1
|
Cheng WJ, Finnsson E, Ágústsson JS, Sands SA, Hang LW. Endotypic traits of supine position and supine-predominant obstructive sleep apnoea in Asian patients. Eur Respir J 2024; 63:2301660. [PMID: 38212076 DOI: 10.1183/13993003.01660-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Over half of all cases of obstructive sleep apnoea (OSA) are classified as supine-related OSA; however, the pathological endotype during supine position is not fully understood. This study aims to investigate the endotypic traits of supine-predominant OSA and explore the variations in endotypic traits between the supine and lateral positions. METHODS We prospectively recruited 689 adult patients with OSA from a single sleep centre between April 2020 and December 2022. Endotypic traits, namely arousal threshold, collapsibility, loop gain and upper airway muscle compensation, were retrieved from polysomnographic signals. We identified spOSA by a supine to non-supine apnoea-hypopnoea index (AHI) ratio >2. We cross-sectionally compared demographic and endotypic traits between supine-predominant OSA and non-positional OSA and examined the associations between supine-predominant OSA and endotypic traits. Additionally, we compared the changes in endotypic traits between supine and lateral positions in patients with supine-predominant OSA and non-positional OSA. RESULTS In our study sample, 75.8% of patients were identified as having supine-predominant OSA. Compared to non-positional OSA, supine-predominant OSA was associated with low collapsibility (β= -3.46 %eupnoea, 95% CI -5.93- -1.00 %eupnoea) and reduced compensation (β= -6.79 %eupnoea, 95% CI -10.60- -2.99 %eupnoea). When transitioning from the lateral to supine position, patients with supine-predominant OSA had a substantial decrease in compensation compared to those with non-positional OSA (-11.98 versus -6.28 %eupnoea). CONCLUSIONS Supine-predominant OSA is the prevalent phenotype of OSA in Asian patients. Inadequate upper airway compensation appears to be a crucial underlying pathology in patients with supine-predominant OSA.
Collapse
Affiliation(s)
- Wan-Ju Cheng
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Miaoli, Taiwan
| | | | | | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Liang-Wen Hang
- College of Medicine, China Medical University, Taichung, Taiwan
- Sleep Medicine Center, Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
2
|
Shi X, Sutherland K, Lobbezoo F, Berkhout E, de Lange J, Cistulli PA, Darendeliler MA, Dalci O, Aarab G. Upper airway morphology in adults with positional obstructive sleep apnea. Sleep Breath 2024; 28:193-201. [PMID: 37466758 PMCID: PMC10954840 DOI: 10.1007/s11325-023-02879-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 06/19/2023] [Accepted: 06/23/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE To compare the anatomical balance and shape of the upper airway in the supine position between adults with positional obstructive sleep apnea (POSA) and adults with non-positional OSA (NPOSA). METHODS Adults diagnosed with OSA (apnea-hypopnea index (AHI) > 10 events/h) were assessed for eligibility. POSA was defined as the supine AHI more than twice the AHI in non-supine positions; otherwise, patients were classified as NPOSA. Cone beam computed tomography (CBCT) imaging was performed for every participant while awake in the supine position. The anatomical balance was calculated as the ratio of the tongue size to the maxillomandibular enclosure size. The upper airway shape was calculated as the ratio of the anteroposterior dimension to the lateral dimension at the location of the minimal cross-sectional area of the upper airway (CSAmin-shape). RESULTS Of 47 participants (28 males, median age [interquartile range] 56 [46 to 63] years, median AHI 27.8 [15.0 to 33.8]), 34 participants were classified as having POSA (72%). The POSA group tended to have a higher proportion of males and a lower AHI than the NPOSA group (P = 0.07 and 0.07, respectively). After controlling for both sex and AHI, the anatomical balance and CSAmin-shape were not significantly different between both groups (P = 0.18 and 0.73, respectively). CONCLUSION Adults with POSA and adults with NPOSA have similar anatomical balance and shape of their upper airway in the supine position. TRIAL REGISTRATION This study was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR Trial ACTRN12611000409976).
Collapse
Affiliation(s)
- Xiaoxin Shi
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, the Netherlands.
- Department of Oral Radiology & Digital Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centers/Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands.
| | - Kate Sutherland
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
- Charles Perkins Centre and Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health University of Sydney, Sydney, Australia
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, the Netherlands
| | - Erwin Berkhout
- Department of Oral Radiology & Digital Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centers/Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands
| | - Peter A Cistulli
- Centre for Sleep Health and Research, Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, Australia
- Charles Perkins Centre and Northern Clinical School, Sydney Medical School, Faculty of Medicine and Health University of Sydney, Sydney, Australia
| | - M Ali Darendeliler
- Discipline of Orthodontics and Paediatric Dentistry, Sydney Dental School, University of Sydney, Sydney, Australia
- Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Sydney, Australia
| | - Oyku Dalci
- Discipline of Orthodontics and Paediatric Dentistry, Sydney Dental School, University of Sydney, Sydney, Australia
- Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Sydney, Australia
| | - Ghizlane Aarab
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, the Netherlands
| |
Collapse
|
3
|
Alemany M. The Metabolic Syndrome, a Human Disease. Int J Mol Sci 2024; 25:2251. [PMID: 38396928 PMCID: PMC10888680 DOI: 10.3390/ijms25042251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
This review focuses on the question of metabolic syndrome (MS) being a complex, but essentially monophyletic, galaxy of associated diseases/disorders, or just a syndrome of related but rather independent pathologies. The human nature of MS (its exceptionality in Nature and its close interdependence with human action and evolution) is presented and discussed. The text also describes the close interdependence of its components, with special emphasis on the description of their interrelations (including their syndromic development and recruitment), as well as their consequences upon energy handling and partition. The main theories on MS's origin and development are presented in relation to hepatic steatosis, type 2 diabetes, and obesity, but encompass most of the MS components described so far. The differential effects of sex and its biological consequences are considered under the light of human social needs and evolution, which are also directly related to MS epidemiology, severity, and relations with senescence. The triggering and maintenance factors of MS are discussed, with especial emphasis on inflammation, a complex process affecting different levels of organization and which is a critical element for MS development. Inflammation is also related to the operation of connective tissue (including the adipose organ) and the widely studied and acknowledged influence of diet. The role of diet composition, including the transcendence of the anaplerotic maintenance of the Krebs cycle from dietary amino acid supply (and its timing), is developed in the context of testosterone and β-estradiol control of the insulin-glycaemia hepatic core system of carbohydrate-triacylglycerol energy handling. The high probability of MS acting as a unique complex biological control system (essentially monophyletic) is presented, together with additional perspectives/considerations on the treatment of this 'very' human disease.
Collapse
Affiliation(s)
- Marià Alemany
- Faculty of Biology, Universitat de Barcelona, 08028 Barcelona, Catalonia, Spain
| |
Collapse
|
4
|
Owen GS, Talati VM, Zhang Y, LoSavio PS, Hutz MJ. The effect of head of bed elevation on upper airway collapsibility during drug-induced sleep endoscopy. J Clin Sleep Med 2024; 20:93-99. [PMID: 37707285 PMCID: PMC10758551 DOI: 10.5664/jcsm.10824] [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: 02/28/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
STUDY OBJECTIVES Drug-induced sleep endoscopy with positive airway pressure evaluates the collapsibility of the upper airway. It is currently unknown whether body position affects this assessment. We sought to determine whether the collapsibility of the airway may change with head of bed elevation. METHODS A prospective, consecutive cohort study was performed by 2 sleep surgeons at a tertiary care center. Inclusion criteria included adults 18 years of age and older with obstructive sleep apnea who were intolerant to continuous positive airway pressure therapy. Patients underwent drug-induced sleep endoscopy with positive airway pressure to evaluate them for alternative treatment options. Patients were evaluated in supine position with the head of bed both level and elevated to 30°. The airway was evaluated using the standardized VOTE scoring system in both positions. RESULTS The 61 patients included in the study were predominantly male (70.5%), middle-aged (51.2 years), and obese (body mass index, 30.2 kg/m2) with moderate-to-severe obstructive sleep apnea (apnea-hypopnea index, 34.1 events/h). The cohort consisted of predominantly positional obstructive sleep apnea (mean supine apnea-hypopnea index 48.7 events/h, nonsupine apnea-hypopnea index 20.8 events/h). All 4 sites of the upper airway demonstrated a significant decrease in airway opening pressures with the head of bed elevated compared to level (P < .01 for all sites). There was no significant difference in VOTE scoring between level and upright positions. CONCLUSIONS Patients with the head of bed elevated to 30° have a significantly lower degree of airway collapsibility compared to patients in the level position but no significant change in VOTE scoring was observed. CITATION Owen GS, Talati VM, Zhang Y, LoSavio PS, Hutz MJ. The effect of head of bed elevation on upper airway collapsibility during drug-induced sleep endoscopy. J Clin Sleep Med. 2024;20(1):93-99.
Collapse
Affiliation(s)
- Grant S. Owen
- Rush Medical College, Rush University Medical Center, Chicago, Illinois
| | - Vidit M. Talati
- Section of Sleep Surgery, Department of Otolaryngology – Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Yanyu Zhang
- Rush Informatics and Biostatistics Core, Rush University Medical Center, Chicago, Illinois
| | - Phillip S. LoSavio
- Section of Sleep Surgery, Department of Otolaryngology – Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
- Section of Sleep Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Michael J. Hutz
- Section of Sleep Surgery, Department of Otolaryngology – Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
- Section of Sleep Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
5
|
Landry SA, Beatty C, Thomson LDJ, Wong AM, Edwards BA, Hamilton GS, Joosten SA. A review of supine position related obstructive sleep apnea: Classification, epidemiology, pathogenesis and treatment. Sleep Med Rev 2023; 72:101847. [PMID: 37722317 DOI: 10.1016/j.smrv.2023.101847] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023]
Abstract
Supine related obstructive sleep apnea (OSA) is the most common clinical and physiological phenotype of OSA. This condition is recognizable by patients, their families and through polysomnographic recordings. Commonly used definitions distinguish the presence of supine related OSA when respiratory events occur at twice the frequency when the patient lies in the supine compared to non-supine sleeping positions. Recent physiology studies have demonstrated that airway obstruction arises more commonly in the supine position particularly at the level of the soft palate and epiglottis. Increased airway collapsibility is reliability observed supine relative to lateral position. To a lesser extent, changes in control of breathing favour less stable ventilation when the supine sleeping posture is adopted. Many treatments have been developed and trialled to help patients avoid sleeping on their back. The last 10 years has seen the emergence of vibrotactile warning devices that are worn on the patients' neck or chest. High quality randomized controlled trial data is accumulating on the efficacy and common pitfalls of the application of these treatments.
Collapse
Affiliation(s)
- Shane A Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Caroline Beatty
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia
| | - Ai-Ming Wong
- Royal Hobart Hospital (Tasmanian Health Service South), Hobart, Australia; Department of Medicine, University of Tasmania, Hobart, Australia; Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia; Monash Partners - Epworth, Victoria, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia; Monash Partners - Epworth, Victoria, Australia.
| |
Collapse
|
6
|
Messineo L, Joosten S, Perger E. Mechanisms relating to sleeping position to the endotypes of sleep disordered breathing. Curr Opin Pulm Med 2023; 29:543-549. [PMID: 37578380 DOI: 10.1097/mcp.0000000000001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) severity varies considerably depending on the body position during sleep in certain subjects. Such variability may be underpinned by specific, body position-related changes in OSA pathophysiological determinants, or endotypes. Also head position relative to trunk may influence OSA endotypes. However, no studies to our knowledge have reviewed the endotype variations according to head or body position up to now. RECENT FINDINGS Several findings illustrate that supine OSA is mostly attributable to unfavorable upper airway anatomy compared to lateral position. However, a reduced lung volume, with consequent ventilatory instability (or elevated loop gain), may also play a role. Furthermore, preliminary findings suggest that prone and reclined positions may have a beneficial effect on collapsibility and loop gain. SUMMARY Sleeping supine induces many unfavorable pathophysiological changes, especially in certain predisposed OSA patients. Little is known on the influence of other sleep positions on key endotypic traits.
Collapse
Affiliation(s)
- Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Simon Joosten
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Victoria, Australia
- Epworth Partners
| | - Elisa Perger
- Istituto Auxologico Italiano, IRCCS, Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan, Italy
| |
Collapse
|
7
|
Aishah A, Tong BKY, Osman AM, Pitcher G, Donegan M, Kwan BCH, Brown E, Altree TJ, Adams R, Mukherjee S, Eckert DJ. Stepwise Add-On and Endotype-informed Targeted Combination Therapy to Treat Obstructive Sleep Apnea: A Proof-of-Concept Study. Ann Am Thorac Soc 2023; 20:1316-1325. [PMID: 37159953 DOI: 10.1513/annalsats.202210-892oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale: Oral appliance therapy (OAT) is an effective treatment for many people with obstructive sleep apnea (OSA). However, OSA pathogenesis is heterogeneous, and, in ∼50% of cases, OAT does not fully control OSA. Objectives: This study aimed to control OSA in individuals with an incomplete response to OAT alone by using additional targeted therapies informed by OSA endotype characterization. Methods: Twenty-three people with OSA (apnea-hypopnea index [AHI], 41 ± 19 events/h) not fully resolved (AHI, >10 events/h) with OAT alone were prospectively recruited. OSA endotypes were characterized pretherapy during a detailed physiology study night. Initially, an expiratory positive airway pressure (EPAP) valve and supine avoidance device therapy were added to target the impaired anatomical endotype. Those with residual OSA (AHI, >10 events/h) then received one or more nonanatomical interventions based on endotype characterization. This included O2 (4 L/min) to reduce high loop gain (unstable respiratory control) and 80/5 mg atomoxetine-oxybutynin to increase pharyngeal muscle activity. Finally, if required, OAT was combined with EPAP and continuous positive airway pressure (CPAP) therapy. Results: Twenty participants completed the study. OSA was successfully controlled (AHI, <10 events/h) with combination therapy in all but one participant (17 of 20 without CPAP). OAT plus EPAP and supine avoidance therapy treated OSA in 10 (50%) participants. OSA was controlled in five (25%) participants with the addition of O2 therapy, one with atomoxetine-oxybutynin, and one required O2 plus atomoxetine-oxybutynin. Two participants required CPAP for their OSA, and another was CPAP intolerant. Conclusions: These novel prospective findings highlight the potential of precision medicine to inform targeted combination therapy to treat OSA. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001995268).
Collapse
Affiliation(s)
- Atqiya Aishah
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Benjamin K Y Tong
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Amal M Osman
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Geoffrey Pitcher
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Michelle Donegan
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Benjamin C H Kwan
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Elizabeth Brown
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Thomas J Altree
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Robert Adams
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Sutapa Mukherjee
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Danny J Eckert
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| |
Collapse
|
8
|
Landry SA, Mann DL, Beare R, McIntyre R, Beatty C, Thomson LDJ, Collet J, Joosten SA, Hamilton GS, Edwards BA. Oronasal vs Nasal Masks: The Impact of Mask Type on CPAP Requirement, Pharyngeal Critical Closing Pressure (P crit), and Upper Airway Cross-Sectional Areas in Patients With OSA. Chest 2023; 164:747-756. [PMID: 36990149 DOI: 10.1016/j.chest.2023.03.025] [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: 09/15/2022] [Revised: 03/08/2023] [Accepted: 03/15/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND CPAP delivered via an oronasal mask is associated with lower adherence, higher residual apnea-hypopnea index (AHI), and increased CPAP therapeutic pressure compared with nasal masks. However, the mechanisms underlying the increased pressure requirements are not well understood. RESEARCH QUESTION How do oronasal masks affect upper airway anatomy and collapsibility? STUDY DESIGN AND METHODS Fourteen patients with OSA underwent a sleep study with both a nasal and oronasal mask, each for one-half of the night (order randomized). CPAP was manually titrated to determine therapeutic pressure. Upper airway collapsibility was assessed using the pharyngeal critical closing pressure (Pcrit) technique. Cine MRI was done to dynamically assess the cross-sectional area of the retroglossal and retropalatal airway throughout the respiratory cycle with each mask interface. Scans were repeated at 4 cm H2O and at the nasal and oronasal therapeutic pressures. RESULTS The oronasal mask was associated with higher therapeutic pressure requirements (ΔM ± SEM; +2.6 ± 0.5; P < .001) and higher Pcrit (+2.4 ± 0.5 cm H2O; P = .001) compared with the nasal mask. The change in therapeutic pressure between masks was strongly correlated with the change in Pcrit (r2 = 0.73; P = .003). Increasing CPAP increased both the retroglossal and retropalatal airway dimensions across both masks. After controlling for pressure and breath phase, the retropalatal cross-sectional area was moderately larger when using a nasal vs an oronasal mask (+17.2 mm2; 95% CI, 6.2-28.2, P < .001) while nasal breathing. INTERPRETATION Oronasal masks are associated with a more collapsible airway than nasal masks, which likely contributes to the need for a higher therapeutic pressure.
Collapse
Affiliation(s)
- Shane A Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.
| | - Dwayne L Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Richard Beare
- National Centre for Healthy Ageing and Peninsula Clinical School, Monash University, Melbourne, VIC, Australia; Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Richard McIntyre
- Monash Biomedical Imaging, Monash University, Melbourne, VIC, Australia; Monash Imaging, Monash Health, Clayton, VIC, Australia
| | - Caroline Beatty
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Monash Partners-Epworth, Clayton, VIC, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Monash Partners-Epworth, Clayton, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
9
|
Turnbull CD, Stradling JR. Endotyping, phenotyping and personalised therapy in obstructive sleep apnoea: are we there yet? Thorax 2023; 78:726-732. [PMID: 37217289 DOI: 10.1136/thorax-2023-220037] [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: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
Obstructive sleep apnoea (OSA) was traditionally thought to be mainly caused by obesity and upper airway crowding, and hence OSA management was not personalised according to particular characteristics, with most symptomatic patients receiving continuous positive airway pressure therapy. Recent advances in our understanding have identified additional potential and distinct causes of OSA (endotypes), and subgroups of patients (phenotypes) with increased risk of cardiovascular complications. In this review, we discuss the evidence to date as to whether there are distinct clinically useful endotypes and phenotypes of OSA, and the challenges to the field in moving towards delivering personalised therapy in OSA.
Collapse
Affiliation(s)
- Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John R Stradling
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Huang Z, Lobbezoo F, Vanhommerig JW, Volgenant CMC, de Vries N, Aarab G, Hilgevoord AAJ. Effects of demographic and sleep-related factors on snoring sound parameters. Sleep Med 2023; 104:3-10. [PMID: 36857868 DOI: 10.1016/j.sleep.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To investigate the effect of frequently reported between-individual (viz., age, gender, body mass index [BMI], and apnea-hypopnea index [AHI]) and within-individual (viz., sleep stage and sleep position) snoring sound-related factors on snoring sound parameters in temporal, intensity, and frequency domains. METHODS This study included 83 adult snorers (mean ± SD age: 42.2 ± 11.3 yrs; male gender: 59%) who underwent an overnight polysomnography (PSG) and simultaneous sound recording, from which a total of 131,745 snoring events were extracted and analyzed. Data on both between-individual and within-individual factors were extracted from the participants' PSG reports. RESULTS Gender did not have any significant effect on snoring sound parameters. The fundamental frequency (FF; coefficient = -0.31; P = 0.02) and dominant frequency (DF; coefficient = -12.43; P < 0.01) of snoring sounds decreased with the increase of age, and the second formant increased (coefficient = 22.91; P = 0.02) with the increase of BMI. Severe obstructive sleep apnea (OSA; AHI ≥30 events/hour), non-rapid eye movement sleep stage 3 (N3), and supine position were all associated with more, longer, and louder snoring events (P < 0.05). Supine position was associated with higher FF and DF, and lateral decubitus positions were associated with higher formants. CONCLUSIONS Within the limitations of the current patient profile and included factors, AHI was found to have greater effects on snoring sound parameters than the other between-individual factors. The included within-individual factors were found to have greater effects on snoring sound parameters than the between-individual factors under study.
Collapse
Affiliation(s)
- Zhengfei Huang
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Clinical Neurophysiology, OLVG, Amsterdam, the Netherlands.
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joost W Vanhommerig
- Department of Research and Epidemiology, OLVG Hospital, Amsterdam, the Netherlands
| | - Catherine M C Volgenant
- Department of Preventive Dentistry, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Nico de Vries
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, OLVG, Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Ghizlane Aarab
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | |
Collapse
|
11
|
Huang W, Li C, Zou J, Wang X, Zhang J, Guan J, Yi H, Yin S. Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: A multi-arm, parallel-group randomized controlled trial. Sleep Med 2023; 102:52-63. [PMID: 36599196 DOI: 10.1016/j.sleep.2022.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/28/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We explored whether a new combination of eye mask sleep position therapy (SPT) and oral appliance therapy (OAT) was more effective at treating positional obstructive sleep apnea (POSA) than was the use of either device alone. METHODS In this randomized controlled trial, 60 POSA subjects diagnosed by standard polysomnography (PSG) were divided into three groups (ratio 1:1:1): SPT, OAT, and SPT combined with OAT (SOT). Participants underwent hospital-based follow-ups during months 1 and 6 after beginning treatment. The primary outcome was the decline in the apnea hypopnea index (AHI) at month 6. The secondary outcomes were changes in oxygen-derived parameters and the curative effect at month 6. RESULTS After 6 months of treatment, PSG showed that SPT, OAT, and SOT all improved the AHI and oxygen-derived parameters. The AHI decline was significantly better in the SOT group than in the OAT or SPT group (71.58% [50.56-84.84%] for SOT, 44.42% [21.23-67.52%] for OAT, and 33.24% [19.03-54.62%] for SPT at 6 months) (P = 0.018 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). In terms of oxygen-derived parameters, only the sleep apnea-specific hypoxic burden (SASHB) improved more in the SOT group (76.89% [57.43-85.91%]) than in the other groups (44.73% [32.38-72.69%] for OAT and 41.82% [15.40-65.24%] for SPT, P = 0.002 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). The efficacies of SPT, OAT, and SOT were 36.84%, 50%, and 80% at 6 months; the SOT group evidenced the highest value (rate ratio [95% confidence interval] 1.78 (1.05-3.03), P = 0.048 and 2.17 (1.16-4.07), P = 0.010, for the comparisons of SOT with OAT and SOT with SPT, respectively). CONCLUSION The combination of SPT and OAT was better than either treatment alone and may represent a good option for the treatment of POSA. TRIAL REGISTRATION Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn/showproj.aspx?proj=42,852; No. ChiCTR1900025584.
Collapse
Affiliation(s)
- Weijun Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Chenyang Li
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jianyin Zou
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoting Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jingyu Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jian Guan
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Hongliang Yi
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.
| | - Shankai Yin
- Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China; Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
12
|
Duration of respiratory events in obstructive sleep apnea: Factors influencing the duration of respiratory events. Sleep Med Rev 2022; 68:101729. [PMID: 36549231 DOI: 10.1016/j.smrv.2022.101729] [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: 08/31/2022] [Revised: 11/15/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022]
Abstract
Several factors influence respiratory event duration during sleep. In general, women have shorter respiratory events compared to men as it appears that women have a more reactive upper airway contributing to the occurrence of short events. In addition, the increased amount of adipose tissue in the upper airways should make the reopening of the upper airways more difficult, leading to long respiratory events. Nevertheless, an increase in body mass index decreases the median duration of apneas, hypopneas, and desaturations in all OSA severity categories. Also, respiratory events are longer in older adults compared to younger ones, and the most likely mechanism explaining this phenomenon appears to be the increased circulatory delay associated with aging. Several studies have also shown that apnea events are longer in rapid eye movement sleep compared to non-rapid eye movement sleep. The main mechanism behind these differences appears to be the greater pharyngeal muscle relaxation during rapid eye movement sleep. Finally, sleeping position affects the duration of respiratory events; apneas and hypopneas are longer in the supine compared to lateral postures regardless of the severity of OSA. In the present report, we discuss the best-known factors influencing the duration of abnormal breathing events during sleep.
Collapse
|
13
|
Combined Airway and Bariatric Surgery (CABS) for Obstructive Sleep Apnea Patients with Morbid Obesity: A Comprehensive Alternative Preliminary Study. J Clin Med 2022; 11:jcm11237078. [PMID: 36498653 PMCID: PMC9738588 DOI: 10.3390/jcm11237078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/18/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Although continuous positive airway pressure is the gold standard for obstructive sleep apnea (OSA), it does not improve obesity. By contrast, bariatric surgery significantly improves obesity but with sustained OSA in the majority of patients. This study proposes a comprehensive technique—combined airway and bariatric surgery (CABS)—to improve both obesity and OSA. The aims of the study are to evaluate the feasibility, safety and efficacy of CABS in morbidly obese OSA patients. The retrospective study enrolled 20 morbidly obese OSA patients (13 males; median age, 44 years; median apnea−hypopnea index (AHI), 63.2 event/h; median body mass index (BMI), 41.4 kg/m2). The study population was divided into two groups based on patients’ volition after shared decision making. The bariatric surgery (BS) group included laparoscopic sleeve gastrectomy (LSG, n = 8) and laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 2). CABS involved bariatric surgery—LSG (n = 8) and LRYGB (n = 2) in conjunction with airway surgery (concurrent nasal/palatal/lingual surgery [n = 8], concurrent palatal/lingual surgery [n = 2]). Patients received a home sleep apnea test at baseline and one year after surgery. The two patient groups were not different in age, sex, preoperative AHI or preoperative BMI. There was no airway compromise, wound bleeding or infection throughout the postoperative period. One year after surgery, patients in both groups achieved significant improvement in AHI and BMI. Furthermore, the improvement in AHI was significantly higher (p = 0.04) in the CABS group than in the BS group despite the insignificant change in BMI reduction (p = 0.63) between the two groups. In the CABS group, the BMI dropped from 40.4 to 28.4 kg/m2 (p < 0.0001) and the AHI decreased from 75.1 to 4.5 event/h (p = 0.0004). The classic success rate for OSA was 90% and the cure rate was 60% in the CABS group. A perioperative assessment of CABS group patients also revealed a significant improvement in the Epworth sleepiness scale, minimal O2 saturation, snoring index and heart rate. CABS is feasible and safe in treating OSA with morbid obesity. CABS achieves more reduction in AHI than BS alone with high success and cure rates for OSA. CABS can also significantly improve quality of life and general health and offers a comprehensive alternative for morbidly obese OSA patients.
Collapse
|
14
|
Wong AM, Landry SA, Joosten SA, Thomson LDJ, Turton A, Stonehouse J, Mansfield DR, Burgess G, Hays A, Sands SA, Andara C, Beatty CJ, Hamilton GS, Edwards BA. Examining the impact of multilevel upper airway surgery on the obstructive sleep apnoea endotypes and their utility in predicting surgical outcomes. Respirology 2022; 27:890-899. [PMID: 35598093 PMCID: PMC9542009 DOI: 10.1111/resp.14280] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Upper airway surgery for obstructive sleep apnoea (OSA) is an alternative treatment for patients who are intolerant of continuous positive airway pressure (CPAP). However, upper airway surgery has variable treatment efficacy with no reliable predictors of response. While we now know that there are several endotypes contributing to OSA (i.e., upper airway collapsibility, airway muscle response/compensation, respiratory arousal threshold and loop gain), no study to date has examined: (i) how upper airway surgery affects all four OSA endotypes, (ii) whether knowledge of baseline OSA endotypes predicts response to surgery and (iii) whether there are any differences when OSA endotypes are measured using the CPAP dial-down or clinical polysomnographic (PSG) methods. METHODS We prospectively studied 23 OSA patients before and ≥3 months after multilevel upper airway surgery. Participants underwent clinical and research PSG to measure OSA severity (apnoea-hypopnoea index [AHI]) and endotypes (measured in supine non-rapid eye movement [NREM]). Values are presented as mean ± SD or median (interquartile range). RESULTS Surgery reduced the AHITotal (38.7 [23.4 to 79.2] vs. 22.0 [13.3 to 53.5] events/h; p = 0.009). There were no significant changes in OSA endotypes, however, large but variable improvements in collapsibility were observed (CPAP dial-down method: ∆1.9 ± 4.9 L/min, p = 0.09, n = 21; PSG method: ∆3.4 [-2.8 to 49.0]%Veupnoea , p = 0.06, n = 20). Improvement in collapsibility strongly correlated with improvement in AHI (%∆AHISupineNREM vs. ∆collapsibility: p < 0.005; R2 = 0.46-0.48). None of the baseline OSA endotypes predicted response to surgery. CONCLUSION Surgery unpredictably alters upper airway collapsibility but does not alter the non-anatomical endotypes. There are no baseline predictors of response to surgery.
Collapse
Affiliation(s)
- Ai-Ming Wong
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane A Landry
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Anthony Turton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Jeremy Stonehouse
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Darren R Mansfield
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Glen Burgess
- Department of Ear, Nose and Throat, Monash Health, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew Hays
- Department of Ear, Nose and Throat, Monash Health, Melbourne, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Christopher Andara
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria
| | - Caroline J Beatty
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria
| |
Collapse
|
15
|
Huang W, Wang X, Xu C, Xu H, Zhu H, Liu S, Zou J, Guan J, Yi H, Yin S. Prevalence, characteristics, and respiratory arousal threshold of positional obstructive sleep apnea in China: a large scale study from Shanghai Sleep Health Study cohort. Respir Res 2022; 23:240. [PMID: 36096792 PMCID: PMC9465879 DOI: 10.1186/s12931-022-02141-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/16/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the prevalence, characteristics, and respiratory arousal threshold (ArTH) of Chinese patients with positional obstructive sleep apnea (POSA) according to the Cartwright Classification (CC) and Amsterdam Positional Obstructive Sleep Apnea Classification (APOC). Methods A large-scale cross-sectional study was conducted in our sleep center from 2007 to 2018 to analyze the clinical and polysomnography (PSG) data of Chinese POSA patients. Low ArTH was defined based on PSG indices. Results Of 5,748 OSA patients, 36.80% met the CC criteria, and 42.88% the APOC criteria, for POSA. The prevalence of POSA was significantly higher in women than men (40.21% and 46.52% vs. 36.13% and 42.18% for CC and APOC, respectively). Chinese POSA patients had a lower apnea hypopnea index (AHI) and lower oxygen desaturation index, shorter duration of oxygen saturation (SaO2) < 90%, and a higher mean SaO2 and higher lowest SaO2 value compared to subjects with non-positional OSA (NPOSA). More than 40% of the POSA patients had a low ArTH; the proportion was extremely high in the supine-isolated-POSA (si-POSA) group and APOC I group. In multivariate logistic regression analyses, higher mean SaO2 and lower AHI during sleep were positive predictors of POSA. Conclusions According to the CC and APOC criteria, more than 1/3 of our Chinese subjects with OSA had POSA. Chinese POSA patients had less severe OSA and nocturnal hypoxia. Compared to NPOSA patients, significantly more patients with POSA had a low ArTH. A low ArTH may be an important endotype in the pathogenesis of POSA, especially in patients with si-POSA and APOC I. Further studies are necessary to develop personalized management strategies for POSA patients. Trial registration: Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn; No. ChiCTR1900025714 (retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02141-3.
Collapse
|
16
|
de Souza EC, Rosa E, de Oliveira Dias JR, Malerbi FK, Leal BC, Junior HPP. Fovea-threatening and fovea-involving peripheral Coats disease: effects of posture and intervention. Int J Retina Vitreous 2022; 8:42. [PMID: 35715849 PMCID: PMC9205031 DOI: 10.1186/s40942-022-00382-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/01/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We believe that our experience with patients presenting with Coats disease and macular sparing should be shared with our colleagues. We would like to show the effect of posture and prompt intervention in cases with fovea-threatening and/or fovea-involving peripheral Coats disease (FTPCD). This association has been poorly debated in our specialty and literature. We call the attention for the unexpexted scenario of observing the lost of the fovea during some types of traditional and prompt interventional treatments of these cases with previous 20/20 vision (something that we have been studying and observing for many years). In order to publish our best representative cases, we have chosen 8 Brazilian patients (age range, 7-62 years; 5 male) with FTPCD. All patients underwent multimodal imaging and different treatments (observation, sleep-posture repositioning, laser, intraocular steroids, and/or anti-vascular endothelial growth factor therapy). All patients, initially, informed to adopt a sleeping lateral-down position, favoring exudation shifting to the fovea pre-treatment. Most promptly-treated patients in this way (n = 4), developed subretinal fluid and exudates in the macula and some had irreversible central visual loss (n = 3). Patients with recent fovea-involving exudation who changed postural sleep position (to protect the foveal area) before and during treatment fared better, with some preserved central vision and an intact fovea (n = 5). The fundus status was correlated with the gravitational effects of posture before and after treatment. Despite prepared as an observational/interventional study, with a small number of cases, the most difficult part is documenting the sleep position of these patients and its influence in the outcomes as there is not good way to prove how well or poorly the positioning occurred in our cases. Finally, we also intended to call the attention to the fact that Coats disease must be studied in all its clinical stage variants and not only seen as a potential blinding and incurable ocular disease. CASE PRESENTATION This study is a retrospective and/or interventional analysis of eight cases with a less severe clinical variant of classic Coats disease that we refer to as fovea-threatening and fovea-involving peripheral Coats disease (FTPCD). All cases were unilateral with no systemic disease or family history of Coats disease. The bilateral anterior segment and intraocular pressure were normal in all patients. The characteristics of all patients are shown in the Table. CONCLUSION The funduscopic features of FTPCD are fundamental to disease understanding and optimal management. Habitual posturing may affect the fundus morphologic features of retinal exudation as observed in all current patients with exudative peripheral Coats disease. When sleep habitual posture is not observed in patients with FTPCD, the effects of prompt invasive treatments can cause rapid visual loss because of foveal subretinal pooling of exudates post-treatment. Initial vigilant adjusting of the habitual sleep posture for several patients with FTPCD, before the indication of traditional invasive treatments (laser and/or pharmacologic medications) can result in improved vision and fundoscopic morphologic features.
Collapse
Affiliation(s)
- Eduardo Cunha de Souza
- Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 455, São Paulo, 01246-903, Brazil.
| | - Evandro Rosa
- Hospital de Olhos Sadalla Amin Ghanem, Joinville, Brazil
| | | | | | | | | |
Collapse
|
17
|
Is Continuous Positive Airway Pressure All There Is? Alternative Perioperative Treatments for Obstructive Sleep Apnea. Anesthesiology 2022; 137:1-3. [DOI: 10.1097/aln.0000000000004251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
|
18
|
Randerath W, de Lange J, Hedner J, Ho JPT, Marklund M, Schiza S, Steier J, Verbraecken J. Current and Novel Treatment Options for OSA. ERJ Open Res 2022; 8:00126-2022. [PMID: 35769417 PMCID: PMC9234427 DOI: 10.1183/23120541.00126-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/24/2022] [Indexed: 12/03/2022] Open
Abstract
Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy. The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd
Collapse
|
19
|
Kazemeini E, Van de Perck E, Dieltjens M, Willemen M, Verbraecken J, Op de Beeck S, Vanderveken OM. Critical to Know Pcrit: A Review on Pharyngeal Critical Closing Pressure in Obstructive Sleep Apnea. Front Neurol 2022; 13:775709. [PMID: 35273554 PMCID: PMC8901991 DOI: 10.3389/fneur.2022.775709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
It is crucial to understand the underlying pathophysiology of obstructive sleep apnea (OSA). Upper airway collapsibility is an important pathophysiological factor that affects the upper airway in OSA. The aim of the current study was to review the existing body of knowledge on the pharyngeal collapsibility in OSA. After a thorough search through Medline, PubMed, Scopus, and Web of science, the relevant articles were found and used in this study. Critical closing pressure (Pcrit) is the gold standard measure for the degree of collapsibility of the pharyngeal airway. Various physiological factors and treatments affect upper airway collapsibility. Recently, it has been shown that the baseline value of Pcrit is helpful in the upfront selection of therapy options. The standard techniques to measure Pcrit are labor-intensive and time-consuming. Therefore, despite the importance of Pcrit, it is not routinely measured in clinical practice. New emerging surrogates, such as finite element (FE) modeling or the use of peak inspiratory flow measurements during a routine overnight polysomnography, may enable clinicians to have an estimate of the pharyngeal collapsibility. However, validation of these techniques is needed.
Collapse
Affiliation(s)
- Elahe Kazemeini
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Ear, Nose, Throat, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Eli Van de Perck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Ear, Nose, Throat, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Ear, Nose, Throat, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Ear, Nose, Throat, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Ear, Nose, Throat, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| |
Collapse
|
20
|
Zeising M, Thiedemann C, Pollmächer T. [Sleep medicine in psychiatry and psychotherapy]. DER NERVENARZT 2022; 93:313-324. [PMID: 35201393 DOI: 10.1007/s00115-022-01262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Abstract
Sleep medicine is a cross-disciplinary subject with high relevance for psychiatry and psychotherapy. The three most common sleep disorders (insomnia, sleep apnea syndrome and restless legs syndrome) are presented here with practical relevance. Cognitive behavioral therapy is the treatment of choice for insomnia, whereas symptomatic drug treatment (especially with GABA receptor agonists) should be used with caution. Sleep-related breathing disorders have a high prevalence of around 24% among psychiatric inpatients in Germany. Typical symptoms of obstructive sleep apnea syndrome should lead to a staged diagnostic process and, if necessary, cardiorespiratory polysomnography. It is not unusual for restless legs syndrome to be caused by psychopharmacological treatment. The primary form was usually treated with dopamine or dopamine agonists but due to the risk of augmentation, alternatives should be considered more often.
Collapse
Affiliation(s)
- Marcel Zeising
- Zentrum für psychische Gesundheit, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland.
| | - Christian Thiedemann
- Universitätsklinik für Neurologie, Landeskrankenhaus-Universitätskliniken Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Thomas Pollmächer
- Zentrum für psychische Gesundheit, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland
| |
Collapse
|
21
|
Pépin JL, Eastwood P, Eckert DJ. Novel avenues to approach non-CPAP therapy and implement comprehensive OSA care. Eur Respir J 2021; 59:13993003.01788-2021. [PMID: 34824053 DOI: 10.1183/13993003.01788-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/16/2021] [Indexed: 11/05/2022]
Abstract
Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, "one size fits all", trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.
Collapse
Affiliation(s)
- Jean-Louis Pépin
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France .,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Peter Eastwood
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| |
Collapse
|
22
|
Sleep Apnea and Hypertension. High Blood Press Cardiovasc Prev 2021; 29:23-31. [PMID: 34739711 DOI: 10.1007/s40292-021-00484-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/30/2021] [Indexed: 12/20/2022] Open
Abstract
Obstructive sleep apnea is a frequent finding in clinical practice especially with the obesity epidemic and the growing awareness of sleep-disordered breathing as a potential and treatable risk factor for cardiovascular diseases. It frequently coexists undiagnosed activating pathophysiological mechanisms known to participate in development and progression of cardiovascular diseases and resistance to therapeutical strategies. The sympathetic activation and the baroreflex and chemoreflex impairment appear to be the main pathophysiological factors that activating several mechanisms elicit cardiac and vascular damage. Data from cross-sectional population-based studies, prospective studies and meta-analysis have clearly shown the implication of OSA in the development of the hypertensive state and the benefits obtained by continuous positive airway pressure on daytime blood pressure and cardiovascular risk.
Collapse
|
23
|
Bosi M, Incerti Parenti S, Sanna A, Plazzi G, De Vito A, Alessandri-Bonetti G. Non-continuous positive airway pressure treatment options in obstructive sleep apnoea: A pathophysiological perspective. Sleep Med Rev 2021; 60:101521. [PMID: 34280847 DOI: 10.1016/j.smrv.2021.101521] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/02/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
The phenotyping of the pathophysiology of obstructive sleep apnoea (OSA) lies at the core of tailored treatments and it is one of the most debated topics in sleep medicine research. Recent sophisticated techniques have broadened the horizon for gaining insight into the variability of the endotypic traits in patients with OSA which account for the heterogeneity in the clinical presentation of the disease and consequently, in the outcome of treatment. However, the implementation of these concepts into clinical practice is still a major challenge for both researchers and clinicians in order to develop tailored therapies targeted to specific endotypic traits that contribute to OSA in each individual patient. This review summarizes available scientific evidence in order to point out the links between endotypic traits (pharyngeal airway collapsibility, upper airway neuromuscular compensation, loop gain and arousal threshold) and the most common non-continuous positive airway pressure (CPAP) treatment options for OSA (mandibular advancement device, upper airway surgery, medication therapy, positional therapy) and to clarify to what extent endotypic traits could help to better predict the success of these therapies. A narrative guide is provided; current design limitations and future avenues of research are discussed, with clinical and research perspectives.
Collapse
Affiliation(s)
- Marcello Bosi
- Centro Disturbi del Sonno, Ospedali Privati Forlì, Forlì, Italy
| | - Serena Incerti Parenti
- Unit of Orthodontics and Sleep Dentistry, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Antonio Sanna
- Azienda USL Toscana Centro, Pneumology and Bronchial Endoscopy Unit, San Giuseppe Hospital, Empoli, FI, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Andrea De Vito
- Head & Neck Department, ENT Unit, Ravenna Hospital, Romagna Health Service, Italy
| | - Giulio Alessandri-Bonetti
- Unit of Orthodontics and Sleep Dentistry, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| |
Collapse
|
24
|
Bosi M, Incerti Parenti S, Fiordelli A, Poletti V, Alessandri-Bonetti G. Upper airway collapsibility in patients with OSA treated with continuous positive airway pressure: a retrospective preliminary study. J Clin Sleep Med 2021; 16:1839-1846. [PMID: 32621580 DOI: 10.5664/jcsm.8674] [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: 01/24/2023]
Abstract
STUDY OBJECTIVES To investigate the prevalence of mildly collapsible upper airways (defined by therapeutic continuous positive airway pressure [CPAP] values ≤ 8 cm H₂O) in moderate to severe obstructive sleep apnea patients treated with CPAP and to determine their clinical, functional, and nocturnal polysomnographic characteristics. METHODS Eighty-seven patients with moderate to severe obstructive sleep apnea consecutively treated with CPAP were retrospectively investigated. Two nocturnal home sleep portable monitoring studies were performed at baseline and during treatment. Participants were categorized according to therapeutic CPAP values: ≤ 8 cm H₂O (group 1), 8-12 cm H₂O (group 2), ≥ 12 cm H₂O (group 3). Anthropometric, awake respiratory function, symptoms, comorbidities, and nocturnal home sleep portable monitoring studies data were collected. RESULTS Mild upper airway collapsibility (therapeutic CPAP values ≤ 8 cm H₂O) was present in 25.3% of patients. They showed more favorable apnea-hypopnea index, oxygen desaturation index, mean nocturnal saturation, sleep time with oxygen saturation < 90%, desaturation nadir, and supine position. Oxygen desaturation index showed a weak association with anatomical collapsibility. Using the receiver operating characteristic curve, the area under the curve for the oxygen desaturation index vs CPAP pressure requirements ≤ 8 cm H₂O was low and oxygen desaturation index ≤ 40.8/h showed a sensitivity of 63.3% and a specificity of 69.2% to detect patients with mild collapsibility. CONCLUSIONS A quarter of moderate to severe patients under CPAP therapy had mild collapsibility and were likely to also be good candidates for alternative and better tolerated non-CPAP therapies. Baseline anthropometric, clinical, and respiratory function characteristics did not predict mild upper airway collapsibility determined by CPAP pressure requirements ≤ 8 cm H₂O.
Collapse
Affiliation(s)
- Marcello Bosi
- Department of Thoracic Diseases, Sleep Respiratory Unit, Umberto I Hospital, Lugo, Italy
| | - Serena Incerti Parenti
- Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Andrea Fiordelli
- Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Venerino Poletti
- Department of Thoracic Diseases, Pulmonary Operative Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Giulio Alessandri-Bonetti
- Unit of Orthodontics, Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| |
Collapse
|
25
|
Zinchuk AV, Chu JH, Liang J, Celik Y, Op de Beeck S, Redeker NS, Wellman A, Yaggi HK, Peker Y, Sands SA. Physiological Traits and Adherence to Therapy of Sleep Apnea in Individuals with Coronary Artery Disease. Am J Respir Crit Care Med 2021; 204:703-712. [PMID: 34156917 DOI: 10.1164/rccm.202101-0055oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Untreated obstructive sleep apnea (OSA) is associated with adverse outcomes in patients with coronary artery disease (CAD). Continuous positive airway pressure (CPAP) is the most common treatment, but despite interventions addressing established adherence determinants, CPAP use remains poor. OBJECTIVES To determine whether physiological traits that cause OSA are associated with long-term CPAP adherence in patients with CAD. METHODS Participants in the RICCADSA trial with objective CPAP adherence (hours/night) over 2 years and analyzable raw polysomnography data were included (n=249). The physiological traits -loop gain, arousal threshold (ArTH), collapsibility and muscle compensation- were measured from polysomnography. Linear mixed models assessed the relationship between the traits and adherence. We also compared actual CPAP adherence between physiology-predicted "poor" (lowest quartile of predicted adherence) and "good" (all others) adherers. MEASUREMENTS AND RESULTS Median (IQR) CPAP use declined from 3.2 (1.0, 5.8) to 3.0 (0.0, 5.6) hours/night over 24-mo (p<0.001). In analyses adjusted for demographics, anthropometrics, OSA characteristics and clinical comorbidities, lower ArTH was associated with worse CPAP adherence (0.7 hours/SD ArTH, p=0.021). Both high and low muscle compensation were associated with lower adherence (p=0.008). Predicted "poor" adherers exhibited markedly lower CPAP use compared to "good" adherers for up to 2 years of follow-up (group differences: 2.0 to 3.2 hours/night, p<0.003 for all). CONCLUSIONS A low ArTH as well as a very low and high muscle compensation are associated with worse long-term CPAP adherence in patients with CAD and OSA. Physiological traits, alongside established determinants, may help predict and improve CPAP adherence.
Collapse
Affiliation(s)
- Andrey V Zinchuk
- Yale School of Medicine, 12228, Section of Pulmonary and Critical Care Medicine, New Haven, Connecticut, United States;
| | - Jen-Hwa Chu
- Yale School of Medicine, 12228, Pulmonary, Critical Care, & Sleep Medicine, New Haven, Connecticut, United States
| | - Jiasheng Liang
- Yale University School of Medicine, 12228, New Haven, Connecticut, United States
| | - Yeliz Celik
- Koc Universitesi, 52979, Koc University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Sara Op de Beeck
- Universiteit Antwerpen Faculteit geneeskunde en gezondheidswetenschappen, 81844, Translational Neurosciences, Wilrijk, Belgium.,Universitair Ziekenhuis Antwerpen, 60202, Ear Nose Throat, Edegem, Belgium
| | - Nancy S Redeker
- Yale University Yale School of Nursing, 16230, New Haven, Connecticut, United States
| | - Andrew Wellman
- Brigham and Women's Hospital Department of Medicine, 370908, Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - H Klar Yaggi
- Yale School of Medicine, 12228, Internal Medicine, New Haven, Connecticut, United States.,VA Connecticut Healthcare System, 19985, Clinical Epidemiology Research Center, West Haven, Connecticut, United States
| | - Yüksel Peker
- Koc Universitesi, 52979, Koc University Research Center for Translational Medicine (KUTTAM) , Istanbul, Turkey.,University of Gothenburg Faculty of Health Sciences, 70712, Molecular and Clinical Medicine/Cardiology, Goteborg, Sweden.,Lund University Faculty of Medicine, 59568, Clinical Sciences, Respiratory Medicine and Allergology, Lund, Sweden.,University of Pittsburgh Medical Center, 6595, Pittsburgh, Pennsylvania, United States
| | - Scott A Sands
- Brigham and Women's Hospital, 1861, Boston, Massachusetts, United States
| |
Collapse
|
26
|
Op de Beeck S, Wellman A, Dieltjens M, Strohl KP, Willemen M, Van de Heyning PH, Verbraecken JA, Vanderveken OM, Sands SA. Endotypic Mechanisms of Successful Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea. Am J Respir Crit Care Med 2021; 203:746-755. [PMID: 32970962 DOI: 10.1164/rccm.202006-2176oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Approximately one-third of patients with obstructive sleep apnea (OSA) treated with hypoglossal nerve stimulation (HGNS) therapy are incomplete responders, despite careful patient selection based on baseline characteristics and drug-induced sleep endoscopy.Objectives: Here we use polysomnographic endotyping to assess the pathophysiological mechanisms underlying favorable versus incomplete responses to HGNS therapy.Methods: Baseline polysomnography data of the STAR (Stimulation Therapy for Apnea Reduction) trial were included. Raw baseline polysomnographic data from 91/126 patients were available for analysis. Traits-loop gain, arousal threshold, collapsibility, and muscle compensation-were calculated from the baseline polysomnography data according to Sands and colleagues (AJRCCM 2018, SLEEP 2018). Logistic regression assessed apnea-hypopnea index (AHI)-adjusted associations between HGNS response (>50% reduction in AHI to <10/h at 1 yr) and OSA traits.Measurements and Main Results: Overall, HGNS treatment reduced AHI from 30.7 (24.9-39.9) to 8.5 (4.0-19.5) events/h (P < 0.0001; median [quartiles 1-3]); N = 53/91 were responders. In adjusted analysis, a favorable response to therapy was independently associated with higher arousal threshold (odds ratio [95% confidence interval]: 6.76 [2.44-23.3], P = 0.001), greater compensation (odds ratio: 4.22 [1.70-12.55] per SD, P = 0.004), and lower loop gain (in milder collapsibility, per significant interaction, P = 0.003). The higher arousal threshold was evident in responders before adjusted analysis. Predicted responders had an approximately fourfold lower treatment AHI versus predicted nonresponders (4.9 [2.7-8.5] vs. 20.7 [10.9-29.7], P < 0.0001; median [quartiles 1-3]); differences remained significant after cross-validation.Conclusions: Favorable responses to HGNS therapy are associated with the pathophysiological traits causing OSA, particularly a higher arousal threshold. Along with established criteria, individuals with favorable traits could potentially be prioritized for precision HGNS therapy.This analysis was a secondary analysis of the STAR trial registered with clinicaltrials.gov (NCT01161420).
Collapse
Affiliation(s)
- Sara Op de Beeck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery.,Multidisciplinary Sleep Disorders Centre, and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Marijke Dieltjens
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery
| | - Kingman P Strohl
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Paul H Van de Heyning
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery
| | - Johan A Verbraecken
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, and.,Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Translational Neurosciences, Faculty of Medicine and Health Sciences, and.,Department of Ear, Nose, and Throat, Head and Neck Surgery.,Multidisciplinary Sleep Disorders Centre, and
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
| | | |
Collapse
|
27
|
Joosten SA, Tan M, Wong AM, Landry SA, Leong P, Sands SA, Beatty C, Thomson L, Stonehouse J, Turton A, Hamilton GS, Edwards BA. A randomized controlled trial of oxygen therapy for patients who do not respond to upper airway surgery for obstructive sleep apnea. J Clin Sleep Med 2021; 17:445-452. [PMID: 33094725 DOI: 10.5664/jcsm.8920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES We aimed to determine whether patients diagnosed with obstructive sleep apnea (OSA) who fail to respond to upper airway surgery may be successfully treated with supplemental oxygen and whether we could identify baseline physiologic endotypes (ie, collapsibility, loop gain, arousal threshold, and muscle compensation) that predict response to oxygen therapy. METHODS We conducted a single night, randomized double-blinded cross over trial in which patients with OSA who failed to respond to upper airway surgery were treated on separate nights with oxygen therapy (4 L/min) or placebo (medical air). Effect of oxygen/air on OSA on key polysomnography outcomes were assessed: apnea-hypopnea index (AHI), AHI without desaturation (ie, flow-based AHI), arousal index, and morning blood pressure. OSA endotypes were estimated from the polysomnography signals to determine whether baseline OSA physiology could be used to predict response to oxygen therapy. RESULTS There was a statistically significant reduction in AHI and flow-based AHI on oxygen vs placebo (flow-based AHI: 42.4 ± 21.5 vs 30.5 ± 17.1 events/h, P = .008). Arousal index was also reduced on oxygen vs placebo (41.1 ± 19.5 vs 33.0 ± 15.3 events/h, P = .006). There was no significant difference in morning blood pressure between oxygen and placebo. Although 7 of 20 individuals experienced a 50% reduction or greater in flow-based AHI on oxygen (responders), there was no difference in the baseline OSA endotypes (or clinical characteristics) between responders and nonresponders. CONCLUSIONS Our findings demonstrate that a proportion of patients who fail to respond to upper airway surgery for OSA respond acutely to treatment with supplemental oxygen. CLINICAL TRIAL REGISTRATION Registry: Australian New Zealand Clinical Trials Registry; Name: Oxygen therapy for treating patients with residual obstructive sleep apnea following upper airway surgery; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373566; Identifier: ACTRN12617001361392.
Collapse
Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners-Epworth, Melbourne, Victoria, Australia.,Contributed equally
| | - Michael Tan
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,Contributed equally
| | - Ai-Ming Wong
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Paul Leong
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts.,The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Caroline Beatty
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Luke Thomson
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Stonehouse
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Anthony Turton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners-Epworth, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
28
|
Standardized framework to report on the role of sleeping position in sleep apnea patients. Sleep Breath 2021; 25:1717-1728. [PMID: 33426584 DOI: 10.1007/s11325-020-02255-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea. METHODS We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these 5 main recommendations. RESULTS In this paper, we present the rationale behind this construct and present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patients should be reported separately for PP and NPP. CONCLUSION Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Assessing the Physiologic Endotypes Responsible for REM- and NREM-Based OSA. Chest 2020; 159:1998-2007. [PMID: 33197399 DOI: 10.1016/j.chest.2020.10.080] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/01/2020] [Accepted: 10/30/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patients with OSA can have the majority of their respiratory events in rapid eye movement (REM) sleep or in non-rapid eye movement (NREM) sleep. No previous studies have linked the different physiologic conditions in REM and NREM sleep to the common polysomnographic patterns seen in everyday clinical practice, namely REM predominant OSA (REMOSA) and NREM predominant OSA (NREMOSA). RESEARCH QUESTION (1) How does OSA physiologic condition change with sleep stage in patients with NREMOSA and REMOSA? (2) Do patients with NREMOSA and REMOSA have different underlying OSA pathophysiologic conditions? STUDY DESIGN AND METHODS We recruited patients with three polysomnographic patterns. (1) REMOSA: twice as many respiratory events in REM sleep, (2) NREMOSA: twice as many events in NREM sleep, and (3) uniform OSA: equal number of events in NREM/REM sleep. We deployed a noninvasive phenotyping method to determine OSA endotype traits (Vpassive, Vactive, loop gain, arousal threshold) in NREM sleep, REM sleep, and total night sleep in each group of patients (NREMOSA, REMOSA, uniform OSA). RESULTS Patients with NREMOSA have significantly worse ventilatory control stability in NREM sleep compared with REM sleep (loop gain, 0.546 [0.456,0.717] in NREM vs 0.365 [0.238,0.459] in REM sleep; P = .0026). Patients with REMOSA displayed a significantly more collapsible airway (ie, lower Vpassive) in REM compared with NREM sleep (98.4 [97.3,99.2] %Veupnea in NREM vs 95.9 [86.4,98.9] %Veupnea in REM sleep; P < .0001). The major between-group difference across the whole night was a significantly higher loop gain in the NREMOSA group (0.561 [0.429,0.675]) compared with the REMOSA group (0.459 [0.388,0.539]; P = .0033). INTERPRETATION This study is the first to link long-recognized polysomnographic patterns of OSA to underlying physiologic differences. Patients with NREMOSA have a higher loop gain in NREM sleep; patients with REMOSA have a worsening of Vpassive in REM sleep.
Collapse
|
31
|
Osman AM, Tong BK, Landry SA, Edwards BA, Joosten SA, Hamilton GS, Cori JM, Jordan AS, Stevens D, Grunstein RR, McEvoy RD, Catcheside PG, Eckert DJ. An assessment of a simple clinical technique to estimate pharyngeal collapsibility in people with obstructive sleep apnea. Sleep 2020; 43:5817777. [DOI: 10.1093/sleep/zsaa067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/31/2020] [Indexed: 01/27/2023] Open
Abstract
Abstract
Study Objectives
Quantification of upper airway collapsibility in obstructive sleep apnea (OSA) could help inform targeted therapy decisions. However, current techniques are clinically impractical. The primary aim of this study was to assess if a simple, novel technique could be implemented as part of a continuous positive airway pressure (CPAP) titration study to assess pharyngeal collapsibility.
Methods
A total of 35 participants (15 female) with OSA (mean ± SD apnea–hypopnea index = 35 ± 19 events/h) were studied. Participants first completed a simple clinical intervention during a routine CPAP titration, where CPAP was transiently turned off from the therapeutic pressure for ≤5 breaths/efforts on ≥5 occasions during stable non-rapid eye movement (non-REM) sleep for quantitative assessment of airflow responses (%peak inspiratory flow [PIF] from preceding 5 breaths). Participants then underwent an overnight physiology study to determine the pharyngeal critical closing pressure (Pcrit) and repeat transient drops to zero CPAP to assess airflow response reproducibility.
Results
Mean PIF of breaths 3–5 during zero CPAP on the simple clinical intervention versus the physiology night were similar (34 ± 29% vs. 28 ± 30% on therapeutic CPAP, p = 0.2; range 0%–90% vs. 0%–95%). Pcrit was −1.0 ± 2.5 cmH2O (range −6 to 5 cmH2O). Mean PIF during zero CPAP on the simple clinical intervention and the physiology night correlated with Pcrit (r = −0.7 and −0.9, respectively, p < 0.0001). Receiver operating characteristic curve analysis indicated significant diagnostic utility for the simple intervention to predict Pcrit < −2 and < 0 cmH2O (AUC = 0.81 and 0.92), respectively.
Conclusions
A simple CPAP intervention can successfully discriminate between patients with and without mild to moderately collapsible pharyngeal airways. This scalable approach may help select individuals most likely to respond to non-CPAP therapies.
Collapse
Affiliation(s)
- Amal M Osman
- Neuroscience Research Australia (NeuRA), School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Benjamin K Tong
- Neuroscience Research Australia (NeuRA), School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Shane A Landry
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jennifer M Cori
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Amy S Jordan
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - David Stevens
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Ronald R Grunstein
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
- Woolcock Institute of Medical Research and the University of Sydney, Glebe, NSW, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Peter G Catcheside
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
- CRC for Alertness, Safety and Productivity, Melbourne, Australia
| |
Collapse
|
32
|
Garg H, Er XY, Howarth T, Heraganahally SS. Positional Sleep Apnea Among Regional and Remote Australian Population and Simulated Positional Treatment Effects. Nat Sci Sleep 2020; 12:1123-1135. [PMID: 33304112 PMCID: PMC7723233 DOI: 10.2147/nss.s286403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/19/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To assess the prevalence of positional sleep apnea (POSA) and its predictors in patients diagnosed to have obstructive sleep apnea (OSA) in the regional and remote population of the Northern Territory of Australia over a two-year study period (2018 and 2019). PATIENTS AND METHODS Of the total 1463 adult patients who underwent a diagnostic polysomnography (PSG), 946 patients were eligible to be included in the study, of them, 810 consecutive patients with OSA (Apnea-Hypopnea Index (AHI) ≥ 5) who slept >4 h and had ≥30 min sleep in both supine and lateral positions were assessed. Patients were considered to have POSA if supine AHI to lateral AHI ratio ≥2. The likely comparative impact of use of continuous positive airway therapy (CPAP) or positional therapy (PT) on disease severity was evaluated using model simulation. RESULTS A total of 495/810 (61%) patients had POSA, the majority were males (68% vs 60%, p=0.013) and non-Indigenous Australians (93% vs 87%, p=0.004). POSA patients were younger (mean difference 2.23 years (95% CI 0.27, 4.19)), less obese (BMI mean difference 3.06 (95% CI 2.11, 4.01)), demonstrated less severe OSA (p < 0.001) and a greater proportion reported alcohol consumption (72% vs 62%, p=0.001) as compared to those with non-POSA. Using the simulation model, if patients with POSA use PT two-thirds (323/495, 65%) would obtain significant improvement of their OSA severity, with one in five (92/495, 19%) displaying complete resolution. Comparing this to simulated CPAP therapy, where the majority (444/495, 90%) will show significant improvement, and one-third (162/495, 33%) will display complete resolution. CONCLUSION POSA needs to be routinely recognised and positional therapy integrated in practice especially in the remote regions and in the developing world when effective methods are in place to monitor positional therapy.
Collapse
Affiliation(s)
- Himanshu Garg
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Xin Yi Er
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Timothy Howarth
- College of Health and Human Sciences, Charles Darwin University, Darwin, Northern Territory, Australia.,Darwin Respiratory and Sleep Health, Darwin Private Hospital, Tiwi, Darwin, Northern Territory, Australia
| | - Subash S Heraganahally
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Darwin Respiratory and Sleep Health, Darwin Private Hospital, Tiwi, Darwin, Northern Territory, Australia.,Flinders University - College of Medicine and Public Health, Adelaide, South Australia
| |
Collapse
|
33
|
Kim LJ, Freire C, Fleury Curado T, Jun JC, Polotsky VY. The Role of Animal Models in Developing Pharmacotherapy for Obstructive Sleep Apnea. J Clin Med 2019; 8:jcm8122049. [PMID: 31766589 PMCID: PMC6947279 DOI: 10.3390/jcm8122049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/12/2019] [Accepted: 11/19/2019] [Indexed: 12/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent disease characterized by recurrent closure of the upper airway during sleep. It has a complex pathophysiology involving four main phenotypes. An abnormal upper airway anatomy is the key factor that predisposes to sleep-related collapse of the pharynx, but it may not be sufficient for OSA development. Non-anatomical traits, including (1) a compromised neuromuscular response of the upper airway to obstruction, (2) an unstable respiratory control (high loop gain), and (3) a low arousal threshold, predict the development of OSA in association with anatomical abnormalities. Current therapies for OSA, such as continuous positive airway pressure (CPAP) and oral appliances, have poor adherence or variable efficacy among patients. The search for novel therapeutic approaches for OSA, including pharmacological agents, has been pursued over the past years. New insights into OSA pharmacotherapy have been provided by preclinical studies, which highlight the importance of appropriate use of animal models of OSA, their applicability, and limitations. In the present review, we discuss potential pharmacological targets for OSA discovered using animal models.
Collapse
|
34
|
PEREGRIM I, GREŠOVÁ S, ŠTIMMELOVÁ J, BAČOVÁ I, FULTON B, TOKÁROVÁ D, GÁBOROVÁ M, BRANDEBUROVÁ A, DONIČOVÁ V, RUSNÁKOVÁ S, TOMORI Z, DONIČ V. Strong Coincidence Between Slow Wave Sleep and Low AHI is Explainable by the High Instability of Slow Wave Sleep to Obstructive Apnea Exposure. Physiol Res 2019; 68:857-865. [DOI: 10.33549/physiolres.934025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
It is well known that in patients with obstructive sleep apnea syndrome (OSAS) the apnea-hypopnea index (AHI) is significantly decreased during slow wave sleep (SWS). It used to be explained by the ability of SWS to stabilize the upper airways against collapse. Another explanation, which is the focus of the current study, is that it is just a result of high instability of SWS to obstructive apnea exposure, i.e. high susceptibility of SWS to transition into lighter sleep stages during exposure to obstructive apneas. A retrospective chart review was performed on 560 males who underwent an overnight polysomnography. Two hundred and eighty-seven patients were eligible for the study. They were divided into 3 groups according to different AHI level. All three groups had a higher SWS occurrence in the lateral position than in the supine position. A special fourth group of patients was created with severe OSAS in the supine position but with very mild OSAS in the lateral position. This group had, in the lateral position, (A) higher AHI in NREM sleep (4.1±3.1/h vs. 0.7±1.2/h, p<0.001) as well as (B) higher SWS occurrence (27.7±15.0 % vs. 21.4±16.2 % of NREM sleep, p<0.05), than the group with the lowest AHI in the study, i.e. AHI<5/h in NREM sleep. These data suggest that strong coincidence between SWS and low AHI is the result of the high instability of SWS to obstructive apnea exposure. The data also support the presence of SWS-rebound in OSAS patients in the lateral body position.
Collapse
Affiliation(s)
- I. PEREGRIM
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - S. GREŠOVÁ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - J. ŠTIMMELOVÁ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - I. BAČOVÁ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - B. FULTON
- Department of Biology, Belmont College, Tennessee, USA
| | - D. TOKÁROVÁ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - M. GÁBOROVÁ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - A. BRANDEBUROVÁ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - V. DONIČOVÁ
- Department of Pathological Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia
| | - S. RUSNÁKOVÁ
- Department of Pathological Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia
| | - Z. TOMORI
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| | - V. DONIČ
- Department of Medical Physiology, Faculty of Medicine, P. J. Šafárik University, Košice, Slovakia,
| |
Collapse
|
35
|
Orr JE, Sands SA, Edwards BA, Deyoung PN, Deacon N, Jen R, Li Y, Owens RL, Malhotra A. Measuring Loop Gain via Home Sleep Testing in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2019; 197:1353-1355. [PMID: 29190428 DOI: 10.1164/rccm.201707-1357le] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jeremy E Orr
- 1 University of California, San Diego La Jolla, California
| | - Scott A Sands
- 2 Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts and
| | | | | | - Naomi Deacon
- 1 University of California, San Diego La Jolla, California
| | - Rachel Jen
- 1 University of California, San Diego La Jolla, California
| | - Yanru Li
- 1 University of California, San Diego La Jolla, California
| | - Robert L Owens
- 1 University of California, San Diego La Jolla, California
| | - Atul Malhotra
- 1 University of California, San Diego La Jolla, California
| |
Collapse
|
36
|
Development of positional obstructive sleep apnea (POSA) after upper airway surgery in OSA patients. Sleep Breath 2019; 24:849-856. [PMID: 31410807 DOI: 10.1007/s11325-019-01910-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/17/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Positional therapy (PT) has become more reliable for obstructive sleep apnea (OSA) patients with the use of new devices. The objectives of this study were to determine the preoperative prevalence of positional OSA (POSA) in our population of surgically treated patients and the proportion of patients who developed POSA after surgery and might improve with additional positional therapy. METHODS This was a retrospective study of surgically treated OSA patients from 1999 to 2017. The Cartwright definition was used to define POSA. All patients completed a sleep study before and 6 months after surgery and a complete upper airway (UA) exploration (awake ± DISE). A total of 125 patients were included. RESULTS The global prevalence of POSA before surgery was 31.2%. In those who were cured by surgery, the preoperative prevalence of POSA was 38.3%. Having POSA was not related with surgical success outcome. For patients not cured by surgery, the proportion of POSA significantly increased from 25.64 to 53.85% after surgery. Eighteen patients of them (23.1%) achieved AHI < 5/h in a lateral position. In those patients, PT with Night-Shift™ was suggested, 50% of them accepted it and 88.9% of them experienced excellent satisfaction. Lateral velum collapse and the absence of concentric collapse at the tongue base had statistical relationships with the development of POSA. CONCLUSIONS The prevalence of POSA is increased after surgery in patients with persistent OSA after surgery. In these patients, the development of POSA gives an extra therapeutic chance as 23.1% of these cases can be successfully treated by using PT.
Collapse
|
37
|
Arias RS, Etienne B, Polotsky VY, Checkley W, Schwartz AR, Pham LV. Upright posture increases oxyhemoglobin saturation in Peruvian highlanders. Respir Physiol Neurobiol 2019; 266:138-143. [PMID: 31048020 DOI: 10.1016/j.resp.2019.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 02/02/2023]
Abstract
At high altitude, hypoxia amplifies oxyhemoglobin saturation (SPO2) swings with changes in respiratory mechanics. Our objective was to examine the effects of posture on SPO2 and determine predictors of postural SPO2 changes in highlanders. 50 native highlanders from Puno, Peru (3825 m) assumed supine and upright-seated postures, in rotating sequence, while undergoing continuous pulse-oximetry. We compared mean SpO2 in each posture with a paired t-test. We examined associations of BMI, age, sex and spirometry with postural SpO2 changes with mixed-effects linear regression. In highlanders, SpO2 was 84% in the supine posture and was 1.0% ± 1.1 (p < 0.0001) greater in the upright-seated posture. Greater postural changes in SpO2 were associated with older age (p = 0.01 for interaction) but not with sex, BMI, FVC or FEV1. In highlanders, SpO2 is higher in the upright-seated compared to supine posture, especially with older age. Because we generally sleep flat, posture may contribute significantly to highlanders' hypoxemic burden during sleep. Postural intervention during sleep may mitigate nocturnal hypoxemia.
Collapse
Affiliation(s)
- Rafael S Arias
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Branden Etienne
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA; Department of Computer Science, University of Maryland, College Park, USA
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, USA; Division of Global Disease Epidemiology and Control, School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Alan R Schwartz
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Luu V Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA.
| |
Collapse
|
38
|
Nakayama H, Kobayashi M, Tsuiki S, Yanagihara M, Inoue Y. Obstructive sleep apnea phenotypes in men based on characteristics of respiratory events during polysomnography. Sleep Breath 2019; 23:1087-1094. [DOI: 10.1007/s11325-019-01785-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 02/04/2023]
|
39
|
Abstract
Sleep-disordered breathing (SDB) in pregnancy can present as snoring and/or obstructive sleep apnea (OSA), and the prevalence is increasing due to the increase in maternal obesity. Pregnant women often present with fatigue and daytime sleepiness rather than the classic symptoms. Habitual snoring, older age, chronic hypertension, and high prepregnancy body mass index are reliable indicators of increased risk for SDB and should trigger further testing. The gold standard for diagnosis of OSA is an overnight laboratory polysomnography. Although there are no studies linking SDB to poor fetal outcomes, fetal well-being remains paramount throughout the course of pregnancy.
Collapse
Affiliation(s)
- Lakshmy Ayyar
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Fidaa Shaib
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Kalpalatha Guntupalli
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| |
Collapse
|
40
|
Deacon-Diaz N, Malhotra A. Inherent vs. Induced Loop Gain Abnormalities in Obstructive Sleep Apnea. Front Neurol 2018; 9:896. [PMID: 30450076 PMCID: PMC6224344 DOI: 10.3389/fneur.2018.00896] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/02/2018] [Indexed: 12/11/2022] Open
Abstract
Unstable ventilatory chemoreflex control, quantified as loop gain, is recognized as one of four key pathophysiological traits that contribute to cause obstructive sleep apnea (OSA). Novel treatments aimed at reducing loop gain are being investigated, with the intention that future OSA treatment may be tailored to the individual's specific cause of apnea. However, few studies have evaluated loop gain in OSA and non-OSA controls and those that have provide little evidence to support an inherent abnormality in either overall chemical loop gain in OSA patients vs. non-OSA controls, or its components (controller and plant gain). However, intermittent hypoxia may induce high controller gain through neuroplastic changes to chemoreflex control, and may also decrease plant gain via oxidative stress induced inflammation and reduced lung function. The inherent difficulties and limitations with loop gain measurements are discussed and areas where further research are required are highlighted, as only by understanding the mechanisms underlying OSA are new therapeutic approaches likely to emerge in OSA.
Collapse
Affiliation(s)
- Naomi Deacon-Diaz
- Department of Medicine, Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA, United States
| | - Atul Malhotra
- Department of Medicine, Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, CA, United States
| |
Collapse
|
41
|
Schmickl CN, Owens RL, Edwards BA, Malhotra A. OSA Endotypes: What Are They and What Are Their Potential Clinical Implications? CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0121-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
42
|
Wong AM, Barnes HN, Joosten SA, Landry SA, Dabscheck E, Mansfield DR, Dharmage SC, Senaratna CV, Edwards BA, Hamilton GS. The effect of surgical weight loss on obstructive sleep apnoea: A systematic review and meta-analysis. Sleep Med Rev 2018; 42:85-99. [PMID: 30001806 DOI: 10.1016/j.smrv.2018.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/22/2018] [Accepted: 06/13/2018] [Indexed: 12/25/2022]
Abstract
This review aimed to examine the relationship between surgical weight loss and obstructive sleep apnoea (OSA) severity (i.e., apnoea-hypopnoea index [AHI]), and how this relationship is altered by the various respiratory events scoring (RES) criteria used to derive the AHI. A systematic search of the literature was performed up to December 2017. Before-and-after studies were considered due to a paucity of randomised controlled trials (RCTs) available to be reviewed in isolation. Primary outcomes included pre- and post-surgery AHI and body mass index (BMI). Secondary outcomes included sleep study type and RES criteria. Meta-analysis was undertaken where possible. Overall, surgical weight loss resulted in reduction of BMI and AHI, however, OSA persisted at follow-up in the majority of subjects. There was high between-study heterogeneity which was largely attributable to baseline AHI and duration of follow-up when analysed using meta-regression. There was insufficient data to evaluate the impact of different RES criteria on OSA severity. Therefore, more RCTs are needed to verify these findings given the high degree of heterogeneity and future studies are strongly encouraged to report the RES criteria used to enable fair and uniform comparisons of the impact of any intervention on OSA severity.
Collapse
Affiliation(s)
- Ai-Ming Wong
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Hayley N Barnes
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Melbourne, Victoria 3004, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Shane A Landry
- Department of Physiology and School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Eli Dabscheck
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Melbourne, Victoria 3004, Australia; Central Clinical School, Monash University, Melbourne, Australia
| | - Darren R Mansfield
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, Australia; School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Victoria, Australia
| | - Shyamali C Dharmage
- Allergy and Lung Health Unit, Centre for Epidemiology & Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Melbourne, Australia
| | - Chamara V Senaratna
- Allergy and Lung Health Unit, Centre for Epidemiology & Biostatistics, Melbourne School of Population & Global Health, The University of Melbourne, Melbourne, Australia; University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - Bradley A Edwards
- Department of Physiology and School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, Australia; School of Clinical Sciences, Monash University, Melbourne, Australia.
| |
Collapse
|
43
|
Himanen SL, Martikkala L, Sulkamo S, Rutanen A, Huupponen E, Tenhunen M, Saunamäki T. Prolonged partial obstruction during sleep is a NREM phenomenon. Respir Physiol Neurobiol 2018; 255:43-49. [PMID: 29803760 DOI: 10.1016/j.resp.2018.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Prolonged partial obstruction (PPO) is a common finding in sleep studies. Although not verified, it seems to emerge in deep sleep. We study the effect of PPO on sleep architecture or sleep electroencephalography (EEG) frequency. METHODS Fifteen OSA patients, 15 PPO + OSA patients and 15 healthy subjects underwent a polysomnography. PPO was detected from Emfit mattress signal. Visual sleep parameters and median NREM sleep frequency of the EEG channels were evaluated. RESULTS The amount of deep sleep (N3) did not differ between the PPO + OSA and control groups (medians 11.8% and 13.8%). PPO + OSA-patients' N3 consisted mostly of PPO. PPO + OSA patients had lighter sleep than healthy controls in three brain areas (Fp2-A1, C4-A1, O1-A2, p-values < 0.05). CONCLUSION PPO evolved in NREM sleep and especially in N3 indicating that upper airway obstruction does not always ameliorate in deep sleep but changes the type. Even if PPO + OSA-patients had N3, their NREM sleep was lighter in three EEG locations. This might reflect impaired recovery function of sleep.
Collapse
Affiliation(s)
- Sari-Leena Himanen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
| | - Lauri Martikkala
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland
| | - Saramia Sulkamo
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Antti Rutanen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Eero Huupponen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland
| | - Mirja Tenhunen
- Department of Clinical Neurophysiology, Medical Imaging Centre and Hospital Pharmacy, Pirkanmaa Hospital District, Tampere, Finland; Department of Medical Physics, Tampere University Hospital, Medical Imaging Centre, Pirkanmaa Hospital District, Tampere, Finland
| | - Tiia Saunamäki
- Tampere University Hospital, Department of Neurology and Rehabilitation, Tampere, Finland
| |
Collapse
|
44
|
Sands SA, Edwards BA, Terrill PI, Taranto-Montemurro L, Azarbarzin A, Marques M, Hess LB, White DP, Wellman A. Phenotyping Pharyngeal Pathophysiology using Polysomnography in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2018; 197:1187-1197. [PMID: 29327943 PMCID: PMC6019932 DOI: 10.1164/rccm.201707-1435oc] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 01/11/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Therapies for obstructive sleep apnea (OSA) could be administered on the basis of a patient's own phenotypic causes ("traits") if a clinically applicable approach were available. OBJECTIVES Here we aimed to provide a means to quantify two key contributors to OSA-pharyngeal collapsibility and compensatory muscle responsiveness-that is applicable to diagnostic polysomnography. METHODS Based on physiological definitions, pharyngeal collapsibility determines the ventilation at normal (eupneic) ventilatory drive during sleep, and pharyngeal compensation determines the rise in ventilation accompanying a rising ventilatory drive. Thus, measuring ventilation and ventilatory drive (e.g., during spontaneous cyclic events) should reveal a patient's phenotypic traits without specialized intervention. We demonstrate this concept in patients with OSA (N = 29), using a novel automated noninvasive method to estimate ventilatory drive (polysomnographic method) and using "gold standard" ventilatory drive (intraesophageal diaphragm EMG) for comparison. Specialized physiological measurements using continuous positive airway pressure manipulation were employed for further comparison. The validity of nasal pressure as a ventilation surrogate was also tested (N = 11). MEASUREMENTS AND MAIN RESULTS Polysomnography-derived collapsibility and compensation estimates correlated favorably with those quantified using gold standard ventilatory drive (R = 0.83, P < 0.0001; and R = 0.76, P < 0.0001; respectively) and using continuous positive airway pressure manipulation (R = 0.67, P < 0.0001; and R = 0.64, P < 0.001; respectively). Polysomnographic estimates effectively stratified patients into high versus low subgroups (accuracy, 69-86% vs. ventilatory drive measures; P < 0.05). Traits were near-identical using nasal pressure versus pneumotach (N = 11, R ≥ 0.98, both traits; P < 0.001). CONCLUSIONS Phenotypes of pharyngeal dysfunction in OSA are evident from spontaneous changes in ventilation and ventilatory drive during sleep, enabling noninvasive phenotyping in the clinic. Our approach may facilitate precision therapeutic interventions for OSA.
Collapse
Affiliation(s)
- Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Allergy, Immunology and Respiratory Medicine, Melbourne, Victoria, Australia
- Central Clinical School
| | - Bradley A. Edwards
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Philip I. Terrill
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Queensland, Australia; and
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
45
|
Prevalence and characteristics of positional sleep apnea in the HypnoLaus population-based cohort. Sleep Med 2018; 48:157-162. [PMID: 29957486 DOI: 10.1016/j.sleep.2018.02.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 02/06/2018] [Accepted: 02/23/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE/BACKGROUND To determine the prevalence of positional obstructive sleep apnea (POSA) and exclusive POSA (ePOSA) in the general population and to assess the factors independently associated with POSA and ePOSA according to gender and menopausal status. PATIENTS/METHODS Participants of the population-based HypnoLaus Sleep Cohort underwent full polysomnography at home. POSA was defined as an apnea-hypopnea index (AHI) ≥5/h, and supine/non-supine AHI ratio (sAHI/nsAHI) ≥2 (ePOSA when non-supine AHI was normalized). RESULTS In this study, 1719 subjects (40-85y.o. 46% men) with at least 30 min spent in both the supine and non-supine positions were included. OSA was present in 1224 subjects (71%) (AHI >5/H). POSA was present in 53% of all subjects, and in 75% of OSA subjects. ePOSA was present in 26% of all subjects and in 36% of OSA subjects. In multivariate analyses, lower AHI and lower BMI were both associated with POSA and ePOSA in males. In premenopausal females, no single factor was associated with POSA while a lower AHI and an Epworth sleepiness scale >10 were associated with ePOSA. In postmenopausal women, a lower BMI was associated with POSA and a lower AHI and a lower Mallampati score with ePOSA. CONCLUSIONS In this large population-based study, we found that POSA is present in 53% of the middle-to-older age general population, and in 75% of OSA subjects. ePOSA was present in 36% of OSA subjects, suggesting that a large proportion of them could be treated with positional therapy. AHI and BMI were differently associated with POSA in men, and pre or post-menopausal women.
Collapse
|
46
|
Landry SA, Joosten SA, Eckert DJ, Jordan AS, Sands SA, White DP, Malhotra A, Wellman A, Hamilton GS, Edwards BA. Therapeutic CPAP Level Predicts Upper Airway Collapsibility in Patients With Obstructive Sleep Apnea. Sleep 2018; 40:3608771. [PMID: 28419320 DOI: 10.1093/sleep/zsx056] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Study Objectives Upper airway collapsibility is a key determinant of obstructive sleep apnea (OSA) which can influence the efficacy of certain non-continuous positive airway pressure (CPAP) treatments for OSA. However, there is no simple way to measure this variable clinically. The present study aimed to develop a clinically implementable tool to evaluate the collapsibility of a patient's upper airway. Methods Collapsibility, as characterized by the passive pharyngeal critical closing pressure (Pcrit), was measured in 46 patients with OSA. Associations were investigated between Pcrit and data extracted from patient history and routine polysomnography, including CPAP titration. Results Therapeutic CPAP level, demonstrated the strongest relationship to Pcrit (r2=0.51, p < .001) of all the variables investigated including apnea-hypopnea index, body mass index, sex, and age. Patients with a mildly collapsible upper airway (Pcrit ≤ -2 cmH2O) had a lower therapeutic CPAP level (6.2 ± 0.6 vs. 10.3 ± 0.4 cmH2O, p < .001) compared to patients with more severe collapsibility (Pcrit > -2 cmH2O). A therapeutic CPAP level ≤8.0 cmH2O was sensitive (89%) and specific (84%) for detecting a mildly collapsible upper airway. When applied to the independent validation data set (n = 74), this threshold maintained high specificity (91%) but reduced sensitivity (75%). Conclusions Our data demonstrate that a patient's therapeutic CPAP requirement shares a strong predictive relationship with their Pcrit and may be used to accurately differentiate OSA patients with mild airway collapsibility from those with moderate-to-severe collapsibility. Although this relationship needs to be confirmed prospectively, our findings may provide clinicians with better understanding of an individual patient's OSA phenotype, which ultimately could assist in determining which patients are most likely to respond to non-CPAP therapies.
Collapse
Affiliation(s)
- Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners - Epworth, Melbourne, Australia
| | - Danny J Eckert
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | - Amy S Jordan
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Atul Malhotra
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Division of Pulmonary and Critical Care Medicine, University of California San Diego, CA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners - Epworth, Melbourne, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
47
|
Eckert DJ. Phenotypic approaches to positional therapy for obstructive sleep apnoea. Sleep Med Rev 2018; 37:175-176. [DOI: 10.1016/j.smrv.2017.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/19/2017] [Indexed: 11/25/2022]
|
48
|
Phenotyping the pathophysiology of obstructive sleep apnea using polygraphy/polysomnography: a review of the literature. Sleep Breath 2018; 22:579-592. [PMID: 29318567 DOI: 10.1007/s11325-017-1613-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/03/2017] [Accepted: 12/19/2017] [Indexed: 12/19/2022]
Abstract
Continuous positive airway pressure (CPAP) is the first-line treatment for the majority of patients affected by obstructive sleep apnea syndrome (OSA). However, long-term compliance with CPAP therapy may result limited and alternatives to CPAP therapy are required to address the increasing need to provide tailored therapeutic options. Understanding the pathophysiological traits (PTs) of OSA patients [upper airway (UA) anatomical collapsibility, loop gain (LG), arousal threshold (AT), and UA gain (UAG)] lies at the heart of the customized OSA treatment. However, sleep research laboratories capable to phenotype OSA patients are sparse and the diagnostic procedures time-consuming, costly, and requiring significant expertise. The question arises whether the use of routine clinical polysomnography or nocturnal portable multi-channel monitoring (PSG/PM) can provide sufficient information to characterize the above traits. The aim of the present review is to deduce if the information obtainable from the clinical PSG/PM analysis, independently of the scope and context of the original studies, is clinically useful to define qualitatively the PTs of individual OSA patients. In summary, it is possible to identify four patterns using PSG/PM that are consistent with an altered UA collapsibility, three that are consistent with altered LG, two with altered AT, and three consistent with flow limitation/UA muscle response. Furthermore, some PSG/PM indexes and patterns, useful for the suitable management of OSA patient, have been discussed. The delivery of this clinical approach to phenotype pathophysiological traits will allow patients to benefit in a wider range of sleep services by facilitating tailored therapeutic options.
Collapse
|
49
|
Johar A, Turnbull CD, Stradling JR. Can postural OSA be usefully identified from its severity alone? BMJ Open Respir Res 2018; 4:e000259. [PMID: 29299327 PMCID: PMC5743902 DOI: 10.1136/bmjresp-2017-000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction When obstructive sleep apnoea (OSA) does not occur throughout sleep, there must be factors influencing its presence or absence. These are most likely to be sleep stage, posture and presleep alcohol, among others. We hypothesised that as OSA severity increases, the likelihood of postural OSA (POSA) would also decrease. Methods Laboratory sleep studies of 39 patients with OSA were manually reviewed to calculate supine and non-supine oxygen desaturation indices (ODI). The usual definition for POSA was used, a ratio of supine to non-supine ODI of ≥2. Results The mean age was 53.2 (SD 12.4) years, the body mass index was 35.0 (SD 8.9) kg/m2 and 74% were male. The median supine ODI was 54.3 (IQR 25.7–73.5) and non-supine ODI was 18.7 (IQR 8.6–38.4). The overall prevalence of POSA was 56%. The prevalence of POSA for ODIs of <40 was 68%, and 35% if ≥40. Conclusions An ODI ≥40, compared with <40, halved the likelihood of POSA from 68% to 35%. Although there is clearly a relationship between overall ODI and POSA, it is not strong enough to diagnose an individual with POSA. However the relationship provides a useful way to prescreen trial subjects to enrich for POSA.
Collapse
Affiliation(s)
- Aihem Johar
- NIHR Oxford Biomedical Research Centre and Oxford Centre for Respiratory Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Chris D Turnbull
- NIHR Oxford Biomedical Research Centre and Oxford Centre for Respiratory Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - John R Stradling
- NIHR Oxford Biomedical Research Centre and Oxford Centre for Respiratory Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| |
Collapse
|
50
|
Joosten SA, Leong P, Landry SA, Sands SA, Terrill PI, Mann D, Turton A, Rangaswamy J, Andara C, Burgess G, Mansfield D, Hamilton GS, Edwards BA. Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea. Sleep 2017; 40:3845961. [PMID: 28531336 DOI: 10.1093/sleep/zsx094] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Study Objectives Upper airway surgery is often recommended to treat patients with obstructive sleep apnea (OSA) who cannot tolerate continuous positive airways pressure. However, the response to surgery is variable, potentially because it does not improve the nonanatomical factors (ie, loop gain [LG] and arousal threshold) causing OSA. Measuring these traits clinically might predict responses to surgery. Our primary objective was to test the value of LG and arousal threshold to predict surgical success defined as 50% reduction in apnea-hypopnea index (AHI) and AHI <10 events/hour post surgery. Methods We retrospectively analyzed data from patients who underwent upper airway surgery for OSA (n = 46). Clinical estimates of LG and arousal threshold were calculated from routine polysomnographic recordings presurgery and postsurgery (median of 124 [91-170] days follow-up). Results Surgery reduced both the AHI (39.1 ± 4.2 vs. 26.5 ± 3.6 events/hour; p < .005) and estimated arousal threshold (-14.8 [-22.9 to -10.2] vs. -9.4 [-14.5 to -6.0] cmH2O) but did not alter LG (0.45 ± 0.08 vs. 0.45 ± 0.12; p = .278). Responders to surgery had a lower baseline LG (0.38 ± 0.02 vs. 0.48 ± 0.01, p < .05) and were younger (31.0 [27.3-42.5] vs. 43.0 [33.0-55.3] years, p < .05) than nonresponders. Lower LG remained a significant predictor of surgical success after controlling for covariates (logistic regression p = .018; receiver operating characteristic area under curve = 0.80). Conclusions Our study provides proof-of-principle that upper airway surgery most effectively resolves OSA in patients with lower LG. Predicting the failure of surgical treatment, consequent to less stable ventilatory control (elevated LG), can be achieved in the clinic and may facilitate avoidance of surgical failures.
Collapse
Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Paul Leong
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology Monash University, Melbourne, Victoria, Australia
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA.,Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Dwayne Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Anthony Turton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Jhanavi Rangaswamy
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Christopher Andara
- Sleep and Circadian Medicine Laboratory, Department of Physiology Monash University, Melbourne, Victoria, Australia
| | - Glen Burgess
- The Ear, Nose and Throat/Head and Neck Surgery Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Science at Monash Health, Monash University
| | - Darren Mansfield
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology Monash University, Melbourne, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|