1
|
Li C, Ma R, Wu X, Wang D, Chen L, Huang Z, Ji D, Wen W, Wu Y. Identifying the pathophysiological traits of obstructive sleep apnea during dexmedetomidine sedation. J Sleep Res 2024; 33:e14079. [PMID: 37876325 DOI: 10.1111/jsr.14079] [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: 06/26/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/26/2023]
Abstract
Dexmedetomidine (DEX) has been described as a safe sedative in clinical practice, but its effects on the pathophysiological traits of obstructive sleep apnea (OSA) are unclear. We estimated the effects of DEX sedation on the four key pathophysiological traits of OSA (pharyngeal collapsibility, dilator muscle function, arousal threshold, and loop gain) in adult patients with OSA by conducting a secondary analysis of a prospective diagnostic trial. Pathophysiological traits estimated from polysomnography and the respiratory parameters under natural sleep and DEX-induced sleep were compared. Bivariate and multivariate linear regression analyses were used to estimate the relationship between pathophysiological traits and OSA severity for both sleep states. Adult patients with OSA had a significantly higher pharyngeal collapsibility (Vpassive: 44.9 [15.7 to 53.8] vs. 53.3 [34.2 to 66.3] %eupnea, p < 0.001), arousal threshold (178.5 [132.5 to 234.6] vs. 140.5 [123.2 to 192.3] %eupnea, p < 0.001), and loop gain (LG1: 0.74 ± 0.25 vs. 0.60 ± 0.17, p < 0.001; LGn: 0.52 ± 0.12 vs. 0.44 ± 0.08, p < 0.001) during DEX-induced sleep compared with natural sleep. There was no significant difference in dilator muscle function or PSG respiratory parameters between natural versus DEX-induced sleep states. Bivariate regression analysis showed varying degrees of correlation between OSA traits and severity. Multiple regression analysis indicated that collapsibility was the strongest predictor of the apnea-hypopnea index for both sleep states. Dexmedetomidine sedation in patients with OSA increased the pharyngeal collapsibility without impairing dilator muscle function, while elevating arousal threshold and increasing loop gain.
Collapse
Affiliation(s)
- Chunbo Li
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Renqiang Ma
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Xingmei Wu
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Dan Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Lin Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Zixuan Huang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Ding Ji
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Weiping Wen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
| | - Yan Wu
- Guangzhou Key Laboratory of Otorhinolaryngology, Guangzhou, China
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
2
|
Nobre ML, Sarmento ACA, de Oliveira PF, Wanderley FF, Diniz Júnior J, Gonçalves AK. Pharmacological treatment for obstructive sleep apnea: A systematic review and meta-analysis. Clinics (Sao Paulo) 2024; 79:100330. [PMID: 38341903 PMCID: PMC10869242 DOI: 10.1016/j.clinsp.2024.100330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/21/2023] [Indexed: 02/13/2024] Open
Abstract
OBJECTIVE Summarize the evidence on drug therapies for obstructive sleep apnea. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Embase, Scopus, Web of Science, SciELO, LILACS, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched on February 17th, 2023. A search strategy retrieved randomized clinical trials comparing the Apnea-Hypopnea Index (AHI) in pharmacotherapies. Studies were selected and data was extracted by two authors independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. RevMan 5.4. was used for data synthesis. RESULTS 4930 articles were obtained, 68 met inclusion criteria, and 29 studies (involving 11 drugs) were combined in a meta-analysis. Atomoxetine plus oxybutynin vs placebo in AHI mean difference of -7.71 (-10.59, -4.83) [Fixed, 95 % CI, I2 = 50 %, overall effect: Z = 5.25, p < 0.001]. Donepezil vs placebo in AHI mean difference of -8.56 (-15.78, -1.33) [Fixed, 95 % CI, I2 = 21 %, overall effect: Z = 2.32, p = 0.02]. Sodium oxybate vs placebo in AHI mean difference of -5.50 (-9.28, -1.73) [Fixed, 95 % CI, I2 = 32 %, overall effect: Z = 2.86, p = 0.004]. Trazodone vs placebo in AHI mean difference of -12.75 (-21.30, -4.19) [Fixed, 95 % CI, I2 = 0 %, overall effect: Z = 2.92, p = 0.003]. CONCLUSION The combination of noradrenergic and antimuscarinic drugs shows promising results. Identifying endotypes may be the key to future drug therapies for obstructive sleep apnea. Moreover, studies with longer follow-up assessing the safety and sustained effects of these treatments are needed. PROSPERO REGISTRATION NUMBER CRD42022362639.
Collapse
Affiliation(s)
- Maria Luísa Nobre
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ayane Cristine Alves Sarmento
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; Department of Clinical Analysis and Toxicology, Universidade Federal do Rio Grande do Norte, RN, Brazil
| | | | | | - José Diniz Júnior
- Department of Surgery, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ana Katherine Gonçalves
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; Department of Gynecology and Obstetrics, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
| |
Collapse
|
3
|
Cheng WJ, Finnsson E, Ágústsson JS, Sands SA, Hang LW. Continuous positive airway pressure and adherence in patients with different endotypes of obstructive sleep apnea. J Sleep Res 2024; 33:e13999. [PMID: 37452710 PMCID: PMC10788376 DOI: 10.1111/jsr.13999] [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: 03/09/2023] [Revised: 05/26/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
Determining the endotypes of obstructive sleep apnea (OSA) has potential implications for precision interventions. Here we assessed whether continuous positive airway pressure (CPAP) treatment outcomes differ across endotypic subgroups. We conducted a retrospective analysis of data obtained from 225 patients with moderate-to-severe OSA from a single sleep centre. Polysomnographic and CPAP titration study data were collected between May 2020 and January 2022. One-month CPAP treatment adherence was followed. Obstructive sleep apnea endotypes, namely arousal threshold, collapsibility, loop gain, and upper airway gain were estimated from polysomnography and dichotomised as high versus low. We examined associations between endotypic subgroups and (1) optimal CPAP titration pressure, (2) CPAP-related improvements in sleep architecture (proportions of slow-wave and rapid eye movement (REM) sleep), and (3) CPAP adherence. We observed that patients with high collapsibility required a higher CPAP pressure than those with low collapsibility (∆ = 0.4 cmH2 O, 95% confidence interval [CI] = 0.3-1.7). A larger increase in slow-wave sleep and in REM sleep proportions after CPAP treatment were observed in patients with a high arousal threshold, high collapsibility, high loop gain, or high upper airway gain than in those with low levels of endotypes. High loop gain and high collapsibility were independently associated with longer CPAP use hours per night (∆ = 0.6 h, 95% CI = 0.2-1.5 and ∆ = 0.3 h, 95% CI = 0.03-1.5, respectively). In conclusion, different endotypic subgroups of OSA exhibit a difference in outcomes of CPAP treatment. Knowledge of endotypes may help clinicians to understand which patients are expected to benefit most from CPAP therapy prior to its administration.
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, 35 Keyan Road, 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
| | - Liang-Wen Hang
- School of Nursing & Graduate Institute of Nursing, China Medical University, Taichung, Taiwan
- Sleep Medicine Center, Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
4
|
Sweetman A, Osman A, Lack L, Crawford M, Wallace D. Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions. Curr Opin Pulm Med 2023; 29:567-573. [PMID: 37642477 DOI: 10.1097/mcp.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions. RECENT FINDINGS People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches. SUMMARY It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.
Collapse
Affiliation(s)
- Alexander Sweetman
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Amal Osman
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Leon Lack
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Megan Crawford
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Douglas Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| |
Collapse
|
5
|
B H S, G D, Sawal A, Balwir TP. Anatomical Basis of Obstructive Sleep Apnoea: A Review of Randomized Controlled Trials. Cureus 2023; 15:e44525. [PMID: 37789996 PMCID: PMC10544646 DOI: 10.7759/cureus.44525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/01/2023] [Indexed: 10/05/2023] Open
Abstract
Repeated obstruction and closure of the upper airway, sporadic hypoxic episodes, and sympathetic activity are symptoms of obstructive sleep apnea (OSA). Obstructive sleep apnoea is due to a combination of altered upper airway structure and muscular function, a low arousal threshold and increased loop gain. Although recurrent upper airway (UA) collapse during sleep is the most frequent clinical hallmark of OSA, the exact cause of this collapse is unknown. Furthermore, while continuous positive airway pressure aids in the management of OSA, many patients find it intolerable. As a result, a better knowledge of the causes of OSA may result in more effective treatments. We did a review of randomized controlled trials that were done in this regard in the last 10 years and whose full-text version is available on the PubMed database. A total of 20 articles were finalized for review after applying our criteria. The articles have proposed different theories regarding the anatomical basis responsible for obstructive sleep apnoea. The theories proposed by different studies in the last decade include reduced genioglossus and hypoglossal nerve activity, the pharyngeal muscles' failure to keep the airway open or tighten it, tonsils and adenoid hypertrophy, an oversensitive ventilatory control system and low respiratory arousal threshold, mandibular position, pharyngeal muscles' high sympathetic drive, cephalometric alterations such as mandibular and hyoid bone position and the length of the soft palate, obesity, and neck fat and fluid re-distribution in the body, from the lower to the upper parts while reclining. Given the diverse etiological characteristics of OSA patients and to increase our knowledge of the condition, additional study into this group is required. Filling any knowledge gaps that may exist in the anatomical basis of the onset of OSA is the main objective of this review paper.
Collapse
Affiliation(s)
- Shrikrishna B H
- Otorhinolaryngology - Head and Neck Surgery, All India Institute of Medical Sciences, Bibinagar, Hyderabad, IND
| | - Deepa G
- Anatomy, Datta Meghe Medical College, Nagpur, IND
| | - Anupama Sawal
- Anatomy, Jawaharlal Nehru Medical College, Sawangi, IND
| | | |
Collapse
|
6
|
Thomas E, Micic G, Adams R, Eckert DJ. Pharmacological management of co-morbid obstructive sleep apnoea and insomnia. Expert Opin Pharmacother 2023; 24:1963-1973. [PMID: 38099435 DOI: 10.1080/14656566.2023.2292186] [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: 09/29/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA. AREAS COVERED This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities. EXPERT OPINION There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.
Collapse
Affiliation(s)
- Emma Thomas
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Gorica Micic
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Robert Adams
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| |
Collapse
|
7
|
Perger E, Bertoli S, Lombardi C. Pharmacotherapy for obstructive sleep apnea: targeting specific pathophysiological traits. Expert Rev Respir Med 2023; 17:663-673. [PMID: 37646222 DOI: 10.1080/17476348.2023.2241353] [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: 02/16/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The pathophysiology of obstructive sleep apnea (OSA) is multi-factorial and complex. Varying OSA's pathophysiological traits have been identified, including pharyngeal collapsibility, upper airway muscle reactivity, arousal threshold, and regulation of the ventilatory drive. Being CPAP of difficult tolerance and other interventions reserved to specific subpopulations new pharmacological treatments for OSA might be resolutive. AREAS COVERED Several existing and newly developed pharmacological drugs can impact one or more endotypes and could therefore be proposed as treatment options for sleep disordered breathing. With this review we will explore different pathophysiological traits as new targets for OSA therapy. This review will summarize the most promising pharmacological treatment for OSA accordingly with their mechanisms of action on upper airway collapsibility, muscle responsiveness, arousal threshold, and loop gain. EXPERT OPINION Only understanding the pathophysiological traits causing OSA in each patient and placing the disease in the framework of patient comorbidities, we will be able to evolve interventions toward OSA. The development of new drug's combinations will permit different approaches and different choices beside conventional treatments. In the next future, we hope that sleep specialists will select the treatment for a specific patient on the base of its pathophysiology, defining a precision medicine for OSA.
Collapse
Affiliation(s)
- Elisa Perger
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Simona Bertoli
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
- Lab of Nutrition and Obesity Research, Istituto Auxologico Italiano, IRCCS, Milan, Carolina
| | - Carolina Lombardi
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| |
Collapse
|
8
|
Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
Collapse
Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
| |
Collapse
|
9
|
Hedner J, Zou D. New pharmacologic agents for obstructive sleep apnoea: what do we know and what can we expect? Curr Opin Pulm Med 2022; 28:522-528. [PMID: 36121301 DOI: 10.1097/mcp.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review provides a condensed description of pharmacological remedies explored in patients with obstructive sleep apnoea (OSA) as well as projections of what we might expect in terms of clinical performance of these drugs. RECENT FINDINGS Conventional drug therapies explored in OSA have generally produced disappointing results and there is a shortage of pharmacological treatment alternatives in this disorder. Recent insights into pathophysiological mechanisms potentially involved in OSA suggest that the condition may be divided into distinct subgroups based on clusters or defined by means of unique functional endotypic criteria. In fact, positive outcomes in clinical trials have now resulted in several drug candidates that show a convincing reduction of sleep disordered breathing in both short and intermediate term. Such drugs may be particularly useful in certain variants of OSA but not in others. These insights have also raised the ambition to create personalized therapies in OSA. Another recent development is the insight that OSA-linked conditions such as obesity, daytime somnolence and various forms of cardiovascular/metabolic disease may provide drug-based targets. For instance, pharmacological obesity therapy may provide not only positive metabolic effects but may also be a way to eliminate the anatomic component in obese OSA patients. SUMMARY Recent insights into the pathophysiology of OSA have opened possibilities to develop personalized therapy. Drugs addressing fundamental aspects of the sleep and breathing disorder provide a particularly promising avenue for development of novel forms of treatment in OSA.
Collapse
Affiliation(s)
- Jan Hedner
- Center for Sleep and Vigilance Disorders, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | |
Collapse
|
10
|
Abstract
Despite extensive research, there is currently no approved drug for obstructive sleep apnea (OSA) treatment. OSA is a heterogeneous condition that involves multiple dominating pathophysiological traits. Drug development in this field needs to address both pathophysiological mechanisms and associated comorbid conditions in order to meet requirements for long-term therapy in OSA. Several drug candidates have been proposed and ongoing phase II trials that target various forms of sleep-disordered breathing have been initiated. The field is moving toward tailored therapeutic approaches in patients with OSA.
Collapse
|
11
|
Altree TJ, Eckert DJ. Obstructive sleep apnea endotypes and their postoperative relevance. Int Anesthesiol Clin 2022; 60:1-7. [PMID: 35125480 DOI: 10.1097/aia.0000000000000357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Thomas J Altree
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
- Respiratory and Sleep Services, Flinders Medical Centre, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
| | - Danny J Eckert
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia
| |
Collapse
|
12
|
A Narrative Review of the Association between Post-Traumatic Stress Disorder and Obstructive Sleep Apnea. J Clin Med 2022; 11:jcm11020415. [PMID: 35054110 PMCID: PMC8780754 DOI: 10.3390/jcm11020415] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 12/10/2022] Open
Abstract
Obstructive sleep apnea (OSA) and post-traumatic stress disorder (PTSD) are often co-morbid with implications for disease severity and treatment outcomes. OSA prevalence is higher in PTSD sufferers than in the general population, with a likely bidirectional effect of the two illnesses. There is substantial evidence to support the role that disturbed sleep may play in the pathophysiology of PTSD. Sleep disturbance associated with OSA may interfere with normal rapid eye movement (REM) functioning and thus worsen nightmares and sleep-related movements. Conversely, hyperarousal and hypervigilance symptoms of PTSD may lower the arousal threshold and thus increase the frequency of sleep fragmentation related to obstructive events. Treating OSA not only improves OSA symptoms, but also nightmares and daytime symptoms of PTSD. Evidence suggests that positive airway pressure (PAP) therapy reduces PTSD symptoms in a dose-dependent fashion, but also presents challenges to tolerance in the PTSD population. Alternative OSA treatments may be better tolerated and effective for improving both OSA and PTSD. Further research avenues will be introduced as we seek a better understanding of this complex relationship.
Collapse
|
13
|
Abstract
Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.
Collapse
Affiliation(s)
- Luu V Pham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Jonathan Jun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| |
Collapse
|
14
|
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
|
15
|
The Association between Use of Benzodiazepine Receptor Agonists and the Risk of Obstructive Sleep Apnea: A Nationwide Population-Based Nested Case-Control Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189720. [PMID: 34574645 PMCID: PMC8467455 DOI: 10.3390/ijerph18189720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022]
Abstract
Obstructive sleep apnea (OSA) is characterized by recurrent upper airway collapse. Benzodiazepine receptor agonists (BZRAs) are associated with pharyngeal muscle relaxation, increased apnea duration, and hypoxia, which might worsen OSA. This study aimed to examine the association between the use of BZRAs and the risk of OSA. The study was conducted using data from the National Health Insurance Database of Taiwan between 2002 and 2011. We only included new users who were never exposed to any BZRAs and identified 1848 participants with OSA, and 1848 matched controls. A logistic regression model was used to determine the association between the use of BZRAs and the development of OSA. BZRA exposure was divided into usage patterns, dosage, duration, and pharmacokinetic class. We found an increased risk of OSA in current users and recent past users compared with distant past users. Patients with a higher cumulative dose of BZRAs were more likely to develop OSA compared to those with a lower cumulative dose. We found an increased risk of OSA in patients treated with BZRAs, especially for current users and those with higher cumulative doses. A reduced risk of OSA was found in Z-drug users compared with benzodiazepine users.
Collapse
|
16
|
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
|
17
|
Sweetman A, Lack L, McEvoy RD, Smith S, Eckert DJ, Osman A, Carberry JC, Wallace D, Nguyen PD, Catcheside P. Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA). Sleep Med Rev 2021; 60:101519. [PMID: 34229295 DOI: 10.1016/j.smrv.2021.101519] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/06/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.
Collapse
Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Leon Lack
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Education Psychology and Social Work, Flinders University, Adelaide, Australia.
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Simon Smith
- Institute for Social Science Research (ISSR), The University of Queensland, Brisbane, 4027, Australia.
| | - Danny J Eckert
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Amal Osman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Jayne C Carberry
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia; University College Dublin, School of Medicine, Dublin, Ireland.
| | - Douglas Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine, Miami, FL, USA; Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL, USA.
| | - Phuc D Nguyen
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Science and Engineering, Flinders University, Adelaide, Australia.
| | - Peter Catcheside
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| |
Collapse
|
18
|
Messineo L, Carter SG, Taranto-Montemurro L, Chiang A, Vakulin A, Adams RJ, Carberry JC, Eckert DJ. Addition of zolpidem to combination therapy with atomoxetine-oxybutynin increases sleep efficiency and the respiratory arousal threshold in obstructive sleep apnoea: A randomized trial. Respirology 2021; 26:878-886. [PMID: 34164887 DOI: 10.1111/resp.14110] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/24/2021] [Accepted: 06/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Atomoxetine combined with oxybutynin (Ato-Oxy) has recently been shown to reduce obstructive sleep apnoea (OSA) severity by >60%. However, Ato-Oxy also modestly reduced the respiratory arousal threshold, which may decrease sleep quality/efficiency. We sought to investigate the additional effect of zolpidem with Ato-Oxy on sleep efficiency (primary outcome), the arousal threshold, OSA severity, other standard polysomnography (PSG) parameters, next-day sleepiness and alertness (secondary outcomes). METHODS Twelve participants with OSA received 10 mg zolpidem plus Ato-Oxy (80-5 mg, respectively) or Ato-Oxy plus placebo prior to overnight in-laboratory PSG according to a double-blind, randomized, crossover design (1-week washout). Participants were fitted with an epiglottic catheter, a nasal mask and pneumotachograph to quantify arousal threshold and airflow. Next-day sleepiness and alertness were assessed via the Karolinska Sleepiness Scale and a driving simulation task. RESULTS The addition of zolpidem increased sleep efficiency by 9% ± 13% (80.9% ± 16.9% vs. 88.2% ± 8.2%, p = 0.037) and the respiratory arousal threshold by 17% ± 18% (-26.6 ± 14.5 vs. -33.8 ± 20.3 cm H2 O, p = 0.004) versus Ato-Oxy + placebo. Zolpidem did not systematically change OSA severity. Combination therapy was well tolerated, and zolpidem did not worsen next-day sleepiness. However, median steering deviation during the driving simulator task increased following the zolpidem combination. CONCLUSION Zolpidem improves sleep efficiency via an increase in the respiratory arousal threshold to counteract potential wake-promoting properties of atomoxetine in OSA. These changes occur without altering the rate of respiratory events or overnight hypoxaemia. However, while the addition of zolpidem does not increase next-day perceived sleepiness, caution is warranted given the potential impact on next-morning objective alertness.
Collapse
Affiliation(s)
- Ludovico Messineo
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Sophie G Carter
- Neuroscience Research Australia (NeuRA), The University of New South Wales, Sydney, New South Wales, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Alan Chiang
- Neuroscience Research Australia (NeuRA), The University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Vakulin
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Robert J Adams
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Jayne C Carberry
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Danny J Eckert
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
19
|
Clinical and PSG Characteristics of Children with Mild OSA and Respiratory Events Terminated Predominantly with Arousal. Can Respir J 2021; 2021:5549423. [PMID: 34194586 PMCID: PMC8203392 DOI: 10.1155/2021/5549423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/10/2021] [Accepted: 05/27/2021] [Indexed: 01/22/2023] Open
Abstract
Objective To analyze the clinical and polysomnographic characteristics in children with mild OSA and respiratory events terminated predominantly with arousal. Methods Children aged 3-10 yrs who had mild obstructive sleep apnea (OSA) were enrolled. All children underwent polysomnography, and patients' data were collected by using sleep-related breathing disorders (SRBD) questionnaire and OSA-18 quality of life questionnaire. Results In total, five hundred and seventy-seven children were eligible. Children in arousal predominant group were younger and showed a lower rate of male and obesity. Compared with that of the nonarousal predominant group, the total arousal index, arousal index related to respiratory event, the percentage of NREM stage 1 (N1%), the fraction of respiratory events that were hypopnea, and the mean and minimum oxygen saturation in the arousal predominant group were significantly greater. The percentage of NREM stage 3 (N%), index of obstructive, central, mixed apnea, the fraction of respiratory events that were obstructive, and central and mixed apnea were significantly lower in arousal predominant group. Conclusion Children with mild OSA in the arousal predominant group had specific characteristics, including younger age, lower rate of male and obesity, worse sleep architecture, higher rates of hypopnea events, and better oxygenation. This trial is registered with NCT02447614.
Collapse
|
20
|
A Phenotypic Approach for Personalised Management of Obstructive Sleep Apnoea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00346-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
21
|
Aishah A, Lim R, Sands SA, Taranto-Montemurro L, Wellman A, Carberry JC, Eckert DJ. Different antimuscarinics when combined with atomoxetine have differential effects on obstructive sleep apnea severity. J Appl Physiol (1985) 2021; 130:1373-1382. [PMID: 33734828 PMCID: PMC8424567 DOI: 10.1152/japplphysiol.01074.2020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The combination of the noradrenergic agent atomoxetine plus the antimuscarinic oxybutynin has recently been shown to improve upper airway physiology and reduce obstructive sleep apnea (OSA) severity. However, the effects of different antimuscarinics when combined with atomoxetine is limited. This study aimed to determine the effects of atomoxetine combined with two different antimuscarinics with varying M-subtype receptor selectivity on OSA severity and upper airway physiology. Ten people with predominantly severe OSA completed a double-blind, randomized, placebo-controlled, cross-over trial. Participants completed three overnight in-laboratory sleep studies after either 80 mg atomoxetine + 5 mg solifenacin succinate (ato-sol) or 80 mg atomoxetine + 2 mg biperiden hydrochloride (ato-bip) or placebo. OSA severity, ventilatory stability (loop gain), respiratory-arousal threshold (via epiglottic manometry), next-day subjective sleepiness [Karolinska Sleepiness Scale (KSS)], and alertness were compared between conditions. Neither drug combination altered the apnea/hypopnea index versus placebo (P = 0.63). Ato-sol caused a shift toward milder respiratory events with reduced frequency of obstructive apneas (13 ± 14 vs. 22 ± 17 events/h; means ± SD, P = 0.04) and increased hypopneas during nonrapid eye movement (NREM) (38 ± 21 vs. 24 ± 18 events/h, P = 0.006) with improved nadir oxygenation versus placebo (83 ± 4 vs. 80 ± 8%, P = 0.03). Both combinations reduced loop gain by ∼10% versus placebo; sleep efficiency and arousal threshold were unaltered. Ato-bip reduced next-day sleepiness versus placebo (KSS = 4.3 ± 2.2 vs. 5.6 ± 1.6, P = 0.03). Atomoxetine + biperiden hydrochloride reduces perceived sleepiness, and atomoxetine + solifenacin modestly improves upper airway function in people with OSA but to a lesser extent versus recently published atomoxetine + oxybutynin (broad M-subtype receptor selectivity) findings. These results provide novel mechanistic insight into the role of noradrenergic and antimuscarinic agents on sleep and breathing and are important for pharmacotherapy development for OSA.NEW & NOTEWORTHY In contrast to recent findings of major reductions in OSA severity when atomoxetine is combined with a nonspecific antimuscarinic, oxybutynin (broad M-subtype receptor selectivity), addition of solifenacin succinate (M2 and M3 muscarinic receptor selectivity) or biperiden (M1 muscarinic receptor selectivity) with atomoxetine had modest effects on upper airway function during sleep, which provide mechanistic insight into the role of noradrenergic and antimuscarinic agents on sleep and breathing and are important for pharmacotherapy development for OSA.
Collapse
Affiliation(s)
- Atqiya Aishah
- 1Neuroscience Research Australia, Faculty of Medicine,
University of New South Wales, Sydney, New South Wales, Australia
| | - Richard Lim
- 1Neuroscience Research Australia, Faculty of Medicine,
University of New South Wales, Sydney, New South Wales, Australia
| | - Scott A. Sands
- 2Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Luigi Taranto-Montemurro
- 2Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- 2Division of Sleep Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jayne C. Carberry
- 1Neuroscience Research Australia, Faculty of Medicine,
University of New South Wales, Sydney, New South Wales, Australia,3Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Danny J. Eckert
- 1Neuroscience Research Australia, Faculty of Medicine,
University of New South Wales, Sydney, New South Wales, Australia,3Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| |
Collapse
|
22
|
Carter SG, Eckert DJ. Effects of hypnotics on obstructive sleep apnea endotypes and severity: Novel insights into pathophysiology and treatment. Sleep Med Rev 2021; 58:101492. [PMID: 33965721 DOI: 10.1016/j.smrv.2021.101492] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023]
Abstract
Impaired upper airway anatomy is the main cause of obstructive sleep apnea (OSA). However, there are other important non-anatomical contributors or "endotypes" including ventilatory control instability, poor pharyngeal dilator muscle responsiveness and waking up too easily to minor respiratory events (low arousal threshold). Recent studies have focused on the potential to target specific OSA causes with novel treatments to reduce OSA severity and improve efficacy with existing non-CPAP therapies which are often suboptimal (e.g., mandibular advancement splints). One novel target is pharmacotherapy with hypnotics to increase the threshold for arousal and reduce OSA severity in the approximately 30% of patients who have a low arousal threshold endotype. This increasing body of work has produced varied and at times unexpected findings which have challenged previous knowledge on the effects of hypnotics on upper airway physiology and breathing during sleep in people with OSA. This review provides a concise overview of the latest research that has investigated the effects of common hypnotics/sedative agents on upper airway physiology and OSA severity and potential implications for OSA pathophysiology, treatment and safety. This includes a summary of the latest knowledge on the effects of hypnotics on OSA endotypes. Priorities for future research are also highlighted.
Collapse
Affiliation(s)
- Sophie G Carter
- Neuroscience Research Australia (NeuRA) Barker Street and the University of New South Wales, Sydney, NSW, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute, Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia.
| |
Collapse
|
23
|
Chen CY, Chen CL, Yu CC. Trazodone improves obstructive sleep apnea after ischemic stroke: a randomized, double-blind, placebo-controlled, crossover pilot study. J Neurol 2021; 268:2951-2960. [PMID: 33625584 DOI: 10.1007/s00415-021-10480-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Low arousal threshold plays a part in the pathogenesis of obstructive sleep apnea (OSA) and may be improved by sedatives. Sedative antidepressants are frequently prescribed for stroke patients due to their high prevalence of insomnia and depression. However, the effect of sedative antidepressants on the severity of OSA in stroke patients has not been studied well. METHODS In a double-blinded randomized crossover pilot study, 22 post-acute ischemic stroke patients (mean age, 61.7 ± 10.6 y) with OSA received 100 mg of trazodone or a placebo just before polysomnography, with approximately 1 week between measures. The study also measured baseline heart rate variability and 24-h ambulatory blood pressure. RESULTS Administration of trazodone significantly increased the percentage time of slow-wave sleep (31.5 ± 13.2 vs. 18.4 ± 8.7%; P < 0.001) and improved almost all the parameters of OSA severity, including the apnea-hypopnea index (AHI, 25.4 ± 15.4 vs. 39.1 ± 18.4 events/h; P < 0.001), the respiratory arousal index (9.8 (5.8-11.95) vs. 14.1 (11.3-18.7) events/h; P < 0.001), and the minimum oxygen saturation (80.2 ± 9.1 vs. 77.1 ± 9.6%; P = 0.016). Responders to therapy (AHI reduced by > 50%; n = 7/22) had predominant OSA during rapid-eye-movement sleep and decreased sympathetic tone, as reflected in significantly lower mean blood pressure, diastolic blood pressure, and normalized low-frequency power. CONCLUSIONS Obstructive sleep apnea with comorbid ischemic stroke may be a distinctive phenotype which responds quite well to trazodone, decreasing OSA severity without increasing nocturnal hypoxia. TRIAL REGISTRATION Clinicaltrials.gov: NCT04162743, 2019/11/10.
Collapse
Affiliation(s)
- Chung-Yao Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan. .,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chia-Ling Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan.,Graduate Institute of Early Intervention, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chieh Yu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| |
Collapse
|
24
|
Messineo L, Eckert DJ, Lim R, Chiang A, Azarbarzin A, Carter SG, Carberry JC. Zolpidem increases sleep efficiency and the respiratory arousal threshold without changing sleep apnoea severity and pharyngeal muscle activity. J Physiol 2020; 598:4681-4692. [PMID: 32864734 DOI: 10.1113/jp280173] [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: 05/15/2020] [Accepted: 07/20/2020] [Indexed: 12/23/2022] Open
Abstract
KEY POINTS A decreased respiratory arousal threshold is one of the main contributors to obstructive sleep apnoea (OSA) pathogenesis. Several recent studies have sought to find a drug capable of increasing the respiratory arousal threshold without impairing pharyngeal muscle activity to reduce OSA severity, with variable success. Here we show that zolpidem increases the respiratory arousal threshold by ∼15%, an effect size which was insufficient to systematically decrease OSA severity as measured by the apnoea-hypopnoea index. Unlike recent physiological findings that showed paradoxical increases in pharyngeal muscle responsiveness during transient manipulations of airway pressure, zolpidem did not alter pharyngeal muscle responsiveness during natural sleep. It did, however, increase sleep efficiency without changing apnoea length, oxygen desaturation, next-day perceived sleepiness and alertness. These novel findings indicate that zolpidem was well tolerated and effective in promoting sleep in people with OSA, which may be therapeutically useful for people with OSA and comorbid insomnia. ABSTRACT A recent physiology study performed using continuous positive airway pressure (CPAP) manipulations indicated that the hypnotic zolpidem increases the arousal threshold and genioglossus responsiveness in people with and without obstructive sleep apnoea (OSA). Thus, zolpidem may stabilise breathing and reduce OSA severity without CPAP. Accordingly, we sought to determine the effects of zolpidem on OSA severity, upper airway physiology and next-day sleepiness and alertness. Nineteen people with OSA with low-to-moderate arousal threshold received 10 mg zolpidem or placebo according to a double-blind, randomised, cross-over design. Participants completed two overnight in-laboratory polysomnographies (1-week washout), with an epiglottic catheter, intramuscular genioglossus electromyography, nasal mask and pneumotachograph to measure OSA severity, arousal threshold and upper airway muscle responsiveness. Next-morning sleepiness and alertness were also assessed. Zolpidem did not change the apnoea-hypopnoea index versus placebo (40.6 ± 12.3 vs. 40.3 ± 16.4 events/h (means ± SD), p = 0.938) or nadir oxyhaemoglobin saturation (79.6 ± 6.6 vs. 79.7 ± 7.4%, p = 0.932), but was well tolerated. Zolpidem increased sleep efficiency by 9 ± 14% (83 ± 11 vs. 73 ± 17%, p = 0.010). Arousal threshold increased by 15 ± 5% with zolpidem throughout all sleep stages (p = 0.010), whereas genioglossus muscle responsiveness did not change. Next-morning sleepiness and alertness were not different between nights. In summary, a single night of 10 mg zolpidem is well tolerated and does not cause next-day impairment in alertness or sleepiness, or overnight hypoxaemia in OSA. However, despite increases in arousal threshold without any change in pharyngeal muscle responsiveness, zolpidem does not alter OSA severity. It does, however, increase sleep efficiency by ∼10%, which may be beneficial in people with OSA and insomnia.
Collapse
Affiliation(s)
- Ludovico Messineo
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia.,Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia.,Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Richard Lim
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia.,Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Alan Chiang
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Sophie G Carter
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | - Jayne C Carberry
- Adelaide Institute for Sleep Health (AISH), Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Adelaide, South Australia, Australia
| |
Collapse
|
25
|
Impact of low arousal threshold on treatment of obstructive sleep apnea in patients with post-traumatic stress disorder. Sleep Breath 2020; 25:597-604. [PMID: 32458377 DOI: 10.1007/s11325-020-02106-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/04/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE We sought to determine the prevalence of low arousal threshold (LAT) in veterans with post-traumatic stress disorder (PTSD) and whether or not LAT is associated with decreased use of continuous positive airway pressure (CPAP). METHODS We conducted a retrospective study of all veterans with documented PTSD who had an apnea hypopnea index > 5/h over a 27-month period. Demographic, clinical characteristics, and CPAP usage were extracted from the medical records. A multivariate analysis was conducted to assess predictors of CPAP use at 3 months in patients with LAT after adjusting for severity of PTSD. RESULTS LAT was identified in 55% of 119 patients with PTSD and newly diagnosed OSA. LAT was associated with younger age (odds ratio [OR] 0.91; 95% confidence interval [CI] 0.86-0.95), lower BMI (OR 0.82; 95% CI 0.73-0.91), presence of insomnia (OR 1.34; 95% CI 1.19-1.81), and use of antidepressant (OR 1.14; 95% CI 1.09-2.01). PTSD severity, REM rebound, and the presence of baseline comorbid insomnia were each associated with CPAP use at 3 months. Neither daytime sleepiness, body mass index (BMI), nor LAT endotype was correlated with CPAP utilization. Insomnia was the only factor associated with decreased CPAP use in patients with PTSD and LAT (P = 0.04). CONCLUSION The LAT endotype is common among veterans with PTSD. An improved understanding of how insomnia in this population affects CPAP utilization would be instrumental in designing targeted therapy to improve sleep quality.
Collapse
|
26
|
Carter SG, Carberry JC, Grunstein RR, Eckert DJ. Randomized Trial on the Effects of High-Dose Zopiclone on OSA Severity, Upper Airway Physiology, and Alertness. Chest 2020; 158:374-385. [DOI: 10.1016/j.chest.2020.02.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 02/13/2020] [Accepted: 02/22/2020] [Indexed: 12/22/2022] Open
|
27
|
Goldstein CA, Berry RB, Kent DT, Kristo DA, Seixas AA, Redline S, Westover MB. Artificial intelligence in sleep medicine: background and implications for clinicians. J Clin Sleep Med 2020; 16:609-618. [PMID: 32065113 PMCID: PMC7161463 DOI: 10.5664/jcsm.8388] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 12/14/2022]
Abstract
None Polysomnography remains the cornerstone of objective testing in sleep medicine and results in massive amounts of electrophysiological data, which is well-suited for analysis with artificial intelligence (AI)-based tools. Combined with other sources of health data, AI is expected to provide new insights to inform the clinical care of sleep disorders and advance our understanding of the integral role sleep plays in human health. Additionally, AI has the potential to streamline day-to-day operations and therefore optimize direct patient care by the sleep disorders team. However, clinicians, scientists, and other stakeholders must develop best practices to integrate this rapidly evolving technology into our daily work while maintaining the highest degree of quality and transparency in health care and research. Ultimately, when harnessed appropriately in conjunction with human expertise, AI will improve the practice of sleep medicine and further sleep science for the health and well-being of our patients.
Collapse
Affiliation(s)
- Cathy A. Goldstein
- Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Richard B. Berry
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida
| | - David T. Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Azizi A. Seixas
- Department of Population Health, Department of Psychiatry, NYU Langone Health, New York, New York
| | - Susan Redline
- Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
28
|
Nocturnal swallowing augments arousal intensity and arousal tachycardia. Proc Natl Acad Sci U S A 2020; 117:8624-8632. [PMID: 32229567 DOI: 10.1073/pnas.1907393117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Cortical arousal from sleep is associated with autonomic activation and acute increases in heart rate. Arousals vary considerably in their frequency, intensity/duration, and physiological effects. Sleep and arousability impact health acutely (daytime cognitive function) and long-term (cardiovascular outcomes). Yet factors that modify the arousal intensity and autonomic activity remain enigmatic. In this study of healthy human adults, we examined whether reflex airway defense mechanisms, specifically swallowing or glottic adduction, influenced cardiac autonomic activity and cortical arousal from sleep. We found, in all subjects, that swallows trigger rapid, robust, and patterned tachycardia conserved across wake, sleep, and arousal states. Tachycardia onset was temporally matched to glottic adduction-the first phase of swallow motor program. Multiple swallows increase the magnitude of tachycardia via temporal summation, and blood pressure increases as a function of the degree of tachycardia. During sleep, swallows were overwhelmingly associated with arousal. Critically, swallows were causally linked to the intense, prolonged cortical arousals and marked tachycardia. Arousal duration and tachycardia increased in parallel as a function of swallow incidence. Our findings suggest that cortical feedback and tachycardia are integrated responses of the swallow motor program. Our work highlights the functional influence of episodic, involuntary airway defense reflexes on sleep and vigilance and cardiovascular function in healthy individuals.
Collapse
|
29
|
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
|
30
|
Targeting Endotypic Traits with Medications for the Pharmacological Treatment of Obstructive Sleep Apnea. A Review of the Current Literature. J Clin Med 2019; 8:jcm8111846. [PMID: 31684047 PMCID: PMC6912255 DOI: 10.3390/jcm8111846] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition with few therapeutic options. To date there is no approved pharmacotherapy for this disorder, but several attempts have been made in the past and are currently ongoing to find one. The recent identification of multiple endotypes underlying this disorder has oriented the pharmacological research towards tailored therapies targeting specific pathophysiological traits that contribute differently to cause OSA in each patient. In this review we retrospectively analyze the literature on OSA pharmacotherapy dividing the medications tested on the basis of the four main endotypes: anatomy, upper airway muscle activity, arousal threshold and ventilatory instability (loop gain). We show how recently introduced drugs for weight loss that modify upper airway anatomy may play an important role in the management of OSA in the near future, and promising results have been obtained with drugs that increase upper airway muscle activity during sleep and reduce loop gain. The lack of a medication that can effectively increase the arousal threshold makes this strategy less encouraging, although recent studies have shown that the use of certain sedatives do not worsen OSA severity and could actually improve patients' sleep quality.
Collapse
|
31
|
Phenotypic approach to pharmacotherapy in the management of obstructive sleep apnoea. Curr Opin Pulm Med 2019; 25:594-601. [DOI: 10.1097/mcp.0000000000000628] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
32
|
Donovan LM, Shah A, Chai-Coetzer CL, Barbé F, Ayas NT, Kapur VK. Redesigning Care for OSA. Chest 2019; 157:966-976. [PMID: 31639334 DOI: 10.1016/j.chest.2019.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023] Open
Abstract
Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.
Collapse
Affiliation(s)
- Lucas M Donovan
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA; University of Washington School of Medicine, Seattle, WA
| | - Aditi Shah
- Leon Judah Blackmore Sleep Disorders Program, University of British Columbia, Vancouver, BC, Canada
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Ferran Barbé
- Institut de Recerca Biomèdica of Lleida and CIBERES, Lleida, Catalonia, Spain
| | - Najib T Ayas
- Leon Judah Blackmore Sleep Disorders Program, University of British Columbia, Vancouver, BC, Canada
| | | |
Collapse
|
33
|
Amatoury J, Jordan AS, Toson B, Nguyen C, Wellman A, Eckert DJ. New insights into the timing and potential mechanisms of respiratory-induced cortical arousals in obstructive sleep apnea. Sleep 2019; 41:5077823. [PMID: 30137568 DOI: 10.1093/sleep/zsy160] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Indexed: 11/14/2022] Open
Abstract
Study Objectives A negative intrathoracic pressure threshold is one commonly proposed mechanism for triggering respiratory-induced arousals in obstructive sleep apnea (OSA). If so, they should occur during inspiration, shortly after maximal negative pressure swings. Alternatively, respiratory-induced arousals may occur throughout the respiratory cycle if other mechanisms also contribute. However, arousal timing has been minimally investigated. This study aimed to (1) determine the temporal relationship between respiratory-induced arousals and breathing phase and (2) characterize neuromuscular and load compensation responses prior to arousal. Methods Fifty-one CPAP-treated OSA patients underwent a sleep physiology study with genioglossus and tensor palatini EMG, nasal mask/pneumotachograph, and epiglottic pressure. Transient CPAP reductions were delivered to induce respiratory-related arousals. Results Of 354 arousals, 65(60-70)%[mean(CI)] occurred during inspiration, 35(30-40)% during expiration. Nadir epiglottic pressure occurred 68(66-69)% into inspiration while inspiratory arousals had a uniform distribution throughout inspiration. Expiratory arousals occurred predominantly in early expiration. CPAP reductions initially reduced minute ventilation by ~2.5 liter/min, which was restored immediately prior to expiratory but not inspiratory arousals. Duty cycle just prior to arousal was greater for inspiratory versus expiratory arousals [0.20(0.18-0.21) vs. 0.13(0.11-0.15)Δbaseline, p = 0.001]. Peak tensor palatini EMG was higher for expiratory versus inspiratory arousals during prearousal breaths [7.6(5.8-9.6) vs. 3.7(3.0-4.5)%Δbaseline, p = 0.001], whereas genioglossus and tonic tensor palatini EMG were similar between arousal types. Conclusions Over one third of respiratory-induced arousals occur during expiration. These findings highlight the importance of nonpressure threshold mechanisms of respiratory-induced arousals in OSA and suggest that expiratory arousals may be a novel marker of enhanced tensor palatini neuromuscular compensation.
Collapse
Affiliation(s)
- Jason Amatoury
- Neuroscience Research Australia (NeuRA), Sydney NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney NSW, Australia.,Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut, Beirut, Lebanon
| | - Amy S Jordan
- Melbourne School of Physiological Sciences, University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Barbara Toson
- Neuroscience Research Australia (NeuRA), Sydney NSW, Australia
| | - Chinh Nguyen
- Neuroscience Research Australia (NeuRA), Sydney NSW, Australia
| | - Andrew Wellman
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney NSW, Australia
| |
Collapse
|
34
|
Edwards BA, Redline S, Sands SA, Owens RL. More Than the Sum of the Respiratory Events: Personalized Medicine Approaches for Obstructive Sleep Apnea. Am J Respir Crit Care Med 2019; 200:691-703. [PMID: 31022356 PMCID: PMC6775874 DOI: 10.1164/rccm.201901-0014tr] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/22/2019] [Indexed: 11/16/2022] Open
Abstract
Traditionally, the presence and severity of obstructive sleep apnea (OSA) have been defined by the apnea-hypopnea index (AHI). Continuous positive airway pressure is generally first-line therapy despite low adherence, because it reliably reduces the AHI when used, and the response to other therapies is variable. However, there is growing appreciation that the underlying etiology (i.e., endotype) and clinical manifestation (i.e., phenotype) of OSA in an individual are not well described by the AHI. We define and review the important progress made in understanding and measuring physiological mechanisms (or endotypes) that help define subtypes of OSA and identify the potential use of genetics to further refine disease classification. This more detailed understanding of OSA pathogenesis should influence clinical treatment decisions as well as help inform research priorities and clinical study design. In short, treatments could be individualized on the basis of the underlying cause of OSA; patients could better understand which symptoms and outcomes will respond to OSA treatment and by how much; and researchers could select populations most likely to benefit from specific treatment approaches for OSA.
Collapse
Affiliation(s)
- Bradley A. Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine and Department of Neurology, Brigham & Women’s Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, California
| |
Collapse
|
35
|
Efficacy of pharmacotherapy for OSA in adults: A systematic review and network meta-analysis. Sleep Med Rev 2019; 46:74-86. [DOI: 10.1016/j.smrv.2019.04.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 01/08/2023]
|
36
|
Lai V, Tong BK, Tran C, Ricciardiello A, Donegan M, Murray NP, Carberry JC, Eckert DJ. Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity. Sleep 2019; 42:5513371. [DOI: 10.1093/sleep/zsz119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/07/2019] [Indexed: 12/21/2022] Open
Abstract
AbstractStudy ObjectivesMandibular advancement splint (MAS) therapy is a well-tolerated alternative to continuous positive airway pressure for obstructive sleep apnea (OSA). Other therapies, including nasal expiratory positive airway pressure (EPAP) valves, can also reduce OSA severity. However, >50% of patients have an incomplete or no therapeutic response with either therapy alone and thus remain at risk of adverse health outcomes. Combining these therapies may yield greater efficacy to provide a therapeutic solution for many incomplete/nonresponders to MAS therapy. Thus, this study evaluated the efficacy of combination therapy with MAS plus EPAP in incomplete/nonresponders to MAS alone.MethodsTwenty-two people with OSA (apnea–hypopnea index [AHI] = 22 [13, 42] events/hr), who were incomplete/nonresponders (residual AHI > 5 events/hr) on an initial split-night polysomnography with a novel MAS device containing an oral airway, completed an additional split-night polysomnography with MAS + oral EPAP valve and MAS + oral and nasal EPAP valves (order randomized).ResultsCompared with MAS alone, MAS + oral EPAP significantly reduced the median total AHI, with further reductions with the MAS + oral/nasal EPAP combination (15 [10, 34] vs. 10 [7, 21] vs. 7 [3, 13] events/hr, p < 0.01). Larger reductions occurred in supine nonrapid eye movement AHI with MAS + oral/nasal EPAP combination therapy (ΔAHI = 23 events/hr, p < 0.01). OSA resolved (AHI < 5 events/hr) with MAS + oral/nasal EPAP in nine individuals and 13 had ≥50% reduction in AHI from no MAS. However, sleep efficiency was lower with MAS + oral/nasal EPAP versus MAS alone or MAS + oral EPAP (78 ± 19 vs. 87 ± 10 and 88 ± 10% respectively, p < 0.05).ConclusionsCombination therapy with a novel MAS device and simple oral or oro-nasal EPAP valves reduces OSA severity to therapeutic levels for a substantial proportion of incomplete/nonresponders to MAS therapy alone.Clinical TrialsName: Targeted combination therapy: Physiological mechanistic studies to inform treatment for obstructive sleep apnea (OSA)URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372279 Registration: ACTRN12617000492358 (Part C)
Collapse
Affiliation(s)
- Victor Lai
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin K Tong
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Carolin Tran
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
| | | | | | | | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| |
Collapse
|
37
|
Carberry JC, Grunstein RR, Eckert DJ. The effects of zolpidem in obstructive sleep apnea - An open-label pilot study. J Sleep Res 2019; 28:e12853. [PMID: 30968498 DOI: 10.1111/jsr.12853] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/29/2019] [Accepted: 02/27/2019] [Indexed: 02/07/2023]
Abstract
New knowledge on hypnotics and their effects on the phenotypic causes of obstructive sleep apnea indicate that zolpidem has therapeutic potential for certain patients. Specifically, zolpidem increases the threshold for arousal threshold and pharyngeal dilator muscle responsiveness. However, the effects of a standard dose of zolpidem (10 mg) on obstructive sleep apnea severity and symptoms have not been investigated. In an open-label pilot study, 12 unselected people with obstructive sleep apnea were recruited following a diagnostic in-laboratory sleep study. Participants then returned for a single-night sleep study in which 10 mg of zolpidem was given just prior to sleep. Tolerability, next-day sleepiness and the effects of zolpidem on polysomnography variables were assessed. Zolpidem was well tolerated and significantly improved the sleep efficiency compared with the no-drug night (77 ± 12% versus 84 ± 9%, p = 0.005). Individual responses on obstructive sleep apnea severity to zolpidem in this unselected obstructive sleep apnea patient population were variable with no overall systematic difference in apnea-hypopnea index (29 ± 18.2 events per hr versus 33 ± 28 events per hr, p = 0.45) or other key respiratory parameters (e.g. event duration or hypoxemia). Next-day sleepiness assessed via the Karolinska Sleepiness Scale was not different between visits (4 ± 1 versus 4 ± 2, p = 0.85). These findings provide the first insight into the effects of a standard dose of zolpidem in obstructive sleep apnea, and highlight its tolerability and potential to improve sleep quality. The variable effects on obstructive sleep apnea severity observed in this pilot also underscore the need for larger trials that incorporate phenotypic characterisation (e.g. arousal threshold, Pcrit and muscle responsiveness) to understand inter-individual heterogeneity and the therapeutic potential of zolpidem for certain people with obstructive sleep apnea.
Collapse
Affiliation(s)
- Jayne C Carberry
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Sydney, NSW, Australia.,Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Ronald R Grunstein
- Woolcock Institute of Medical Research and the University of Sydney, Sydney, NSW, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA) and the University of New South Wales, Sydney, NSW, Australia.,Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| |
Collapse
|
38
|
Kitipornchai L, Jones A, MacKay SG. Patient Phenotyping in OSA. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00221-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
39
|
Nigam G, Camacho M, Riaz M. The effect of nonbenzodiazepines sedative hypnotics on apnea-hypopnea index: A meta-analysis. Ann Thorac Med 2019; 14:49-55. [PMID: 30745935 PMCID: PMC6341859 DOI: 10.4103/atm.atm_198_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION: Nonbenzodiazepine (non-BZD) sedative hypnotics (NBSH) refer to non-BZD sedatives that act as BZD receptor agonists such as zolpidem, zaleplon, and eszopiclone. Today, there is a high prevalence of insomnia with or without concurrent obstructive sleep apnea (OSA). Our goal was to study how NBSH use impacts the baseline apnea–hypopnea index (AHI) in patients with or without OSA. METHODS: PubMed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were searched. RESULTS: Seventeen studies comprising a cumulative total of 2099 patients were identified in the last 30 years (between 1988 and 2017) that evaluated the effect of NBSH on respiratory parameters during sleep. The AHI mean (M) ± standard deviation (SD) in NBSH group was 13.17 ± 16.27 versus 15.94 ± 19.31 (mean difference [MD]-95% confidence interval [CI], 2.77 [1.463–4.076]). Six studies (100 patients) compared zolpidem with either placebo or no medication and demonstrated an AHI MD of −0.61 events/h (95% CI − 1.94, 0.71), overall effect Z = 0.9, P = 0.36. Four studies (362 patients) compared eszopiclone with placebo and demonstrated an AHI MD of −5.73 events/h0 (95% CI − 8.90, −0.2.57). Two large studies (979 patients) compared both zolpidem and eszopiclone to no medication and found AHI MD of −1.66 events/h (95% CI − 5.87, 0.2.55). CONCLUSIONS: The majority of patients using NBSH did not develop any worsening of existing AHI, when using NBSH, regardless of their baseline AHI values (mild, moderate, severe, or no OSA). On average, the AHI improved minimally with NBSH and eszopiclone showed the largest difference in AHI with an MD of −5.73 events/h.
Collapse
Affiliation(s)
- Gaurav Nigam
- Department of Medicine and Sleep Medicine, Clay County Hospital, Flora, Illinois, USA
| | - Macario Camacho
- Division of Otolaryngology, Sleep Surgery and Sleep Medicine, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Muhammad Riaz
- Astria Health Center, Euclid, Grandview, Washington, USA
| |
Collapse
|
40
|
Sutherland K, Kairaitis K, Yee BJ, Cistulli PA. From CPAP to tailored therapy for obstructive sleep Apnoea. Multidiscip Respir Med 2018; 13:44. [PMID: 30524729 PMCID: PMC6276208 DOI: 10.1186/s40248-018-0157-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/30/2018] [Indexed: 12/20/2022] Open
Abstract
Obstructive Sleep Apnoea (OSA) is a common sleep disorder that is associated with daytime symptoms and a range of comorbidity and mortality. Continuous Positive Airway Pressure (CPAP) therapy is highly efficacious at preventing OSA when in use and has long been the standard treatment for newly diagnosed patients. However, CPAP therapy has well recognised limitations in real world effectiveness due to issues with patient acceptance and suboptimal usage. There is a clear need to enhance OSA treatment strategies and options. Although there are a range of alternative treatments (e.g. weight loss, oral appliances, positional devices, surgery, and emerging therapies such as sedatives and oxygen), generally there are individual differences in efficacy and often OSA will not be completely eliminated. There is increasing recognition that OSA is a heterogeneous disorder in terms of risk factors, clinical presentation, pathophysiology and comorbidity. Better characterisation of OSA heterogeneity will enable tailored approaches to therapy to ensure treatment effectiveness. Tools to elucidate individual anatomical and pathophysiological phenotypes in clinical practice are receiving attention. Additionally, recognising patient preferences, treatment enhancement strategies and broader assessment of treatment effectiveness are part of tailoring therapy at the individual level. This review provides a narrative of current treatment approaches and limitations and the future potential for individual tailoring to enhance treatment effectiveness.
Collapse
Affiliation(s)
- Kate Sutherland
- 1Charles Perkins Centre, The University of Sydney, Sydney, Australia.,2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,3Centre for Sleep Health & Research, Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
| | - Kristina Kairaitis
- 1Charles Perkins Centre, The University of Sydney, Sydney, Australia.,2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,4Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, University of Sydney, Sydney, Australia.,5Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, Australia
| | - Brendon J Yee
- 2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,6NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS) and NHMRC NeuroSleep Centre Woolcock Institute of Medical Research, Sydney, Australia.,7Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter A Cistulli
- 1Charles Perkins Centre, The University of Sydney, Sydney, Australia.,2Faculty of Medicine & Health, The University of Sydney School of Medicine, Sydney, Australia.,3Centre for Sleep Health & Research, Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
| |
Collapse
|
41
|
Carter SG, Carberry JC, Grunstein RR, Eckert DJ. Polysomnography with an epiglottic pressure catheter does not alter obstructive sleep apnea severity or sleep efficiency. J Sleep Res 2018; 28:e12773. [DOI: 10.1111/jsr.12773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | - Danny J. Eckert
- Neuroscience Research Australia (NeuRA) Sydney NSW Australia
| |
Collapse
|
42
|
Mazzotti DR, Lim DC, Sutherland K, Bittencourt L, Mindel JW, Magalang U, Pack AI, de Chazal P, Penzel T. Opportunities for utilizing polysomnography signals to characterize obstructive sleep apnea subtypes and severity. Physiol Meas 2018; 39:09TR01. [PMID: 30047487 DOI: 10.1088/1361-6579/aad5fe] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a heterogeneous sleep disorder with many pathophysiological pathways to disease. Currently, the diagnosis and classification of OSA is based on the apnea-hypopnea index, which poorly correlates to underlying pathology and clinical consequences. A large number of in-laboratory sleep studies are performed around the world every year, already collecting an enormous amount of physiological data within an individual. Clinically, we have not yet fully taken advantage of this data, but combined with existing analytical approaches, we have the potential to transform the way OSA is managed within an individual patient. Currently, respiratory signals are used to count apneas and hypopneas, but patterns such as inspiratory flow signals can be used to predict optimal OSA treatment. Electrocardiographic data can reveal arrhythmias, but patterns such as heart rate variability can also be used to detect and classify OSA. Electroencephalography is used to score sleep stages and arousals, but specific patterns such as the odds-ratio product can be used to classify how OSA patients responds differently to arousals. OBJECTIVE In this review, we examine these and many other existing computer-aided polysomnography signal processing algorithms and how they can reflect an individual's manifestation of OSA. SIGNIFICANCE Together with current technological advance, it is only a matter of time before advanced automatic signal processing and analysis is widely applied to precision medicine of OSA in the clinical setting.
Collapse
Affiliation(s)
- Diego R Mazzotti
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, United States of America
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Tomazini Martins R, Carberry JC, Gandevia SC, Butler JE, Eckert DJ. Effects of morphine on respiratory load detection, load magnitude perception, and tactile sensation in obstructive sleep apnea. J Appl Physiol (1985) 2018; 125:393-400. [DOI: 10.1152/japplphysiol.00065.2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pharyngeal and respiratory sensation is impaired in obstructive sleep apnea (OSA). Opioids may further diminish respiratory sensation. Thus protective pharyngeal neuromuscular and arousal responses to airway occlusion that rely on respiratory sensation could be impaired with opioids to worsen OSA severity. However, little is known about the effects of opioids on upper airway and respiratory sensation in people with OSA. This study was designed to determine the effects of 40 mg of MS-Contin on tactile sensation, respiratory load detection, and respiratory magnitude perception in people with OSA during wakefulness. A double-blind, randomized, crossover design (1 wk washout) was used. Twenty-one men with untreated OSA (apnea/hypopnea index = 26 ± 17 events/h) recruited from a larger clinical study completed the protocol. Tactile sensation using von Frey filaments on the back of the hand, internal mucosa of the cheek, uvula, and posterior pharyngeal wall were not different between placebo and morphine [e.g., median (interquartile range) posterior wall = 0.16 (0.16, 0.4) vs. 0.4 (0.14, 1.8) g, P = 0.261]. Similarly, compared with placebo, morphine did not alter respiratory load detection thresholds for nadir mask pressure detected = −2.05 (−3.37, −1.55) vs. −2.19 (−3.36, −1.41) cmH2O, P = 0.767], or respiratory load magnitude perception [mean ± SD Borg scores during a 5 resistive load (range: 5–126 cmH2O·l−1·s−1) protocol = 4.5 ± 1.6 vs. 4.2 ± 1.2, P = 0.347] but did reduce minute ventilation during quiet breathing (11.4 ± 3.3 vs. 10.7 ± 2.6 l/min, P < 0.01). These findings indicate that 40 mg of MS-Contin does not systematically impair tactile or respiratory sensation in men with mild to moderate, untreated OSA. This suggests that altered respiratory sensation to acute mechanical stimuli is not likely to be a mechanism that contributes to worsening of OSA with a moderate dose of morphine.NEW & NOTEWORTHY Forty milligrams of MS-Contin does not alter upper airway tactile sensation, respiratory load detection thresholds, or respiratory load magnitude perception in people with obstructive sleep apnea but does decrease breathing compared with placebo during wakefulness. Despite increasing concerns of harm with opioids, the current findings suggest that impaired respiratory sensation to acute mechanical stimuli with this dose of MS-Contin is unlikely to be a direct mechanism contributing to worsening sleep apnea severity in people with mild-to-moderate disease.
Collapse
Affiliation(s)
- Rodrigo Tomazini Martins
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| | - Jayne C. Carberry
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| | - Simon C. Gandevia
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane E. Butler
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| | - Danny J. Eckert
- Neuroscience Research Australia (NeuRA), Randwick, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Faculty of Medicine, Sydney, New South Wales, Australia
| |
Collapse
|
44
|
Carter SG, Carberry JC, Cho G, Fisher LP, Rollo CM, Stevens DJ, D'Rozario AL, McKenzie DK, Grunstein RR, Eckert DJ. Effect of 1 month of zopiclone on obstructive sleep apnoea severity and symptoms: a randomised controlled trial. Eur Respir J 2018; 52:13993003.00149-2018. [PMID: 29976648 DOI: 10.1183/13993003.00149-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/23/2018] [Indexed: 12/11/2022]
Abstract
Hypnotic use in obstructive sleep apnoea (OSA) is contraindicated due to safety concerns. Recent studies indicate that single-night hypnotic use worsens hypoxaemia in some and reduces OSA severity in others depending on differences in pathophysiology. However, longer clinical trial data are lacking. This study aimed to determine the effects of 1 month of zopiclone on OSA severity, sleepiness and alertness in patients with low-moderate respiratory arousal thresholds without major overnight hypoxaemia.69 participants completed a physiology screening night with an epiglottic catheter to quantify arousal threshold. 30 eligible patients (apnoea-hypopnoea index (AHI) 22±11 events·h-1) then completed standard in-laboratory polysomnography (baseline) and returned for two additional overnight sleep studies (nights 1 and 30) after receiving either nightly zopiclone (7.5 mg) or placebo during a 1-month, double-blind, randomised, parallel trial (ANZCTR identifier ANZCTRN12613001106729).The change in AHI from baseline to night 30 was not different between zopiclone versus placebo groups (-5.9±10.2 versus -2.4±5.5 events·h-1; p=0.24). Similarly, hypoxaemia, next-day sleepiness and driving simulator performance were not different.1 month of zopiclone does not worsen OSA severity, sleepiness or alertness in selected patients without major overnight hypoxaemia. As the first study to assess the effect of a hypnotic on OSA severity and sleepiness beyond single-night studies, these findings provide important safety data and insight into OSA pathophysiology.
Collapse
Affiliation(s)
| | | | - Garry Cho
- The Woolcock Institute of Medical Research, Sydney, Australia
| | | | | | - David J Stevens
- The Woolcock Institute of Medical Research, Sydney, Australia
| | - Angela L D'Rozario
- The Woolcock Institute of Medical Research, Sydney, Australia.,School of Psychology, Faculty of Science, Brain and Mind Centre and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | | | - Ronald R Grunstein
- The Woolcock Institute of Medical Research, Sydney, Australia.,Royal Prince Alfred Hospital and Sydney Local Heath District, Camperdown, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, Australia
| |
Collapse
|
45
|
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]
|
46
|
|
47
|
Wijesuriya NS, Gainche L, Jordan AS, Berlowitz DJ, LeGuen M, Rochford PD, O'Donoghue FJ, Ruehland WR, Carberry JC, Butler JE, Eckert DJ. Genioglossus reflex responses to negative upper airway pressure are altered in people with tetraplegia and obstructive sleep apnoea. J Physiol 2018; 596:2853-2864. [PMID: 29658103 DOI: 10.1113/jp275222] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
KEY POINTS Protective reflexes in the throat area (upper airway) are crucial for breathing. Impairment of these reflexes can cause breathing problems during sleep such as obstructive sleep apnoea (OSA). OSA is very common in people with spinal cord injury for unknown reasons. This study shows major changes in protective reflexes that serve to keep the upper airway open in response to suction pressures in people with tetraplegia and OSA. These results help us understand why OSA is so common in people with tetraplegia and provide new insight into how protective upper airway reflexes work more broadly. ABSTRACT More than 60% of people with tetraplegia have obstructive sleep apnoea (OSA). However, the specific causes are unknown. Genioglossus, the largest upper-airway dilator muscle, is important in maintaining upper-airway patency. Impaired genioglossus muscle function following spinal cord injury may contribute to OSA. This study aimed to determine if genioglossus reflex responses to negative upper-airway pressure are altered in people with OSA and tetraplegia compared to non-neurologically impaired able-bodied individuals with OSA. Genioglossus reflex responses measured via intramuscular electrodes to ∼60 brief (250 ms) pulses of negative upper-airway pressure (∼-15 cmH2 O at the mask) were compared between 13 participants (2 females) with tetraplegia plus OSA and 9 able-bodied controls (2 females) matched for age and OSA severity. The initial short-latency excitatory reflex response was absent in 6/13 people with tetraplegia and 1/9 controls. Genioglossus reflex inhibition in the absence of excitation was observed in three people with tetraplegia and none of the controls. When the excitatory response was present, it was significantly delayed in the tetraplegia group compared to able-bodied controls: excitation onset latency (mean ± SD) was 32 ± 16 vs. 18 ± 9 ms, P = 0.045; peak excitation latency was 48 ± 17 vs. 33 ± 8 ms, P = 0.038. However, when present, amplitude of the excitation response was not different between groups, 195 ± 26 vs. 219 ± 98% at baseline, P = 0.55. There are major differences in genioglossus reflex morphology and timing in response to rapid changes in airway pressure in people with tetraplegia and OSA. Altered genioglossus function may contribute to the increased risk of OSA in people with tetraplegia. The precise mechanisms mediating these differences are unknown.
Collapse
Affiliation(s)
| | - Laura Gainche
- University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep (IBAS), Melbourne, Australia
| | - Amy S Jordan
- University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep (IBAS), Melbourne, Australia
| | - David J Berlowitz
- University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep (IBAS), Melbourne, Australia.,Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Mariannick LeGuen
- University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep (IBAS), Melbourne, Australia
| | - Peter D Rochford
- Institute for Breathing and Sleep (IBAS), Melbourne, Australia.,Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Fergal J O'Donoghue
- University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep (IBAS), Melbourne, Australia.,Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Warren R Ruehland
- University of Melbourne, Melbourne, Australia.,Institute for Breathing and Sleep (IBAS), Melbourne, Australia.,Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), Randwick, NSW, Australia.,University of New South Wales, Syndney, Australia
| | - Jane E Butler
- Neuroscience Research Australia (NeuRA), Randwick, NSW, Australia.,University of New South Wales, Syndney, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Randwick, NSW, Australia.,University of New South Wales, Syndney, Australia
| |
Collapse
|
48
|
Effect of 4-Aminopyridine on Genioglossus Muscle Activity during Sleep in Healthy Adults. Ann Am Thorac Soc 2018; 14:1177-1183. [PMID: 28387543 DOI: 10.1513/annalsats.201701-006oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE The reduction in upper airway muscle activity from wakefulness to sleep plays a key role in the development of obstructive sleep apnea. Potassium (K+) channels have been recently identified as the downstream mechanisms through which hypoglossal motoneuron membrane excitability is reduced both in non-rapid eye movement (NREM) sleep and REM sleep. In animal models, the administration of 4-aminopyridine (4-AP), a voltage-gated K+ channel blocker, increased genioglossus activity during wakefulness and across all sleep stages. OBJECTIVES We tested the hypothesis that administration of a single dose of 4-AP 10 mg extended release would increase genioglossus activity (electromyography of the genioglossus muscle [EMGGG]) during wakefulness and sleep, and thereby decrease pharyngeal collapsibility. METHODS We performed a randomized controlled crossover proof-of-concept trial in 10 healthy participants. Participants received active treatment or placebo in randomized order 3 hours before bedtime in the physiology laboratory. RESULTS EMGGG during wakefulness and NREM sleep and upper airway collapsibility measured during NREM sleep were unchanged between placebo and 4-AP nights. Tonic but not phasic EMGGG during REM sleep was higher on the 4-AP night when measured as a percentage of maximal voluntary activation (median [interquartile range] 0.3 [0.5] on placebo vs. 0.8 [1.9] %max on 4 AP; P = 0.04), but not when measured in μV or as a percentage of wakefulness value. CONCLUSIONS A single dose of 4-AP 10 mg extended release showed only a small increase in tonic EMGGG during REM sleep in this group of healthy subjects. We speculate that a higher dose of 4-AP may further increase EMGGG. However, given the potentially severe, dose-related adverse effects of this drug, including seizures, the administration of 4-AP does not appear to be an effective strategy to increase genioglossus activity during sleep in humans. Clinical Trial registered with clinicaltrials.gov (NCT02656160).
Collapse
|
49
|
Abstract
PURPOSE OF REVIEW In this review, we discuss the current treatment options for sleep-disordered breathing (SDB) in patients with heart failure (HF). We address the role of positive airway pressure (PAP) devices and other emerging therapies. The review includes discussion of recent trials that reported negative consequences for the PAP devices in patients with heart failure. RECENT FINDINGS Optimal guideline-directed medical therapies of HF and PAP devices have been the mainstay treatments for HF patients with SDB. Recently, randomized controlled trials (RCTs) evaluated the effect of PAP on clinical outcomes in patients with cardiovascular (CV) disease and heart failure and found no benefit in decreasing fatal and non-fatal CV events. The Sleep Apnea Cardiovascular Endpoints (SAVE) trial evaluated continuous positive airway pressure (CPAP) ventilation in patients with CV disease and obstructive sleep apnea (OSA) and did not observe any improvement in CV effect. In patients with HF and central sleep apnea (CSA), adaptive servo-ventilation (ASV) was hypothesized to help HF outcomes, but the Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure (SERVE-HF) trial did not show any mortality benefit. Instead, the trial suggested an increase in all-cause and CV mortality in the treatment arm. currently, studies have not shown the use of PAP therapy to improve any risks of CV outcomes or death in HF patients with sleep apnea, but some associations with improvements in symptoms from OSA have been observed.
Collapse
|
50
|
|