological characteristics of OSA patients and to increase our knowledge of the condition, additional study into this group is required. Filling any knowledge gaps that may exist in the anatomical basis of the onset of OSA is the main objective of this review paper.
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Affiliation(s)
- Shrikrishna B H
- Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, Bibinagar, Hyderabad, IND
| | - Deepa G
- Anatomy, Datta Meghe Medical College, Nagpur, IND
| | - Anupama Sawal
- Anatomy, Jawaharlal Nehru Medical College, Sawangi, IND
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Lukachan GA, Chung F, Yadollahi A, Auckley D, Eissa M, Rahman N, McCluskey S, Singh M. Perioperative trends in neck and leg fluid volume in surgical patients: a prospective observational proof-of-concept study. Can J Anaesth 2023; 70:191-201. [PMID: 36450944 DOI: 10.1007/s12630-022-02362-6] [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: 04/07/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The severity of obstructive sleep apnea (OSA) may increase postoperatively. The changes in segmental fluid volume, especially neck fluid volume, may be related to increasing airway collapsibility and thus worsening of OSA in the postoperative period. Our objective was to evaluate the feasibility of performing bioelectrical impedance analysis (BIA) and to describe the trend and predictors of changes in segmental fluid volumes in patients receiving general anesthesia for noncardiac surgery. METHODS We conducted a prospective observational proof-of-concept cohort study of adult patients undergoing elective inpatient noncardiac surgery. Patients underwent a portable sleep study before surgery, and segmental fluid volumes (neck fluid volume [NFV], NFV phase angle, and leg fluid volume [LFV]) were measured using BIA at set time points: preoperative period (preop), in the postanesthesia care unit (PACU), the night following surgery at 10 pm (N 0), and the following day at 10 am (POD 1). Linear regression models were constructed to evaluate for significant predictors of overall segmental fluid changes. The variables included in the models were sex, preoperative apnea-hypopnea index (AHI), fluid balance, body mass index (BMI), cumulative opioids, and the timepoint of measurement. RESULTS Thirty-five adult patients (20/35 females, 57%) were included. For the feasibility outcome, measure of recruitment was 50/66 (76%) and two measures of protocol adherence were fluid measurements (34/39, 87%) and preoperative sleep study (35/39, 90%). There was a significant increase in NFV from preop to N 0 and in LFV from preop to PACU. Neck fluid volume also increased from PACU to N 0 and PACU to POD 1, while LFV decreased during the same intervals. The overall changes in NFV were associated with the preop AHI, BMI, and opioids after adjusting for body position and pneumoperitoneum. CONCLUSIONS This proof-of-concept study showed the feasibility and variability of segmental fluid volumes in the perioperative period using BIA. We found an increase in NFV and LFV in the immediate postoperative period in both males and females, followed by the continued rise in NFV and a simultaneous decrease in LFV, which suggest the occurrence of rostral fluid shift. Preoperative AHI, BMI, and opioids predicted the NFV changes. STUDY REGISTRATION ClinicalTrials.gov; NCT02666781, registered 25 January 2016; NCT03850041, registered 20 February 2019.
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Affiliation(s)
- Gincy A Lukachan
- Department of Anesthesia, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Frances Chung
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Azadeh Yadollahi
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Mohamed Eissa
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
- Department of Anesthesiology and Pain Management, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Nayeemur Rahman
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Stuart McCluskey
- Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mandeep Singh
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
- Department of Anesthesiology and Pain Management, Women's College Hospital, University of Toronto, Toronto, ON, Canada.
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Baniak LM, Orbell SL, Luyster FS, Henker R, Strollo PJ. Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway. Sleep Med Rev 2023; 67:101712. [PMID: 36442290 DOI: 10.1016/j.smrv.2022.101712] [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: 06/30/2022] [Revised: 10/14/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022]
Abstract
Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.
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Affiliation(s)
- Lynn M Baniak
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Staci L Orbell
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Faith S Luyster
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard Henker
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Strollo
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Lévy P, Naughton MT, Tamisier R, Cowie MR, Bradley TD. Sleep Apnoea and Heart Failure. Eur Respir J 2021; 59:13993003.01640-2021. [PMID: 34949696 DOI: 10.1183/13993003.01640-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022]
Abstract
Heart Failure (HF) and Sleep-Disordered-Breathing (SDB) are two common conditions that frequently overlap and have been studied extensively in the past three decades. Obstructive Sleep Apnea (OSA) may result in myocardial damage, due to intermittent hypoxia increased sympathetic activity and transmural pressures, low-grade vascular inflammation and oxidative stress. On the other hand, central sleep apnoea and Cheyne-Stokes respiration (CSA-CSR) occurs in HF, irrespective of ejection fraction either reduced (HFrEF), preserved (HFpEF) or mildly reduced (HFmrEF). The pathophysiology of CSA-CSR relies on several mechanisms leading to hyperventilation, breathing cessation and periodic breathing. Pharyngeal collapse may result at least in part from fluid accumulation in the neck, owing to daytime fluid retention and overnight rostral fluid shift from the legs. Although both OSA and CSA-CSR occur in HF, the symptoms are less suggestive than in typical (non-HF related) OSA. Overnight monitoring is mandatory for a proper diagnosis, with accurate measurement and scoring of central and obstructive events, since the management will be different depending on whether the sleep apnea in HF is predominantly OSA or CSA-CSR. SDB in HF are associated with worse prognosis, including higher mortality than in patients with HF but without SDB. However, there is currently no evidence that treating SDB improves clinically important outcomes in patients with HF, such as cardiovascular morbidity and mortality.
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Affiliation(s)
- Patrick Lévy
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France .,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Matt T Naughton
- Alfred Hospital, Department of Respiratory Medicine and Monash University, Melbourne, Australia.,All authors contributed equally to the manuscript
| | - Renaud Tamisier
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France.,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Martin R Cowie
- Royal Brompton Hospital and Faculty of Lifesciences & Medicine, King"s College London, London, UK.,All authors contributed equally to the manuscript
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Centre for Sleep Medicine and Circadian Biology of the University of Toronto and Department of Medicine of the University Health Network Toronto General Hospital, Canada.,All authors contributed equally to the manuscript
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Brown DL, Yadollahi A, He K, Xu Y, Piper B, Case E, Chervin RD, Lisabeth LD. Overnight Rostral Fluid Shifts Exacerbate Obstructive Sleep Apnea After Stroke. Stroke 2021; 52:3176-3183. [PMID: 34266303 DOI: 10.1161/strokeaha.120.032688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Overnight shifts of fluid from lower to upper compartments exacerbate obstructive sleep apnea (OSA) in some OSA populations. Given the high prevalence of OSA after stroke, decreased mobility and use of IV fluids among hospitalized patients with stroke, and improvement in OSA in the months after stroke, we hypothesized that overnight fluid shifts occur and are associated with OSA among patients with subacute ischemic stroke. METHODS Within a population-based project, we performed overnight sleep apnea tests (ApneaLink Plus) during ischemic stroke hospitalizations. Before sleep that evening, and the following morning before rising from bed, we assessed neck and calf circumference, and leg fluid volume (bioimpedance spectroscopy). The average per subject overnight change in the 3 fluid shift measurements was calculated and compared with zero. Linear regression was used to test the crude association between each of the 3 fluid shift measurements and the respiratory event index (REI). RESULTS Among the 292 participants, mean REI was 24 (SD=18). Within individuals, calf circumference decreased on average by 0.66 cm (SD=0.75 cm, P<0.001), leg fluid volume decreased by a mean of 135.6 mL (SD=132.8 mL, P<0.001), and neck circumference increased by 0.20 cm (SD=1.71 cm, P=0.07). In men, when the overnight change of calf circumference was negative, an interquartile range (0.8 cm) decrease in calf circumference overnight was significantly associated with a 25.1% increase in REI (P=0.02); the association was not significant in women. The relationship between overnight change in leg fluid volume and REI was U shaped. CONCLUSIONS This population-based, multicenter, cross-sectional study showed that in hospitalized patients with ischemic stroke, nocturnal rostral fluid shifts occurred, and 2 of the 3 measures were associated with greater OSA severity. Interventions that limit overnight fluid shifts should be tested as potential treatments for OSA among patients with subacute ischemic stroke.
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Affiliation(s)
- Devin L Brown
- Stroke Program, University of Michigan, Ann Arbor. (D.L.B., L.D.L.)
| | - Azadeh Yadollahi
- University Health Network-Toronto Rehabilitation Institute, Canada (A.Y., B.P.).,Institute of Biomaterials & Biomedical Engineering, University of Toronto, Canada (A.Y., B.P.)
| | - Kevin He
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor. (K.H., Y.X.)
| | - Yuliang Xu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor. (K.H., Y.X.)
| | - Bryan Piper
- University Health Network-Toronto Rehabilitation Institute, Canada (A.Y., B.P.).,Institute of Biomaterials & Biomedical Engineering, University of Toronto, Canada (A.Y., B.P.)
| | - Erin Case
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor. (E.C., L.D.L.)
| | - Ronald D Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor. (R.D.C.)
| | - Lynda D Lisabeth
- Stroke Program, University of Michigan, Ann Arbor. (D.L.B., L.D.L.).,Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor. (E.C., L.D.L.)
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MacKay SG, Lewis R, McEvoy D, Joosten S, Holt NR. Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association . Respirology 2020; 25:1292-1308. [PMID: 33190389 PMCID: PMC7839593 DOI: 10.1111/resp.13967] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 12/11/2022]
Abstract
Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.
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Affiliation(s)
- Stuart G MacKay
- University of Wollongong, Wollongong, NSW, Australia.,Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia.,Department of Otolaryngology Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW, Australia
| | - Richard Lewis
- Hollywood Medical Centre, Perth, WA, Australia.,Department of Otolaryngology Head and Neck Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Doug McEvoy
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Respiratory and Sleep Service, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Simon Joosten
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, VIC, Australia.,School of Clinical Sciences, Melbourne, VIC, Australia
| | - Nicolette R Holt
- The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Abstract
AIMS Arterial hypertension is highly prevalent and difficult to control in patients with obstructive sleep apnea (OSA). High sympathoadrenergic activity is a hallmark physiological phenomenon in OSA. We hypothesized that an antihypertensive drug with inhibitory properties on this activity, such as beta blockers (BBs), may be particularly efficacious in OSA patients. METHODS Hypertensive OSA patients receiving blood pressure-lowing treatment in the European Sleep Apnea Database (ESADA) (n = 5818, 69% men, age 58 ± 11 years, body mass index 33 ± 7 kg/m2, apnea hypopnea index 34 ± 26 events/h) were analyzed. Reported medications [BB, diuretic, renin-angiotensin blocker (RAB), calcium channel blocker (CCB), and centrally acting antihypertensive (CAH)] were classified according to ATC code. Office blood pressure was compared in patients with monotherapy or combination therapy controlling for confounders. RESULTS Poorly controlled SBP according to the ESC/ESH guidelines was found in 66% of patients. Patients receiving monotherapy with RAB, CCB or CAH had 2.2 (95% CI 1.4-3.0), 3.0 (1.9-4.1) and 3.0 (1.7-4.7) mmHg higher SBP compared with those on BB (adjusted model, P = 0.007, 0.008 and 0.017, respectively). In those with a combination of two antihypertensive drugs, SBP was 5.5 (4.0-7.1), 5.1 (3.7-6.6), 4.3 (2.5-6.1) and 3.1 (1.6-4.6) mmHg higher in those on CCB/RAB, BB/RAB, BB/CCB or diuretic/RAB compared with those on BB/diuretic (adjusted model, P < 0.001, <0.001, 0.018 and 0.036, respectively). CONCLUSION Poorly controlled blood pressure was common in OSA patients with antihypertensive medication. Treatment with BB alone or BB in combination with a diuretic was associated with the lowest systolic pressure in this large clinical cohort.
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Sabetian P, Yadollahi A, Yoo PB. Reduced genioglossus muscle activity caused by fluid overload in anesthetized rats. Physiol Rep 2020; 8:e14445. [PMID: 32633469 PMCID: PMC7339833 DOI: 10.14814/phy2.14445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/16/2020] [Accepted: 04/19/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Although the precise cause of obstructive sleep apnea (OSA) remains unknown, various anatomical or structural factors are thought to influence upper airway patency. Recent clinical studies show that OSA is frequently observed among patients with fluid-retaining states, such as heart/renal failure and postsurgery. It is important to note that a cause-effect relationship is not yet established, and our understanding of the effects of fluid overload is limited. The goal of this study was to investigate an animal model that can characterize the physiological changes that occur in response to fluid overload. METHOD Acute nonsurvival experiments were conducted in 16 Sprague-Dawley rats. Rats were initially anesthetized by inhaled isoflurane, while the femoral vein was cannulated and urethane (1.2-1.5 g/Kg body weight) was gradually delivered intravenously to induce anesthesia. Additional doses of urethane were delivered as necessary to maintain a surgical plane of anesthesia. A surgical incision was made on the cervical area to catheterize carotid artery to measure blood pressure. A pair of stainless-steel wires was injected into the tongue to measure genioglossus muscle activity (GGEMG). All physiological measurements were recorded as intravenous infusion of saline was provided to the rat (infusion rate = 22 ml/kg over 30 min). RESULTS Acute saline overloading resulted in a 33% decrease in GGEMG, when compared to baseline. There was also a gradual drop in the respiratory rate (13% decrease) that reached statistical significance at 10 min after infusion was stopped. The blood pressure exhibited a 14% increase which subsequently returned to baseline within 40 min stopping infusion. There were no significant changes in the heart rate. CONCLUSION The results of this study indicate that systemic fluid overload can affect significant changes in different physiological systems including reduction in genioglossus muscle activity, increase in blood pressure, and change autonomic nervous system function.
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Affiliation(s)
- Parisa Sabetian
- Institute of Biomaterials and Biomedical EngineeringUniversity of TorontoTorontoONCanada
| | - Azadeh Yadollahi
- Institute of Biomaterials and Biomedical EngineeringUniversity of TorontoTorontoONCanada
- Toronto Rehabilitation InstituteUniversity Health NetworkUniversity of TorontoTorontoONCanada
| | - Paul B. Yoo
- Institute of Biomaterials and Biomedical EngineeringUniversity of TorontoTorontoONCanada
- Toronto Rehabilitation InstituteUniversity Health NetworkUniversity of TorontoTorontoONCanada
- Department of Electrical and Computer EngineeringUniversity of TorontoTorontoONCanada
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Wang S, Zhang H, Huang X, Wang C, Lin H, Xu H, Ji C, Huang Y. A pilot study in men to show the effects of postural fluid shifts on the severity of obstructive sleep apnea. Sleep Breath 2020; 24:1623-1631. [PMID: 32166715 DOI: 10.1007/s11325-020-02044-x] [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: 06/04/2019] [Revised: 02/20/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Studies reveal that rostral fluid shifts due to body posture changes from standing to lying down may narrow the upper airway. However, without credible and direct experimental evidence, it remains unclear what the role of natural fluid redistribution in the neck is in affecting obstructive sleep apnea (OSA) severity. Our aim is using direct experimental evidence to determine whether or not postural fluid shifts affect OSA severity. METHODS We performed overnight polysomnography on two consecutive nights for 22 men. The bed was set horizontally on the control night, while its tail part was lowered by 30° on the experimental night to reduce the amount of fluid shifted into the neck. We measured sleep and anthropometric parameters on each night. RESULTS The mean (95% CI) apnea-hypopnea index (AHI) in the supine head and trunk position decreased from 66.6 events per hour (57.6-75.6) to 61.2 (52.0-70.4) (t = 4.507, p <0.001), and the oxygen desaturation index from 69.5 events per hour (56.4-82.6) to 61.6 (50.5-72.6) (t = 3.293, p = 0.004), from the control to the experimental night with a decrease in the change of leg fluid volume from 17.7% (15.7-19.8) to 4.7% (1.9-7.5) (t = 11.659, p < 0.001). CONCLUSIONS Our findings provide direct experimental evidence to show that natural fluid shift caused by the day-to-night posture change does contribute to OSA pathogenesis and severity. It is likely that the neck fluid increase from an actual day-to-night position change, with 90° change in posture, would produce a much larger AHI increase than the 11.2% found in this study, which contains only a 30° change in posture. These findings suggest that reducing the amount of fluid in the neck region may relieve airway obstructions for patients with moderate and severe OSA.
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Affiliation(s)
- Songjian Wang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Han Zhang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Xiaoqing Huang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Cunting Wang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Hongyi Lin
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Huixiang Xu
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Changjin Ji
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Yaqi Huang
- School of Biomedical Engineering, Capital Medical University, 10 Xitoutiao, Youanmenwai, Beijing, 100069, China. .,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China.
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11
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Bailly S, Galerneau LM, Ruckly S, Seiller A, Terzi N, Schwebel C, Dupuis C, Tamisier R, Mourvillier B, Pepin JL, Timsit JF. Impact of obstructive sleep apnea on the obesity paradox in critically ill patients. J Crit Care 2019; 56:120-124. [PMID: 31896445 DOI: 10.1016/j.jcrc.2019.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Patients admitted to an intensive care unit (ICU) frequently suffer from multiple chronic diseases, including obstructive sleep apnea (OSA). Until recently OSA was not considered as a key determinant in an ICU patient's prognosis. The objective of this study was to document the impact of OSA on the prognosis of ICU patients. METHODS Data were retrospectively collected concerning adult patients admitted to ICU at two university hospitals. In a nested study OSA status was checked using the hospital electronic medical records to identify exposed and unexposed cases. The following outcomes were considered: length of stay in the ICU, ICU mortality, in-hospital mortality, ventilator-associated pneumonia (VAP). RESULTS Out of 5146 patients included in the study, 289 had OSA at ICU admission (5.6%). After matching, the overall impact of OSA on length of ICU stay was not significant (p = .24). In a predefined subgroup analysis, there was a significant impact of OSA on the length of ICU stay for patients with BMI over 40 kg/m2 (IRR: 1.56 [1.05; 2.32], p = .03). OSA status had no impact on ICU or hospital mortality and VAP. CONCLUSION In general, known OSA did not increase the ICU stay except for patients with both OSA and morbid obesity.
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Affiliation(s)
- Sébastien Bailly
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; EFCR laboratory, Grenoble Alpes University Hospital, Grenoble, France.
| | - Louis-Marie Galerneau
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Stéphane Ruckly
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Alexandre Seiller
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Nicolas Terzi
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Carole Schwebel
- Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France; INSERM U1039 Radiopharmaceutiques Biocliniques, Grenoble, France
| | - Claire Dupuis
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, Paris, France
| | - Renaud Tamisier
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; EFCR laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Bernard Mourvillier
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, Paris, France
| | - Jean-Louis Pepin
- Univ. Grenoble Alpes, INSERM U1042, HP2, 38000 Grenoble, France; EFCR laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-François Timsit
- INSERM U1137, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, Paris, France
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12
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Targeting Endotypic Traits with Medications for the Pharmacological Treatment of Obstructive Sleep Apnea. A Review of the Current Literature. J Clin Med 2019; 8:jcm8111846. [PMID: 31684047 PMCID: PMC6912255 DOI: 10.3390/jcm8111846] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition with few therapeutic options. To date there is no approved pharmacotherapy for this disorder, but several attempts have been made in the past and are currently ongoing to find one. The recent identification of multiple endotypes underlying this disorder has oriented the pharmacological research towards tailored therapies targeting specific pathophysiological traits that contribute differently to cause OSA in each patient. In this review we retrospectively analyze the literature on OSA pharmacotherapy dividing the medications tested on the basis of the four main endotypes: anatomy, upper airway muscle activity, arousal threshold and ventilatory instability (loop gain). We show how recently introduced drugs for weight loss that modify upper airway anatomy may play an important role in the management of OSA in the near future, and promising results have been obtained with drugs that increase upper airway muscle activity during sleep and reduce loop gain. The lack of a medication that can effectively increase the arousal threshold makes this strategy less encouraging, although recent studies have shown that the use of certain sedatives do not worsen OSA severity and could actually improve patients' sleep quality.
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13
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Holt NR, Downey G, Naughton MT. Perioperative considerations in the management of obstructive sleep apnoea. Med J Aust 2019; 211:326-332. [PMID: 31522464 DOI: 10.5694/mja2.50326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Obstructive sleep apnoea (OSA) is characterised by repetitive compromise of the upper airway, causing impaired ventilation, sleep fragmentation, and daytime functional impairment. It is a heterogeneous condition encompassing different phenotypes. The prevalence of OSA among patients presenting for elective surgery is growing, largely attributable to an increase in age and obesity rates, and most patients remain undiagnosed and untreated at the time of surgery. This condition is an established risk factor for increased perioperative cardiopulmonary morbidity, heightened in the presence of concurrent medical comorbidities. Therefore, it is important to perform preoperative OSA screening and risk stratification - using the STOP-Bang screening questionnaire, nocturnal oximetry, and ambulatory and in-laboratory polysomnography, for example. Postoperative risk assessment is an evolving process that encompasses evaluation of upper airway compromise, ventilatory control instability, and pain-sedation mismatch. Optimal postoperative OSA management comprises continuation of regular positive airway pressure, a multimodal opioid-sparing analgesia strategy to limit respiratory depression, avoidance of supine position, and cautious intravenous fluid administration. Supplemental oxygen does not replace a patient's regular positive airway pressure therapy and should be administered cautiously to avoid risk of hypoventilation and worsening of hypercapnia. Continuous pulse oximetry monitoring with specified targets of peripheral oxygen saturation measured by pulse oximetry is encouraged.
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Affiliation(s)
- Nicolette R Holt
- Royal Melbourne Hospital, Melbourne, VIC.,Peter MacCallum Cancer Centre, Melbourne, VIC
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14
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Thoracic fluid accumulation and asthma symptoms: A new contributor mechanism. Porto Biomed J 2019; 4:e40. [PMID: 33501392 PMCID: PMC7819536 DOI: 10.1097/j.pbj.0000000000000040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/18/2019] [Indexed: 11/26/2022] Open
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15
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Fiori CZ, Martinez D, Montanari CC, Lopez P, Camargo R, Sezerá L, Gonçalves SC, Fuchs FD. Diuretic or sodium-restricted diet for obstructive sleep apnea-a randomized trial. Sleep 2019; 41:4829728. [PMID: 29669139 DOI: 10.1093/sleep/zsy016] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 12/26/2017] [Indexed: 01/10/2023] Open
Abstract
Study Objectives Interventions that decrease leg fluid retention reduce obstructive sleep apnea (OSA) severity in nonrandomized experiments. We aimed to investigate in a randomized trial the effect of interventions that reduce fluid volume on OSA severity. Methods Men diagnosed with severe OSA were randomized to receive daily spironolactone 100 mg + furosemide 20 mg or nutritional counseling to sodium-restricted diet plus placebo pill or placebo pill. All participants underwent home sleep apnea testing at baseline and after 1 week follow-up. The change in apnea-hypopnea index (AHI) was the primary outcome. Results The study included 54 participants and all were assessed at follow-up. The average baseline value of the AHI was similar among groups and from baseline to follow-up the AHI reduced 14.4 per cent (δ value -7.3 events per hour; 95% confidence interval, -13.8 to -0.9) in the diuretic group, 22.3 per cent (-10.7; 95% CI, -15.6 to -5.7) in the diet group, and 0.8 per cent (0.4; 95% CI, -2.5 to 3.2) in the placebo group (p = .001 for time × group interaction). None of the patients had their AHI returned to normal. The reduction in the total body water was 2.2 ± 2.2 L in the diuretic group (p < .001) and 1.0 ± 1.6 l in the low salt diet group (p = .002). Sleepiness and neck circumference were significantly reduced only in the diet group (p = .007 and p < .001 for the time × group interactions, respectively). Conclusions Interventions to reduce bodily fluid content in men with severe OSA promoted a limited decrease of apnea frequency. This finding suggests that rostral fluid displacement affects only partially the OSA severity and/or that other factors prevail in determining pharyngeal collapsibility. Clinical Trial Sodium-Restricted Diet and Diuretic in the Treatment of Severe Sleep Apnea (DESALT), https://clinicaltrials.gov/ct2/show/NCT01945801 ClinicalTrials.gov number: NCT01945801.
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Affiliation(s)
- Cintia Zappe Fiori
- Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Interdisciplinary Sleep Research Laboratory, Hospital de Clínicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, Brazil
| | - Denis Martinez
- Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Interdisciplinary Sleep Research Laboratory, Hospital de Clínicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, Brazil.,Graduate Studies Program in Medical Sciences, School of Medicine, UFRGS, Brazil.,Division of Cardiology, HCPA, Porto Alegre, RS, Brazil
| | - Carolina Caruccio Montanari
- Interdisciplinary Sleep Research Laboratory, Hospital de Clínicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, Brazil.,Graduate Studies Program in Medical Sciences, School of Medicine, UFRGS, Brazil
| | - Pedro Lopez
- Interdisciplinary Sleep Research Laboratory, Hospital de Clínicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, Brazil.,Exercise Research Laboratory, UFRGS, Porto Alegre, RS, Brazil
| | - Rodrigo Camargo
- Interdisciplinary Sleep Research Laboratory, Hospital de Clínicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, Brazil
| | - Lauren Sezerá
- Interdisciplinary Sleep Research Laboratory, Hospital de Clínicas de Porto Alegre (LIPES-HCPA), Porto Alegre, RS, Brazil
| | - Sandro Cadaval Gonçalves
- Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Division of Cardiology, HCPA, Porto Alegre, RS, Brazil
| | - Flavio Danni Fuchs
- Graduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Division of Cardiology, HCPA, Porto Alegre, RS, Brazil
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16
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Targeting volume overload and overnight rostral fluid shift: A new perspective to treat sleep apnea. Sleep Med Rev 2018; 42:160-170. [DOI: 10.1016/j.smrv.2018.07.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/25/2018] [Accepted: 07/31/2018] [Indexed: 01/15/2023]
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17
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Saha S, Moussavi Z, Hadi P, Bradley TD, Yadollahi A. Effects of Increased Pharyngeal Tissue Mass Due to Fluid Accumulation in the Neck on the Acoustic Features of Snoring Sounds in Men. J Clin Sleep Med 2018; 14:1653-1660. [PMID: 30353800 DOI: 10.5664/jcsm.7366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 06/13/2018] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVES Snoring sounds are generated by the vibration of pharyngeal tissue due to the upper airway narrowing. While recorded by a microphone placed over the neck, snoring can pass through the pharyngeal tissue surrounding the upper airway. Thus, changes in the pharyngeal tissue content may change the acoustic properties of the snoring sounds. Rostral fluid shift and the consequent increases in neck fluid volume (NFV) and neck circumference (NC) can increase pharyngeal tissue mass. Therefore, the goal of this study was to investigate the relationship between increases in pharyngeal tissue mass, as assessed by increased NFV and NC, and snoring sounds features. METHODS We obtained data from a previous study where 20 males who were not obese participated in a daytime polysomnography and their NC and NFV were measured before and after sleep. During sleep, snoring sounds were recorded with a microphone placed over the neck. Spectral centroid of the snoring sounds was estimated. Then, the first five snoring segments were selected from the first and last 30 minutes of stage N2 sleep. RESULTS We found a significant decrease in the snoring spectral centroid from the beginning to end of sleep. We also found that spectral centroid from the end of sleep in frequency ranges below 200 Hz was inversely correlated with the increases in NFV and NC from before to after sleep. CONCLUSIONS These results suggest that snoring spectral centroid can be used as a noninvasive and convenient method to assess variations in the pharyngeal tissue mass.
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Affiliation(s)
- Shumit Saha
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Zahra Moussavi
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - T Douglas Bradley
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Azadeh Yadollahi
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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18
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Zhi YX, Vena D, Popovic MR, Bradley TD, Yadollahi A. Detecting inspiratory flow limitation with temporal features of nasal airflow. Sleep Med 2018; 48:70-78. [DOI: 10.1016/j.sleep.2018.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 03/01/2018] [Accepted: 04/17/2018] [Indexed: 12/25/2022]
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19
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Wolf J, Narkiewicz K. Managing comorbid cardiovascular disease and sleep apnea with pharmacotherapy. Expert Opin Pharmacother 2018; 19:961-969. [PMID: 29792524 DOI: 10.1080/14656566.2018.1476489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Highly prevalent sleep disordered breathing (SDB) has been recognized as an independent cardiovascular disease (CVD) risk factor. Although these two entities often coexist, there is a shortage of sufficiently-powered studies testing the interplay between the course of sleep apnea and CVD pharmacotherapy. The mutual relationship between treated/untreated obstructive sleep apnea (OSA) with ongoing cardiovascular pharmacotherapies is an evident gap in clinical expertise. AREAS COVERED In this article, the authors review the available evidence and outline future research directions concerning the reciprocal relationship between the pharmacological treatment of CVD and SDB. Several attempts have been made to identify the most efficacious hypotensive agents for patients with both OSA and hypertension. Various cardiovascular drugs are also evaluated in terms of their influence on sleep apnea severity. EXPERT OPINION The question of whether OSA should be included in cardiovascular pharmacotherapy individualization algorithms is a matter of debate and more evidence is needed. Cautious intensification of diuretics with the use of aldosterone receptor antagonists deserves attention when both high blood pressure and sleep apnea coexist.
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Affiliation(s)
- Jacek Wolf
- a Faculty of Medicine, Department of Hypertension and Diabetology , Medical University of Gdańsk , Gdańsk , Poland
| | - Krzysztof Narkiewicz
- a Faculty of Medicine, Department of Hypertension and Diabetology , Medical University of Gdańsk , Gdańsk , Poland
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20
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21
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Vena D, Bradley TD, Millar PJ, Floras JS, Rubianto J, Gavrilovic B, Perger E, Yadollahi A. Heart Rate Variability Responses of Individuals With and Without Saline-Induced Obstructive Sleep Apnea. J Clin Sleep Med 2018; 14:503-510. [PMID: 29609720 DOI: 10.5664/jcsm.7032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES Postoperative development of obstructive sleep apnea (OSA) has been attributed to the fluid overloaded state of patients during the postoperative period. In this context, alterations in cardiac autonomic regulation caused by OSA may explain the increased postoperative risk for adverse cardiovascular events. This study tests the hypothesis that individuals with fluid overload-induced OSA will experience autonomic dysregulation, compared to those without fluid overload-induced OSA. METHODS Twenty-one normotensive, nonobese (mean body mass index 24.5 kg/m2) males (mean age 37 years) underwent a sleep study. Participants were randomly assigned to infusion with saline during sleep either at the minimum rate (control) or as a bolus of 22 mL/kg body weight (intervention). Participants were blinded to the intervention and crossed over to the other study arm after 1 week. Measures of heart rate variability were calculated from electrocardiography recordings presaline and postsaline infusion in the intervention arm. Heart rate variability measures computed were: standard deviation of the RR interval; root mean square of successive differences; low-frequency, high-frequency, and total power; and the ratio of low-frequency to high-frequency power. RESULTS Although presaline infusion values were similar, postsaline infusion values of the standard deviation of the RR interval and high-frequency power were lower in the group whose apnea-hypopnea index increased in response to saline infusion, compared to the group whose apnea-hypopnea index did not increase in response to saline infusion (P < .05 for both). CONCLUSIONS Fluid overload-induced OSA is accompanied by a reduction in heart rate variability, consistent with vagal withdrawal. Future work should explore autonomic dysregulation in the postoperative period and its association with adverse events.
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Affiliation(s)
- Daniel Vena
- Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - T Douglas Bradley
- Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Philip J Millar
- Toronto General Research Institute, University Health Network, Toronto, Canada.,Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada
| | - John S Floras
- Department of Medicine, University of Toronto, Toronto, Canada.,Toronto General Research Institute, University Health Network, Toronto, Canada
| | - Jonathan Rubianto
- Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
| | - Bojan Gavrilovic
- Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
| | - Elisa Perger
- Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
| | - Azadeh Yadollahi
- Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
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22
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Linares IMP, Guimaraes FS, Eckeli A, Crippa ACS, Zuardi AW, Souza JDS, Hallak JE, Crippa JAS. No Acute Effects of Cannabidiol on the Sleep-Wake Cycle of Healthy Subjects: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study. Front Pharmacol 2018; 9:315. [PMID: 29674967 PMCID: PMC5895650 DOI: 10.3389/fphar.2018.00315] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/19/2018] [Indexed: 12/17/2022] Open
Abstract
Cannabidiol (CBD) is a component of Cannabis sativa that has a broad spectrum of potential therapeutic effects in neuropsychiatric and other disorders. However, few studies have investigated the possible interference of CBD on the sleep-wake cycle. The aim of the present study was to evaluate the effect of a clinically anxiolytic dose of CBD on the sleep-wake cycle of healthy subjects in a crossover, double-blind design. Twenty-seven healthy volunteers that fulfilled the eligibility criteria were selected and allocated to receive either CBD (300 mg) or placebo in the first night in a double-blind randomized design (one volunteer withdrew from the study). In the second night, the same procedure was performed using the substance that had not been administered in the previous occasion. CBD or placebo were administered 30 min before the start of polysomnography recordings that lasted 8 h. Cognitive and subjective measures were performed immediately after polysomnography to assess possible residual effects of CBD. The drug did not induce any significant effect (p > 0.05). Different from anxiolytic and antidepressant drugs such as benzodiazepines and selective serotonin reuptake inhibitors, acute administration of an anxiolytic dose of CBD does not seem to interfere with the sleep cycle of healthy volunteers. The present findings support the proposal that CBD do not alter normal sleep architecture. Future studies should address the effects of CBD on the sleep-wake cycle of patient populations as well as in clinical trials with larger samples and chronic use of different doses of CBD. Such studies are desirable and opportune.
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Affiliation(s)
- Ila M. P. Linares
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Francisco S. Guimaraes
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Alan Eckeli
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Ana C. S. Crippa
- Department of Pediatrics, Neuropediatrics, Federal University of Paraná, Curitiba, Brazil
| | - Antonio W. Zuardi
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Jose D. S. Souza
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - Jaime E. Hallak
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
| | - José A. S. Crippa
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Instituto Nacional de Ciência e Tecnologia Translacional em Medicina, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brasília, Brazil
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23
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da Silva BC, Kasai T, Coelho FM, Zatz R, Elias RM. Fluid Redistribution in Sleep Apnea: Therapeutic Implications in Edematous States. Front Med (Lausanne) 2018; 4:256. [PMID: 29404327 PMCID: PMC5786568 DOI: 10.3389/fmed.2017.00256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/22/2017] [Indexed: 12/14/2022] Open
Abstract
Sleep apnea (SA), a condition associated with increased cardiovascular risk, has been traditionally associated with obesity and aging. However, in patients with fluid-retaining states, such as congestive heart failure and end-stage renal disease, both prevalence and severity of SA are increased. Recently, fluid shift has been recognized to play an important role in the pathophysiology of SA, since the fluid retained in the legs during the day shifts rostrally while recumbent, leading to edema of upper airways. Such simple physics, observed even in healthy individuals, has great impact in patients with fluid overload. Correction of the excess fluid volume has risen as a potential target therapy to improve SA, by attenuation of nocturnal fluid shift. Such strategy has gained special attention, since the standard treatment for SA, the positive airway pressure, has low compliance rates among its users and has failed to reduce cardiovascular outcomes. This review focuses on the pathophysiology of edema and fluid shift, and summarizes the most relevant findings of studies that investigated the impact of treating volume overload on SA. We aim to expand horizons in the treatment of SA by calling attention to a potentially reversible condition, which is commonly underestimated in clinical practice.
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Affiliation(s)
- Bruno Caldin da Silva
- Renal Division, Department of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Takatoshi Kasai
- Cardiovascular Respiratory Sleep Medicine, Department of Cardiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Fernando Morgadinho Coelho
- Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil.,Department of Psychobiology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Roberto Zatz
- Renal Division, Department of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Rosilene M Elias
- Renal Division, Department of Medicine, Universidade de São Paulo, São Paulo, Brazil
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24
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Shokrollahi M, Rudzicz F, Vena D, Bradley TD, Yadollahi A. A novel approach for acoustic estimation of neck fluid volume between men and women. Med Biol Eng Comput 2017; 56:113-123. [PMID: 28676955 DOI: 10.1007/s11517-017-1675-1] [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: 10/11/2016] [Accepted: 06/25/2017] [Indexed: 11/24/2022]
Abstract
Obstructive Sleep apnea can be caused by fluid shift from the legs to the neck that narrows the upper airway (UA) and contributes to changes in tracheal sound. Tracheal sound is generated from the turbulent airflow in the pharynx and respiratory airways and it has recently been used to estimate increases in neck fluid volume (NFV). However, tracheal sound is also highly variable among people, especially across the sexes. In this paper, a novel method is proposed to select tracheal sound features towards estimating NFV in men and women separately. To validate this method, it was applied to the tracheal sound data of 28 healthy individuals. Our proposed feature selection algorithm is based on sparse representations and incorporates NFV to maximize the relevance of selected features. This feature selection eliminates the dependence of the previous methods on calibrating the model for every individual. Two models, regression and Kalman filters, are then used to estimate NFV from selected features. Kalman filter obtains the highest performance, estimating NFV with more than 90% accuracy in both men and women. This algorithm can be used to develop non-invasive acoustic technologies to investigate the effects of fluid on UA anatomy in general applications. These results could be used to develop convenient devices to monitor the neck edema and its contribution to sleep apnea severity in fluid retaining patients such as heart or renal failure.
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Affiliation(s)
- Mehrnaz Shokrollahi
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Computer Science, University of Toronto, Toronto, Canada
| | - Frank Rudzicz
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Computer Science, University of Toronto, Toronto, Canada
| | - Daniel Vena
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Room 12-106, 550 University Ave., Toronto, ON, M5G 2A2, Canada
| | - T Douglas Bradley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Canada
| | - Azadeh Yadollahi
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada. .,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Room 12-106, 550 University Ave., Toronto, ON, M5G 2A2, Canada.
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25
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Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C, Patrawala S, Lam D, Kumar A, Joshi GP, Fleetham J, Ayas N, Collop N, Doufas AG, Eikermann M, Englesakis M, Gali B, Gay P, Hernandez AV, Kaw R, Kezirian EJ, Malhotra A, Mokhlesi B, Parthasarathy S, Stierer T, Wappler F, Hillman DR, Auckley D. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2017; 123:452-73. [PMID: 27442772 PMCID: PMC4956681 DOI: 10.1213/ane.0000000000001416] [Citation(s) in RCA: 200] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.
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Affiliation(s)
- Frances Chung
- From the *Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York; ‡Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; §Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph's Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph's Health care, Western University, London, Ontario, Canada; ‖Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care, Salzburg, Austria; ¶Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College New York, New York; #Department of Anesthesia, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; **Department of Medicine, University of California San Diego, San Diego, California; ††Sparrow Hospital, Lansing, Michigan; ‡‡Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Texas; §§Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada; ‖‖University of British Columbia, Vancouver, BC, Canada; ¶¶Department of Medicine, Emory University, Atlanta, Georgia; ##Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California; ***Department of Anesthesia, Critical Care and Pain Medicine, Harvard University, Cambridge, Massachusetts; †††Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; ‡‡‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; §§§Department of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, Minnesota; ‖‖‖School of Medicine, Universidad Peruana de Ciencias Apl
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26
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Lyons OD, Inami T, Perger E, Yadollahi A, Chan CT, Bradley TD. The effect of fluid overload on sleep apnoea severity in haemodialysis patients. Eur Respir J 2017; 49:49/4/1601789. [PMID: 28381432 DOI: 10.1183/13993003.01789-2016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/05/2017] [Indexed: 12/25/2022]
Abstract
As in heart failure, obstructive and central sleep apnoea (OSA and CSA, respectively) are common in end-stage renal disease. Fluid overload characterises end-stage renal disease and heart failure, and in heart failure plays a role in the pathogenesis of OSA and CSA. We postulated that in end-stage renal disease patients, those with sleep apnoea would have greater fluid volume overload than those without.End-stage renal disease patients on thrice-weekly haemodialysis underwent overnight polysomnography on a nondialysis day to determine their apnoea-hypopnoea index (AHI). Extracellular fluid volume of the total body, neck, thorax and right leg were measured using bioelectrical impedance.28 patients had an AHI ≥15 (sleep apnoea group; OSA:CSA 21:7) and 12 had an AHI <15 (no sleep apnoea group). Total body extracellular fluid volume was 2.6 L greater in the sleep apnoea group than in the no sleep apnoea group (p=0.006). Neck, thorax, and leg fluid volumes were also greater in the sleep apnoea than the no sleep apnoea group (p<0.05), despite no difference in body mass index (p=0.165).These findings support a role for fluid overload in the pathogenesis of both OSA and CSA in end-stage renal disease.
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Affiliation(s)
- Owen D Lyons
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada.,Dept of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Toru Inami
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada
| | - Elisa Perger
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada
| | - Azadeh Yadollahi
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Christopher T Chan
- Dept of Medicine, University Health Network Toronto General Hospital, Toronto, ON, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada .,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada.,Dept of Medicine, University Health Network Toronto General Hospital, Toronto, ON, Canada
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27
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Singh B, Yadollahi A, Lyons O, Alshaer H, Bradley TD. The effect of sitting and calf activity on leg fluid and snoring. Respir Physiol Neurobiol 2017; 240:1-7. [PMID: 28214605 DOI: 10.1016/j.resp.2017.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/24/2017] [Accepted: 02/13/2017] [Indexed: 11/28/2022]
Abstract
Prolonged sitting may promote leg fluid retention that redistributes to the neck during sleep and contributes to snoring. This could be attenuated by calf activity while sitting. In 16 healthy non-obese subjects we measured leg fluid volume (LFV) below the knees using bioelectrical impedance while sitting for 4h, snoring using a portable BresoDx™ device, and Mallampati grade. Using a double cross-over study design, subjects were randomized to one of two arms and crossed-over one week later: control arm - no calf exercise while sitting; intervention arm - calf contraction against a pedal resistance while sitting. The effects of sitting±calf activity on LFV and snoring were compared. We found that LFV increased by 216±101.0ml (p<0.0001) after sitting. Calf activity while sitting attenuated LFV by 53.8ml (p<0.0001) and, in all five subjects with severe upper airway narrowing (Mallampati grade IV), reduced snoring duration (from 357±132.9 to 116.2±72.1s/h, p=0.02) suggesting reduced overnight rostral fluid shift to the neck.
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Affiliation(s)
- Bhajan Singh
- Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON M5G 2A2, Canada; Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia; Faculty of Science, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia; West Australian Sleep Disorders Research Institute, QEII Medical Centre, Hospital Avenue, Nedlands, WA 6009, Australia.
| | - Azadeh Yadollahi
- Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON M5G 2A2, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, 164 College St, Toronto, ON M5S 3G9, Canada.
| | - Owen Lyons
- Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON M5G 2A2, Canada.
| | - Hisham Alshaer
- Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON M5G 2A2, Canada.
| | - T Douglas Bradley
- Sleep Research Laboratory, University Health Network, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, ON M5G 2A2, Canada; Centre for Sleep Medicine and Circadian Biology, University of Toronto, 27 King's College Cir, Toronto, ON M5S, Canada; Department of Medicine, University Health Network, Toronto General Hospital, 585 University Ave, Toronto, ON M5G 2N2, Canada.
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28
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Yadollahi A, Vena D, Lyons OD, Bradley TD. Relationship of Fluid Accumulation in the Neck to Sleep Structure in Men during Daytime Sleep. J Clin Sleep Med 2016; 12:1365-1371. [PMID: 27397662 DOI: 10.5664/jcsm.6190] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 05/31/2016] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVES Induction of fluid overload during sleep in older men causes fluid accumulation in the neck, worsens obstructive sleep apnea (OSA), and reduces sleep efficiency and slow wave sleep. However, it is not clear whether disrupted sleep structure was related to age, fluid accumulation, or to OSA severity as assessed by the apnea-hypopnea index (AHI). We hypothesize that fluid accumulation in the neck is a significant contributor to the sleep structure. METHODS Twenty non-obese men, 46 ± 11 years, underwent a daytime sleep study following a night of sleep deprivation. Before and after sleep, neck circumference (NC), upper airway cross-sectional area, and neck fluid volume (NFV) were assessed. Stepwise regression analyses were used to determine factors that contributed to sleep structure, AHI, and arousal frequency. Independent factors were age, NC, ΔNC, ΔNFV, and AHI (excluded for AHI and arousal). RESULTS Subjects slept for 145 ± 44 minutes with a mean AHI of 26 ± 25. After sleep, NC and NFV increased and the upper airway narrowed (all: p < 0.001). ΔNC and ΔNFV correlated directly with %N2 and inversely with %N3 sleep. Regression analyses revealed that only ΔNC correlated directly with %N2 sleep (r2 = 0.44, p = 0.001). ΔNC, ΔNFV, and pre-sleep NC correlated inversely with %N3 sleep (r2 = 0.76, p < 0.001). Pre-sleep NC and ΔNC correlated directly with AHI and arousal frequency. CONCLUSIONS Fluid accumulation in the neck and larger neck circumference are related to impaired sleep structure with reduced %N3 sleep. Fluid accumulation in the neck had stronger contribution to sleep structure than AHI or age.
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Affiliation(s)
- Azadeh Yadollahi
- Toronto Rehabilitation Institute-University Health Network, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Daniel Vena
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Owen D Lyons
- Toronto Rehabilitation Institute-University Health Network, Toronto, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Canada
| | - T Douglas Bradley
- Toronto Rehabilitation Institute-University Health Network, Toronto, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Canada
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29
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Gildeh N, Drakatos P, Higgins S, Rosenzweig I, Kent BD. Emerging co-morbidities of obstructive sleep apnea: cognition, kidney disease, and cancer. J Thorac Dis 2016; 8:E901-E917. [PMID: 27747026 DOI: 10.21037/jtd.2016.09.23] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Obstructive sleep apnea (OSA) causes daytime fatigue and sleepiness, and has an established relationship with cardiovascular and metabolic disease. Recent years have seen the emergence of an evidence base linking OSA with an increased risk of degenerative neurological disease and associated cognitive impairment, an accelerated rate of decline in kidney function with an increased risk of clinically significant chronic kidney disease (CKD), and with a significantly higher rate of cancer incidence and death. This review evaluates the evidence base linking OSA with these seemingly unrelated co-morbidities, and explores potential mechanistic links underpinning their development in patients with OSA, including intermittent hypoxia (IH), sleep fragmentation, sympathetic excitation, and immune dysregulation.
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Affiliation(s)
- Nadia Gildeh
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, IOPPN, King's College and Imperial College, London, UK;; Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Panagis Drakatos
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, IOPPN, King's College and Imperial College, London, UK;; Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sean Higgins
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, IOPPN, King's College and Imperial College, London, UK;; Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ivana Rosenzweig
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, IOPPN, King's College and Imperial College, London, UK;; Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK;; Danish Epilepsy Centre, Dianalund, Denmark
| | - Brian D Kent
- Sleep and Brain Plasticity Centre, Department of Neuroimaging, IOPPN, King's College and Imperial College, London, UK;; Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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30
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Gavrilovic B, Popovic MR, Yadollahi A. Modeling sleep apnea severity using bioimpedance measurements. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:5998-6001. [PMID: 26737658 DOI: 10.1109/embc.2015.7319758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Obstructive sleep apnea (OSA) is a common disorder in adults characterized by repetitive collapse of the pharynx. OSA prevalence increases in fluid retaining patients such as those with heart or renal failure, and worsens with overnight fluid accumulation in the neck. The objective of this study was to develop a new method of measuring changes in intracellular water (ICW) in the neck, and investigate metrics that represent total neck impedance and their relationship to sleep apnea severity. In 18 non-obese men, neck fluid volume (NFV) was measured before and after sleep using bioelectrical impedance at 50 kHz. For each participant, resistance and reactance was extracted from the impedance measurements. A model was developed to estimate the cell membrane capacitance which could represent changes in intracellular fluid in the neck. OSA severity was assessed using polysomnography to estimate the apnea-hypopnea index (AHI) as well as the obstructive AHI (OAHI). Our results showed a strong correlation between the changes in NFV from before to after sleep with the changes in cell membrane capacitance from before to after sleep, indicating an increase in ICW in the neck during sleep. Using linear stepwise regression we were also able to develop models to accurately predict AHI and OAHI using baseline anthropometric and bioimpedance measurements. These promising results demonstrate that non-invasive measurements of bioimpedance can be used to develop a novel biomarker to model sleep apnea severity, and assess patients at high risk of OSA.
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31
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Shokrollahi M, Saha S, Hadi P, Rudzicz F, Yadollahi A. Snoring sound classification from respiratory signal. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2016:3215-3218. [PMID: 28268992 DOI: 10.1109/embc.2016.7591413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Snoring is common in the general population and the irregularity could lead to the presence of Obstructive sleep apnea. Diagnosis of OSA could therefore be made by snoring sound analysis. However, there is still a shortage of robust methods to automatically detect snoring sounds without the need to calibrate for every individual. In this paper, a novel method based on neural network is proposed to classify breathing sound episodes from snoring and non-snoring sound segments. Our snore detection algorithm was applied to the tracheal sounds of nine individuals with different OSA severities. On the testing dataset, the classifier achieved a sensitivity and specificity of 95.9% and 97.6% respectively. Our results indicate that using such a method could help to detect snoring sounds with high accuracy which would be useful in the diagnosis of sleep apnea.
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32
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Gavrilovic B, Bradley TD, Vena D, Lyons OD, Gabriel JM, Popovic MR, Yadollahi A. Factors predisposing to worsening of sleep apnea in response to fluid overload in men. Sleep Med 2016; 23:65-72. [PMID: 27692279 DOI: 10.1016/j.sleep.2016.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/03/2016] [Accepted: 05/22/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is highly prevalent in patients with fluid-retaining conditions. Using bioimpedance measurements, previous studies have shown that the greater the amount of fluid redistributed from the legs to the neck overnight, the greater the severity of OSA. Our objective was to investigate factors that predispose the development or worsening of OSA in response to experimental fluid overload. METHODS Fifteen normotensive and non-obese adult men with and without OSA underwent polysomnography (PSG) during which normal saline was infused intravenously at a minimal rate to keep the vein open (control) or as a bolus of 22 ml/kg body weight (approximately 2 L) in a random order and crossed over after a week. RESULTS AND CONCLUSIONS Before and after sleep, neck circumference and bioimpedance were measured to calculate neck resistance, reactance, phase angle, and fluid volume. Subjects who experienced more than a twofold increase in apnea-hypopnea index (AHI) or obstructive AHI from control to intervention and had an AHI>10 during intervention were considered susceptible to the development or worsening of OSA. Baseline neck circumference and phase angle before saline infusion were independently associated with increased susceptibility to developing or worsening OSA in response to saline infusion. In non-obese men, a larger neck circumference and bioimpedance phase angle of the neck, which may be associated with larger pharyngeal tissue content, is associated with increased susceptibility for worsening of OSA in response to fluid overloading.
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Affiliation(s)
- Bojan Gavrilovic
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - T Douglas Bradley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Vena
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Owen D Lyons
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Joseph M Gabriel
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Milos R Popovic
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Azadeh Yadollahi
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada.
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33
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Saha S, Bradley TD, Taheri M, Moussavi Z, Yadollahi A. A Subject-Specific Acoustic Model of the Upper Airway for Snoring Sounds Generation. Sci Rep 2016; 6:25730. [PMID: 27210576 PMCID: PMC4876448 DOI: 10.1038/srep25730] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 04/21/2016] [Indexed: 11/17/2022] Open
Abstract
Monitoring variations in the upper airway narrowing during sleep is invasive and expensive. Since snoring sounds are generated by air turbulence and vibrations of the upper airway due to its narrowing; snoring sounds may be used as a non-invasive technique to assess upper airway narrowing. Our goal was to develop a subject-specific acoustic model of the upper airway to investigate the impacts of upper airway anatomy, e.g. length, wall thickness and cross-sectional area, on snoring sounds features. To have a subject-specific model for snoring generation, we used measurements of the upper airway length, cross-sectional area and wall thickness from every individual to develop the model. To validate the proposed model, in 20 male individuals, intensity and resonant frequencies of modeled snoring sounds were compared with those measured from recorded snoring sounds during sleep. Based on both modeled and measured results, we found the only factor that may positively and significantly contribute to snoring intensity was narrowing in the upper airway. Furthermore, measured resonant frequencies of snoring were inversely correlated with the upper airway length, which is a risk factor for upper airway collapsibility. These results encourage the use of snoring sounds analysis to assess the upper airway anatomy during sleep.
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Affiliation(s)
- Shumit Saha
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
| | - T Douglas Bradley
- Toronto Rehabilitation Institute-University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Mahsa Taheri
- Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
| | - Zahra Moussavi
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Canada
| | - Azadeh Yadollahi
- Toronto Rehabilitation Institute-University Health Network, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
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34
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Lam T, Singh M, Yadollahi A, Chung F. Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea? Anesth Analg 2016; 122:1335-9. [DOI: 10.1213/ane.0000000000001169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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35
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Mendelson M, Lyons OD, Yadollahi A, Inami T, Oh P, Bradley TD. Effects of exercise training on sleep apnoea in patients with coronary artery disease: a randomised trial. Eur Respir J 2016; 48:142-50. [PMID: 27076578 DOI: 10.1183/13993003.01897-2015] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/12/2016] [Indexed: 01/10/2023]
Abstract
Overnight fluid shift from the legs to the neck and lungs may contribute to the pathogenesis of obstructive sleep apnoea (OSA) and central sleep apnoea (CSA). We hypothesised that exercise training will decrease the severity of OSA and CSA in patients with coronary artery disease (CAD) by decreasing daytime leg fluid accumulation and overnight rostral fluid shift.Patients with CAD and OSA or CSA (apnoea-hypopnoea index >15 events per h) were randomised to 4 weeks of aerobic exercise training or to a control group. Polysomnography, with measurement of leg, thoracic and neck fluid volumes and upper-airway cross-sectional area (UA-XSA) before and after sleep, was performed at baseline and follow-up.17 patients per group completed the study. Apnoea-hypopnoea index decreased significantly more in the exercise group than in the control group (31.1±12.9 to 20.5±9.4 versus 28.1±13.5 to 27.0±15.1 events per h, p=0.047), in association with a greater reduction in the overnight change in leg fluid volume (579±222 to 466±163 versus 453±164 to 434±141 mL, p=0.04) and by a significantly greater increase in the overnight change in UA-XSA in the exercise group (p=0.04).In patients with CAD and sleep apnoea, exercise training decreases sleep apnoea severity via attenuation of overnight fluid shift and an increase in UA-XSA.
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Affiliation(s)
- Monique Mendelson
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada
| | - Owen D Lyons
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada Dept of Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Azadeh Yadollahi
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada Institute of Biomaterial and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Toru Inami
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada Dept of Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Paul Oh
- Cardiac Rehabilitation and Prevention, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, ON, Canada Dept of Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
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36
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Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the Perioperative Setting: Evidence of Support. Chest 2016; 149:586-597. [PMID: 26469321 PMCID: PMC5831563 DOI: 10.1378/chest.15-1777] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 09/27/2015] [Accepted: 09/28/2015] [Indexed: 12/18/2022] Open
Abstract
OSA is a commonly encountered comorbid condition in surgical patients. The risk of cardiopulmonary complications is increased by two to threefold with OSA. Among the different treatment options for OSA, CPAP is an efficacious modality. This review examines the evidence regarding the use of CPAP in the preoperative and postoperative periods in surgical patients with diagnosed and undiagnosed OSA.
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Affiliation(s)
- Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network University of Toronto, Toronto, Ontario, Canada.
| | - Mahesh Nagappa
- Department of Anesthesiology, Toronto Western Hospital, University Health Network University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesiology, Toronto Western Hospital, University Health Network University of Toronto, Toronto, Ontario, Canada
| | - Babak Mokhlesi
- Department of Medicine, Sleep Disorders Center and the Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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37
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Vena D, Yadollahi A. The effect of fluid overload by saline infusion on heart rate variability in men during sleep. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:2047-50. [PMID: 26736689 DOI: 10.1109/embc.2015.7318789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Fluid shift from the legs and into the neck during sleep has been shown to increase tissue pressure around the upper airway and increase sleep apnea severity. Recently, acute fluid overload via saline infusion during sleep was shown to increase sleep apnea severity in an older men (≥ 40 years of age) but not the younger men (<;40 years of age). The purpose of this study was to estimate the changes in the autonomic nervous system response to saline infusion in the younger and older men using well studied time- and frequency domain heart rate variability metrics (HRV). Eighteen healthy men (10 in the younger group and 8 in the older group) slept for up to 3 hours during the day while ≈ 2L of saline was intravenously injected during sleep. An electrocardiogram was collected continuously during the sleep period. Two five minute segments of stage 1 or 2 sleep were selected for analysis of HRV: one before saline infusion and one after completion of saline infusion. Time- and frequency domain metrics of HRV were used to characterize autonomic nervous system response. Results generally showed increased HRV as measured by time-domain statistical measures in the younger men after saline infusion. In the frequency domain, the change in high frequency power from pre- to post-saline infusion was significantly greater in the younger compared to the older men. In addition, there was a borderline significant trend showing an increase in HF power from pre- to post-saline infusion in the younger, but not the older men. These results suggest that only in the younger men and not the older men, parasympathetic nervous activity increased in response to acute fluid overload. This might be one of the mechanisms that increased the severity of OSA in older and not the younger men.
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Furlan SF, Braz CV, Lorenzi-Filho G, Drager LF. Management of Hypertension in Obstructive Sleep Apnea. Curr Cardiol Rep 2015; 17:108. [DOI: 10.1007/s11886-015-0663-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lyons OD, Chan CT, Yadollahi A, Bradley TD. Effect of ultrafiltration on sleep apnea and sleep structure in patients with end-stage renal disease. Am J Respir Crit Care Med 2015; 191:1287-94. [PMID: 25822211 DOI: 10.1164/rccm.201412-2288oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
RATIONALE In end-stage renal disease (ESRD), a condition characterized by fluid overload, both obstructive and central sleep apnea (OSA and CSA) are common. This observation suggests that fluid overload is involved in the pathogenesis of OSA and CSA in this condition. OBJECTIVES To test the hypothesis that fluid removal by ultrafiltration (UF) will reduce severity of OSA and CSA in patients with ESRD. METHODS At baseline, on a nondialysis day, patients with ESRD on thrice-weekly hemodialysis underwent overnight polysomnography along with measurement of total body extracellular fluid volume (ECFV), and ECFV of the neck, thorax, and right leg before and after sleep. The following week, on a nondialysis day, subjects with an apnea-hypopnea index (AHI) greater than or equal to 20 had fluid removed by UF, followed by repeat overnight polysomnography with fluid measurements. MEASUREMENTS AND MAIN RESULTS Fifteen patients (10 men) with an AHI greater than or equal to 20 (10 OSA; 5 CSA) participated. Mean age was 53.5 ± 10.4 years and mean body mass index was 25.3 ± 4.8 kg/m(2). Following removal of 2.17 ± 0.45 L by UF, the AHI decreased by 36% (43.8 ± 20.3 to 28.0 ± 17.7; P < 0.001) without affecting uremia. The reduction in AHI correlated with the reduction in total body ECFV (r = 0.567; P = 0.027) and was associated with reductions in ECFV of the right leg (P = 0.001), overnight change in ECFV of the right leg (P = 0.044), ECFV of the thorax (P = 0.001), and ECFV of the neck (P = 0.003). CONCLUSIONS These findings indicate that fluid overload contributes to the pathogenesis of OSA and CSA in ESRD, and that fluid removal by UF attenuates sleep apnea without altering uremic status.
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Affiliation(s)
- Owen D Lyons
- 1 Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, Toronto, Canada
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Affiliation(s)
- Brian D Kent
- 1 Sleep Disorders Centre/Lane Fox Unit Guy's & St Thomas' National Health Service Foundation Trust London, United Kingdom
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Chung F, Liao P, Yang Y, Andrawes M, Kang W, Mokhlesi B, Shapiro CM. Postoperative Sleep-Disordered Breathing in Patients Without Preoperative Sleep Apnea. Anesth Analg 2015; 120:1214-24. [DOI: 10.1213/ane.0000000000000774] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lam TD, Singh M, Chung F. Salt Content in IV Fluids Given Intraoperatively May Influence Postoperative OSA Severity. Sleep 2015; 38:989. [PMID: 25581924 DOI: 10.5665/sleep.4756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/24/2014] [Indexed: 11/03/2022] Open
Affiliation(s)
- Thach D Lam
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Roumelioti ME, Brown LK, Unruh ML. The Relationship Between Volume Overload in End-Stage Renal Disease and Obstructive Sleep Apnea. Semin Dial 2015; 28:508-13. [PMID: 25940851 DOI: 10.1111/sdi.12389] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Obstructive sleep apnea (OSA) is common, underdiagnosed, and undertreated among patients with end-stage renal disease (ESRD). As in all cases, pathogenesis of OSA is related to repeated upper airway (UA) occlusion or narrowing, but in ESRD, additional contributory factors likely include uremic destabilization of central respiratory control and anatomic changes in the UA related to fluid status. Pulmonary congestion is common in acute and chronic kidney failure and is a consequence of cardiomyopathy and fluid overload, two potentially reversible risk factors. Emerging evidence suggests that volume overload also reduces the UA caliber. The diminution in UA area as well as destabilization of ventilatory control in ESRD have been postulated as causes of increased OSA prevalence and severity in these patients, and creates a vicious cycle wherein OSA exacerbates fluid overload disorders such as in congestive heart failure (CHF) and ESRD, which then further worsen OSA. Dialysis modalities may differ in their effects on volume status, the accumulation of uremic toxins, and acid-base status, and as a consequence, on the emergence and severity of OSA. Given the contribution of excess fluid to both the severity of nocturnal hypoxia and UA narrowing, establishing and maintaining dry weight is of particular importance when managing OSA in ESRD. Clinical trials to determine the extent to which more aggressive fluid removal in ESRD patients may alleviate OSA are needed.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Lee K Brown
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, and the Program in Sleep Medicine, University of New Mexico Health Sciences Centre, Albuquerque, New Mexico
| | - Mark L Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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White LH, Lyons OD, Yadollahi A, Ryan CM, Bradley TD. Night-to-night variability in obstructive sleep apnea severity: relationship to overnight rostral fluid shift. J Clin Sleep Med 2015; 11:149-56. [PMID: 25406274 PMCID: PMC4298772 DOI: 10.5664/jcsm.4462] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/14/2014] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVES Overnight rostral fluid shift from the legs to the neck may narrow the pharynx and contribute to obstructive sleep apnea (OSA) pathogenesis. We hypothesized that night-to-night changes in the apnea-hypopnea index (AHI) would be associated with changes in overnight rostral fluid shift. METHODS Twenty-six patients with OSA (AHI ≥10) underwent two polysomnograms 14 days apart with measurement of neck and leg fluid volumes (LFV), neck circumference and upper-airway cross-sectional area before and after sleep. RESULTS Although mean AHI did not differ between polysomnograms, 35% of patients had a difference in AHI >10, indicating significant intra-individual variability. There were direct correlations between change in non-rapid-eye movement (NREM), but not REM AHI and change in evening LFV between polysomnograms (r = 0.440, p = 0.036 and r = 0.005, p = 0.982, respectively) and between change in supine, but not non-supine AHI and change in evening LFV (r = 0.483, p = 0.020 and r = 0.269, p = 0.280, respectively). An increase in evening LFV between polysomnograms was associated with a greater overnight decrease in LFV (r = 0.560, p = 0.005) and a greater overnight increase in neck fluid volume (r = 0.498, p = 0.016). Additionally, a greater overnight increase in neck circumference was associated with a greater overnight increase in neck fluid volume between polysomnograms (r = 0.453, p = 0.020) and a greater overnight decrease in upper-airway cross-sectional area (r = -0.587, p = 0.005). CONCLUSION Intra-individual variability in OSA severity may be partly explained by day-to-day changes in evening leg fluid volume and overnight rostral fluid shift, which may be most important in the pathogenesis of OSA during NREM and supine sleep.
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Affiliation(s)
- Laura H. White
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
| | - Owen D. Lyons
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
| | - Azadeh Yadollahi
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Institute of Biomaterial and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh M. Ryan
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
- Department of Medicine of the University Health Network Toronto General Hospital, Toronto, Ontario, Canada
| | - T. Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
- Department of Medicine of the University Health Network Toronto General Hospital, Toronto, Ontario, Canada
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Saha S, Taheri M, Mossuavi Z, Yadollahi A. Effects of changing in the neck circumference during sleep on snoring sound characteristics. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2015:2235-2238. [PMID: 26736736 DOI: 10.1109/embc.2015.7318836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Rostral fluid shift during sleep from the lower body part into the neck can increase neck circumference (NC) and narrow the upper airway. Such narrowing in the upper airway may increase turbulence of airflow passing through the upper airway; thus, induce snoring. The objective of this study was to investigate the effects of changes in NC during sleep on snoring sound characteristics. Fifteen non-obese men slept supine, and their sleep was monitored by a regular polysomnography. Snoring sounds were recorded with a microphone attached to the neck. NC was measured before and after sleep with a measuring tape. Snoring sounds' average power was calculated in different frequency ranges of 100 - 4000 Hz, 100 - 150 Hz, 150 - 450 Hz, 450 - 600 Hz, 600 - 1200 Hz, 1200 - 1800 Hz, 1800 - 2500 Hz and 2500 - 4000 Hz. Statistical analysis showed that increases in NC after sleep were strongly correlated with higher average power of the snoring sounds in the frequency ranges of 100-4000 Hz (r=0.74, P=0.004), 100-150 Hz (r=0.70, P=0.008), 150-450 Hz (r=0.73, P=0.005), and 450 - 600 Hz (r= 0.65, P=0.025). These results encourage the use of snoring sound analysis for monitoring the effects of fluid accumulation in the neck in relation to sleep apnea.
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White LH, Bradley TD, Logan AG. Pathogenesis of obstructive sleep apnoea in hypertensive patients: role of fluid retention and nocturnal rostral fluid shift. J Hum Hypertens 2014; 29:342-50. [DOI: 10.1038/jhh.2014.94] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/23/2014] [Accepted: 09/03/2014] [Indexed: 11/09/2022]
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Ramachandran SK. Can intravenous fluids explain increased postoperative sleep disordered breathing and airway outcomes? Sleep 2014; 37:1587-8. [PMID: 25197801 DOI: 10.5665/sleep.4062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/03/2022] Open
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