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Sands SA, Collet J, Gell LK, Calianese N, Hess LB, Vena D, Azarbarzin A, Bertisch SM, Landry S, Thomson L, Joosten SA, Hamilton GS, Edwards BA. Combination pharmacological therapy targeting multiple mechanisms of sleep apnoea: a randomised controlled cross-over trial. Thorax 2024; 79:259-268. [PMID: 38286618 DOI: 10.1136/thorax-2023-220184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/23/2023] [Indexed: 01/31/2024]
Abstract
RATIONALE Acetazolamide and atomoxetine-plus-oxybutynin ('AtoOxy') can improve obstructive sleep apnoea (OSA) by stabilising ventilatory control and improving dilator muscle responsiveness respectively. Given the different pathophysiological mechanisms targeted by each intervention, we tested whether AtoOxy-plus-acetazolamide would be more efficacious than AtoOxy alone. METHODS In a multicentre randomised crossover trial, 19 patients with moderate-to-severe OSA received AtoOxy (80/5 mg), acetazolamide (500 mg), combined AtoOxy-plus-acetazolamide or placebo at bedtime for three nights (half doses on first night) with a 4-day washout between conditions. Outcomes were assessed at baseline and night 3 of each treatment period. Mixed model analysis compared the reduction in Apnoea-Hypopnoea Index (AHI) from baseline between AtoOxy-plus-acetazolamide and AtoOxy (primary outcome). Secondary outcomes included hypoxic burden and arousal index. RESULTS Although AtoOxy lowered AHI by 49 (33, 62)%baseline (estimate (95% CI)) vs placebo, and acetazolamide lowered AHI by+34 (14, 50)%baseline vs placebo, AtoOxy-plus-acetazolamide was not superior to AtoOxy alone (difference: -2 (-18, 11)%baseline, primary outcome p=0.8). Likewise, the hypoxic burden was lowered with AtoOxy (+58 (37, 71)%baseline) and acetazolamide (+37 (5, 58)%baseline), but no added benefit versus AtoOxy occurred when combined (difference: -13 (-5, 39)%baseline). Arousal index was also modestly reduced with each intervention (11%baseline-16%baseline). Mechanistic analyses revealed that similar traits (ie, higher baseline compensation, lower loop gain) were associated with both AtoOxy and acetazolamide efficacy. CONCLUSIONS While AtoOxy halved AHI, and acetazolamide lowered AHI by a third, the combination of these leading experimental interventions provided no greater efficacy than AtoOxy alone. Failure of acetazolamide to further increase efficacy suggests overlapping physiological mechanisms. TRIAL REGISTRATION NUMBER NCT03892772.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne M Bertisch
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shane Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Luke Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
- School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
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Gell LK, Vena D, Grace K, Azarbarzin A, Messineo L, Hess LB, Calianese N, Labarca G, Taranto-Montemurro L, White DP, Wellman A, Sands SA. Drive versus Pressure Contributions to Genioglossus Activity in Obstructive Sleep Apnea. Ann Am Thorac Soc 2023; 20:1326-1336. [PMID: 37411045 PMCID: PMC10502881 DOI: 10.1513/annalsats.202301-083oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/26/2023] [Indexed: 07/08/2023] Open
Abstract
Rationale: Loss of pharyngeal dilator muscle activity is a key determinant of respiratory events in obstructive sleep apnea (OSA). After the withdrawal of wakefulness stimuli to the genioglossus at sleep onset, mechanoreceptor negative pressure and chemoreceptor ventilatory drive feedback govern genioglossus activation during sleep, but the relative contributions of drive and pressure stimuli to genioglossus activity across progressive obstructive events remain unclear. We recently showed that drive typically falls during events, whereas negative pressures increase, providing a means to assess their individual contributions to the time course of genioglossus activity. Objectives: For the first time, we critically test whether the loss of drive could explain the loss of genioglossus activity observed within events in OSA. Methods: We examined the time course of genioglossus activity (EMGgg; intramuscular electromyography), ventilatory drive (intraesophageal diaphragm electromyography), and esophageal pressure during spontaneous respiratory events (using the ensemble-average method) in 42 patients with OSA (apnea-hypopnea index 5-91 events/h). Results: Multivariable regression demonstrated that the falling-then-rising time course of EMGgg may be well explained by falling-then-rising drive and rising negative pressure stimuli (model R = 0.91 [0.88-0.98] [95% confidence interval]). Overall, EMGgg was 2.9-fold (0.47-∞) more closely associated with drive than pressure stimuli (ratio of standardized coefficients, βdrive:βpressure; ∞ denotes absent pressure contribution). However, individual patient results were heterogeneous: approximately one-half (n = 22 of 42) exhibited drive-dominant responses (i.e., βdrive:βpressure > 2:1), and one-quarter (n = 11 of 42) exhibited pressure-dominant EMGgg responses (i.e., βdrive:βpressure < 1:2). Patients exhibiting more drive-dominant EMGgg responses experienced greater event-related EMGgg declines (12.9 [4.8-21.0] %baseline/standard deviation of βdrive:βpressure; P = 0.004, adjusted analysis). Conclusions: Loss of genioglossus activity precipitating events in patients with OSA is strongly associated with a contemporaneous loss of drive and is greatest in those whose activity tracks drive rather than pressure stimuli. These findings were upheld for events without prior arousal. Responding to falling drive rather than rising negative pressure during events may be deleterious; future therapeutic strategies whose aim is to sustain genioglossus activity by preferentially enhancing responses to rising pressure rather than falling drive are of interest.
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Affiliation(s)
- Laura K. Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Kevin Grace
- Department of Neurological Surgery, University of California, Davis, Sacramento, California
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
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Gell LK, Vena D, Alex RM, Azarbarzin A, Calianese N, Hess LB, Taranto-Montemurro L, White DP, Wellman A, Sands SA. Neural ventilatory drive decline as a predominant mechanism of obstructive sleep apnoea events. Thorax 2022; 77:707-716. [PMID: 35064045 PMCID: PMC10039972 DOI: 10.1136/thoraxjnl-2021-217756] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/18/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In the classic model of obstructive sleep apnoea (OSA), respiratory events occur with sleep-related dilator muscle hypotonia, precipitating increased neural ventilatory 'drive'. By contrast, a drive-dependent model has been proposed, whereby falling drive promotes dilator muscle hypotonia to precipitate respiratory events. Here we determine the extent to which the classic versus drive-dependent models of OSA are best supported by direct physiological measurements. METHODS In 50 OSA patients (5-91 events/hour), we recorded ventilation ('flow', oronasal mask and pneumotach) and ventilatory drive (calibrated intraoesophageal diaphragm electromyography, EMG) overnight. Flow and drive during events were ensemble averaged; patients were classified as drive dependent if flow fell/rose simultaneously with drive. Overnight effects of lower drive on flow, genioglossus muscle activity (EMGgg) and event risk were quantified (mixed models). RESULTS On average, ventilatory drive fell (rather than rose) during events (-20 (-42 to 3)%baseline, median (IQR)) and was strongly correlated with flow (R=0.78 (0.24 to 0.94)). Most patients (30/50, 60%) were classified as exhibiting drive-dependent event pathophysiology. Lower drive during sleep was associated with lower flow (-17 (-20 to -14)%/drive) and EMGgg (-3.5 (-3.8 to -3.3)%max/drive) and greater event risk (OR: 2.2 (1.8 to 2.5) per drive reduction of 100%eupnoea); associations were concentrated in patients with drive-dependent OSA (ie, flow: -37 (-40 to -34)%/drive, OR: 6.8 (5.3 to 8.7)). Oesophageal pressure-without tidal volume correction-falsely suggested rising drive during events (classic model). CONCLUSIONS In contrast to the prevailing view, patients with OSA predominantly exhibit drive-dependent event pathophysiology, whereby flow is lowest at nadir drive, and lower drive raises event risk. Preventing ventilatory drive decline is therefore considered a target for OSA intervention.
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Affiliation(s)
- Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Raichel M Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Vena D, Taranto-Montemurro L, Azarbarzin A, Op de Beeck S, Marques M, Vanderveken OM, Edwards BA, Gell L, Calianese N, Hess LB, Radmand R, Hamilton GS, Joosten SA, Verbraecken J, Braem M, White DP, Redline S, Sands SA, Wellman A. Clinical polysomnographic methods for estimating pharyngeal collapsibility in obstructive sleep apnea. Sleep 2022; 45:zsac050. [PMID: 35238379 PMCID: PMC9189952 DOI: 10.1093/sleep/zsac050] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea has major health consequences but is challenging to treat. For many therapies, efficacy is determined by the severity of underlying pharyngeal collapsibility, yet there is no accepted clinical means to measure it. Here, we provide insight into which polysomnographic surrogate measures of collapsibility are valid, applicable across the population, and predictive of therapeutic outcomes. METHODS Seven promising polysomnography-derived surrogate collapsibility candidates were evaluated: Vpassive (flow at eupneic ventilatory drive), Vmin (ventilation at nadir drive), event depth (depth of the average respiratory event), oxygen desaturation slope and mean oxygen desaturation (events-related averages), Fhypopneas (fraction of events scored as hypopneas), and apnea index. Evaluation included (1) validation by comparison to physiological gold-standard collapsibility values (critical closing pressure, Pcrit), (2) capacity to detect increased collapsibility with older age, male sex, and obesity in a large community-based cohort (Multi-Ethnic Study of Atherosclerosis, MESA), and (3) prediction of treatment efficacy (oral appliances and pharmacological pharyngeal muscle stimulation using atomoxetine-plus-oxybutynin). RESULTS Pcrit was significantly correlated with Vmin (r = -0.54), event depth (r = 0.49), Vpassive (r = -0.38), Fhypopneas (r = -0.46), and apnea index (r = -0.46; all p < .01) but not others. All measures detected greater collapsibility with male sex, age, and obesity, except Fhypopneas and apnea index which were not associated with obesity. Fhypopneas and apnea index were associated with oral appliance and atomoxetine-plus-oxybutynin efficacy (both p < .05). CONCLUSIONS Among several candidates, event depth, Fhypopneas, and apnea index were identified as preferred pharyngeal collapsibility surrogates for use in the clinical arena.
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Affiliation(s)
- Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Laboratório do sono, Instituto do Coração (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Bradley A Edwards
- Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Laura Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Radmand
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Johan Verbraecken
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Multidisciplinary Sleep Disorder Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Marc Braem
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
- Division of Special Care Dentistry, Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Messineo L, Eckert DJ, Taranto-Montemurro L, Vena D, Azarbarzin A, Hess LB, Calianese N, White DP, Wellman A, Gell L, Sands SA. Ventilatory Drive Withdrawal Rather Than Reduced Genioglossus Compensation as a Mechanism of Obstructive Sleep Apnea in REM Sleep. Am J Respir Crit Care Med 2022; 205:219-232. [PMID: 34699338 PMCID: PMC8787251 DOI: 10.1164/rccm.202101-0237oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Rationale: REM sleep is associated with reduced ventilation and greater obstructive sleep apnea (OSA) severity than non-REM (nREM) sleep for reasons that have not been fully elucidated. Objectives: Here, we use direct physiological measurements to determine whether the pharyngeal compromise in REM sleep OSA is most consistent with 1) withdrawal of neural ventilatory drive or 2) deficits in pharyngeal pathophysiology per se (i.e., increased collapsibility and decreased muscle responsiveness). Methods: Sixty-three participants with OSA completed sleep studies with gold standard measurements of ventilatory "drive" (calibrated intraesophageal diaphragm EMG), ventilation (oronasal "ventilation"), and genioglossus EMG activity. Drive withdrawal was assessed by examining these measurements at nadir drive (first decile of drive within a stage). Pharyngeal physiology was assessed by examining collapsibility (lowered ventilation at eupneic drive) and responsiveness (ventilation-drive slope). Mixed-model analysis compared REM sleep with nREM sleep; sensitivity analysis examined phasic REM sleep. Measurements and Main Results: REM sleep (⩾10 min) was obtained in 25 patients. Compared with drive in nREM sleep, drive in REM sleep dipped to markedly lower nadir values (first decile, estimate [95% confidence interval], -21.8% [-31.2% to -12.4%] of eupnea; P < 0.0001), with an accompanying reduction in ventilation (-25.8% [-31.8% to -19.8%] of eupnea; P < 0.0001). However, there was no effect of REM sleep on collapsibility (ventilation at eupneic drive), baseline genioglossus EMG activity, or responsiveness. REM sleep was associated with increased OSA severity (+10.1 [1.8 to 19.8] events/h), but this association was not present after adjusting for nadir drive (+4.3 [-4.2 to 14.6] events/h). Drive withdrawal was exacerbated in phasic REM sleep. Conclusions: In patients with OSA, the pharyngeal compromise characteristic of REM sleep appears to be predominantly explained by ventilatory drive withdrawal rather than by preferential decrements in muscle activity or responsiveness. Preventing drive withdrawal may be the leading target for REM sleep OSA.
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Affiliation(s)
- Ludovico Messineo
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, Adelaide, South Australia, Australia;,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Danny J. Eckert
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - David P. White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Laura Gell
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and,Department of Allergy Immunology and Respiratory Medicine, Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
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Mann DL, Georgeson T, Landry SA, Edwards BA, Azarbarzin A, Vena D, Hess LB, Wellman A, Redline S, Sands SA, Terrill PI. Frequency of flow limitation using airflow shape. Sleep 2021; 44:6317693. [PMID: 34240221 DOI: 10.1093/sleep/zsab170] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/27/2021] [Indexed: 12/26/2022] Open
Abstract
STUDY OBJECTIVES The presence of flow limitation during sleep is associated with adverse health consequences independent of obstructive sleep apnea (OSA) severity (apnea-hypopnea index, AHI), but remains extremely challenging to quantify. Here we present a unique library and an accompanying automated method that we apply to investigate flow limitation during sleep. METHODS A library of 117,871 breaths (N=40 participants) were visually classified (certain flow limitation, possible flow limitation, normal) using airflow shape and physiological signals (ventilatory drive per intra-esophageal diaphragm EMG). An ordinal regression model was developed to quantify flow limitation certainty using flow-shape features (e.g. flattening, scooping); breath-by-breath agreement (Cohen's ƙ) and overnight flow limitation frequency (R 2, %breaths in certain or possible categories during sleep) were compared against visual scoring. Subsequent application examined flow limitation frequency during arousals and stable breathing, and associations with ventilatory drive. RESULTS The model (23 features) assessed flow limitation with good agreement (breath-by-breath ƙ=0.572, p<0.001) and minimal error (overnight flow limitation frequency R 2=0.86, error=7.2%). Flow limitation frequency was largely independent of AHI (R 2=0.16) and varied widely within individuals with OSA (74[32-95]%breaths, mean[range], AHI>15/hr, N=22). Flow limitation was unexpectedly frequent but variable during arousals (40[5-85]%breaths) and stable breathing (58[12-91]%breaths), and was associated with elevated ventilatory drive (R 2=0.26-0.29; R 2<0.01 AHI v. drive). CONCLUSIONS Our method enables quantification of flow limitation frequency, a key aspect of obstructive sleep-disordered breathing that is independent of the AHI and often unavailable. Flow limitation frequency varies widely between individuals, is prevalent during arousals and stable breathing, and reveals elevated ventilatory drive.
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Affiliation(s)
- Dwayne L Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia.,Institute for Social Science Research, The University of Queensland, Brisbane, Australia.,Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Thomas Georgeson
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Shane A Landry
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, School of Biomedical Sciences and Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
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7
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Vena D, Azarbarzin A, Marques M, Op de Beeck S, Vanderveken OM, Edwards BA, Calianese N, Hess LB, Radmand R, Hamilton GS, Joosten SA, Taranto-Montemurro L, Kim SW, Verbraecken J, Braem M, White DP, Sands SA, Wellman A. Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow. Sleep 2021; 43:5733095. [PMID: 32043131 DOI: 10.1093/sleep/zsaa004] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/20/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES Oral appliance therapy is an increasingly common option for treating obstructive sleep apnea (OSA) in patients who are intolerant to continuous positive airway pressure (CPAP). Clinically applicable tools to identify patients who could respond to oral appliance therapy are limited. METHODS Data from three studies (N = 81) were compiled, which included two sleep study nights, on and off oral appliance treatment. Along with clinical variables, airflow features were computed that included the average drop in airflow during respiratory events (event depth) and flow shape features, which, from previous work, indicates the mechanism of pharyngeal collapse. A model was developed to predict oral appliance treatment response (>50% reduction in apnea-hypopnea index [AHI] from baseline plus a treatment AHI <10 events/h). Model performance was quantified using (1) accuracy and (2) the difference in oral appliance treatment efficacy (percent reduction in AHI) and treatment AHI between predicted responders and nonresponders. RESULTS In addition to age and body mass index (BMI), event depth and expiratory "pinching" (validated to reflect palatal prolapse) were the airflow features selected by the model. Nonresponders had deeper events, "pinched" expiratory flow shape (i.e. associated with palatal collapse), were older, and had a higher BMI. Prediction accuracy was 74% and treatment AHI was lower in predicted responders compared to nonresponders by a clinically meaningful margin (8.0 [5.1 to 11.6] vs. 20.0 [12.2 to 29.5] events/h, p < 0.001). CONCLUSIONS A model developed with airflow features calculated from routine polysomnography, combined with age and BMI, identified oral appliance treatment responders from nonresponders. This research represents an important application of phenotyping to identify alternative treatments for personalized OSA management.
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Affiliation(s)
- Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Turner Institute for Brain and Mental Health, Notting Hill, Australia
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Reza Radmand
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,School of Clinical Sciences, Monash University, Clayton, Australia
| | - Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Australia.,School of Clinical Sciences, Monash University, Clayton, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sang-Wook Kim
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Department of Otorhinolaryngology, Gyeongsang National University College of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem, Belgium
| | - Marc Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Division of Special Care Dentistry, Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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8
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Taranto-Montemurro L, Messineo L, Azarbarzin A, Vena D, Hess LB, Calianese NA, White DP, Wellman A, Sands SA. Effects of the Combination of Atomoxetine and Oxybutynin on OSA Endotypic Traits. Chest 2020; 157:1626-1636. [PMID: 32006590 DOI: 10.1016/j.chest.2020.01.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 12/12/2019] [Accepted: 01/12/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We recently showed that administration of the combination of the noradrenergic drug atomoxetine plus the antimuscarinic oxybutynin (ato-oxy) prior to sleep greatly reduced OSA severity, likely by increasing upper airway dilator muscle activity during sleep. In patients with OSA who performed the ato-oxy trial with an esophageal pressure catheter to estimate ventilatory drive, the effect of the drug combination (n = 17) and of the single drugs (n = 6) was measured on the endotypic traits over a 1-night administration and compared vs placebo. This study also tested if specific traits were predictors of complete response to treatment (reduction in apnea-hypopnea index [AHI] > 50% and < 10 events/h). METHODS The study was a double-blind, randomized, placebo-controlled trial. The arousal threshold, collapsibility (ventilation at eupneic drive [Vpassive]), ventilation at arousal threshold, and loop gain (stability of ventilatory control, LG1), were calculated during spontaneous breathing during sleep. Muscle compensation (upper airway response) was calculated as a function of ventilation at arousal threshold adjusted for Vpassive. Ventilation was expressed as a percentage of the eupneic level of ventilation (%eupnea). Data are presented as mean [95% CI]. RESULTS Compared with placebo, ato-oxy increased Vpassive by 73 [54 to 91]%eupnea (P < .001) and muscle compensation by 29 [8 to 51]%eupnea (P = .012), reduced the arousal threshold by -9 [-14 to -3]% (P = .022) and LG1 by -11 [-22 to 2]% (P = .022). Atomoxetine alone significantly reduced arousal threshold and LG1. Both agents alone improved collapsibility (Vpassive) but not muscle compensation. Patients with lower AHI, higher Vpassive, and higher fraction of hypopneas over total events had a complete response with ato-oxy. FINDINGS Ato-oxy markedly improved the measures of upper airway collapsibility, increased breathing stability, and slightly reduced the arousal threshold. Patients with relatively lower AHI and less severe upper airway collapsibility had the best chance for OSA resolution with ato-oxy.
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Affiliation(s)
- Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA.
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA; Respiratory Medicine and Sleep Laboratory, Department of Internal Medicine, Spedali Civili di Brescia, University of Brescia, Brescia, Italy; Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Nicole A Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA
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9
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Marques M, Genta PR, Azarbarzin A, Taranto-Montemurro L, Messineo L, Hess LB, Demko G, White DP, Sands SA, Wellman A. Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea. J Physiol 2019; 597:5399-5410. [PMID: 31503323 PMCID: PMC8359733 DOI: 10.1113/jp278164] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/25/2019] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS •Some patients with obstructive sleep apnoea (OSA) respond well to oral appliance therapy, whereas others do not for reasons that are unclear. •In the present study, we used gold-standard measurements to demonstrate that patients with a posteriorly-located tongue (natural sleep endoscopy) exhibit a preferential improvement in collapsibility (lowered critical closing pressure) with oral appliances. •We also show that patients with both posteriorly-located tongue and less severe collapsibility (predicted responder phenotype) exhibit greater improvements in severity of obstructive sleep apnoea (i.e. reduction in event frequency by 83%, in contrast to 48% in predicted non-responders). •The present study suggests that the structure and severity of pharyngeal obstruction determine the phenotype of sleep apnoea patients who benefit maximally from oral appliance efficacy. ABSTRACT A major limitation to the administration of oral appliance therapy for obstructive sleep apnoea (OSA) is that therapeutic responses remain unpredictable. In the present study, we tested the hypotheses that oral appliance therapy (i) reduces pharyngeal collapsibility preferentially in patients with posteriorly-located tongue and (ii) is most efficacious (reduction in apnoea-hypopnea index; AHI) in patients with a posteriorly-located tongue and less-severe baseline pharyngeal collapsibility. Twenty-five OSA patients underwent upper airway endoscopy during natural sleep to assess tongue position (type I: vallecula entirely visible; type II: vallecula obscured; type III: vallecula and glottis obscured), as well as obstruction as a result of other pharyngeal structures (e.g. epiglottis). Additional sleep studies with and without oral appliance were performed to measure collapsibility (critical closing pressure; Pcrit) and assess treatment efficacy. Overall, oral appliance therapy reduced Pcrit by 3.9 ± 2.4 cmH2 O (mean ± SD) and AHI by 69 ± 19%. Therapy lowered Pcrit by an additional 2.7 ± 0.9 cmH2 O in patients with posteriorly-located tongue (types II and III) compared to those without (type I) (P < 0.008). Posteriorly-located tongue (p = 0.03) and lower collapsibility (p = 0.04) at baseline were significant determinants of (greater-than-average) treatment efficacy. Predicted responders (type II and III and Pcrit < 1 cmH2 O) exhibited a greater reduction in the AHI (83 ± 9 vs. 48 ± 8% baseline, P < 0.001) and a lower treatment AHI (9 ± 6 vs. 32 ± 15 events h-1 , P < 0.001) than predicted non-responders. The site and severity of pharyngeal collapse combine to determine oral appliance efficacy. Specifically, patients with a posteriorly-located tongue plus less-severe collapsibility are the strongest candidates for oral appliance therapy.
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Affiliation(s)
- Melania Marques
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Laboratorio do sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Pedro R Genta
- Laboratorio do sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Respiratory Medicine and Sleep Laboratory, Department of Experimental and Clinical Sciences, University of Brescia and Spedali Civili, Brescia, Italy
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gail Demko
- Sleep Apnea Dentists of New England, Weston, MA, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, VIC, Australia
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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10
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Sands SA, Edwards BA, Terrill PI, Butler JP, Owens RL, Taranto-Montemurro L, Azarbarzin A, Marques M, Hess LB, Smales ET, de Melo CM, White DP, Malhotra A, Wellman A. Identifying obstructive sleep apnoea patients responsive to supplemental oxygen therapy. Eur Respir J 2018; 52:13993003.00674-2018. [PMID: 30139771 DOI: 10.1183/13993003.00674-2018] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/29/2018] [Indexed: 11/05/2022]
Abstract
A possible precision-medicine approach to treating obstructive sleep apnoea (OSA) involves targeting ventilatory instability (elevated loop gain) using supplemental inspired oxygen in selected patients. Here we test whether elevated loop gain and three key endophenotypic traits (collapsibility, compensation and arousability), quantified using clinical polysomnography, can predict the effect of supplemental oxygen on OSA severity.36 patients (apnoea-hypopnoea index (AHI) >20 events·h-1) completed two overnight polysomnographic studies (single-blinded randomised-controlled crossover) on supplemental oxygen (40% inspired) versus sham (air). OSA traits were quantified from the air-night polysomnography. Responders were defined by a ≥50% reduction in AHI (supine non-rapid eye movement). Secondary outcomes included blood pressure and self-reported sleep quality.Nine of 36 patients (25%) responded to supplemental oxygen (ΔAHI=72±5%). Elevated loop gain was not a significant univariate predictor of responder/non-responder status (primary analysis). In post hoc analysis, a logistic regression model based on elevated loop gain and other traits (better collapsibility and compensation; cross-validated) had 83% accuracy (89% before cross-validation); predicted responders exhibited an improvement in OSA severity (ΔAHI 59±6% versus 12±7% in predicted non-responders, p=0.0001) plus lowered morning blood pressure and "better" self-reported sleep.Patients whose OSA responds to supplemental oxygen can be identified by measuring their endophenotypic traits using diagnostic polysomnography.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Dept of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
| | - Bradley A Edwards
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Sleep and Circadian Medicine Laboratory, Dept of Physiology, Monash University, Melbourne, Australia.,School of Psychological Sciences, Monash University, Melbourne, Australia.,Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - James P Butler
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert L Owens
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Erik T Smales
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Camila M de Melo
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Atul Malhotra
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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11
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Sands SA, Edwards BA, Terrill PI, Taranto-Montemurro L, Azarbarzin A, Marques M, Hess LB, White DP, Wellman A. Phenotyping Pharyngeal Pathophysiology using Polysomnography in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med 2018; 197:1187-1197. [PMID: 29327943 PMCID: PMC6019932 DOI: 10.1164/rccm.201707-1435oc] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 01/11/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Therapies for obstructive sleep apnea (OSA) could be administered on the basis of a patient's own phenotypic causes ("traits") if a clinically applicable approach were available. OBJECTIVES Here we aimed to provide a means to quantify two key contributors to OSA-pharyngeal collapsibility and compensatory muscle responsiveness-that is applicable to diagnostic polysomnography. METHODS Based on physiological definitions, pharyngeal collapsibility determines the ventilation at normal (eupneic) ventilatory drive during sleep, and pharyngeal compensation determines the rise in ventilation accompanying a rising ventilatory drive. Thus, measuring ventilation and ventilatory drive (e.g., during spontaneous cyclic events) should reveal a patient's phenotypic traits without specialized intervention. We demonstrate this concept in patients with OSA (N = 29), using a novel automated noninvasive method to estimate ventilatory drive (polysomnographic method) and using "gold standard" ventilatory drive (intraesophageal diaphragm EMG) for comparison. Specialized physiological measurements using continuous positive airway pressure manipulation were employed for further comparison. The validity of nasal pressure as a ventilation surrogate was also tested (N = 11). MEASUREMENTS AND MAIN RESULTS Polysomnography-derived collapsibility and compensation estimates correlated favorably with those quantified using gold standard ventilatory drive (R = 0.83, P < 0.0001; and R = 0.76, P < 0.0001; respectively) and using continuous positive airway pressure manipulation (R = 0.67, P < 0.0001; and R = 0.64, P < 0.001; respectively). Polysomnographic estimates effectively stratified patients into high versus low subgroups (accuracy, 69-86% vs. ventilatory drive measures; P < 0.05). Traits were near-identical using nasal pressure versus pneumotach (N = 11, R ≥ 0.98, both traits; P < 0.001). CONCLUSIONS Phenotypes of pharyngeal dysfunction in OSA are evident from spontaneous changes in ventilation and ventilatory drive during sleep, enabling noninvasive phenotyping in the clinic. Our approach may facilitate precision therapeutic interventions for OSA.
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Affiliation(s)
- Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Allergy, Immunology and Respiratory Medicine, Melbourne, Victoria, Australia
- Central Clinical School
| | - Bradley A. Edwards
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Sleep and Circadian Medicine Laboratory, Department of Physiology, and
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Philip I. Terrill
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Queensland, Australia; and
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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