Central sleep apnea is not uncommon in children with neurologic disorders. The mechanisms include increased ventilatory chemosensitivity to carbon dioxide level. Conventional treatments include oxygen, noninvasive ventilation, and in patients with heart failure, improving cardiac output. Here, we present a case of a 9-year-old male with Angelman syndrome, epilepsy, insomnia, and central sleep apnea. The patient was initially evaluated for nighttime awakenings and pauses in breathing. Sustained-release melatonin was used to improve his nighttime awakenings. A polysomnography confirmed central sleep apnea. We saw a reduction in arousals and improvement in insomnia with sustained-release melatonin. On a repeat study, central sleep apnea was improved. We hypothesize that sustained-release melatonin, by improving sleep continuity and reducing arousals, might improve central sleep apnea. Studies are needed to test the hypothesis. PMID:23220792
Jain, Sejal V; Simakajornboon, Narong; Arthur, Todd M
Sodium oxybate (?-hydroxybutyric acid, GHB) is a neurotransmitter in the human brain which exerts sedative effects and is used therapeutically in the treatment of narcolepsy. Current safety recommendations have been formulated for the use of GHB in patients with preexisting breathing disorders. We report the case of a 39-year-old female with narcolepsy and cataplexy revealing the de novo emergence of central sleep apneas in a Cheyne-Stokes pattern under constant treatment with GHB. After discontinuation of GHB, polysomnographic re-evaluation demonstrated the disappearance of central sleep apneas. To our knowledge, this is the first report of de novo central sleep apneas induced by GHB in a patient without pre-existing sleep-disordered breathing, suggesting that there is a need for further investigation and potentially an extension of the safety guidelines to patients without a pre-existing breathing disorder. PMID:23834969
Frase, Lukas; Schupp, Jonas; Sorichter, Stephan; Randelshofer, Wolfgang; Riemann, Dieter; Nissen, Christoph
By the current definition, complex sleep apnea (CompSA) refers to the emergence of central sleep apnea (CSA) during the treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP). However, new-onset CSA has been described with use of other treatments for OSA, including tracheostomy, maxillofacial surgery, and mandibular advancement device. We present a patient with CSA beginning after endoscopic sinus and nasal surgery for nasal obstruction in the setting of mild OSA. This case highlights the importance of non-PAP mechanisms in the pathogenesis of CompSA. Citation: Goldstein C; Kuzniar TJ. The emergence of central sleep apnea after surgical relief of nasal obstruction in obstructive sleep apnea. J Clin Sleep Med 2012;8(3):321-322.
Goldstein, Cathy; Kuzniar, Tomasz J.
Complex sleep apnea is the term used to describe a form of sleep disordered breathing in which repeated central apneas (>5/hour) persist or emerge when obstructive events are extinguished with positive airway pressure (PAP) and for which there is not a clear cause for the central apneas such as narcotics or systolic heart failure. The driving forces in the pathophysiology are felt to be ventilator instability associated oscillation in PaCO2 arterial partial pressure of Carbon Dioxide, continuous cositive airway pressure (CPAP) related increased CO2 carbon dioxide elimination, and activation of airway and pulmonary stretch receptors triggering these central apneas. The prevalence ranges from 0.56% to 18% with no clear predictive characteristics as compared to simple obstructive sleep apnea. Prognosis is similar to obstructive sleep apnea. The central apnea component in most patients on followup using CPAP therap, has resolved. For those with continued central apneas on simple CPAP therapy, other treatment options include bilevel PAP, adaptive servoventilation, permissive flow limitation and/or drugs.
Khan, Muhammad Talha; Franco, Rose Amy
Background: There are no standard therapies for the management of central sleep apnea (CSA). Either positive pressure therapy (PAP) or supplemental oxygen (O2) may stabilize respiration in CSA by reducing ventilatory chemoresponsiveness. Additionally, increasing opioid use and the presence of comorbid conditions in US veterans necessitates investigations into alternative titration protocols to treat CSA. The goal was to report on the effectiveness of titration with PAP, used alone or in conjunction with O2, for the management of CSA associated with varying comorbidities and opioid use. Methods: This was a retrospective chart review over 3 years, performed at a VA sleep disorders center. The effects of CPAP, CPAP+O2, and BPAP+O2, used in a step-wise titration protocol, on consecutive patients diagnosed with CSA were studied. Results: CSA was diagnosed in 162 patients. The protocol was effective in eliminating CSA (CAI ? 5/h) in 84% of patients. CPAP was effective in 48%, while CPAP+O2 combination was effective in an additional 25%, and BPAP+O2 in 11%. The remaining 16% were non-responders. Forty-seven patients (29%) were on prescribed opioid therapy for chronic pain, in whom CPAP, CPAP+O2, or BPAP+O2 eliminated CSA in 54%, 28%, and 10% cases,, respectively. CPAP, CPAP+O2, and BPAP+O2 each produced significant declines in the AHI, CAI, and arousal index, and an increase in the SpO2. Conclusion: The data demonstrate that using a titration protocol with CPAP and then PAP with O2 effectively eliminates CSA in individuals with underlying comorbid conditions and prescription opioid use. Comparative studies with other therapeutic modalities are required. Commentary: A commentary on this article appears in this issue on page 565. Citation: Chowdhuri S; Ghabsha A; Sinha P; Kadri M; Narula S; Badr MS. Treatment of central sleep apnea in US veterans. J Clin Sleep Med 2012;8(5):555-563.
Chowdhuri, Susmita; Ghabsha, Ahmed; Sinha, Prabhat; Kadri, Medina; Narula, Simranjit; Badr, M. Safwan
Background: The incidence of apnea in neonates depends on a number of factors, including sleep state and thermoregulation. Objective: To assess the role of thermal drive (body heat loss [BHL]) in the mechanisms underlying short episodes of central apnea during active and quiet sleep in neonates. Material and Method: Twenty-two neonates (postconceptional age: 36.3 ± 0.9 weeks) were exposed at thermoneutral (incubator temperature: 32.5°C), warm (34.2°C), and cool (30.4°C) conditions during 3 consecutive morning naps. Oxygen consumption (V·O2), skin and rectal temperatures, and central apnea were scored during active sleep and quiet sleep. The thermal drive was expressed as BHL calculated using indirect partitional calorimetry. Results: As expected, apnea occurred more frequently in active sleep than in quiet sleep (P < 0.001). The frequency of apnea in active sleep was higher in the warm condition (P < 0.05). In contrast, apnea episodes were less frequent (P < 0.05) and shorter (P < 0.05) for cool exposure, during which V·O2 and rectal temperature increased. The frequency (P < 0.001, r2 = 0.31), mean (P < 0.05, r2=0.06), and maximum (P < 0.001, r2 = 0.19) durations of apnea were correlated with the BHL: the greater the BHL (body cooling), the less frequent and the shorter the apnea episodes. In contrast, no relationship between apnea and mean skin or rectal temperature was observed. Conclusion: Apneic events were more closely related to BHL than to body temperatures. In cool exposure, the decreases in the duration and frequency of apneic episodes suggest that these events depend on the metabolic drive (which is proportional to energy expenditure). Citation: Tourneux P; Cardot V; Museux N; Chardon K; Léké A; Telliez F; Libert JP; Bach V. Influence of thermal drive on central sleep apnea in the preterm neonate. SLEEP 2008;31(4):549-556.
Tourneux, Pierre; Cardot, Virginie; Museux, Nathanaelle; Chardon, Karen; Leke, Andre; Telliez, Frederic; Libert, Jean-Pierre; Bach, Veronique
A 55-year-old obese man was admitted to our hospital because of a severe morning headache. He snored and had recurrent episodes of sleep apnea that began 10 years earlier and had since become much worse. An overnight polysomnographic recording confirmed that he had sleep apnea syndrome, predominantly of the central type. The apneas were more frequent when he lay on his back (apnea index 54.5) than on his side (apnea index 1.2). He was treated with sleep position adjustment and nasal bi-level positive airway pressure, inspiratory positive airway pressure at 5 cmH2O and expiratory positive airway pressure at 2 cmH2O. His snoring, headache, and oxygen desaturation resolved. This case suggests that airway collapse may cause central apnea, and that nasal continuous positive airway pressure, and nasal bi-level positive airway pressure and adjustment of sleep position can be effective in some patients with central-type sleep apnea syndrome. PMID:9168657
Morishima, Y N; Inoue, M; Ohtsuka, M; Saitoh, T; Kamahara, K; Funayama, Y; Ninomiya, H; Satoh, H; Uchida, Y; Homma, T; Hasegawa, S
Study Objectives: Complex sleep apnea is defined as sleep disordered breathing secondary to simultaneous upper airway obstruction and respiratory control dysfunction. The objective of this study was to assess the utility of an electrocardiogram (ECG)-based cardiopulmonary coupling technique to distinguish obstructive from central or complex sleep apnea. Design: Analysis of archived polysomnographic datasets. Setting: A laboratory for computational signal analysis. Interventions: None. Measurements and Results: The PhysioNet Sleep Apnea Database, consisting of 70 polysomnograms including single-lead ECG signals of approximately 8 hours duration, was used to train an ECG-based measure of autonomic and respiratory interactions (cardiopulmonary coupling) to detect periods of apnea and hypopnea, based on the presence of elevated low-frequency coupling (e-LFC). In the PhysioNet BIDMC Congestive Heart Failure Database (ECGs of 15 subjects), a pattern of “narrow spectral band” e-LFC was especially common. The algorithm was then applied to the Sleep Heart Health Study–I dataset, to select the 15 records with the highest amounts of broad and narrow spectral band e-LFC. The latter spectral characteristic seemed to detect not only periods of central apnea, but also obstructive hypopneas with a periodic breathing pattern. Applying the algorithm to 77 sleep laboratory split-night studies showed that the presence of narrow band e-LFC predicted an increased sensitivity to induction of central apneas by positive airway pressure. Conclusions: ECG-based spectral analysis allows automated, operator-independent characterization of probable interactions between respiratory dyscontrol and upper airway anatomical obstruction. The clinical utility of spectrographic phenotyping, especially in predicting failure of positive airway pressure therapy, remains to be more thoroughly tested. Citation: Thomas RJ; Mietus JE; Peng CK; Gilmartin G; Daly RW; Goldberger AL; Gottlieb DJ. Differentiating obstructive from central and complex sleep apnea using an automated electrocardiogram-based method. SLEEP 2007;30(12):1756-1769.
Thomas, Robert Joseph; Mietus, Joseph E.; Peng, Chung-Kang; Gilmartin, Geoffrey; Daly, Robert W.; Goldberger, Ary L.; Gottlieb, Daniel J.
Study Objectives: In obstructive sleep apnea (OSA), arousals generally occur at apnea termination and help restore airflow. However, timing of arousals in central sleep apnea (CSA) has not been objectively quantified, and since arousals can persist even when CSA is alleviated, may not play the same defensive role as they do in OSA. We hypothesized that arousals following central events would occur longer after event termination than following obstructive events and would be related to circulation time. Methods: We examined polysomnograms from 20 patients with heart failure (HF) (left ventricular ejection fraction ? 45%): 10 with OSA and 10 with CSA (apneahypopnea index ? 15). Twenty central or obstructive apneas or hypopneas were analyzed in each patient. Results: Compared to the OSA group in whom arousals generally occurred at obstructive event termination, in the CSA group they occurred longer after central event termination (0.9 ± 1.1 versus 8.0 ± 4.1 s, p < 0.0001), but before peak hyperpnea. Time from arousal to peak hyperpnea did not differ between groups (4.3 ± 1.1 vs 4.8 ± 1.6 s, p = 0.416). Unlike the OSA group, latency from apnea termination to arousal correlated with circulation time in the CSA group (r = 0.793, p = 0.006). Conclusions: In HF patients with CSA, apnea-to-arousal latency is longer than in those with OSA, and arousals usually follow resumption of airflow. These observations provide evidence that arousals are less likely to act as a protective mechanism to facilitate resumption of airflow following apneas in CSA than in OSA. Citation: Simms T; Brijbassi M; Montemurro LT; Bradley TD. Differential timing of arousals in obstructive and central sleep apnea in patients with heart failure. J Clin Sleep Med 2013;9(8):773-779.
Simms, Taryn; Brijbassi, Melissa; Montemurro, Luigi Taranto; Bradley, T. Douglas
The presence of insomnia in patients with sleep apnea seems paradoxical as excessive sleepiness is one of the major symptoms of sleep apnea. However, recent research has shown that about half of patients with sleep disorder breathing experience insomnia. Moreover, patients complaining of insomnia or non-restorative sleep may also present with moderate to severe sleep apnea syndromes. Thus, in recent years, clinicians have become more aware of the possible association between insomnia and sleep apnea. This article reviews data published on different aspects of this co-occurrence. PMID:24602685
Bayon, V; Léger, D
Study Objectives: To compare the treatment effect of noninvasive positive pressure ventilation (NPPV) and anticyclic servoventilation in patients with continuous positive airway pressure (CPAP)-induced central sleep apnea (complex sleep apnea). Design: Randomized controlled trial. Setting: Sleep center. Patients: Thirty patients who developed complex sleep apnea syndrome (CompSAS) during CPAP treatment. Interventions: NPPV or servoventilation. Measurements and Results: Patients were randomized to NPPV or servo-ventilation. Full polysomnography (PSG) was performed after 6 weeks. On CPAP prior to randomization, patients in the NPPV and servoventilator arm had comparable apnea-hypopnea indices (AHI, 28.6 ± 6.5 versus 27.7 ± 9.7 events/h (mean ± standard deviation [SD])), apnea indices (AI,19 ± 5.6 versus 21.1 ± 8.6 events/h), central apnea indices (CAI, 16.7 ± 5.4 versus 18.2 ± 7.1 events/h), oxygen desaturation indices (ODI,17.5 ± 13.1 versus 24.3 ± 11.9 events/h). During initial titration NPPV and servoventilation significantly improved the AHI (9.1 ± 4.3 versus 9 ± 6.4 events/h), AI (2 ± 3.1 versus 3.5 ± 4.5 events/h) CAI (2 ± 3.1 versus 2.5 ± 3.9 events/h) and ODI (10.1 ± 4.5 versus 8.9 ± 8.4 events/h) when compared to CPAP treatment (all P < 0.05). After 6 weeks we observed the following differences: AHI (16.5 ± 8 versus 7.4 ± 4.2 events/h, P = 0.027), AI (10.4 ± 5.9 versus 1.7 ± 1.9 events/h, P = 0.001), CAI (10.2 ± 5.1 versus 1.5 ± 1.7 events/h, P < 0.0001)) and ODI (21.1 ± 9.2 versus 4.8 ± 3.4 events/h, P < 0.0001) for NPPV and servoventilation, respectively. Other sleep parameters were unaffected by any form of treatment. Conclusions: After 6 weeks, servoventilation treated respiratory events more effectively than NPPV in patients with complex sleep apnea syndrome. Citation: Dellweg D; Kerl J; Hoehn E; Wenzel M; Koehler D. Randomized controlled trial of noninvasive positive pressure ventilation (NPPV) versus servoventilation in patients with CPAP-induced central sleep apnea (complex sleep apnea). SLEEP 2013;36(8):1163-1171.
Dellweg, Dominic; Kerl, Jens; Hoehn, Ekkehard; Wenzel, Markus; Koehler, Dieter
Central sleep apnea is common in patients with advanced heart failure. Apneic episodes are associated with hypoxemia, hypercapnia, and neurohumoral activation resulting in a rise in pulmonary vascular resistance. This case report describes a patient with a left ventricular assist device implanted for severe heart failure in whom unrecognized central sleep apnea resulted in under-filling of the left ventricle and a reduction in left ventricular assist device inflow. Citation: Schaffer SA; Bercovitch RS; Ross HJ; Rao V. Central Sleep apnea interfering with adequate left ventricular filling in a patient with left ventricular assist device. J Clin Sleep Med 2013;9(2):161–162.
Schaffer, S. Allan; Bercovitch, Robert S.; Ross, Heather J.; Rao, Vivek
Complex sleep apnea syndrome (CompSAS) is a distinct form of sleep-disordered breathing characterized as central sleep apnea (CSA), and presents in obstructive sleep apnea (OSA) patients during initial treatment with a continuous positive airway pressure (CPAP) device. The mechanisms of why CompSAS occurs are not well understood, though we have a high loop gain theory that may help to explain it. It is still controversial regarding the prevalence and the clinical significance of CompSAS. Patients with CompSAS have clinical features similar to OSA, but they do exhibit breathing patterns like CSA. In most CompSAS cases, CSA events during initial CPAP titration are transient and they may disappear after continued CPAP use for 4~8 weeks or even longer. However, the poor initial experience of CompSAS patients with CPAP may not be avoided, and nonadherence with continued therapy may often result. Treatment options like adaptive servo-ventilation are available now that may rapidly resolve the disorder and relieve the symptoms of this disease with the potential of increasing early adherence to therapy. But these approaches are associated with more expensive and complicated devices. In this review, the definition, potential plausible mechanisms, clinical characteristics, and treatment approaches of CompSAS will be summarized. PMID:23861580
Wang, Juan; Wang, Yan; Feng, Jing; Chen, Bao-Yuan; Cao, Jie
: Obstructive sleep apnea is a common condition in childhood and has a significant impact on health, learning, academic performance, and quality of life. The purpose of this article is to review the epidemiology, etiology, risk factors, clinical presentation, diagnostic procedures, and treatment of obstructive sleep apnea. PMID:25036250
Weiss, Miriam; Owens, Judith
Sleep-disordered breathing is associated with an altered sympatho- an increase in the negative intrathoracic pressure and in the vagal balance determined by the nocturnal cyclic alternating of afferents inputs from lung and chest wall, thus affecting the apneas and hyperventilation. The aim of this study was to determine autonomic function (5). Instead, central apneas (CA), which whether the autonomic modulation
Lucia Spicuzza; Luciano Bernardi; Alessandro Calciati; Giuseppe Ugo Di Maria
Introduction: Central sleep apnea (CSA) may occur in patients with snoring and obstructive sleep apnea-hypopnea (OSAH) during commencement of continuous positive airway pressure (CRAP) therapy. The presence of CSA may limit the effectiveness of CPAP therapy. The aims of this study were to assess the prevalence of CSA amongst patients starting CPAP for OSAH and to identify possible predictors of this condition. Methods: We reviewed the polysomnograms (PSGs) and clinical records of 99 consecutive patients with a primary diagnosis of OSAH who were referred for an in-laboratory CPAP titration study. Patients with a CSA Index of ?5 per hour at or near (±1 cm H2O) prescribed CPAP level formed the CSA-CPAP group. The remaining patients made up the noCSA-CPAP group. Demographic, baseline and CPAP titration PSG variables were compared between the 2 two groups. Results: 13 subjects (13.1%) had CSA-CPAP. Patients with and without CSA-CPAP did not differ with respect to age or body mass index. 46% of patients with CSA-CPAP had CSA on their baseline PSGs compared with 8% in the noCSA-CPAP group (p <0.01). CSA-CPAP patients also had a higher apnea-hypopnea index (72.1 vs. 52.7 p = 0.02), a higher arousal index (43.3 vs. 29.2 p <0.01), and a higher mixed apnea index (6.8 vs. 1.3 p = 0.03), on their baseline PSGs. Therapeutic CPAP could not be determined in 2 CSA-CPAP patients due to a very high frequency (of severe) central apneas. In the remaining 11, the CPAP prescription to eliminate obstructive events was higher than in the noCSA-CPAP group (11.0 vs. 9.3 p = 0.08). AHI was greater both at or near prescribed CPAP (48.8 vs. 6.7 p <0.01) and overall (47.4 vs. 14.9 p <0.01). A history of ischemic heart disease or heart failure was more frequent amongst patients with CSA-CPAP than those without (p = 0.03). Conclusion: A significant minority of patients with a primary diagnosis of OSAH have either emergence or persistence of CSA on CPAP. Risk factors include male sex, history of cardiac disease, and CSA on baseline PSG. Citation: Lehman S; Antic NA; Thompson C; Catcheside PG; Mercer J; McEvoy RD. Central sleep apnea on commencement of continuous positive airway pressure in patients with a primary diagnosis of obstructive sleep apnea-hypopnea. J Clin Sleep Med 2007;3(5):462-466.
Lehman, Sanaz; Antic, Nick A.; Thompson, Courtney; Catcheside, Peter G.; Mercer, Jeremy; McEvoy, R. Doug
... of a small study published in the journal Sleep Medicine that suggests that when moderately obese apnea patients lose just 5% of their body weight they can stop early-stage disease from getting worse. Starting in 2004, researchers tracked ...
The nose and pharynx begin the upper airway system and represent a continuum. This is the biologic basis for the mutual influences of rhinitis and obstructive sleep apnea (OSA). Sleep-disordered breathing has a large differential diagnosis that includes snoring, upper airway resistance syndrome, and severe OSA. Nasal obstruction is an independent risk factor for OSA, but there is no correlation of daytime nasal resistance with the severity of OSA. However, nasal resistance was an independent predictor of apnea-hypopnea index in a recent study of nonobese OSA patients. Rhinitis alone is associated with mild OSA, but commonly causes microarousals and sleep fragmentation. Reduction of nasal inflammation with topical treatment improves sleep quality and subsequent daytime sleepiness and fatigue. Patient compliance with the nasal continuous positive airway pressure (nCPAP) device is relatively low, in part due to adverse nasal effects. PMID:15056401
Staevska, Maria T; Mandajieva, Mariana A; Dimitrov, Vasil D
The nose and pharynx begin the upper airway system and represent a continuum. This is the biologic basis for the mutual influences\\u000a of rhinitis and obstructive sleep apnea (OSA). Sleep-disordered breathing has a large differential diagnosis that includes\\u000a snoring, upper airway resistance syndrome, and severe OSA. Nasal obstruction is an independent risk factor for OSA, but there\\u000a is no correlation
Maria T. Staevska; Mariana A. Mandajieva; Vasil D. Dimitrov
Obstructive sleep apnea (OSA) affects millions of Americans and is estimated to be as prevalent as asthma and diabetes. Given the fact that obesity is a major risk factor for OSA, and given the current global rise in obesity, the prevalence of OSA will increase in the future. Individuals with sleep apnea are often unaware of their sleep disorder. It is usually first recognized as a problem by family members who witness the apneic episodes or is suspected by their primary care doctor because of the individual's risk factors and symptoms. The vast majority remain undiagnosed and untreated, despite the fact that this serious disorder can have significant consequences. Individuals with untreated OSA can stop breathing hundreds of times a night during their sleep. These apneic events can lead to fragmented sleep that is of poor quality, as the brain arouses briefly in order for the body to resume breathing. Untreated, sleep apnea can have dire health consequences and can increase the risk of hypertension, diabetes, heart disease, and heart failure. OSA management has also become important in a number of comorbid neurological conditions, including epilepsy, stroke, multiple sclerosis, and headache. Diagnosis typically involves use of screening questionnaires, physical exam, and an overnight polysomnography or a portable home study. Treatment options include changes in lifestyle, positive airway pressure, surgery, and dental appliances.
Ho, Matthew L.; Brass, Steven D.
Study Objectives: Obesity is a recognized risk factor for obstructive sleep apnea syndrome (OSAS). We evaluated whether total trunk and central fat mass (CFM) is associated with OSAS in elderly subjects. Design: Cross-sectional. Setting: Body composition assessment by dual-energy X-ray absorbsiometry (DEXA). Participants: 749 volunteers aged 67.2 ± 0.8 years (59.4% women). Intervention: All participants underwent evaluation of their body composition by DEXA in parallel with clinical and polygraphic assessments. The presence of OSAS was defined by an apnea plus hypopnea index (AHI) ? 15. Measurements and Results: A total of 44.8% of the population had an AHI < 15, and 55.2% presented OSAS. OSAS subjects were more frequently overweight and had a higher total trunk fat mass and central fat mass (CFM). Correlation analyses revealed that body mass index (r = 0.27, P < 0.001), neck circumference (r = 0.35, P < 0.001), and CFM (r = 0.23, P < 0.001) were significantly related to AHI. Logistic regression analysis indicated that in mild OSAS cases (> 15AHI < 30), BMI (OR: 1.10; 95% CI: 1.03-1.18; P = 0.008), and male gender (OR: 1.49; 95% CI: 1.05-2.12, P = 0.03) were key factors explaining an AHI between 15 and 30. In severe cases (AHI > 30), male gender (OR: 3.65; 95% CI: 2.40-5.55; P < 0.001) and CFM (OR: 1.10; 95% CI: 1.03-1.19; P = 0.009) were significant independent predictors of OSAS. Clinical Trial Registration: NCT 00759304 and NCT 00766584. Conclusions: Although central fat mass plays a role in the occurrence of severe OSAS in men older than 65 years of age, its low discriminative sensitivity in mild OSAS cases does not warrant systematic use of DEXA for the diagnosis of OSAS. Citation: Degache F; Sforza E; Dauphinot V; Celle S; Garcin A; Collet P; Pichot V; Barthélémy JC; Roche F. Relation of central fat mass to obstructive sleep apnea in the elderly. SLEEP 2013;36(4):501-507.
Degache, Francis; Sforza, Emilia; Dauphinot, Virginie; Celle, Sebastien; Garcin, Arnauld; Collet, Philippe; Pichot, Vincent; Barthelemy, Jean-Claude; Roche, Frederic
Complete or partial collapse of the upper airway during sleep has different effects on the human body ranging from noisy breathing (snoring) to significant cardiovascular sequelae as seen in obstructive sleep apnea (OSA). Snoring is very common in the adult population and has been associated with morbidity in epidemiological studies. A variety of treatments may be used for primary snoring (snoring without symptoms) but none are universally successful. The upper airway resistance syndrome is thought to occur when incomplete obstruction of the upper airway results in frequent disruptions in sleep. Whether it is a true "syndrome" or just one end of the continuum of OSA is unclear. Obstructive sleep apnea causes not only sleep disruption but oxygen desaturation. It has been associated with numerous cardiovascular sequelae, including hypertension (systemic and pulmonary), arrhythmias, and stroke. Nasal continuous positive airway pressure (CPAP) is the current treatment of choice, with lesser alternatives including oral appliances, surgery, and weight loss. Further study on outcomes is required to determine how aggressively to treat these syndromes. PMID:16052414
Collop, Nancy A
Three cases of hypersomnolence, snoring and documented sleep apnea are reported. All three patients were profoundly myxedematous, both clinically and biochemically. Polygraphic studies during sleep documented the presence of repetitive episodes of obstructive sleep apnea in all three patients. These were accompanied by arterial oxygen desaturation. After becoming euthyroid following the administration of the l-thyroxine all patients underwent a repeat evaluation in the sleep laboratory. These studies revealed nearly complete resolution of obstructive sleep apnea in all patients. In addition, several sleep parameters showed marked improvement. These data strongly suggest that the presence of profound daytime sleepiness in hypothyroid patients could be indicative of a potentially lethal complication of myxedema, obstructive sleep apnea. PMID:7234872
Orr, W C; Males, J L; Imes, N K
Recent increases in our awareness to the high prevalence of sleep disorders in general, and of sleep-disordered breathing among children, in particular, has led to concentrated efforts aiming to understand the pathophysiological mechanisms, clinical manifestations and potential consequences of such conditions. In this review, I will briefly elaborate on some of the pathogenetic elements leading to the occurrence of obstructive sleep apnea (OSA) in children, focus on the psycho-behavioral consequences of pediatric OSA, and review the evidence on the potential mechanisms underlying the close association between CNS morbidity and the episodic hypoxia and sleep fragmentation that characterize OSA.
The aim of this study was to validate the use of pulse transit time (PTT) as a method to monitor sleep apnea in children. PTT was estimated as the interval between the ECGR-wave and the point at which the pulse wave at the finger reached 50% amplitude. First, we assessed changes in the PTT during breathing against known resistances in
J. Pagani; M. P. Villa; G. Calcagnini; E. Lombardozzi; F. Censi; S. Poli; P. Bartolini; V. Barbaro; R. Ronchetti
Since two decades, sleep breathing disorders are more wisely recognized by the Belgian medical community. Among these, the Obstructive Sleep Apnea Syndrome (OSA) is the best known but its frontiers with others syndromes such as the Upper Airway Resistance Syndrome (UARS), the Central Sleep Apnea Syndrome (CSAS) or the Overlap Syndrome are still matter of discussion. Its causes are plurifactorial, and many recent publications draw the attention to its long term effects in the cardiovascular and neuropsychiatric fields. This article summarizes the present definitions and features associated with OSA, from clinical and neurophysiological perspectives, and the different consequences to which untreated or underdiagnosed patients are exposed. PMID:15035539
Cambron, L; Roelants, F; Deflandre, E; Raskin, S; Poirrier, R
Purpose To describe a case of bilateral and simultaneous central retinal vein occlusion (RVO) in a young patient diagnosed with obstructive sleep apnea syndrome (OSAS). Case Report A 38-year-old man with morbid obesity and daytime sleepiness presented with a history of bilateral vision loss. His visual acuity (VA) was hand movements, and fundus examination (FE) revealed bilateral central RVO. General medical examination revealed untreated hypertension and type II respiratory failure. Laboratory tests for thrombophilia showed increased hematocrit (59%) and high levels of fibrinogen and C-reactive protein. Other causes of congenital and acquired hypercoagulability were ruled out. Pathologic polysomnography led to the diagnosis of OSAS. The patient was treated with antihypertensive drugs and continuous positive air pressure. In addition, he received intravitreal ranibizumab. At 10 months after presentation, his VA was no light perception in the right eye and hand movements in the left eye. FE revealed bilateral retinal and optic nerve atrophy, and the occurrence of a nonarteritic anterior ischemic neuropathy in the right eye was considered.
Govetto, Andrea; Dominguez, Ramon; Rojas, Laura; Pereiro, Maria; Lorente, Ramon
Obstructive sleep apnea (OSA) is a major public health problem in the US that afflicts at least 2% to 4% of middle-aged Americans and incurs an estimated annual cost of 3.4 billion dollars. At Stanford, we utilize a multispecialty team approach combining the expertise of sleep medicine specialists (adult and pediatric), maxillofacial and ear, nose, and throat surgeons, and orthodontists to determine the most appropriate therapy for complicated OSA patients. The major treatment modality for children with OSA is tonsillectomy and adenoidectomy with or without radiofrequency treatment of the nasal inferior turbinate. Children with craniofacial anomalies resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or more invasive maxillary/mandibular surgery. Continuous positive airway pressure (PAP) therapy is used in children with OSA who are not surgical candidates or have failed surgery. As a last resort, tracheotomy may be used in patients with persistent or severe OSA who do not respond to other measures. The cornerstone of treatment in adults utilizes PAP: continuous PAP, bilevel PAP, or auto PAP. Treatment of nasal obstruction, appropriate titration, attention to mask-fit issues, desensitization for claustrophobia, use of heated humidification for nasal dryness and nasal pain with continuous PAP, patient education, regular follow-up, use of compliance software (in selected individuals), and referral to support groups (AWAKE) are measures that can improve patient compliance. Adjunctive treatment modalities include lifestyle/behavioral/pharmacologic measures. Oral appliances can be used in patients with symptomatic mild sleep apnea or upper airway resistance syndrome. Patients who are unwilling or unable to tolerate continuous PAP or who have obvious upper airway obstruction may benefit from surgery. Surgical success depends on appropriate patient selection, the procedure performed, and the experience of the surgeon. Phase I surgeries have a success rate of 50% to 60%, whereas phase II surgeries have a success rate greater than 90%. PMID:15157408
Guilleminault, Christian; Abad, Vivien C.
Sleep dramatically influences cardiovascular regulation. Changes in sleep duration or quality as seen in sleep disorders may prevent blood pressure to fall during sleep as expected in human physiology. This supports the increased prevalence of hypertension and drug-resistant hypertension in those with sleep loss. Other cardiovascular outcomes i.e. coronary lesions seem to be associated with sleep duration. Systemic inflammation, oxidative stress and endothelial dysfunction seem to be associated with both sleep loss and sleep disorders. The most critical example is Obstructive Sleep Apnea (OSA). Sympathetic activation, oxidative stress and systemic inflammation are the main intermediary mechanisms associated with sleep apnea and intermittent hypoxia. There are now convincing data regarding the associations between hypertension, arrhythmias, stroke, coronary heart disease, increased cardiovascular mortality and OSA. There are also data in OSA and in animal models supporting the link between sleep apnea and atherosclerosis and dysmetabolism. Whether treating sleep apnea enables the reversal of chronic cardiovascular and metabolic consequences of OSA, remains to be studied in adequately designed studies, particularly in comparison with usual treatment strategies. PMID:22202016
Levy, Patrick; Tamisier, Renaud; Arnaud, Claire; Monneret, Denis; Baguet, Jean Philippe; Stanke-Labesque, Francoise; Dematteis, Maurice; Godin-Ribuot, Diane; Ribuot, Christophe; Pepin, Jean-Louis
In this paper it is aimed to classify sleep apnea syndrome (SAS) by using discrete wavelet transforms (DWT) and an artificial neural network (ANN). The abdominal and thoracic respiration signals are separated into spectral components by using multi-resolution DWT. Then the energy of these spectral components are applied to the inputs of the ANN. The neural network was configured to give three outputs to classify the SAS situation of the subject. The apnea can be mainly classified into three types: obstructive sleep apnea (OSA), central sleep apnea (CSA) and mixed sleep apnea (MSA). During OSA, the airway is blocked while respiratory efforts continue. During CSA the airway is open, however, there are no respiratory efforts. In this paper we aim to classify sleep apnea in one of three basic types: obstructive, central and mixed. A significant result was obtained. PMID:19762012
Sezgin, Necmettin; Emin Tagluk, M
Obstructive sleep apnea (OSA) is a condition of repetitive upper airway collapse, which occurs during sleep. Recent literature has emphasized the role of OSA in contributing to glucose intolerance, dyslipidemia, and hypertension. OSA is associated with the development of cardiovascular disease, although definitive data are sparse with regard to the prevention of cardiovascular disease and CPAP therapy. CPAP provides effective treatment for OSA, but patient adherence remains challenging. Aside from daytime symptom improvement, it is difficult to monitor the adequacy of treatment response. Thus, the search for a biomarker becomes critical. The discovery of an ideal biomarker for OSA has the potential to provide information related to diagnosis, severity, prognosis, and response to treatment. In addition, because large-scale randomized controlled trials are both ethically and logistically challenging in assessing hard cardiovascular outcomes, certain biomarkers may be reasonable surrogate outcome measures. This article reviews the literature related to potential biomarkers of OSA with the recognition that an ideal biomarker does not exist at this time.
Bajwa, Ednan K.; Malhotra, Atul
Study Objectives: Adaptive servoventilation (ASV) is often used to treat central sleep apnea (CSA) and complex sleep apnea syndrome (CompSAS). Both CompSAS and CSA may occur in the setting of CHF and with the use of chronic opioids. We hypothesized that ASV would be less successful in treatment of CSA and CompSAS secondary to opioid use than in CHF patients. Methods: Consecutive patients were studied between January and December 2009 who underwent ASV titration for CSA or CompSAS due to CHF (defined as EF < 45%, or > 50% with evidence for diastolic dysfunction on echocardiogram) and chronic opioid users (defined by the use of opioids > 6 months). Results: Study included one hundred and eight patients with 77 males (71.3%) and 31 females (28.7%). Subjects had severe sleep apnea at baseline (AHI 45.6 ± 27.4) and inadequate control of sleep disordered breathing on CPAP (AHI 50.0 ± 32.2, CAI 36.6 ± 32). No significant differences were found between the groups in overall ASV success, defined as AHI < 10/h (p = 0.236). ASV was successful in 28 (59.6%) of those in the opioid group, compared to 43 (70.5%) of those in the CHF group. When ASV success was defined as AHI < 5/h at optimum EEP, there was again no significant difference between the groups (p-value = 0.812). Logistic regression showed unit increases in BMI, unit increases in HCO3, and presence of CSR were each associated with decreased likelihood of ASV success. Conclusion: We did not find a statistically significant difference in the effectiveness of ASV between CHF patients and chronic opioid users, with the overall success rate approaching 70%, as defined by an AHI < 10/h. Commentary: A commentary on this article appears in this issue on page 577. Citation: Ramar K; Ramar P; Morgenthaler TI. Adaptive servoventilation in patients with central or complex sleep apnea related to chronic opioid use and congestive heart failure. J Clin Sleep Med 2012;8(5):569-576.
Ramar, Kannan; Ramar, Priya; Morgenthaler, Timothy I.
Obstructive sleep apnea (OSA) in children has emerged not only as a relatively prevalent condition but also as a disease that imposes a large array of morbidities, some of which may have long-term implications, well into adulthood. The major consequences of pediatric OSA involve neurobehavioral, cardiovascular, and endocrine and metabolic systems. The underlying pathophysiological mechanisms of OSA-induced end-organ injury are now being unraveled, and clearly involve oxidative and inflammatory pathways. However, the roles of individual susceptibility (as dictated by single-nucleotide polymorphisms), and of environmental and lifestyle conditions (such as diet, physical, and intellectual activity), may account for a substantial component of the variance in phenotype. Moreover, the clinical prototypic pediatric patient of the early 1990s has been insidiously replaced by a different phenotypic presentation that strikingly resembles that of adults afflicted by the disease. As such, analogous to diabetes, the terms type I and type II pediatric OSA have been proposed. The different manifestations of these two entities and their clinical course and approaches to management are reviewed.
Capdevila, Oscar Sans; Kheirandish-Gozal, Leila; Dayyat, Ehab; Gozal, David
Study Objectives: The aim of the study was to investigate the effect of ambient temperature on sleep, sleep apnea, and morning alertness in patients with obstructive sleep apnea. Design: Randomized controlled trial. Setting: In-hospital investigations. Participants: Forty patients with obstructive sleep apnea naïve to treatment, with an apnea-hypopnea index of 10-30. Interventions: Three different nights in room temperatures of 16°C, 20°C, and 24°C. Measurements: Overnight polysomnography and Karolinska Sleepiness Scale. Results: The obstructive apnea-hypopnea index was 30 ± 17 at 16°C room temperature, 28 ± 17 at 20°C, and 24 ± 18 at 24°C. The obstructive apnea-hypopnea index was higher at 16°C room temperature versus 24°C (P = 0.001) and at 20°C room temperature versus 24°C (P = 0.033). Total sleep time was a mean of 30 min longer (P = 0.009), mean sleep efficiency was higher (77 ± 11% versus 71 ± 13% respectively, P = 0.012), and the patients were significantly more alert according to the Karolinska Sleepiness Scale (P < 0.028) in the morning at 16°C room temperature versus 24°C. The amount of sleep in different sleep stages was not affected by room temperature. Conclusions: Untreated patients with obstructive sleep apnea sleep longer, have better sleep efficiency, and are more alert in the morning after a night's sleep at 16°C room temperature compared with 24°C, but obstructive sleep apnea is more severe at 16°C and 20°C compared with 24°C. Clinical Trial Information: This study is registered in ClinicalTrials.gov number NCT00544752. Citation: Valham F; Sahlin C; Stenlund H; Franklin KA. Ambient temperature and obstructive sleep apnea: effects on sleep, sleep apnea, and morning alertness. SLEEP 2012;35(4):513-517.
Valham, Fredrik; Sahlin, Carin; Stenlund, Hans; Franklin, Karl A.
Sleep Apnea Syndrome (SAS) is a very common sleep disorder. SAS is considered as clinically relevant when the breath stops during more than 10 seconds and oc- curs more than five times per sleep hour. In this paper, we present a noninvasive automatic approach to sleep apnea classification. Only noninvasive records of the respiratory and cardiac activities (Nasal Airway Flow
Tarik AL-ANI; Daniel NOVAK; Frédéric LOFASO
Summary The pulmonary artery pressure values of 65 patients with sleep apnea syndrome were measured at rest and during ergometer exercise up to 100 W. Pulmonary hypertension at rest was found in 13, and during exercise in 31 more patients. Only 8 patients with pathological pressure findings suffered from pulmonary hypertension in combination with a pulmonary or cardiac disease. In
T. Podszus; W. Bauer; J. Mayer; T. Penzel; J. H. Peter; P. von Wichert
Symptoms of sleep-disordered breathing, especially obstructive sleep apnea syndrome (OSAS), are common in asthma patients and have been associated with asthma severity. It is known that asthma symptoms tend to be more severe at night and that asthma-related deaths are most likely to occur during the night or early morning. Nocturnal symptoms occur in 60-74% of asthma patients and are markers of inadequate control of the disease. Various pathophysiological mechanisms are related to the worsening of asthma symptoms, OSAS being one of the most important factors. In patients with asthma, OSAS should be investigated whenever there is inadequate control of symptoms of nocturnal asthma despite the treatment recommended by guidelines having been administered. There is evidence in the literature that the use of continuous positive airway pressure contributes to asthma control in asthma patients with obstructive sleep apnea and uncontrolled asthma.
Salles, Cristina; Terse-Ramos, Regina; Souza-Machado, Adelmir; Cruz, Alvaro A
Study Objectives: We describe the respiratory, cardiac, and sleep-related characteristics of two types of sleep-related respiratory pauses in children that can fulfill current criteria of pathological apnea, but often seem to be benign: prolonged expiratory apnea (PEA) and post-sigh central apnea (PSCA). Methods: All outpatient comprehensive overnight polysomnography completed on children without significant underlying medical conditions completed during an 18-month period were retrospectively reviewed for the presence of augmented breaths followed by a respiratory pause. Events were identified as a PEA or PSCA based on characteristic features. Physiologic parameters associated with the respiratory events were recorded and compared. Results: Fifty-seven (29 PEA and 28 PEA) events were identified in 17 patients (8.5 ± 3.5 years old). Median durations of PEA and PSCA were not significantly different. For both PEA and PSCA, average heart rate (HR) during the augmented breath before the respiratory pause differed from lowest instantaneous HR during the first half of the pause. When compared to each other, the lowest instantaneous HR recorded in the first half of PEA was lower than that for PSCA (63.9 [59.41–68.3] vs 66.75 [61.7–80.75]) beats per min, p = 0.03. No PEA or PSCA event was associated with an oxygen desaturation more than 3% from baseline. Conclusion: PEA and PSCA have stereotypic HR changes and resemble pathologic apneas but appear to be benign. Clinical significance of PEA and PSCA is yet to be determined. Consistent recognition of the events is required, given their frequency of occurrence and potential for misclassification. Citation: Haupt ME; Goodman DM; Sheldon SH. Sleep related expiratory obstructive apnea in children. J Clin Sleep Med 2012;8(6):673-679.
Haupt, Mark E.; Goodman, Denise M.; Sheldon, Stephen H.
Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by repetitive episodes of airflow cessation resulting in brief arousals and intermittent hypoxemia. Several studies have documented significant daytime cognitive and behavioral dysfunction that seems to extend beyond that associated with simple sleepiness and that persists in some patients after therapeutic intervention. A still unanswered question is whether cognitive symptoms in OSA are primarily a consequence of sleep fragmentation and hypoxemia, or whether they coexist independently from OSA. Moreover, very little is known about OSA effects on cognitive performances in the elderly in whom an increased prevalence of OSA is present. In this review we will consider recent reports in the association between sleep apnea and cognition, with specific interest in elderly subjects, in whom sleep disturbances and age-related cognitive decline naturally occur. This will allow us to elucidate the behavioral and cognitive functions in OSA patients and to gain insight into age differences in the cognitive impairment. Clinically, these outcomes will aid clinicians in the evaluation of diurnal consequences of OSA and the need to propose early treatment. PMID:22661967
Sforza, Emilia; Roche, Frédéric
Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by repetitive episodes of airflow cessation resulting in brief arousals and intermittent hypoxemia. Several studies have documented significant daytime cognitive and behavioral dysfunction that seems to extend beyond that associated with simple sleepiness and that persists in some patients after therapeutic intervention. A still unanswered question is whether cognitive symptoms in OSA are primarily a consequence of sleep fragmentation and hypoxemia, or whether they coexist independently from OSA. Moreover, very little is known about OSA effects on cognitive performances in the elderly in whom an increased prevalence of OSA is present. In this review we will consider recent reports in the association between sleep apnea and cognition, with specific interest in elderly subjects, in whom sleep disturbances and age-related cognitive decline naturally occur. This will allow us to elucidate the behavioral and cognitive functions in OSA patients and to gain insight into age differences in the cognitive impairment. Clinically, these outcomes will aid clinicians in the evaluation of diurnal consequences of OSA and the need to propose early treatment.
Sforza, Emilia; Roche, Frederic
Obstructive sleep apnea (OSA) is a common respiratory disorder during sleep, in which the airways are collapsed and impair the respiration. Apnea is s cessation of airflow to the lungs which lasts at least for 10s. The current gold standard method for OSA assessment is full night polysomnography (PSG); however, its high cost, inconvenience for patients and immobility have persuaded researchers to seek simple and portable devices to detect OSA. In this paper, we report on developing a new system for OSA detection and monitoring, which only requires two data channels: tracheal breathing sounds and the blood oxygen saturation level (S(a)O(2)). A fully automated method was developed that uses the energy of breathing sounds signals to segment the signals into sound and silent segments. Then, the sound segments are classified into breath, snore (if exists) and noise segments. The S(a)O(2) signal is analyzed to find the rises and drops in the S(a)O(2) signal. Finally, a fuzzy algorithm was developed to use this information and detect apnea and hypopnea events. The method was evaluated on the data of 40 patients simultaneously with full night PSG study, and the results were compared with those of the PSG. The results show high correlation (96%) between our system and PSG. Also, the method has been found to have sensitivity and specificity values of more than 90% in differentiating simple snorers from OSA patients. PMID:19963947
Yadollahi, Azadeh; Moussavi, Zahra
The essential feature of obstructive sleep apnea (OSA) in chil- dren is increased upper airway resistance during sleep. Airway narrowing may be due to craniofacial abnormalities and\\/or soft tissue hypertrophy. The resultant breathing patterns during sleep are highly variable, but include obstructive cycling, in- creased respiratory effort, flow limitation, tachypnea, and\\/or gas exchange abnormalities. Consequently, sleep disruption occurs, ranging from
Eliot S. Katz; Carolyn M. D'Ambrosio
Hypopneas or pauses in respiratory effort frequently precede episodes of obstructive sleep apnea resulting in mixed apneas. We studied five subjects after chronic tracheostomy for obstructive sleep apnea. During stable non-REM (NREM) sleep, subjects breathed entirely through the tracheostomy. Tracheostomy occlusion caused experimental obstructive apnea which lasted 13.9 +/- 4.7 sec and ended with transient arousal and pharyngeal opening. At the end of the apnea there was marked hyperventilation (inspired minute ventilation rose 21.6 +/- 3.5 L on the first breath) followed by hypocapnia, hypopnea, and pauses in inspiratory effort as the subjects resumed NREM sleep. Hypocapnia was greater before inspiratory pauses lasting at least 5 sec than before shorter pauses (PETco2, 4.2 +/- 1.8 mm Hg below baseline vs 1.2 +/- 2.5 mm Hg below baseline). In three patients, pauses in inspiratory effort following experimental obstructive apnea were prevented by administration of 4 percent CO2 and 40 percent O2 inspired gas. This study suggests that: hyperventilation with hypocapnia occurs at the termination of obstructive apneas, and hypocapnia may be responsible for the attenuation or cessation of respiratory effort initiating the subsequent cycle of obstruction. PMID:3086045
Iber, C; Davies, S F; Chapman, R C; Mahowald, M M
We present a polysomnogram-documented report of central sleep apnea (427 events) and moderately severe decreases in arterial oxygen saturation (to 81%) associated with the Arnold-Chiari malformation (ACM). Daytime hypersomnolence and other symptoms had significantly impaired our patient's work performance. After surgical correction of the ACM, there was marked improvement in symptomatology. A post-surgery polysomnogram revealed marked improvement in the number of central apneas (74 events) and only mild decreases in oxygen saturation (to 94%). PMID:4051328
Balk, R A; Hiller, F C; Lucas, E A; Scrima, L; Wilson, F J; Wooten, V
Central sleep apnea is a period of at least 10 s without airflow, during which no ventilatory effort is present. Most of the central apneas occur in Non-Rapid eye movement (NREM) sleep. Central apnea occuring in Rapid eye movement (REM) sleep is extremely rare. We present our patient who had a diagnosis of obstructive sleep apnea in another sleep center since 2003. His Auto Continuous Positive Airway Pressure (CPAP) machine was disrupted so he admitted to our center to renew his machine and for daytime sleepiness while using his machine. The polysomnography revealed central apneas ending with respiratory arousals and periodic leg movements in rapid eye movement (REM) stage. We found no cause for central apneas. The patient benefited from servo ventilator therapy. We present this case as an unusual form of central apnea with the review of the literatures. Even the patients diagnosed as obstructive sleep apnea should be analyzed carefully. The diagnosis and the therapeutic approach may change in the favor of the patient. PMID:23956554
Yüceege, Melike; F?rat, Hikmet; Kuyucu, Mutlu; Ard?ç, Sad?k
Obstructive sleep apnea (OSA) is a highly significant condition based both on the high prevalence in community and significant consequences. Obstructive sleep apnea syndrome (OSAS), OSA together with hypersomnolence, is seen in 4% of middle-aged men and 2% of middle-aged women. OSA is associated with impaired quality of life and increased risks of motor vehicle accidents, cardiovascular disease (including hypertension and coronary artery disease), and metabolic syndrome. There is some evidence for the use of conservative interventions such as weight loss and position modification. CPAP remains the mainstay of treatment in this condition with high-level evidence supporting its efficacy. Continuous positive airway pressure (CPAP) is an intrusive therapy, with long-term adherence rates of less than 70%. Dental appliances have been shown to be effective therapy in some subjects but are limited by the inability to predict treatment responders. Alternative treatments are discussed but there is little role for upper airway surgery (except in a select few experienced institutions) or pharmacological treatment. The current levels of evidence for the different treatment regimens are reviewed.
Hukins, Craig A
Obesity is a major risk factor for cardiovascular disease, the number one killer of Americans. It is also a major risk factor\\u000a for obstructive sleep apnea, which is rising in the US population as the obesity epidemic continues. Obstructive sleep apnea,\\u000a in turn, has been implicated as a risk factor for hypertension, glucose dysregulation, and cardiovascular disease. Understanding\\u000a the pathophysiologic
Muhammad Iqbal; Syed Shah; Sonalis Fernandez; Jocelyne Karam; Girardin Jean-Louis; Samy I. McFarlane
We report obstructive sleep apnea in a 3-year-old boy with tracheomalacia secondary to tracheotomy that resolved after placement of a metallic stent in the region of tracheomalacia. The tracheal location of obstruction during sleep in this case contrasts with the usual location in the pharynx or, less often, the larynx. This case also demonstrates the utility of polysomnography in managing decannulation of tracheostomies. Citation: Muzumdar H; Nandalike K; Bent J; Arens R. Obstructive sleep apnea due to extrathoracic tracheomalacia. J Clin Sleep Med 2013;9(2):163–164.
Muzumdar, Hiren; Nandalike, K.; Bent, J.; Arens, Raanan
Study Objectives: To compare the breathing instability and upper airway collapsibility between patients with pure OSA (i.e. 100% of apneas are obstructive) and patients with predominant OSA (i.e., coexisting obstructive and central apneas). Design: A cross-sectional study with data scored by a fellow being blinded to the subjects' classification. The results were compared between the 2 groups with unpaired student t-test. Setting and interventions: Standard polysomnography technique was used to document sleep-wake state. Ventilator in pressure support mode was used to introduce hypocapnic apnea during CO2 reserve measurement. CPAP with both positive and negative pressures was used to produce obstructive apnea during upper airway collapsibility measurement. Participants: 21 patients with OSA: 12 with coexisting central/mixed apneas and hypopneas (28% ± 6% of total), and 9 had pure OSA. Measurements: The upper airway collapsibility was measured by assessing the critical closing pressure (Pcrit). Breathing stability was assessed by measuring CO2 reserve (i.e., ?PCO2 [eupnea-apnea threshold]) during NREM sleep. Results: There was no difference in Pcrit between the 2 groups (pure OSA vs. predominant OSA: 2.0 ± 0.4 vs. 2.7 ± 0.4 cm H2O, P = 0.27); but the CO2 reserve was significantly smaller in predominant OSA group (1.6 ± 0.7 mm Hg) than the pure OSA group (3.8 ± 0.6 mm Hg) (P = 0.02). Conclusions: The present data indicate that breathing stability rather than upper airway collapsibility distinguishes OSA patients with a combination of obstructive and central events from those with pure OSA. Citation: Xie A; Bedekar A; Skatrud JB; Teodorescu M; Gong Y; Dempsey JA. The heterogeneity of obstructive sleep apnea (predominant obstructive vs pure obstructive apnea). SLEEP 2011;34(6):745-750.
Xie, Ailiang; Bedekar, Ajay; Skatrud, James B.; Teodorescu, Mihaela; Gong, Yuansheng; Dempsey, Jerome A.
... study generates several records of activity during several hours of sleep, usually about six. Generally, these records include an ... a "split-night study," in which the first hours are devoted to diagnosis. If obstructive sleep apnea is found, the patient is awakened and ...
One of the less well-documented, potentially modifiable stroke risk factor is the obstructive sleep apnea. Obstructive sleep apnea increases cardiovascular morbidity and mortality, including stroke risk. The article summarizes the pathophysiological factors in sleep apnea syndrome which can increase stroke risk. PMID:24733103
Magyar, Mária Tünde
Background Obstructive sleep apnea (OSA) is becoming increasingly prevalent in North America and has been described in association with specific chronic diseases, particularly cardiovascular diseases. In primary care, where the prevalence of co-occurring chronic conditions is very high, the potential association with OSA is unknown. The purpose of this study was to explore the association between OSA and 1) the presence and severity of multimorbidity (multiple co-occurring chronic conditions), and 2) subcategories of multimorbidity. Methods A cluster sampling technique was used to recruit 120 patients presenting with OSA of various severities from the records of a sleep laboratory in 2008. Severity of OSA was based on the results of the polysomnography. Patients invited to participate received a mail questionnaire including questions on sociodemographic characteristics and the Disease Burden Morbidity Assessment (DBMA). They also consented to give access to their medical records. The DBMA was used to provide an overall multimorbidity score and sub-score of diseases affecting various systems. Results Bivariate analysis did not demonstrate an association between OSA and multimorbidity (r?=?0.117; p?=?0.205). However, severe OSA was associated with multimorbidity (adjusted odds ratio?=?7.33 [1.67-32.23], p?=?0.05). OSA was moderately correlated with vascular (r?=?0.26, p?=?0.01) and metabolic syndrome (r?=?0.26, p?=?0.01) multimorbidity sub-scores. Conclusions This study showed that severe OSA is associated with severe multimorbidity and sub-scores of multimorbidity. These results do not allow any causal inference. More research is required to confirm these associations. However, primary care providers should be aware of these potential associations and investigate OSA when deemed appropriate.
Health-related quality of life (HRQOL) is increasingly recognized as an important parameter in the assessment of the morbidity\\u000a associated with obstructive sleep apnea (OSA). Generic and sleep disorder-specific instruments consistently demonstrate impairment\\u000a in multiple domains of HRQOL in OSA, particularly in the domains of sleep, energy, fatigue, and vigilance. Sleep disorder-specific\\u000a tools are potentially more sensitive than generic tools in
Amy D. Atkeson; Robert C. Basner
Obstructive sleep apnea (OSA) is a common condition characterized by repetitive episodes of complete (apnea) or partial (hypopnea) obstruction of the upper airway during sleep, resulting in oxygen desaturation and arousal from sleep. Intermittent hypoxia (IH) resulting from OSA may cause structural neuron damage and dysfunction in the central nervous system (CNS). Clinically, it manifests as neurocognitive and behavioral deficits with oxidative stress and inflammatory impairment as its pathophysiological basis, which are mediated by microglia at the cellular level. Microglia are dominant proinflammatory cells in the CNS. They induce CNS oxidative stress and inflammation, mainly through mitochondria, reduced nicotinamide adenine dinucleotide phosphate oxidase, and the release of excitatory toxic neurotransmitters. The balance between neurotoxic versus protective and anti- versus proinflammatory microglial factors might determine the final roles of microglia after IH exposure from OSA. Microglia inflammatory impairments will continue and cascade persistently upon activation, ultimately resulting in clinically significant neuron damage and dysfunction in the CNS. In this review article, we summarize the mechanisms of structural neuron damage in the CNS and its concomitant dysfunction due to IH from OSA, and the potential roles played by microglia in this process.
Yang, Qingchan; Wang, Yan; Feng, Jing; Cao, Jie; Chen, Baoyuan
Obstructive sleep apnea (OSA) occurs commonly in the U.S. population and is seen in both obese as well as non-obese individuals. OSA is a disease characterized by periodic upper airway collapse during sleep, which then results in either apnea, hypopnea, or both. The disorder leads to a variety of medical complications. Neuropsychiatric complications include daytime somnolence, cognitive dysfunction, and depression. Increased incidence of motor vehicle accidents has been documented in these patients and probably reflects disordered reflex mechanisms or excessive somnolence. More importantly, vascular disorders such as hypertension, stroke, congestive cardiac failure, arrhythmias, and atherosclerosis occur frequently in these patients. The lungs may be affected by pulmonary hypertension and worsening of asthma. Recent data from several laboratories demonstrate that obstructive sleep apnea is characterized by an inflammatory response. Cytokines are elaborated during the hypoxemic episodes leading to inflammatory responses as marked clinically by elevated C-reactive protein (CRP). As elevated CRP levels are considered markers of the acute phase response and characterize progression of vascular injury in coronary artery disease, it is likely that obstructive sleep apnea could lead to worsening of vasculopathy. Moreover, as inflammatory mechanisms regulate bronchial asthma, it is also likely that cytokines and superoxide radicals generated during hypoxemic episodes could exacerbate reactive airway disease. Patients with Cough, Obstructive sleep apnea, Rhinosinusitis, and Esophageal reflux clustered together can be categorized by the acronym, "CORE", syndrome. The purpose of this manuscript is to review the inflammatory responses that occur in patients with obstructive sleep apnea and relate them to the occurrence of cardiopulmonary disease. PMID:15353323
Arter, Jim L; Chi, David S; M, Girish; Fitzgerald, S Matthew; Guha, Bhuvana; Krishnaswamy, Guha
Obstructive sleep apnea is a chronic condition characterized by frequent episodes of upper airway collapse during sleep. Its effect on nocturnal sleep quality and ensuing daytime fatigue and sleepiness are widely acknowledged. Increasingly, obstructive sleep apnea is also being recognized as an independent risk factor for several clinical consequences, including systemic hypertension, cardiovascular disease, stroke, and abnormal glucose metabolism. Estimates of disease prevalence are in the range of 3% to 7%, with certain subgroups of the population bearing higher risk. Factors that increase vulnerability for the disorder include age, male sex, obesity, family history, menopause, craniofacial abnormalities, and certain health behaviors such as cigarette smoking and alcohol use. Despite the numerous advancements in our understanding of the pathogenesis and clinical consequences of the disorder, a majority of those affected remain undiagnosed. Simple queries of the patient or bed-partner for the symptoms and signs of the disorder, namely, loud snoring, observed apneas, and daytime sleepiness, would help identify those in need of further diagnostic evaluation. The primary objective of this article is to review some of the epidemiologic aspects of obstructive sleep apnea in adults.
Punjabi, Naresh M.
Sleep Apnea Syndrome (SAS) is a very common sleep disorder. SAS is considered as clinically relevant when the breath stops during more than 10 seconds due to different factors and occurs more than five times per sleep hour. In this paper, we present an automatic approach to sleep apnea classification. This system uses only noninvasive records of the respiratory and
P. T. Pozzo Mendoza; T. Al-ani; D. Novak; L. Lhotska; L. Rigaux
Obstructive sleep apnea is increasingly recognized as an important contributor to cognitive impairment, metabolic derangements, and cardiovascular disease and mortality. Identifying the mechanisms by which this prevalent disorder influences health outcomes is now of utmost importance. As the prevalence of this disorder steadily increases, therapies are needed to prevent or reverse sleep apnea morbidities now more than ever before. Oxidative stress is implicated in cardiovascular morbidities of sleep apnea. What role oxidative stress plays in neural injury and cognitive impairments has been difficult to understand without readily accessible tissue to biopsy in persons with and without sleep apnea. An improved understanding of the role oxidative stress plays in neural injury in sleep apnea may be developed by integrating information gained examining neural tissue in animal models of sleep apnea with key features of redox biochemistry and clinical sleep apnea studies where extra-neuronal oxidative stress characterizations have been performed. Collectively, this information sets the stage for developing and testing novel therapeutic approaches to treat and prevent, not only central nervous system injury and dysfunction in sleep apnea, but also the cardiovascular and potentially metabolic conditions associated with this prevalent, disabling disorder.
Zhang, Jing; Veasey, Sigrid
The obstructive sleep apnea syndrome is a disorder of sleep and breathing that is being recognized with increasing frequency. The pathophysiologic consequences range from mild sleepiness to life-threatening cardiovascular and respiratory decompensation. The primary forms of treatment are directed at modifying the upper airway with either an operation or continuous positive airway pressure. Aside from tracheostomy, which is virtually always successful, other forms of treatment have met with varying results. Ancillary therapy, including oxygen, weight loss and drugs, is often helpful but seldom curative. Follow-up sleep studies are necessary to evaluate the effectiveness of treatment. Selecting therapy for a patient with obstructive sleep apnea requires a comprehensive evaluation including polysomnography, special examinations of the upper airway and assessing the cardiopulmonary status. Therapy is based on the severity of disease and must be tailored to each patient.
Wiggins, Robert V.; Schmidt-Nowara, Wolfgang W.
Pediatric obstructive sleep apnea (OSA) has become widely recog- nized only in the last few decades as a likely cause of significant morbidity among children. Many of the clinical characteristics of pediatricOSA,andthedeterminantsofitsepidemiology,differfrom those of adult OSA. We systematically reviewed studies on the epidemiology of conditions considered part of a pediatric sleep- disordered breathing (SDB) continuum, ranging from primary snoringtoOSA.Wehighlightanumberofmethodologicchallenges, including
Julie C. Lumeng; Ronald D. Chervin
In our institutions we routinely do posttracheostomy sleep studies on patients being treated for obstructive sleep apnea. We have identified several patients who failed to show objective evidence of improvement after tracheostomy. From our studies we have found that both mechanical obstruction and concomitant respiratory control dysfunction caused this failure. A unique tracheostomy tube was constructed to treat the subset of patients with internal collapse of the tracheostomy tube. Images
Rodman, David M.; Martin, Richard J.
We report obstructive sleep apnea in a 3-year-old boy with tracheomalacia secondary to tracheotomy that resolved after placement of a metallic stent in the region of tracheomalacia. The tracheal location of obstruction during sleep in this case contrasts with the usual location in the pharynx or, less often, the larynx. This case also demonstrates the utility of polysomnography in managing decannulation of tracheostomies. PMID:23372471
Muzumdar, Hiren; Nandalike, K; Bent, J; Arens, Raanan
Objective. To determine whether chil- dren with a clinical assessment suggestive of obstructive sleep apnea (OSA) but with negative polysomnography (PSG) have improvement in their clinical assessment score after tonsillectomy and adenoidectomy (T&A) as compared with similar children who do not undergo surgery. Methods. In a prospective, randomized, investigator- blinded, controlled trial, 59 otherwise healthy children (mean age: 6.3 years
Nira A. Goldstein; Vasanthi Pugazhendhi; Sudha M. Rao; Jeremy Weedon; Thomas F. Campbell; Andrew C. Goldman; J. Christopher Post; Madu Rao
The study was conducted to find out the association of various naso-oro-pharyngeal structures with sleep macro-architecture in suspected obstructive sleep apnea subjects. Study included 51 subjects with suspected obstructive sleep apnea. Subjects with possible central apnea and those consuming any substance that can affect sleep architecture were excluded. Level I polysomnography was performed after thorough physical examination. Overnight study was scored in 30 s epochs to find out the polysomnographic variables. Surgical treatment was offered wherever indicated. Subjects with moderate to severe obstructive sleep apnea were manually titrated on CPAP with the polysomnogram. SPSS v 17.0 was used for statistical analysis. We did not find any difference in the sleep architecture between genders. Sleep Efficiency was better in subjects with dental overjet, dental attrition, high tongue base, macroglossia, lesser oral cavity volume, edematous uvula, increased submental fat, hypertrophied facial muscles and Mallampatti grade III-IV. Shorter Sleep Latency was seen in subjects with tender TMJ and Mallampatti Gr III-IV. REM latency was shorter in subjects with high tongue base, macroglossia and hypertrophied muscles of mastication. Increased REM was observed in subjects with high tongue base, edematous uvula and tender TMJ. Enlarged tonsils had reversed effect with poor sleep efficiency, increased REM latency and decreased REM. CPAP therapy (N = 20) lessened awake time, decreased N2 and increased REM. Oro-pharyngeal structures affect the sleep architecture in suspected OSA subjects. Nasal structures do not affect the sleep architecture in these subjects and enlarged tonsils have opposite effect. Sleep architecture changes on the titration night with CPAP. PMID:24533364
Singhal, Pawan; Gupta, Ravi; Sharma, Rajanish; Mishra, Prakash
A chinstrap alone improved severe obstructive sleep apnea as well as or better than the use of CPAP. Citation: Vorona RD; Ware JC; Sinacori JT; Ford ML; Cross JP. Treatment of severe obstructive sleep apnea syndrome with a chinstrap. J Clin Sleep Med 2007;3(7):729–730.
Vorona, Robert D.; Ware, J. Catesby; Sinacori, John T.; Ford, Melvin L.; Cross, J. Parker
Obstructive sleep apnea is associated with abnormalities in neurop- sychologic function, and defects in respiratory control may contrib- ute to pathogenesis. Abnormalities may be reflected in structural brain changes. Twenty-seven male untreated patients with severe sleep apnea without comorbidities, and 24 age-matched control subjects, had T1-weighted brain imaging in a high-resolution mag- netic resonance scanner. Twenty-three patients with sleep apnea
Fergal J. O'Donoghue; Regula S. Briellmann; Peter D. Rochford; David F. Abbott; Gaby S. Pell; Chow Huat; Patrick Chan; Natalie Tarquinio; Graeme D. Jackson; Robert J. Pierce
Sleep apnea in neurologically compromised children is common but underrecognized. It can be secondary to diseases at all locations\\u000a on the neuroaxis and may independently alter their presentation, severity, and course. As a primary and secondary illness,\\u000a it is associated with significant neurological morbidities. In its severe manifestation, it can cause life-threatening short-\\u000a and long-term systemic morbidities. The authors review
Gabor Szuhay; Josh Rotenberg
Untreated obstructive sleep apnea (OSA) is an independent risk factor for hypertension, myocardial infarction, and stroke. The repetitive hypoxia/reoxygenation and sleep fragmentation associated with OSA impair endothelial function. Endothelial dysfunction, in turn, may mediate increased risk for cardiovascular diseases. Specifically, in OSA, endothelial nitric oxide availability and repair capacity are reduced, whereas oxidative stress and inflammation are enhanced. Treatment of OSA improves endothelial vasomotor tone and reduces inflammation. We review the evidence and possible mechanisms of endothelial dysfunction as well as the effect of treatment on endothelial function in OSA. PMID:19249441
Atkeson, Amy; Yeh, Susie Yim; Malhotra, Atul; Jelic, Sanja
Objective Animal models have shown a quantal slowing of respiratory pattern when exposed to opioid agonist, in a pattern similar to\\u000a that observed in central sleep apnea. We postulated that opioid-induced hypoventilation is more likely to be associated with\\u000a sleep apnea rather than hypoventilation alone. Since we did not have a direct measure of hypoventilation we used hypoxemia\\u000a as an indirect
Mohammed Mogri; Himanshu Desai; Lynn Webster; Brydon J. B. Grant; M. Jeffery Mador
Rationale: Central sleep apnea (CSA) may occasionally occur in patients with obstructive sleep apnea during titration with a continuous positive airway pressure (CPAP) device. Objectives: To determine the prevalence and the natural history of CPAP-emergent CSA. Methods: This is a retrospective study of 1286 patients with a diagnosis of OSA who underwent titration with a positive airway device during a 1-year period. Patients were seen in consultation and underwent full-night attended polysomnography followed by full-night attended CPAP titration. Four weeks after CPAP therapy, patients returned to the clinic for follow-up, and objective adherence to CPAP was recorded. In patients who had CSA on CPAP, a second full-night attended CPAP titration was recommended. Results: Eighty-four of the 1286 patients developed a central apnea index (CAI) of 5 or greater per hour while on CPAP. The incidence of CSA varied from 3% to 10% monthly, with an overall incidence of 6.5%. Forty--two of the 84 patients returned for a second CPAP titration. In 33 patients, CSA was eliminated. In each of the remaining 9 patients, the CAI remained at 5 or greater per hour, with an average of 13 per hour. These patients characteristically had the most severe OSA, and 5 had a CAI of 5 or more per hour at baseline. Two of the 9 patients were on opioids Conclusions: In this large retrospective study of 1286 patients with a diagnosis of OSA, 6.5% had CPAP-emergent or persistent CSA. However, CPAP-emergent CSA was generally transitory and was eliminated within 8 weeks after CPAP therapy. The prevalence of CPAP-persistent CSA was about 1.5%. Severity of OSA, a CAI of 5 or greater per hour, and use of opioids were potential risk factors. Citation: Javaheri S; Smith J; Chung E. The prevalence and natural history of complex sleep apnea. J Clin Sleep Med 2009;5(3):205-211.
Javaheri, Shahrokh; Smith, Jason; Chung, Eugene
Pediatric obstructive sleep apnea (OSA) is not always resolved or improved with adenotonsillectomy. Persistent or complex cases of pediatric OSA may be due to sites of obstruction in the airway other than the tonsils and adenoids. Identifying these areas in the past has been problematic, and therefore, therapy for OSA in children who have failed adenotonsillectomy has often been unsatisfactory. Sleep endoscopy is a technique that can enable the surgeon to determine the level of obstruction in a sleeping child with OSA. With this knowledge, site-specific surgical therapy for persistent and complex pediatric OSA may be possible.
Lin, Aaron C.; Koltai, Peter J.
Obstructive sleep apnea and hypopnea syndrome is characterized by repeated airway collapse during sleep. The li-terature describes multiple causes of the disease. The main cause is a reduction of the expansion forces of the pharyngeal dilator muscles, as in situations of genioglossal muscle dysfunction, and discoordination between the inspiratory activity of the muscle and respiratory effort, which play an important role in progression of the disease. Other described causes are soft tissue disorders, such as macroglossia or tonsillar hypertrophy, and skeletal structural alterations such as micrognathia and retrognathia. The syndrome is also more frequent in obese people, where the accumulation of fat in the neck region produces narrowing of the pharyngeal airway, thereby diminishing the passage of air. This review focuses on the pathogenesis, epidemiology, main features and diagnosis of the disease, and on its main forms of treatment. Key words:Sleep apnea, obstructive sleep apnea, sleep apnea syndrome, obstructive sleep apnea syndrome.
Azagra-Calero, Eva; Barrera-Mora, Jose M.; Llamas-Carreras, Jose M.; Solano-Reina, Enrique
This cross-sectional study evaluates the prevalence and extent to which high risk for obstructive sleep apnea (OSA) is associated with general obesity and central obesity among college students in Punta Arenas, Chile. Risk for OSA was assessed using the Berlin Questionnaire and trained research nurses measured anthropometric indices. Overweight was defined as body mass index (BMI) of 25–29.9?kg/m2 and general obesity was defined as BMI ? 30?kg/m2. Central obesity was defined as waist circumference ?90 centimeters (cm) for males and ?80?cm for females. Multivariate logistic regression models were fit to obtain adjusted odds ratios (OR) and 95% confidence intervals (CI). Prevalence of high risk for OSA, general obesity, and central obesity were 7.8%, 12.8%, and 42.7%, respectively. Students at high risk for OSA had greater odds of general obesity (OR 9.96; 95% CI: 4.42–22.45) and central obesity (OR 2.78; 95% CI 1.43–5.40). Findings support a strong positive association of high risk for OSA with obesity.
Barbosa, Clarita; Andrade, Asterio; Frye, Megan; Williams, Michelle A.
Study Objectives: Abdominal obesity, particularly common in centrally obese males, may have a negative impact on upper airway (UA) function during sleep. For example, cranial displacement of the diaphragm with raised intra-abdominal pressure may reduce axial tension exerted on the UA by intrathoracic structures and increase UA collapsibility during sleep. Design: This study aimed to examine the effect of abdominal compression on UA function during sleep in obese male obstructive sleep apnea patients. Setting: Participants slept in a sound-insulated room with physiologic measurements controlled from an adjacent room. Participants: Fifteen obese (body mass index: 34.5 ± 1.1 kg/m2) male obstructive sleep apnea patients (apnea-hypopnea index: 58.1 ± 6.8 events/h) aged 50 ± 2.6 years participated. Interventions: Gastric (PGA) and transdiaphragmatic pressures (PDI), UA closing pressure (UACP), UA airflow resistance (RUA), and changes in end-expiratory lung volume (EELV) were determined during stable stage 2 sleep with and without abdominal compression, achieved via inflation of a pneumatic cuff placed around the abdomen. UACP was assessed during brief mask occlusions. Measurements and Results: Abdominal compression significantly decreased EELV by 0.53 ± 0.24 L (P = 0.045) and increased PGA (16.2 ± 0.8 versus 10.8 ± 0.7 cm H2O, P < 0.001), PDI (11.7 ± 0.9 versus 7.6 ± 1.2 cm H2O, P < 0.001) and UACP (1.4 ± 0.8 versus 0.9 ± 0.9 cm H2O, P = 0.039) but not RUA (6.5 ± 1.4 versus 6.9 ± 1.4 cm H2O·L/s, P = 0.585). Conclusions: Abdominal compression negatively impacts on UA collapsibility during sleep and this effect may help explain strong associations between central obesity and obstructive sleep apnea. Citation: Stadler DL; McEvoy RD; Sprecher KE; Thomson KJ; Ryan MK; Thompson CC; Catcheside PG. Abdominal compression increases upper airway collapsibility during sleep in obese male obstructive sleep apnea patients. SLEEP 2009;32(12):1579-1587.
Stadler, Daniel L.; McEvoy, R. Doug; Sprecher, Kate E.; Thomson, Kieron J.; Ryan, Melissa K.; Thompson, Courtney C.; Catcheside, Peter G.
Background Unrecognized obstructive sleep apnea (OSA) is highly prevalent in obesity. Both obesity and OSA are associated with vascular endothelial inflammation and increased risk for cardiovascular diseases. We investigated directly whether endothelial alterations that are commonly attributed to obesity are in fact related to OSA. Methods and Results Seventy-one subjects with body mass index (BMI) ranging from normal to obese underwent attended polysomnography. To assess directly vascular inflammation and oxidative stress, we quantified expression of nuclear factor kappa B (NF?B) and nitrotyrosine by immunofluorescence in freshly harvested venous endothelial cells. To evaluate basal endothelial nitric oxide (NO) production and activity, we quantified expression of endothelial NO synthase (eNOS) and phosphorylated eNOS (P-eNOS). Vascular reactivity was measured by brachial artery flow-mediated dilation (FMD). Expression of eNOS and P-eNOS and FMD were significantly lower whereas expression of nitrotyrosine was significantly greater in OSA patients (n=38) than in OSA-free subjects (n=33) regardless of central adiposity. Expression of NF?B was greater in obese OSA patients than in obese OSA-free subjects (p=0.004). Protein expression and FMD were not significantly affected by increasing BMI or central obesity in OSA patients and in OSA-free subjects. After 4 weeks of continuous positive airway pressure (CPAP) therapy, FMD and expression of eNOS and P-eNOS significantly increased whereas expression of nitrotyrosine and NF?B significantly decreased in OSA patients who adhered with CPAP?4 hours daily. Conclusions Untreated OSA rather than obesity is a major determinant of vascular endothelial dysfunction, inflammation and elevated oxidative stress in obese patients.
Jelic, Sanja; Lederer, David J.; Adams, Tessa; Padeletti, Margherita; Colombo, Paolo C.; Factor, Phillip H.; Le Jemtel, Thierry H.
We examined the influence of gender on the polysomnographic features of obstructive sleep apnea (OSA) in a retrospective study of 830 patients with OSA diagnosed by overnight polysomnogra- phy (PSG). The severity of OSA was determined from the apnea- hypopnea index (AHI) for total sleep time (AHI TST ), and was clas- sified as mild (5 to 25 events\\/h), moderate
KRISTINE S. THORNLEY; PATRICK J. HANLY
Uvulopalatopharyngoplasty (UPPP) is an operation that is frequently performed for the treatment of obstructive sleep apnea (OSA). While UPPP usually eliminates or decreases snoring and often reduces excessive daytime sleepiness, the decrease in the number of episodes of apnea and hypopnea, and the improvement in oxygen saturation (SaO2) have been less predictable. We compared preoperative and postoperative polysomnography (PSG) in 27 patients with OSA and found that no single PSG parameter could accurately reflect the changes in respiration seen after UPPP. We suggest that a combination of indices including the apnea index, the apnea and hypopnea index, the frequency and severity of decreases in SaO2, and the lowest SaO2 be used to assess the effect of UPPP. Using this combination we determined that 30% of our patients were markedly improved, 33% were somewhat improved, and 37% were unimproved. To rely solely on the patient's subjective improvement often results in overestimating the therapeutic results of surgery, whereas to rely only on one PSG parameter may underestimate or overestimate the degree of improvement. PMID:3724323
Wetmore, S J; Scrima, L; Snyderman, N L; Hiller, F C
Sleep related breathing disorders are a common symptom in children with craniosynostosis syndromes, as upper airways may be narrowed by midfacial hypoplasia.To better characterize the sleep related apneas, 24 children with syndromal craniofacial dysplasia underwent 68 poly-somnographies. 9 patients had reexaminations after therapeutic procedures. 4 patients had severe obstructive sleep apnea syndrom (OSAS), 8 patients had moderate and 11 patients mild obstructive sleep apnea respectivly. Only one child had no obstructive sleep apnea. Children with Morbus Crouzon tended to have moderate to severe breathing disorders (9/14) whereas Apert patients mostly had no or light breathing disorders (6/7). Number of central apneas was increased as well. Sleep architecture was not significantly impaired. Apneas were more frequent during REM-sleep. Nasal CPAP, BiPAP and adenotonsillectomy improved respiratory parameters.Pulse oxymetry can be used as a screening method because of the good correla-tion of oxygen desaturation index with severity of OSAS. Frequent examinations and, if necessary, adaptation of therapy is indicated as OSAS in -these children may be rapidly changing. We suggest a guideline for diagnostics and therapy. PMID:22131155
Hein, A; Schweitzer, T; Strabburg, H-M; Wurm, M
Rationale: Home respiratory polygraphy (HRP) may be a cost-effective alternative to polysomnography (PSG) for diagnosis and treatment election in patients with high clinical probability of obstructive sleep apnea (OSA), but there is conflicting evidence on its use for a wider spectrum of patients. Objectives: To determine the efficacy and cost of OSA management (diagnosis and therapeutic decision making) using (1) PSG for all patients (PSG arm); (2) HRP for all patients (HRP arm); and (3) HRP for a subsample of patients with high clinical probability of being treated with continuous positive airway pressure (CPAP) and PSG for the remainder (elective HRP arm). Methods: Multicentric study of 366 patients with intermediate-high clinical probability of OSA, randomly subjected to HRP and PSG. We explored the diagnostic and therapeutic decision agreements between the PSG and both HRP arms for several HRP cutoff points and calculated costs for equal diagnostic and/or therapeutic decision efficacy. Results: For equal diagnostic and therapeutic decision efficacy, PSG arm costs were 18% higher than HRP arm costs and 20% higher than elective HRP arm costs. HRP arm costs tended to be lower than elective HRP arm costs, and both tended to be lower than PSG arm costs if patient costs were omitted. Conclusion: Home respiratory polygraphy is a less costly alternative than polysomnography for the diagnosis and therapeutic decision making for patients with suspected obstructive sleep apnea. We found no advantage in cost terms, however, in using home respiratory polygraphy for all patients or home respiratory polygraphy for the most symptomatic patients and polysomnography for the rest. Citation: Masa JF; Corral J; Sanchez de Cos J; Duran-Cantolla J; Cabello M; Hernández-Blasco L; Monasterio C; Alonso A; Chiner E; Aizpuru F; Vázquez-Polo FJ; Zamorano J; Montserrat JM. Effectiveness of three sleep apnea management alternatives. SLEEP 2013;36(12):1799-1807.
Masa, Juan F.; Corral, Jaime; Sanchez de Cos, Julio; Duran-Cantolla, Joaquin; Cabello, Marta; Hernandez-Blasco, Luis; Monasterio, Carmen; Alonso, Alberto; Chiner, Eusebi; Aizpuru, Felipe; Vazquez-Polo, Francisco-Jose; Zamorano, Jose; Montserrat, Jose M.; Garcia-Ledesma, Estefania; Pereira, Ricardo; Cancelo, Laura; Martinez, Angeles; Sacristan, Lirios; Salord, Neus; Carrera, Miguel; Sancho-Chust, Jose N.; Negrin, Miguel A.; Embid, Cristina
The aim of the present study was to investigate the prevalence of obstructive sleep apnea syndrome (OSAS) among the Norwegian population with Treacher Collins syndrome (TCS). A secondary aim was to establish whether TCS phenotype severity is associated with OSAS severity. A prospective case study design was used. Individuals who were 5 years old and above with a known diagnosis of TCS in Norway were invited to participate in a study. The study included genetic testing, medical and dental examinations and polysomnography. All participants demonstrated disturbed respiration during sleep; 18/19 met the diagnostic criteria for OSAS. Subjectively evaluated snoring was not a reliable predictor of OSAS. We found no significant association between TCS phenotype severity and the severity of OSAS. OSAS is common in TCS, but there is no association with the phenotype severity. Individuals diagnosed with TCS must undergo sleep studies to identify the presence of OSAS. PMID:21626120
Akre, Harriet; Øverland, Britt; Åsten, Pamela; Skogedal, Nina; Heimdal, Ketil
The obstructive sleep apnea syndrome is common and its prevalence is expected to increase with the current obesity epidemic. If left untreated, it is associated with important morbidity such as growth failure, neurocognitive impairment, systemic and pulmonary hypertension, and endothelial dysfunction. Recent research has shown that many children, especially the obese or those with other underlying medical conditions, have residual obstructive sleep apnea after adenotonsillectomy (the primary treatment for childhood obstructive sleep apnea). These children could be effectively treated with continuous positive airway pressure but poor adherence is a significant limitation of this therapy. Therefore, new treatment modalities for the pediatric obstructive sleep apnea syndrome are needed. Current research has focused on newer therapies for pediatric obstructive sleep apnea, such as anti-inflammatories, dental treatments, high-flow nasal cannula, and weight loss. However, there are few randomized controlled trials assessing the effectiveness of these therapies. Further research is warranted. PMID:23931720
Tapia, Ignacio E; Marcus, Carole L
The presence of anterior and posterior nasal packs in patients with epistaxis is known to be associated with cardiorespiratory problems and sometimes death, although the mechanism has not been well understood. To determine the incidence and severity of obstructive sleep apnea in patients with epistaxis treated with both anterior and posterior nasal packs, we obtained polysomnograms on twelve patients while the packs were in place. Ten of these patients demonstrated obstructive sleep apnea. The apnea index (apneas/hour sleep) ranged from 1 to 83, with a mean of 29; the hypopnea index (hypopneas/hour sleep) ranged from 9 to 33, with a mean of 20; and the lowest oxygen saturation (SaO2) ranged from 17% to 91%, with a mean of 77%. Ten patients returned for another polysomnogram after removal of the packs. These baseline studies showed improvement in the apnea index and in the lowest SaO2 in all patients, although four patients still demonstrated at least mild obstructive sleep apnea. This study demonstrates that nasal packs used for the treatment of epistaxis may induce obstructive sleep apnea or markedly exacerbate underlying obstructive sleep apnea and, therefore, contribute to the sudden deaths that have been reported in epistaxis patients. PMID:3138619
Wetmore, S J; Scrima, L; Hiller, F C
The global epidemic of childhood and adolescent obesity and its immediate as well as long-term consequences for obese individuals and society as a whole cannot be overemphasized. Obesity in childhood and adolescence is associated with an increased risk of adult obesity and clinically significant consequences affecting the cardiovascular and metabolic systems. Importantly, obesity is additionally complicated by obstructive sleep apnea (OSA), occurring in up to 60% of obese children. OSA, which is diagnosed using the gold standard polysomnogram (PSG), is characterised by snoring, recurrent partial (hypopneas) or complete (apneas) obstruction of the upper airway. OSA is frequently associated with intermittent oxyhemoglobin desaturations, sleep disruption, and sleep fragmentation. There is emerging data that OSA is associated with cardiovascular burden including systemic hypertension, changes in ventricular structure and function, arterial stiffness, and metabolic syndromes. Thus, OSA in the context of obesity may independently or synergistically magnify the underlying cardiovascular and metabolic burden. This is of importance as early recognition and treatment of OSA in obese children are likely to result in the reduction of cardiometabolic burden in obese children. This paper summarizes the current state of understanding of obesity-related OSA. Specifically, this paper will discuss epidemiology, pathophysiology, cardiometabolic burden, and management of obese children and adolescents with OSA. PMID:22957216
Narang, Indra; Mathew, Joseph L
Obstructive sleep apnea (OSA) can affect all ages from infants to adults. The clinical pathology is initially age-dependent and symptoms first become comparable to those in adults during adolescence. Significant indications for OSA during childhood are craniofacial dysmorphia, failure to thrive, susceptibility to infections or delayed development of speech. Prior to puberty children can become conspicuous due to agitation, attention deficits, poor school performance or secondary enuresis. Crucial for anesthesia is a presumptive diagnosis in order to consider OSA for the forthcoming strategy. Safety aspects in the treatment of OSA children are especially related to the perioperative securing of the airway and a sufficiently long monitoring of respiratory functions. PMID:22273826
Schnoor, J; Ilgner, J; Merkenschlager, A
Chiari I malformation is characterized by downward herniation of the cerebellar tonsils through the foramen magnum. Scant data are available on the clinical course, relationship to the extent of herniation on magnetic resonance imaging in Chiari I malformation and the presence of sleep-disordered breathing on polysomnography. Retrospective analysis was performed looking at polysomnographic findings of children diagnosed with Chiari I malformation. Details on how Chiari I malformation was diagnosed, brainstem magnetic resonance imaging findings, and indications for obtaining the polysomnogram in these patients were reviewed. We also reviewed available data on children who had decompression surgery followed by postoperative polysomnography findings. Twenty-two children were identified in our study (11 males, median age 10 years, range 1 to 18). Three had central sleep apnea, five had obstructive sleep apnea, and one had both obstructive and central sleep apnea. Children with sleep-disordered breathing had excessive crowding of the brainstem structures at the foramen magnum and were more likely to have a greater length of herniation compared with those children without sleep-disordered breathing (P = 0.046). Patients with central sleep apneas received surgical decompression, and their conditions were significantly improved on follow-up polysomnography. These data suggest that imaging parameters may correlate with the presence of sleep-disordered breathing in children with Chiari I malformation. PMID:23498564
Khatwa, Umakanth; Ramgopal, Sriram; Mylavarapu, Alexander; Prabhu, Sanjay P; Smith, Edward; Proctor, Mark; Scott, Michael; Pai, Vidya; Zarowski, Marcin; Kothare, Sanjeev V
We report a case of severe obstructive sleep apnea (OSA) in a patient with symptomatic daytime cardiac bradyarrhythmia. Continuous positive airway pressure therapy prevented atrioventricular blocks that emerged after cardiac pacing for sick sinus syndrome. OSA could be associated with daytime bradyarrhythmia. Citation: Ji KH; Kim DH; Yun CH. Severe obstructive sleep apnea syndrome with symptomatic daytime bradyarrhythmia. J Clin Sleep Med 2009;5(3):246–247.
Ji, Ki-Hwan; Kim, Dae Hyeok; Yun, Chang-Ho
Objective This study was designed to assess the sensitivity and specificity of a portable sleep apnea recording device (ApneaLink™) using standard polysomnography (PSG) as a reference and to evaluate the possibility of using the ApneaLink™ as a case selection technique for patients with suspected obstructive sleep apnea (OSA).\\u000a \\u000a \\u000a \\u000a Materials and methods Fifty patients (mean age 48.7?±?12.6 years, 32 males) were recruited during a
Hui Chen; Alan A. Lowe; Yuxing Bai; Peter Hamilton; John A. Fleetham; Fernanda R. Almeida
Attention deficit and hyperactivity are known possible symptoms or correlates of obstructive sleep apnea (OSA). However, these associations may be missed in children, because children often fail to report excessive daytime sleepiness, and attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are common primary diagnoses in themselves. We report on a 17-year-old, slender, non-snoring male who presented to his pediatrician with a prolonged history of four complaints: inattention, fidgeting, frequent sinusitis, and somnolence. He was diagnosed with ADHD, while the somnolence, which often abated somewhat upon use of antibiotics for sinusitis, was attributed to the sinus infections. A later sleep study revealed OSA, and thorough additional testing proved that the original ADHD diagnosis was in error. All four conditions were allayed with proper use of a continuous positive airway pressure (CPAP) machine. (J. of Att. Dis. 2013; XX(X) 1-XX). PMID:23529886
Blesch, Lauri; Breese McCoy, Sarah J
Study Objectives: Obstructive Sleep Apnea (OSA) is associated with a poor prognosis in patients with coronary artery disease. We hypothesized that abnormalities of coronary blood flow (CBF) associated with obstructive apneas may predispose patients to ischemia. We aimed to determine CBF during respiratory events in patients with OSA. Setting: University Hospital. Patients: Ten subjects undergoing elective percutaneous coronary intervention Design: We measured CBF and myocardial work (rate-pressure product [RPP]) in a non-culprit coronary artery in patients sleeping in the cardiac catheterization laboratory. Hemodynamic responses were matched to spontaneously occurring respiratory events. Measurements and Results: Events comprised a mixture of obstructive apneas, central apneas and hypopneas. RPP increased at the termination of each type of respiratory event. Following the rise in RPP, there was a delay, identified with breakpoint analysis, before CBF began to increase (P < 0.001) that differed in duration with event type: 8 sec for obstructive apnea, 5 sec for central apnea, and 4 sec for hypopnea. The delay in CBF with obstructive apnea was associated with an increase in coronary vascular resistance of 16% ± 4% (P < 0.05). Stepwise multilinear regression analysis showed the increase in CBF was predicted by the rise in RPP (R = 0.52, P < 0.001) and presence of arousal from sleep (R = 0.30, P < 0.05), but not the degree of O2 desaturation. Conclusion: Following obstructive apneas there is a transient uncoupling of CBF from myocardial work and an increase in CVR. This disturbed flow-metabolic coupling may lead to nocturnal myocardial ischemia in patients with both OSA and coronary artery disease. Citation: Hamilton GS; Meredith IT; Walker AM; Solin P. Obstructive sleep apnea leads to transient uncoupling of coronary blood flow and myocardial work in humans. SLEEP 2009;32(2):263-270.
Hamilton, Garun S.; Meredith, Ian T.; Walker, Adrian M.; Solin, Peter
The role of chemical control instability in the pathogenesis of ob- structive sleep apnea (OSA) is not clear. We studied 32 patients with OSA during sleep while their upper airway was stabilized with continuous positive airway pressure. Twelve patients had repeti- tive OSA whenever they were asleep, regardless of body position or sleep stage, and were classified as having severe
MAGDY YOUNES; MICHELE OSTROWSKI; WAYNE THOMPSON; COLLEEN LESLIE; WARREN SHEWCHUK
OBJECTIVE: Obstructive sleep apnea is frequent during the acute phase of stroke, and it is associated with poorer outcomes. A well-established relationship between supine sleep and obstructive sleep apnea severity exists in non-stroke patients. This study investigated the frequency of supine sleep and positional obstructive sleep apnea in patients with ischemic or hemorrhagic stroke. METHODS: Patients who suffered their first acute stroke, either ischemic or hemorrhagic, were subjected to a full polysomnography, including the continuous monitoring of sleep positions, during the first night after symptom onset. Obstructive sleep apnea severity was measured using the apnea-hypopnea index, and the NIHSS measured stroke severity. RESULTS: We prospectively studied 66 stroke patients. The mean age was 57.6±11.5 years, and the mean body mass index was 26.5±4.9. Obstructive sleep apnea (apnea-hypopnea index ?5) was present in 78.8% of patients, and the mean apnea-hypopnea index was 29.7±26.6. The majority of subjects (66.7%) spent the entire sleep time in a supine position, and positional obstructive sleep apnea was clearly present in the other 23.1% of cases. A positive correlation was observed between the NIHSS and sleep time in the supine position (rs?=?0.5; p<0.001). CONCLUSIONS: Prolonged supine positioning during sleep was highly frequent after stroke, and it was related to stroke severity. Positional sleep apnea was observed in one quarter of stroke patients, which was likely underestimated during the acute phase of stroke. The adequate positioning of patients during sleep during the acute phase of stroke may decrease obstructive respiratory events, regardless of the stroke subtype.
Camilo, Millene R.; Fernandes, Regina M. F.; Sander, Heidi H.; Nobre, Fernando; Santos-Pontelli, Taiza; dos Santos, Antonio C.; de Araujo, Draulio B.; Leite, Joao P.; Pontes-Neto, Octavio M.
Obstructive sleep apnea syndrome (OSAS) was first reported in 1976 by Guilleminault. This condition has been defined as a disorder of breathing during sleep characterized by prolonged partial/complete upper airway obstruction that disrupts normal ventilation and normal sleep patterns. The prevalence of this condition varies among the different populations but it is between 1 and 2% in preschool children when adenoid and tonsils volume has a major peak. Loud snoring is very common in these children but not always present. The diagnosis may be suggested by the facial appearance and by personal history but it must be confirmed by a polysomnography recording. OSAS has many associated morbidities which involve the cardiovascular system, the neurocognitive performance, the growth and the metabolic homeostasis. Obesity is a common associated condition and it impairs the therapeutic success. It should be considered when planning the treatment program: it should be stressed the obesity epidemic has already reached the European countries and it is now contributing to the "adult type" of OSAS which was quite rare in childhood until few years ago. The adenotonsillectomy is the most common therapeutic intervention but it is curative only in 2/3 of patients. Orthodontic approaches, associated with orofacial muscle reinforcing physiotherapy are helpful in most of these patients. To conclude we must stress that this condition is quite common and should be promptly diagnosed to prevent the multisystem morbidities; a multidisciplinary approach should be always offered to the parents of these children. PMID:23992879
Nespoli, Luigi; Caprioglio, Alberto; Brunetti, Luigia; Nosetti, Luana
Executive Summary Objective The objective of this review was to determine the clinical effectiveness of oral appliances compared to ‘no treatment’, continuous positive airway pressure (CPAP), or surgery for the management of obstructive sleep apnea (OSA). Clinical Need: Condition and Target Population OSA is characterized by repeated occurrences of upper airway collapse and obstruction during sleep. The condition leads to excessive daytime sleepiness, diminished quality of life, and increased risks of accidents, cardiovascular disease and death. In the general population, the prevalence of OSA is estimated to be 4% in men and 2% in women. Risk factors for OSA include obesity, male gender, increasing age, alcohol use, sedative use, and a family history of OSA. Description of Oral Appliances Oral appliances for OSA fall into two broad categories: mandibular advancement splints (MAS), also known as mandibular repositioning devices, and tongue repositioning or retaining devices. The aim of MAS devices is to advance the mandible forward slightly to enlarge the upper airway and prevent it from collapsing. Similarly, tongue repositioning devices suction the tongue forward to prevent it from falling back and obstructing the airway during sleep. The alternatives to oral appliances include continuous positive airway pressure (CPAP) devices, surgery, drug therapy, positional devices, and lifestyle modification. CPAP is the gold standard of treatment, but despite its effectiveness, compliance rates for CPAP have declined because required systems are noisy and because wearing the mask can be uncomfortable, causing claustrophobia in some users. Evidence-Based Analysis Methods Research Questions Are oral appliances effective in improving sleep-disordered breathing in patients with OSA compared to alternative treatments? Are there safety concerns with oral appliances? What is the evidence regarding patient preference, quality of life, and compliance for oral appliances? If effective, are oral appliances cost effective? Literature Search A literature search was conducted up to February 2009. Systematic reviews, meta-analyses and randomized controlled trials (RCTs) with more than 20 adults with OSA were eligible for inclusion. The primary outcomes of interest were the Apnea Hypopnea Index (AHI), measures of daytime sleepiness, patient preference, compliance, and adverse events. Summary of Findings Five systematic reviews and 16 RCTs that met the inclusion criteria were identified. The systematic reviews consistently concluded that CPAP was more effective than oral appliances at improving sleep disordered breathing, although there may be a niche area for the latter, especially among those with mild OSA as CPAP is difficult to tolerate by some users. Based on the results of the RCTs analyzed for this review, MAS devices are less effective than CPAP when AHI is used as the outcome of interest. MAS devices were shown to decrease AHI levels, but whether this reduction is clinically meaningful is uncertain. The Epworth Sleepiness Scale (ESS) was not able to achieve statistical significance in comparisons of MAS versus CPAP and MAS versus placebo. Nonetheless, after treatment with either MAS or CPAP, patients seem to be able to achieve normal ESS levels. The ESS has substantial limitations including its subjective nature and low construct validity (i.e. it is unclear if the scale is an accurate measure of sleepiness). Adverse events among patients with MAS devices in the RCTs were common, but mostly mild and transient. Jaw discomfort was the most commonly reported adverse event. Based on the results of the RCTs, compliance does not seem to be better or worse with MAS or CPAP. Similarly, there is no clear patient preference for MAS or CPAP among the studies reporting preference and satisfaction. Keywords Obstructive sleep apnea, oral appliances, mandibular advancement splints, tongue repositioning devices
Atrial fibrillation (AF) and obstructive sleep apnea (OSA) are very prevalent diseases in modern society. Recent years have seen the emergence of a wide body of literature suggesting an important association between these two diseases. This review will provide a summary of this evidence as it currently exists. First, it will review the literature suggesting an association between AF and OSA by highlighting the prevalence of AF in OSA, the correlation of AF prevalence with OSA severity and the trend towards increased AF recurrence in patients with OSA after treatment for AF. Second, it will identify the possible pathophysiologic mechanisms for this association. In doing so, it will discuss the investigated effects of intrathoracic pressure changes, autonomic instability and atrial remodeling. Finally, it will review the evidence of the effect of treatment of OSA on AF, highlighting the role of continuous positive airway pressure (CPAP) in the treatment of OSA and its impact on AF prevalence and recurrence.
Digby, Genevieve C; Baranchuk, Adrian
Study Objectives: Alterations in the serotonin (5-HT) system have been suggested as a mechanism of sleep apnea in humans and rodents. The objective is to evaluate the contribution of 5-HT to this disorder. Design: We studied sleep and breathing (whole-body plethysmography) in mutant mice that lack monoamine oxidase A (MAOA) and have increased concentrations of monoamines, including 5-HT. Measurements and Results: Compared to wild-type mice, the mutants showed similar amounts of slow wave sleep (SWS) and rapid eye movement sleep (REMS), but exhibited a 3-fold increase in SWS and REMS apnea indices. Acute administration of the MAOA inhibitor clorgyline decreased REMS amounts and increased the apnea index in wild-type but not mutant mice. Parachlorophenylalanine, a 5-HT synthesis inhibitor, reduced whole brain concentrations of 5-HT in both strains, and induced a decrease in apnea index in mutant but not wild-type mice. Conclusion: Our results show that MAOA deficiency is associated with increased sleep apnea in mice and suggest that an acute or chronic excess of 5-HT contributes to this phenotype. Citation: Real C; Popa D; Seif I; Callebert J; Launay JM; Adrien J; Escourrou P. Sleep apneas are increased in mice lacking monoamine oxidase A.
Real, Caroline; Popa, Daniela; Seif, Isabelle; Callebert, Jacques; Launay, Jean-Marie; Adrien, Joelle; Escourrou, Pierre
Introduction: Treatment of pediatric obstructive sleep apnea syndrome is surgical. The incidence of postoperative respiratory complications in this population is 5-25%. Aim: The aim of the authors was to present the preoperative evaluation and monitoring procedure elaborated in Heim Pál Children Hospital, Budapest. Method: 142 patients were involved in the study. Patient history was obtained and physical examination was performed in all cases. Thereafter, polysomnography was carried out, the severity of the obstructive sleep apnea syndrome was determined, and the patients underwent tonsilloadenotomy. Results: 45 patients with mild, 50 patients with moderate and 47 patients with severe obstructive sleep apnea syndrome were diagnosed. There was no complication in patients with mild disease, while complications were observed in 6 patients in the moderate group and 24 patients in the severe group (desaturation, apnea, stridor, stop breathing) (p<0.000). In patients with severe obstructive sleep apnea syndrome, no significant difference was noted in preoperative apnoea-hypapnea index (p = 0.23) and in nadir oxygen saturation values (p = 0.73) between patients with and without complication. Conclusions: Patients with severe obstructive sleep apnea syndrome should be treated in hospital where pediatric intensive care unit is available. Orv. Hetil., 2014, 155(18), 703-707. PMID:24776384
Benedek, Pálma; Kiss, Gabriella; Csábi, Eszter; Katona, Gábor
Study Objectives: Central sleep apnea can be refractory to traditional positive airway pressure (PAP) therapy (CPAP or bilevel PAP), whether appearing first as a feature of baseline polysomnography or only later once PAP is applied in what is termed “complex sleep apnea” (CompSA). This retrospective study examined the efficacy of adaptive servoventilation (ASV) in 25 consecutive patients with PAP-refractory central sleep apnea, most exhibiting predominantly obstructive apnea during baseline polysomnography. Methods: Patient characteristics were: age = 59.8 ± 16.5 yr; BMI = 30.4 ± 6.1 kg/m2; apnea/hypopnea index (AHI) = 48.5 ± 30.2/h; and central apnea index (CAI) = 10.8 ± 16.0/h. Following unsuccessful PAP titrations, patients underwent ASV titration. Eighteen met established criteria for CompSA. Results: On traditional PAP, AHI did not improve significantly compared to baseline, whether based on the entire titration (38.5 ± 23.4/h, p = 0.10) or the final PAP pressure(s) (44.4 ± 25.9/h, p = 0.54); CAI tripled across the titration (27.4 ± 23.5/h, p = 0.001) and at the final pressure(s) (34.8 ± 24.2/h, p < 0.001). On ASV, AHI fell to 11.4 ± 8.2/h across the titration (p < 0.001) and decreased further to 3.6 ± 4.2/h at the optimal end expiratory pressure (p < 0.001). AHI was ? 5/h in 80% of patients and < 10/h in 92%. ASV virtually eliminated central apneas at optimal end expiratory pressure (0.7 ± 2.2/h, p < 0.001). Respiratory arousals showed parallel improvements on ASV but not PAP. Conclusions: ASV proved superior to traditional PAP in reducing the AHI, CAI, and respiratory arousals in a heterogeneous patient group with sleep disordered breathing in whom central apneas emerged or persisted on PAP. Citation: Brown SE; Mosko SS; Davis JA; Pierce RA; Godfrey-Pixton TV. A retrospective case series of adaptive servoventilation for complex sleep apnea. J Clin Sleep Med 2011;7(2):187-195.
Brown, Stephen E.; Mosko, Sarah S.; Davis, James A.; Pierce, R. Ander; Godfrey-Pixton, Tamera V.
For over two decades clinical studies have been conducted which suggest the existence of a relationship between depression and Obstructive Sleep Apnea (OSA). Recently, Ohayon underscored the evidence for a link between these two disorders in the general population, showing that 800 out of 100,000 individuals had both, a breathing-related sleep disorder and a major depressive disorder, with up to 20% of the subjects presenting with one of these disorders also having the other. In some populations, depending on age, gender and other demographic and health characteristics, the prevalence of both disorders may be even higher: OSA may affect more than 50% of individuals over the age of 65, and significant depressive symptoms may be present in as many as 26% of a community-dwelling population of older adults. In clinical practice, the presence of depressive symptomatology is often considered in patients with OSA, and may be accounted for and followed-up when considering treatment approaches and response to treatment. On the other hand, sleep problems and specifically OSA are rarely assessed on a regular basis in patients with a depressive disorder. However, OSA might not only be associated with a depressive syndrome, but its presence may also be responsible for failure to respond to appropriate pharmacological treatment. Furthermore, an undiagnosed OSA might be exacerbated by adjunct treatments to antidepressant medications, such as benzodiazepines. Increased awareness of the relationship between depression and OSA might significantly improve diagnostic accuracy as well as treatment outcome for both disorders. In this review, we will summarize important findings in the current literature regarding the association between depression and OSA, and the possible mechanisms by which both disorders interact. Implications for clinical practice will be discussed.
Schroder, Carmen M; O'Hara, Ruth
Background Sleep spindles, as detected on scalp electroencephalography (EEG), are considered to be markers of thalamo-cortical network integrity. Since obstructive sleep apnea (OSA) is a known cause of brain dysfunction, the aim of this study was to investigate sleep spindle frequency distribution in OSA. Seven non-OSA subjects and 21 patients with OSA (11 mild and 10 moderate) were studied. A matching pursuit procedure was used for automatic detection of fast (?13Hz) and slow (<13Hz) spindles obtained from 30min samples of NREM sleep stage 2 taken from initial, middle and final night thirds (sections I, II and III) of frontal, central and parietal scalp regions. Results Compared to non-OSA subjects, Moderate OSA patients had higher central and parietal slow spindle percentage (SSP) in all night sections studied, and higher frontal SSP in sections II and III. As the night progressed, there was a reduction in central and parietal SSP, while frontal SSP remained high. Frontal slow spindle percentage in night section III predicted OSA with good accuracy, with OSA likelihood increased by 12.1%for every SSP unit increase (OR 1.121, 95% CI 1.013 - 1.239, p=0.027). Conclusions These results are consistent with diffuse, predominantly frontal thalamo-cortical dysfunction during sleep in OSA, as more posterior brain regions appear to maintain some physiological spindle frequency modulation across the night. Displaying changes in an opposite direction to what is expected from the aging process itself, spindle frequency appears to be informative in OSA even with small sample sizes, and to represent a sensitive electrophysiological marker of brain dysfunction in OSA.
Obstructive sleep apnea (OSA) continues to garner widespread attention, mostly because of its health-related consequences such as cardiovascular disorders and associated comorbid symptoms such as daytime sleepiness and snoring. OSA is characterized by repeated episodes of partial or complete upper airway closure during sleep, resulting in frequent arousals and sleep fragmentation, apneas and hypopneas, and intermittent hypoxemia. These perturbations can lead to chronic cardiovascular disorders such as hypertension. Among the many risk factors in the pathogenesis of OSA, obesity is one of the most important.1 Obesity, per se, may also predispose to cardiovascular disorders. In this review, the authors explore the complex interactions between obesity, cardiovascular diseases, and OSA.
Ramar, Kannan; Caples, Sean M.
Intermittent vagus nerve stimulation can reduce the frequency of seizures in patients with refractory epilepsy. Stimulation of vagus nerve afferent fibers can also cause vocal cord dysfunction, laryngeal spasm, cough, dyspnea, nausea, and vomiting. Vagus nerve stimulation causes an increase in respiratory rate, decrease in respiratory amplitude, decrease in tidal volume, and decrease in oxygen saturation during periods of device activation. It usually does not cause an arousal, or a change in heart rate or blood pressure. Most patients have an increase in their apnea-hypopnea index (AHI). Patients with VNS can have central apneas, obstructive hypopneas, and obstructive apneas. These respiratory events can be reduced with changes in the vagus nerve stimulator operational parameters or with the use of CPAP. In summary, there are complex relationships between epilepsy and obstructive sleep apneas. In particular, patients with refractory epilepsy need assessment for undiagnosed and untreated obstructive sleep apnea before implantation of vagus nerve stimulator devices. Patients with vagus nerve stimulators often have an increase in apneic events after implantation, and these patients need screening for sleep apnea both before and after implantation. PMID:21897779
Parhizgar, Fuzhan; Nugent, Kenneth; Raj, Rishi
Obstructive sleep apnea (OSA) and insomnia are among the most common sleep diagnoses encountered in the sleep clinic population,\\u000a however little is known about potential interactions or associations between the two disorders. This retrospective, cross-sectional\\u000a study was designed to determine the prevalence of insomnia complaints in patients undergoing evaluation for OSA and to ascertain\\u000a which clinical and polysomnographic features are
Suzanne B. Krell; Vishesh K. Kapur
A non-obese patient who was admitted initially with hypoglycemia had multiple episodes of cardiopulmonary arrests requiring\\u000a resuscitations and a short period of mechanical ventilation. A subsequent sleep study confirmed the diagnosis of severe obstructive\\u000a sleep apnea (OSA) and documented an episode of near-arrest with cerebral hypoxia during rapid eye movement sleep. We suggest\\u000a that OSA coupled with impairment of arousal
See Meng Khoo; J. J. Mukherjee; Jason Phua; Dong Xia Shi
In this paper, a novel technique based on signal processing of breath sounds during wakefulness for prediction of obstructive sleep apnea (OSA) is proposed. We recorded tracheal breath sounds of 35 people with various severity of OSA and 17 non-apneic individuals; the breath sounds were recorded in supine and upright positions during both nose and mouth breathing at medium flow rate. Power spectrum, Kurtosis and Katz fractal dimension of the recorded signals in every posture and breathing maneuver were calculated. We used one-way ANOVA to select the features with most significant differences between the groups followed by the Maximum Relevancy Minimum Redundancy (mRMR) method to reduce the number of characteristic features to three, and investigated the separability of the groups based on the three selected features. The results are encouraging for classification of patients using the selected features. Once being verified on a larger population, the proposed method offers a fast, simple and non-invasive screening tool for prediction of OSA during wakefulness. PMID:22254425
Montazeri, Aman; Moussavi, Zahra
Obstructive sleep apnea (OSA) in children is a frequent disease for which optimal diagnostic methods are still being defined. Treatment of OSA in children should include providing space, improving craniofacial growth, resolving all symptoms, and preventing the development of the disease in the adult years. Adenotonsillectomy (T&A) has been the treatment of choice and thought to solve young patient's OSA problem, which is not the case for most adults. Recent reports showed success rates that vary from 27.2% to 82.9%. Children snoring regularly generally have a narrow maxilla compared to children who do not snore. The impairment of nasal breathing with increased nasal resistance has a well-documented negative impact on early childhood maxilla-mandibular development, making the upper airway smaller and might lead to adult OSA. Surgery in young children should be performed as early as possible to prevent the resulting morphologic changes and neurobehavioral, cardiovascular, endocrine, and metabolic complications. Close postoperative follow-up to monitor for residual disease is equally important. As the proportion of obese children has been increasing recently, parents should be informed about the weight gain after T&A. Multidisciplinary evaluation of the anatomic abnormalities in children with OSA leads to better overall treatment outcome.
Pacemaker apnea scan algorithms are able to screen for sleep apnea. We investigated whether these systems were able to accurately detect sleep-disordered breathing (SDB) in two patients from an outpatient clinic. The first patient suffered from ischemic heart failure and severe central sleep apnea (CSA) and underwent adaptive servoventilation therapy (ASV). The second patient suffered from dilated cardiomyopathy and moderate obstructive sleep apnea (OSA). Pacemaker read-outs did not match polysomnography (PSG) recordings well and overestimated the apnea-hypopnea index. However, ASV therapy-induced SDB improvements were adequately recognized by the apnea scan of the Boston Scientific INVIVE® cardiac resynchronization therapy pacemaker. Detection of obstructive respiratory events using impedance-based technology may underestimate the number of events, as frustrane breathing efforts induce impedance changes without significant airflow. By contrast, in the second case, apnea scan overestimated the number of total events and of obstructive events, perhaps owing to a very sensitive but less specific hypopnea definition and detection within the diagnostic algorithm of the device. These two cases show that a pacemaker apnea scan is able to reflect SDB, but PSG precision is not met by far. The device scan revealed the decline of SDB through ASV therapy for CSA in one patient, but not for OSA in the second case. To achieve reliable monitoring of SDB, further technical developments and clinical studies are necessary. PMID:24519661
Fox, Henrik; Nölker, Georg; Gutleben, Klaus-Jürgen; Bitter, Thomas; Horstkotte, Dieter; Oldenburg, Olaf
Sleep apnea syndrome (SAS), which is associated with symptoms like chronic snoring, sleep apnea, and daytime excessive sleepiness, causes problems in daily lives. It has been pointed out that sleep of those who have apnea attacks is characterized by snoring in many cases, and thus attempts have been made to conduct screening for sleep apnea syndrome by analyzing snoring sounds.
A. Nobuyuki; N. Yasuhiro; T. Taiki; Y. Miyae; M. Kiyoko; H. Terumasa
Context Untreated sleep apnea is a prevalent but treatable condition of breathing pauses during sleep. With approximately 15% of the US population affected, understanding of the total health burden is necessary to guide policy, population initiatives, and clinical practice to reduce the prevalence of this condition. Objective To outline the history and need for a population approach to understanding sleep apnea and provide a review of the first longitudinal population study of this disorder. Data Source The results of cross-sectional and longitudinal data from 1500 participants in the Wisconsin Sleep Cohort, initiated 2 decades ago, illustrate the population burden of sleep apnea. Results The prevalence of sleep apnea is increasing with trends of increased obesity. Prospective findings from 4- to 15-year follow-up data indicate untreated sleep apnea predicts increased blood pressure, hypertension, stroke, depression, and mortality. Conclusions The high prevalence of untreated sleep apnea and links to serious morbidity and mortality underscore the population burden of this condition and the need for greater clinical recognition and strategies to reduce prevalence.
Young, Terry; Palta, Mari; Dempsey, Jerome; Peppard, Paul E.; Nieto, F. Javier; Hla, K. Mae
Obstructive sleep apnea is a common disorder in childhood, particularly in the last decade when an increased prevalence of obesity has been documented. The neurocognitive and behavioral problems associated with this disorder have been known for a long time. However, the increased knowledge of cardiovascular and metabolic complications in adults with sleep apnea has been followed by a better understanding of the systemic effects of upper airway obstruction in children. Obstructive sleep apnea (OSA) has been shown to induce autonomic imbalance in children and to affect blood pressure, cerebral blood flow and cardiac function in an early phase. OSA may also induce chronic systemic inflammation and may contribute to the development of metabolic syndrome in obese children. Very recent research indicates that in children primary snoring, the mildest form of the sleep-disordered breathing spectrum, may also be associated with morbidity. It is, therefore, likely that these respiratory sleep disorders do not simply influence children's' performance in private and social life, but may more seriously affect children's' health. The aim of this review is to outline early systemic complications of obstructive sleep apnea and primary snoring in infants and children. PMID:19058983
Spicuzza, Lucia; Leonardi, Salvatore; La Rosa, Mario
Background and purpose: We questioned the role of respiratory events in obstructive sleep apnea syndrome (OSAS) and of upper airway resistance syndrome (UARS) on heart rate (HR) during sleep, paying specific attention to the termination of the abnormal breathing events and examining the presence of arousals or termination with only central nervous system (CNS) activation. Patients and methods: Twenty patients,
Christian Guilleminault; Dalva Poyares; Agostinho Rosa; Yu-Shu Huang
Study Objectives: Investigate the relationship between gestational age and weight for gestational age and sleep apnea diagnosis in a cohort of children aged up to 6 years old. Design: A cohort study, using record linked population health data. Setting: New South Wales, Australia. Participants: 398,961 children, born between 2000 and 2004, aged 2.5 to 6 years. Measurements: The primary outcome was sleep apnea diagnosis in childhood, first diagnosed between 1 and 6 years of age. Children with sleep apnea were identified from hospital records with the ICD-10 code G47.3: sleep apnea, central or obstructive. Results: A total of 4,145 (1.0%) children with a first diagnosis of sleep apnea were identified. Mean age at first diagnosis was 44.2 months (SD 13.9). Adenoidectomy, tonsillectomy, or both were common among the children diagnosed with sleep apnea (85.6%). Children born preterm compared to term were significantly more likely to be diagnosed with sleep apnea (< 32 weeks versus term hazard ratio 2.74 [95% CI: 2.16, 3.49]) this remained even after adjustment for known confounding variables. Children born small for gestational age were not at increased risk of sleep apnea compared to children born appropriate for gestational age, hazard ratio 0.95 (95% CI 0.86-1.06). Conclusions: This is the largest study investigating preterm birth and sleep apnea diagnosis and suggests that diagnosis of sleep disordered breathing is more prevalent in children born preterm, but not those who are small for gestational age. Citation: Raynes-Greenow CH; Hadfield RM; Cistulli PA; Bowen J; Allen H; Roberts CL. Sleep apnea in early childhood associated with preterm birth but not small for gestational age: a population-based record linkage study. SLEEP 2012;35(11):1475-1480.
Raynes-Greenow, Camille H.; Hadfield, Ruth M.; Cistulli, Peter A.; Bowen, Jenny; Allen, Hugh; Roberts, Christine L.
Sleep apnea is an entity characterized by repetitive upper airway obstruction resulting in nocturnal hypoxia and sleep fragmentation. It is estimated that 2%–4% of the middle-aged population has sleep apnea with a predilection in men relative to women. Risk factors of sleep apnea include obesity, gender, age, menopause, familial factors, craniofacial abnormalities, and alcohol. Sleep apnea has been increasingly recognized as a major health burden associated with hypertension and increased risk of cardiovascular disease and death. Increased airway collapsibility and derangement in ventilatory control responses are the major pathological features of this disorder. Polysomnography (PSG) is the gold-standard method for diagnosis of sleep apnea and assessment of sleep apnea severity; however, portable sleep monitoring has a diagnostic role in the setting of high pretest probability sleep apnea in the absence of significant comorbidity. Positive pressure therapy is the mainstay therapy of sleep apnea. Other treatment modalities, such as upper airway surgery or oral appliances, may be used for the treatment of sleep apnea in select cases. In this review, we focus on describing the sleep apnea definition, risk factor profile, underlying pathophysiologic mechanisms, associated adverse consequences, diagnostic modalities, and treatment strategies.
Gharibeh, Tarek; Mehra, Reena
Sleep apnea is a breathing disorder that results from momentary and cyclic collapse of the upper airway, leading to intermittent hypoxia (IH). IH can lead to the formation of free radicals that increase oxidative stress, and this mechanism may explain the association between central sleep apnea and nonalcoholic steatohepatitis. We assessed the level of inflammation in the lung and liver tissue from animals subjected to intermittent hypoxia and simulated sleep apnea. A total of 12 C57BL/6 mice were divided into two groups and then exposed to IH (n = 6) or a simulated IH (SIH) (n = 6) for 35 days. We observed an increase in oxidative damage and other changes to endogenous antioxidant enzymes in mice exposed to IH. Specifically, the expression of multiple transcription factors, including hypoxia inducible factor (HIF-1?), nuclear factor kappa B (NF-?B), and tumor necrosis factor (TNF-?), inducible NO synthase (iNOS), vascular endothelial growth factor (VEGF), and cleaved caspase 3 were shown to be increased in the IH group. Overall, we found that exposure to intermittent hypoxia for 35 days by simulating sleep apnea leads to oxidative stress, inflammation, and increased activity of caspase 3 in the liver and lung.
da Rosa, Darlan Pase; Forgiarini, Luiz Felipe; Baronio, Diego; Feijo, Cristiano Andrade; Martinez, Denis; Marroni, Norma Possa
Our clinical experience suggested existence of a third group, stage-independent-OSA besides two known groups: REM-dependent-OSA and NREM-dependent-OSA. This study was planned to compare the characteristics of this group with the other two. All the subjects undergoing diagnostic video-polysomnographies with AHI >5/h were included in this study. Based upon the ratio of AHI during REM and NREM sleep, various groups were formed. REM-dependent-OSA was defined as AHI-REM/AHI-NREM >2; all other subjects were included in Not-REM-dependent-OSA (A-1 analysis). This group was further bifurcated into two groups: Non-REM-dependent OSA (NREM-dependent-OSA) where AHI-NREM/AHI-REM >2 and remaining subjects were included in the sleep-stage-independent-OSA group (A-2 analysis). SPSS v 17.0 was used to calculate independent sample t test (A-1 analysis) and Kruskall-Wallis test (A-2 analysis). Using A-1 approach, REM-dependent-OSA group was found to be suffering from mild-moderate OSA (90 %). REM-dependent OSA group had lower AHI-NREM (P < 0.001; 95 % CI 22.11-36.81) and lower AHI-total (P < 0.001; 95 % CI 15.39-30.73). Surprisingly, AHI-REM and DI-REM were not significantly different between these groups. A-2 analysis showed that overall, REM-dependent-OSA had lowest AHI-total while the stage-independent group had highest (P < 0.001). However, on analysis of REM-dependent-OSA, it was found that few of the subjects from this group had severe OSA (AHI-total > 30/h). The NREM-AHI increased linearly as we moved from REM-dependent-OSA to stage-independent-OSA with a significant difference across groups (P < 0.001). However, similar trend was not observed for AHI-REM. This study showed that a third group, sleep-stage-independent-OSA also exists when OSA is classified according to the proportion of apnea across sleep stages. This classification partially corresponds with the severity of illness. PMID:23283530
Gupta, Ravi; Lahan, Vivekananda; Sindhwani, Girish
Objectives: Cysts in the region of the larynx seldom caused clinical significant symptoms. The adult patients with laryngeal cysts complained primarily of hoarseness, dysphagia, and stridor. However, laryngeal cysts may result in obstructive sleep apnea syndrome.Methods: We report a case of a 47-year-old woman who arrived at our hospital with progressive snoring and daytime sleepness for more than 12 months.
Li-Ang Lee; Tuan-Jen Fang; Hsueh-Yu Li
Obstructive sleep apnea (OSA) has been recognized as a cause of sleep disruption and daytime somnolence. During the past two\\u000a decades, emerging evidence has implicated OSA as a comorbidity in a number of cardiovascular disease conditions (1). More recently, the effects of OSA have been linked to the activation of a number of mechanisms that may contribute to the\\u000a development
Virend K. Somers
Opinion statement Obstructive sleep apnea (OSA), a highly prevalent disorder, has historically been under-recognized. As its diagnosis and recognition\\u000a increases, physicians other than sleep specialists will need to gain familiarity with the management of this disorder, which\\u000a is so closely tied to increased morbidity, mortality, and an overall health care burden. Most patients with OSA have been\\u000a managed primarily with positive
Ninon Pachikara; Reena Mehra
Travelers to high altitude may have disturbed sleep due to periodic breathing with frequent central apneas. We tested whether a mask with added dead space could reduce the central apneas of altitude. 16 subjects were recruited, age 18-35, residing at 4600?ft (1400?m). They each slept one night with full polysomnographic monitoring, including end tidal CO2, in a normobaric hypoxia tent simulating 12,000?ft. (3658?m) altitude. Those who had a central apnea index (CAI) >20/h returned for a night in the tent for dead space titration, during which they slept with increasing amounts of dead space, aiming for a CAI <5/h or <10% of baseline. Then each subject slept another night with the titrated amount of dead space. Of the 16 subjects, 5 had a central apnea index >20/h mean 49.1, range 21.4-131.5/hr. In each of the 5, the dead space mask reduced the CAI by at least 88% to a mean of 3.1, range 0.9-7.1/h, (p=0.04). Hypopnea index was unchanged. Three subjects required 500?cc of dead space or less. One subject required 860?cc, and one required 2.1?L. Morning symptoms and arousal index were not significantly affected by the dead space mask. Dead space did not appear to increase the CO2 reserve. At 12,000?ft., central apneas can be effectively reduced with a dead space mask, but clinical utility will require further evaluation. PMID:23795738
Patz, David S; Patz, Michael D; Hackett, Peter H
Study Objectives: Determining the presence and severity of obstructive sleep apnea (OSA) is based on apnea and hypopnea event rates per hour of sleep. Making this determination presents a diagnostic challenge, given that summary metrics do not consider certain factors that influence severity, such as body position and the composition of sleep stages. Methods: We retrospectively analyzed 300 consecutive diagnostic PSGs performed at our center to determine the impact of body position and sleep stage on sleep apnea severity. Results: The median percent of REM sleep was 16% (reduced compared to a normal value of ~25%). The median percent supine sleep was 65%. Fewer than half of PSGs contained > 10 min in each of the 4 possible combinations of REM/NREM and supine/non-supine. Half of patients had > 2-fold worsening of the apnea-hypopnea index (AHI) in REM sleep, and 60% had > 2-fold worsening of AHI while supine. Adjusting for body position had greater impact on the AHI than adjusting for reduced REM%. Misclassification—specifically underestimation of OSA severity—is attributed more commonly to body position (20% to 40%) than to sleep stage (~10%). Conclusions: Supine-dominance and REM-dominance commonly contribute to AHI underestimation in single-night PSGs. Misclassification of OSA severity can be mitigated in a patient-specific manner by appropriate consideration of these variables. The results have implications for the interpretation of single-night measurements in clinical practice, especially with trends toward home testing devices that may not measure body position or sleep stage. Citation: Eiseman NA; Westover MB; Ellenbogen JM; Bianchi MT. The impact of body posture and sleep stages on sleep apnea severity in adults. J Clin Sleep Med 2012;8(6):655-666.
Eiseman, Nathaniel A.; Westover, M. Brandon; Ellenbogen, Jeffrey M.; Bianchi, Matt T.
The purpose of this study was to explore the relationship between sleep apnea indicators and injury in older farmers from Kentucky and South Carolina. Participants reported at least 1 day of farm work during the preceding year (n = 756) and received income from farming. The primary outcome variable was occurrence of injuries because of farm work in the past
Karen Heaton; Andres Azuero; Deborah Reed
Obstructive sleep apnea in the ambulatory surgery setting has become a more significant concern in recent years because its identification and recognition are a critical part of preoperative patients' risk assessment. The types of surgeries that can be performed on an outpatient basis have increased and include many specialty procedures that previously were performed on an inpatient basis only. Ambulatory
Yvonne Mull; Marshall Bedder
Background: Limited information exists regarding the development of pulmonary hypertension in patients with obstructive sleep apnea (OSA) in the absence of lung and heart comorbidity. Objectives: The aims of this study were to investigate whether OSA patients without any other cardiac or lung disease develop pulmonary hypertension, and to assess the effect of continuous positive airway pressure (CPAP) treatment on
Manos Alchanatis; Georgia Tourkohoriti; Stavros Kakouros; Epaminondas Kosmas; Stylianos Podaras; John B. Jordanoglou
The interaction between craniofacial structure assessed by lateral cephalometry, and tongue, soft palate, and upper airway size determined from computed tomography (CT) scans was examined in 25 control subjects and 80 patients with obstructive sleep apnea (OSA). On the basis of the cephalometric analyses, the patients with OSA had retruded mandibles with large ANB angle differences, elongated maxillary and mandibular
Alan A. Lowe; John A. Fleetham; Satoshi Adachi; C. Francis Ryan
With the growing epidemic of obesity in an aging population, obstructivesleepapnea(OSA)isincreasinglyencounteredin clinical practice. Given the acute cardiopulmonary stressors consequent to repetitive upper airway collapse, as well as evidence for cardiovas- cular homeostatic dysregulation in subjects with sleep apnea, there is ample biologic plausibility that OSA imparts increased cardiovas- cular risk, independent of comorbid disease. Indeed, observational studies have suggested strong
Jason M. Golbin; Virend K. Somers; Sean M. Caples
Atrial fibrillation (AF) and obesity are coinciding epidemics. Obstructive sleep apnea (OSA) correlates directly with obesity and is highly prevalent among middle-aged adults. Emerging evidence supports a strong association between AF and OSA. The rate of AF among patients with OSA is low but is nevertheless higher than that in the general population. The prevalence of OSA among patients with
Apoor S Gami; Paul A Friedman; Mina K Chung; Sean M Caples; Virend K Somers
Study Objective: Animal data suggest that ?9-TetraHydroCannabinol (?9THC) stabilizes autonomic output during sleep, reduces spontaneous sleep-disordered breathing, and blocks serotonin-induced exacerbation of sleep apnea. On this basis, we examined the safety, tolerability, and efficacy of dronabinol (?9THC), an exogenous Cannabinoid type 1 and type 2 (CB1 and CB2) receptor agonist in patients with Obstructive Sleep Apnea (OSA). Design and Setting: Proof of concept; single-center dose-escalation study of dronabinol. Participants: Seventeen adults with a baseline Apnea Hypopnea Index (AHI) ?15/h. Baseline polysomnography (PSG) was performed after a 7-day washout of Continuous Positive Airway Pressure treatment. Intervention: Dronabinol was administered after baseline PSG, starting at 2.5?mg once daily. The dose was increased weekly, as tolerated, to 5?mg and finally to 10?mg once daily. Measurements and Results: Repeat PSG assessments were performed on nights 7, 14, and 21 of dronabinol treatment. Change in AHI (?AHI, mean?±?SD) was significant from baseline to night 21 (?14.1?±?17.5; p?=?0.007). No degradation of sleep architecture or serious adverse events was noted. Conclusion: Dronabinol treatment is safe and well-tolerated in OSA patients at doses of 2.5–10?mg daily and significantly reduces AHI in the short-term. These findings should be confirmed in a larger study in order to identify sub-populations with OSA that may benefit from cannabimimetic pharmacologic therapy.
Prasad, Bharati; Radulovacki, Miodrag G.; Carley, David W.
Endothelial activation and inflammation are important mediators of accelerated atherogenesis and consequent increased cardiovascular morbidity in obstructive sleep apnea (OSA). Repetitive episodes of hypoxia/reoxygenation associated with transient cessation of breathing during sleep in OSA resemble ischemia/reperfusion injury and may be the main culprit underlying endothelial dysfunction in OSA. Additional factors such as repetitive arousals resulting in sleep fragmentation and deprivation and individual genetic susceptibility to vascular manifestations of OSA contribute to impaired endothelial function in OSA. The present review focuses on possible mechanisms that underlie endothelial activation and inflammation in OSA. PMID:19337546
Atkeson, Amy; Jelic, Sanja
Obstructive sleep apnea (OSA) is a breathing disorder during sleep that has implications beyond disrupted sleep. It is increasingly recognized as an independent risk factor for cardiac, neurologic, and perioperative morbidities. Yet this disorder remains undiagnosed in a substantial portion of our population. It is imperative for all physicians to remain vigilant in identifying patients with signs and symptoms consistent with OSA. This review focuses on updates in the areas of terminology and testing, complications of untreated OSA, perioperative considerations, treatment options, and new developments in this field.
Park, John G.; Ramar, Kannan; Olson, Eric J.
Delirium is a transient global disorder of cognition related to a variety of structural or functional neural disorders. Descriptions and characterizations of delirium associated with obstructive sleep apnea syndrome (OSAS) are rare. We describe a 52-year-old man with severe OSAS associated with sudden onset of delirium and with a fluctuating nighttime course, prolonged for several days. The delirium disappeared after treatment with continuous positive airway pressure (CPAP). The patient remained free of symptoms under CPAP during a follow-up of 8 years. Citation: Lombardi C; Rocchi R; Montagna P; Silani V; Parati G. Obstructive sleep apnea syndrome: a cause of acute delirium. J Clin Sleep Med 2009;5(6):569-570.
Lombardi, Carolina; Rocchi, Raffaele; Montagna, Pasquale; Silani, Vincenzo; Parati, Gianfranco
Maxillomandibular advancement (MMA) is a surgical option for obstructive sleep apnea (OSA). MMA involves forward-fixing the maxilla and mandible approximately 10? mm via Le Fort I maxillary and sagittal split mandibular osteotomies. We retrospectively reviewed outcomes from 24 consecutive OSA patients who underwent MMA at our institution. MMA resulted in an 83% reduction in the group mean apnea-hypopnea index (AHI) per polysomnography an average of 6.7 months after surgery. Forty-two percent of patients achieved a post-MMA AHI of less than 5 events/hour sleep and 71% achieved an AHI less than or equal to 10 events/hour sleep. The Epworth Sleepiness Scale score decreased by an average of 5 post-surgery. No parameters predictive of cure for OSA by MMA were identified. PMID:22518154
Varghese, Ranji; Adams, Nathan G; Slocumb, Nancy L; Viozzi, Christopher F; Ramar, Kannan; Olson, Eric J
Background: Patients with obstructive sleep apnea syndrome (OSAS) have an increased risk of cardiovascular events including myocardial infarction and stroke. Objective: To determine whether in vivo platelet activation and the generation of procoagulant platelet-derived microparticles (PMP) are increased during sleep in patients with OSAS. Methods: In vivo platelet activation and PMP formation was determined using flow cytometry in 12 patients
Thomas Geiser; Florian Buck; Beat J. Meyer; Claudio Bassetti; André Haeberli; Matthias Gugger
Maintaining the patency of the upper airway during MRI sleep studies, without an artificial airway placement in sedated or anesthetized patients with severe obstructive sleep apnea (OSA) is a major challenge. We report two cases in which a continuous positive airway pressure (CPAP) was used instead of artificial airway to allow interpretation of the dynamic component of the study. PMID:24845266
Fleck, Robert J; Amin, Raouf S; Shott, Sally R; Mahmoud, Mohamed A
Prolonged P-wave duration, indicating atrial conduction delay, is a marker of left atrial abnormality and is reported as a potent precursor of atrial fibrillation (AF). Several studies have shown that obstructive sleep apnea (OSA) is associated with AF. We evaluated the relationship between OSA and prolonged P-wave duration. Consecutive subjects who underwent overnight polysomnography and showed a normal sinus rhythm, had no history of AF or ischemic heart disease, and showed no evidence of heart failure were enrolled. Apnea-hypopnea index (AHI) is defined as the number of apnea and hypopnea events per hour of sleep. P-wave duration was determined on the basis of the mean duration of three consecutive beats in lead II from a digitally stored electrocardiogram. A total of 250 subjects (middle-aged, predominantly male, mildly obese, with a mean P-wave duration of 106 ms) were enrolled. In addition to age, male gender, body mass index (BMI), hypertension, dyslipidemia, and uric acid and creatinine levels, AHI (r = 0.56; P < 0.001) had significant univariable relationship with P-wave duration. Multivariate regression analysis showed that age, BMI, male gender, and AHI (partial correlation coefficient, 0.47; P < 0.001) were significantly independently correlated to P-wave duration. Severity of OSA is significantly associated with delayed atrial conduction time. Obstructive sleep apnea may lead to progression of atrial remodeling as an AF substrate. PMID:22975715
Maeno, Ken-Ichi; Kasai, Takatoshi; Kasagi, Satoshi; Kawana, Fusae; Ishiwata, Sugao; Ohno, Minoru; Yamaguchi, Tetsu; Narui, Koji
Purpose The present study attempted to characterize the phenotype of men and women of different ages with a laboratory diagnosis of\\u000a obstructive sleep apnea (OSA) using demographic, subjective complaints and medical history and to determine the best fitting\\u000a apnea–hypopnea index (AHI) cutoff point for OSA diagnosis in each group.\\u000a \\u000a \\u000a \\u000a \\u000a Methods Data collected from 23,806 patients examined by a whole-night polysomnography were retrospectively
Itay E. Gabbay; Peretz Lavie
Seizure disorder and sleep apnea are common chronic disorders in children, but the relationship between sleep apnea and seizure control has not been studied in the pediatric population. This retrospective review included nine children with neurodevelopmental disorders who had well-documented sleep apneic episodes and seizure disorders. Seizure frequency was reduced in five patients (56%) in the first 12 months after
Susan Koh; Sally L Ward; Meei Lin; Lan S Chen
Rationale: Adaptive servoventilation devices are marketed to overcome sleep disordered breathing with apneas and hypopneas of both central and obstructive mechanisms often experienced by patients with chronic heart failure. The clinical efficacy of these devices is still questioned. Study Objectives: This study challenged the detection and treatment capabilities of the three commercially available adaptive servoventilation devices in response to sleep disordered breathing events reproduced on an innovative bench test. Methods: The bench test consisted of a computer-controlled piston and a Starling resistor. The three devices were subjected to a flow sequence composed of central and obstructive apneas and hypopneas including Cheyne-Stokes respiration derived from a patient. The responses of the devices were separately evaluated with the maximum and the clinical settings (titrated expiratory positive airway pressure), and the detected events were compared to the bench-scored values. Results: The three devices responded similarly to central events, by increasing pressure support to raise airflow. All central apneas were eliminated, whereas hypopneas remained. The three devices responded differently to the obstructive events with the maximum settings. These obstructive events could be normalized with clinical settings. The residual events of all the devices were scored lower than bench test values with the maximum settings, but were in agreement with the clinical settings. However, their mechanisms were misclassified. Conclusion: The tested devices reacted as expected to the disordered breathing events, but not sufficiently to normalize the breathing flow. The device-scored results should be used with caution to judge efficacy, as their validity depends upon the initial settings. Citation: Zhu K; Kharboutly H; Ma J; Bouzit M; Escourrou P. Bench test evaluation of adaptive servoventilation devices for sleep apnea treatment. J Clin Sleep Med 2013;9(9):861-871.
Zhu, Kaixian; Kharboutly, Haissam; Ma, Jianting; Bouzit, Mourad; Escourrou, Pierre
Sleep has been regarded as a testing situation for the autonomic nervous system, because its activity is modulated by sleep stages. Sleep-related breathing disorders also influence the autonomic nervous system and can cause heart rate changes known as cyclical variation. We investigated the effect of sleep stages and sleep apnea on autonomic activity by analyzing heart rate variability (HRV). Since
Thomas Penzel; Jan W. Kantelhardt; Ludger Grote; Jörg-Hermann Peter; Armin Bunde
Sleep disordered breathing is a spectrum of diseases that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA). Obstructive sleep apnea is a common sleep disorder and is estimated to have an incidence of 24% in men and 9% in women. However, many authors believe that up to 93% of women and 82% of men with moderate to severe OSA remain undiagnosed. There is a strong link between sleep disordered breathing and hypertension, believed to be due to sleep fragmentation, intermittent hypoxemia, and increased sympathetic tone, which results in a higher mortality and morbidity rate among these patients. It is therefore desirable to attempt to diagnose all patients with OSA, to institute early treatment intervention, and to prevent development of cardiovascular complications. The gold standard for diagnosing OSA remains the attended overnight level I polysomnogram. However, in view of the limited resources, including limited number of recording beds, high cost, long waiting lists, and labor requirements, many authors have explored the use of clinical predictors or questionnaires that may help to identify higher-risk patients. Screening devices in the form of single or multiple channel monitoring systems have also been introduced and may represent an alternative method to diagnose OSA. The ideal screening device should be cheap, readily accessible, easily used with minimal instructions, have no risk or side effects to the patient, and be safe and accurate. We review a variety of clinical predictive formulae and several screening devices available for the diagnosis of OSA. PMID:16500475
Pang, Kenny P; Terris, David J
Purpose Sleep and sleep position have a significant impact on physical, cardiac and mental health, and have been evaluated in numerous\\u000a studies particularly in terms of lateral sleeping positions and their association with diseases. We retrospectively examined\\u000a the relationship between the sleeping position and position-specific apnea-hypopnea index (AHI) in obstructive sleep apnea-hypopnea\\u000a (OSA) patients.\\u000a \\u000a \\u000a \\u000a \\u000a Methods We assessed the sleeping body position and
Ozcan Ozeke; Ozcan Erturk; Mutlu Gungor; Serap B?len H?zel; Dilek Ayd?n; Mehmet Kutlu Celenk; Hazim D?ncer; Gurler Il?c?n; Fuat Ozgen; Can Ozer
Background: Reduced upper airway muscle activity during sleep is fundamental to obstructive sleep apnea (OSA) pathogenesis. Hypoglossal nerve stimulation (HGNS) counteracts this problem, with potential to reduce OSA severity. Study Objectives: To examine safety and efficacy of a novel HGNS system (HGNS, Apnex Medical, Inc.) in treating OSA. Participants: Twenty-one patients, 67% male, age (mean ± SD) 53.6 ± 9.2 years, with moderate to severe OSA and unable to tolerate continuous positive airway pressure (CPAP). Design: Each participant underwent surgical implantation of the HGNS system in a prospective single-arm interventional trial. OSA severity was defined by apnea-hypopnea index (AHI) during in-laboratory polysomnography (PSG) at baseline and 3 and 6 months post-implant. Therapy compliance was assessed by nightly hours of use. Symptoms were assessed using the Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Calgary Sleep Apnea Quality of Life Index (SAQLI), and the Beck Depression Inventory (BDI). Results: HGNS was used on 89% ± 15% of nights (n = 21). On these nights, it was used for 5.8 ± 1.6 h per night. Nineteen of 21 participants had baseline and 6-month PSGs. There was a significant improvement (all P < 0.05) from baseline to 6 months in: AHI (43.1 ± 17.5 to 19.5 ± 16.7), ESS (12.1 ± 4.7 to 8.1 ± 4.4), FOSQ (14.4 ± 2.0 to 16.7 ± 2.2), SAQLI (3.2 ± 1.0 to 4.9 ± 1.3), and BDI (15.8 ± 9.0 to 9.7 ± 7.6). Two serious device-related adverse events occurred: an infection requiring device removal and a stimulation lead cuff dislodgement requiring replacement. Conclusions: HGNS demonstrated favorable safety, efficacy, and compliance. Participants experienced a significant decrease in OSA severity and OSA-associated symptoms. Clinical Trial Information: Name: Australian Clinical Study of the Apnex Medical HGNS System to Treat Obstructive Sleep Apnea. Registration Number: NCT01186926. URL: http://clinicaltrials.gov/ct2/show/NCT01186926. Citation: Eastwood PR; Barnes M; Walsh JH; Maddison KJ; Hee G; Schwartz AR; Smith PL; Malhotra A; McEvoy RD; Wheatley JR; O'Donoghue FJ; Rochford PD; Churchward T; Campbell MC; Palme CE; Robinson S; Goding GS; Eckert DJ; Jordan AS; Catcheside PG; Tyler L; Antic NA; Worsnop CJ; Kezirian EJ; Hillman DR. Treating obstructive sleep apnea with hypoglossal nerve stimulation. SLEEP 2011;34(11):1479-1486.
Eastwood, Peter R.; Barnes, Maree; Walsh, Jennifer H.; Maddison, Kathleen J.; Hee, Geoffrey; Schwartz, Alan R.; Smith, Philip L.; Malhotra, Atul; McEvoy, R. Douglas; Wheatley, John R.; O'Donoghue, Fergal J.; Rochford, Peter D.; Churchward, Tom; Campbell, Matthew C.; Palme, Carsten E.; Robinson, Sam; Goding, George S.; Eckert, Danny J.; Jordan, Amy S.; Catcheside, Peter G.; Tyler, Louise; Antic, Nick A.; Worsnop, Christopher J.; Kezirian, Eric J.; Hillman, David R.
Loeys-Dietz syndrome is a recently recognized connective tissue disorder characterized by severe craniofacial and skeletal abnormalities as well as arterial tortuosity with aggressive aneurysm formation. Marfan syndrome, a classic connective tissue disorder, is known to be associated with a risk of obstructive sleep apnea, but sleep-related breathing disorders have not been previously documented in Loeys-Dietz syndrome. The propositus had the prototypic features of Loeys-Dietz syndrome with a de novo mutation in TGFBR2. He developed severe obstructive sleep apnea during his infancy. Continuous positive airway pressure was introduced at age 7 years and provided significant improvement in his nocturnal apnea and sleep apnea-related symptoms, such as enuresis. Marfan syndrome is known to be associated with a high risk of sleep apnea because of its characteristic craniofacial and connective tissue abnormalities. Similarly, the severe craniofacial abnormalities in Loeys-Dietz syndrome may predispose patients to severe obstructive sleep apnea, even at a very young age. Despite the severity of obstructive sleep apnea in the propositus, the administration of continuous positive airway pressure was highly effective in alleviating his symptoms. In summary, severe obstructive sleep apnea was successfully treated using continuous positive airway pressure in a patient with Loeys-Dietz syndrome. Careful evaluation and aggressive intervention for the alleviation of obstructive sleep apnea is warranted in Loeys-Dietz syndrome. PMID:23686861
Takenouchi, Toshiki; Saito, Hideyuki; Maruoka, Ryo; Oishi, Naoki; Torii, Chiharu; Maeda, Jun; Takahashi, Takao; Kosaki, Kenjiro
Obstructive sleep apnea (OSA) is a prevalent and treatable disorder of neurological and medical importance that is traditionally diagnosed through multi-channel laboratory polysomnography(PSG). However, OSA testing is increasingly performed with portable home devices using limited physiological channels. We tested the hypothesis that single channel respiratory effort alone could support automated quantification of apnea and hypopnea events. We developed a respiratory event detection algorithm applied to thoracic strain-belt data from patients with variable degrees of sleep apnea. We optimized parameters on a training set (n=57) and then tested performance on a validation set (n=59). The optimized algorithm correlated significantly with manual scoring in the validation set (R(2) = 0.73 for training set, R(2) = 0.55 for validation set; p<0.05). For dichotomous classification, the AUC was >0.92 and >0.85 using apnea-hypopnea index cutoff values of 5 and 15, respectively. Our findings demonstrate that manually scored AHI values can be approximated from thoracic movements alone. This finding has potential applications for automating laboratory PSG analysis as well as improving the performance of limited channel home monitors. PMID:24936142
Bianchi, M T; Lipoma, T; Darling, C; Alameddine, Y; Westover, M B
Obstructive sleep apnea (OSA) is a prevalent and treatable disorder of neurological and medical importance that is traditionally diagnosed through multi-channel laboratory polysomnography(PSG). However, OSA testing is increasingly performed with portable home devices using limited physiological channels. We tested the hypothesis that single channel respiratory effort alone could support automated quantification of apnea and hypopnea events. We developed a respiratory event detection algorithm applied to thoracic strain-belt data from patients with variable degrees of sleep apnea. We optimized parameters on a training set (n=57) and then tested performance on a validation set (n=59). The optimized algorithm correlated significantly with manual scoring in the validation set (R2 = 0.73 for training set, R2 = 0.55 for validation set; p<0.05). For dichotomous classification, the AUC was >0.92 and >0.85 using apnea-hypopnea index cutoff values of 5 and 15, respectively. Our findings demonstrate that manually scored AHI values can be approximated from thoracic movements alone. This finding has potential applications for automating laboratory PSG analysis as well as improving the performance of limited channel home monitors.
Bianchi, M.T.; Lipoma, T.; Darling, C.; Alameddine, Y.; Westover, M.B.
Purpose Cognitive functions in community-dwelling adults at high risk of obstructive sleep apnea have not been described and nor are\\u000a associations between cognitive functions and obstructive sleep apnea severity fully understood. The study aimed to describe\\u000a verbal memory and executive function in community-dwelling adults identified by the Berlin Questionnaire and to investigate\\u000a associations between these cognitive domains and different obstructive sleep
Harald Hrubos-Strøm; Inger H. Nordhus; Gunnar Einvik; Anna Randby; Torbjørn Omland; Kjetil Sundet; Torbjørn Moum; Toril Dammen
Abstract Question A 4-year-old child was diagnosed by polysomnography as experiencing mild obstructive sleep apnea (OSA). Despite the child being inattentive and distracted during the day at school, his parents prefer to avoid surgical treatment (adenotonsillectomy). Are there any non-surgical treatments for mild OSA in young children? Answer Obstructive sleep apnea in children is caused mainly by adenotonsillar hypertrophy and can lead to considerable morbidities, including neurocognitive and behavioural disturbances. Surgical removal of the tonsils and adenoids is the treatment of choice. In recent years, however, a new understanding of the inflammatory components of OSA has led to the assumption that anti-inflammatory treatment can reduce adenotonsillar size and improve OSA symptoms. Evidence from a few studies suggests that intranasal steroids and oral leukotriene receptor antagonists have beneficial effects, but data from randomized controlled trials are still lacking.
Friedman, Bat-Chen; Goldman, Ran D.
Obstructive sleep apnea (OSA), characterized by recurrent upper airway (UA) collapse during sleep, is associated with significant morbidity and disorders. Polysomnogram is employed in the evaluation of OSA and apnea-hypopnea number per hour reflects severity. For normal breathing, it is essential that the collapsible UA is patent. However, obstruction of the UA is quite common in adults and infants. Normally, important reflex mechanisms defend against the UA collapse. The muscle activity of UA dilators, including the genioglossus, tensor palatini (TP), and pharyngeal constrictors, is due to the integrated mechanism of afferent sensory input ? to motor function. Snoring is harsh breathing to prevent UA obstruction. Unfortunately, snoring vibrations, pharyngeal suction collapse, negative pressure, and hypoxia cause pathological perturbations including dysfunctional UA afferent sensory activity. The current paper posits that peripheral sensory stimulation paradigm, which has been shown to be efficacious in improving several neurological conditions, could be an important therapeutic strategy in OSA also.
Daulatzai, Mak Adam
Obstructive sleep apnea (OSA) occurs in 2% of middle-aged women and 4% of middle-aged men with a higher prevalence among obese subjects. This condition is considered as an independent risk factor for cerebrovascular and cardiovascular diseases. One of the major pathophysiological characteristics of OSA is intermittent hypoxia. Hypoxia can lead to oxidative stress and overproduction of reactive oxygen species, which can lead to endothelial dysfunction, a hallmark of atherosclerosis. Many animal models, such as the rodent model of intermittent hypoxia, mimic obstructive sleep apnea in human patients and allow more in-depth investigation of biological and cellular mechanisms of this condition. This review discusses the role of oxidative stress in cardiovascular disease resulting from OSA in humans and animal models.
Background Obstructive sleep apnea (OSA) is a highly prevalent disorder with considerable morbidity and mortality. Vigilance and attentiveness are often impaired in OSA patients. In occupational medicine settings, subjective reports of sleepiness are notoriously inaccurate, making the identification of objective measures of vigilance potentially important for risk assessments of fitness for duty. In order to evaluate the effects of OSA on attentiveness and vigilance, we conducted a cross-sectional study to examine the association between OSA and psychomotor vigilance task (PVT) performance. Methods Patients attending sleep clinics for evaluation of possible sleep apnea were recruited. The subjects underwent either a standard overnight laboratory polysomnography or home sleep study. Subjective daytime sleepiness was assessed by Epworth sleepiness scale, and vigilance was tested using a portable device. The participants were asked to respond to the PVT signals using their dominant hand. Each PVT administration lasted 10 minutes, with stimuli signals appearing randomly at variable intervals of 2–10 seconds. Results Mean age of the participants was 46±15 years, and mean body mass index was 34.3±9.8 kg/m2. Participants with higher Epworth scores had worse PVT performance (P<0.05). In multivariate analyses, age, body mass index, and poor sleep efficiency (measured by Pittsburgh sleep quality index score) were associated with worse PVT performance (P<0.05). In contrast, PVT performance did not differ significantly across categories of apnea hypopnea index severity. Subgroup analysis demonstrated that women had worse performance on all PVT measures (P<0.05). Conclusion PVT performance can be utilized for risk assessments of sleepiness and may be particularly useful among populations where subjective reports are unreliable.
Batool-Anwar, Salma; Kales, Stefanos N; Patel, Sanjay R; Varvarigou, Vasileia; DeYoung, Pamela N; Malhotra, Atul
Study Objectives: Abnormal ventilatory drive may contribute to the pathophysiology of the childhood obstructive sleep apnea syndrome (OSAS). Concomitant with the obesity epidemic, more adolescents are developing OSAS. However, few studies have specifically evaluated the obese adolescent group. The authors hypothesized that obese adolescents with OSAS would have a blunted hypercapnic ventilatory response (HCVR) while awake and blunted ventilatory responses to carbon dioxide (CO2) during sleep compared with obese and lean adolescents without OSAS. Design: CVR was measured during wakefulness. During nonrapid eye movement (NREM) and rapid eye movement (REM) sleep, respiratory parameters and genioglossal electromyogram were measured during CO2 administration in comparison with room air in obese adolescents with OSAS, obese control study participants, and lean control study participants. Setting: Sleep laboratory. Participants: Twenty-eight obese patients with OSAS, 21 obese control study participants, and 37 lean control study participants. Results: The obese OSAS and obese control groups had a higher HCVR compared with the lean control group during wakefulness. During both sleep states, all 3 groups had a response to CO2; however, the obese OSAS group had lower percentage changes in minute ventilation, inspiratory flow, inspiratory time, and tidal volume compared with the 2 control groups. There were no significance differences in genioglossal activity between groups. Conclusions: HCVR during wakefulness is increased in obese adolescents. Obese adolescents with OSAS have blunted ventilatory responses to CO2 during sleep and do not have a compensatory prolongation of inspiratory time, despite having normal CO2 responsivity during wakefulness. Central drive may play a greater role than upper airway neuromotor tone in adapting to hypercapnia. Citation: Yuan H; Pinto SJ; Huang J; McDonough JM; Ward MB; Lee YN; Bradford RM; Gallagher PR; Shults J; Konstantinopoulou S; Samuel JM; Katz ES; Hua S; Tapia IE; Marcus CL. Ventilatory responses to hypercapnia during wakefulness and sleep in obese adolescents with and without obstructive sleep apnea syndrome. SLEEP 2012;35(9):1257–1267.
Yuan, Haibo; Pinto, Swaroop J.; Huang, Jingtao; McDonough, Joseph M.; Ward, Michelle B.; Lee, Yin N.; Bradford, Ruth M.; Gallagher, Paul R.; Shults, Justine; Konstantinopoulou, Sophia; Samuel, John M.; Katz, Eliot S.; Hua, Shucheng; Tapia, Ignacio E.; Marcus, Carole L.
Summary. Assessment of reactive oxygen species (ROS) is highly important in neurodegenerative disorders and neuroleptic treatment.\\u000a However, conflicting results have been reported, which may arise from methodological difficulties. Obstructive sleep apnea\\u000a (OSA) syndrome with episodic hypoxia-reoxygenation is proposed as a human model for the investigation of ROS measurements.\\u000a Despite a broad analytical approach comprising lipid peroxidation and amino acid oxidation products,
W. Jordan; S. Cohrs; D. Degner; A. Meier; A. Rodenbeck; G. Mayer; J. Pilz; E. Rüther; J. Kornhuber; S. Bleich
The metabolic syndrome, an emerging public health problem, represents a constellation of cardiovascular risk factors. It has\\u000a been suggested that the presence of obstructive sleep apnea (OSA) may increase the risk of developing some of the features\\u000a of the metabolic syndrome, including hypertension, insulin resistance, and type 2 diabetes. In this article, we discuss the\\u000a parallels between the metabolic syndrome
Anna Svatikova; Robert Wolk; Apoor S. Gami; Michal Pohanka; Virend K. Somers
Obstructive sleep apnea (OSA) is a recognized cause of secondary hypertension. OSA episodes produce surges in systolic and\\u000a diastolic pressure that keep mean blood pressure levels elevated at night. In many patients, blood pressure remains elevated\\u000a during the daytime, when breathing is normal. Contributors to this diurnal pattern of hypertension include sympathetic nervous\\u000a system overactivity and alterations in vascular function
John M. Dopp; Kevin J. Reichmuth; Barbara J. Morgan
BACKGROUND Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. METHODS We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. RESULTS The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P = 0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). CONCLUSIONS As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.)
Marcus, Carole L.; Moore, Renee H.; Rosen, Carol L.; Giordani, Bruno; Garetz, Susan L.; Taylor, H. Gerry; Mitchell, Ron B.; Amin, Raouf; Katz, Eliot S.; Arens, Raanan; Paruthi, Shalini; Muzumdar, Hiren; Gozal, David; Thomas, Nina Hattiangadi; Ware, Janice; Beebe, Dean; Snyder, Karen; Elden, Lisa; Sprecher, Robert C.; Willging, Paul; Jones, Dwight; Bent, John P.; Hoban, Timothy; Chervin, Ronald D.; Ellenberg, Susan S.; Redline, Susan
Epidemiological studies provide strong evidence that obstructive sleep apnea (OSA) is associated with cardiovascular complications\\u000a such as systemic hypertension, congestive heart failure, and atrial fibrillation. Successful OSA treatment with continuous\\u000a positive airway pressure (CPAP) has resulted in coincident reductions in systemic hypertension, improvements in left ventricular\\u000a systolic function, and reductions in sympathetic nervous activity. These data suggest that successful treatment
Olivier M. Vanderveken; An Boudewyns; Quan Ni; Bhavani Kashyap; Johan Verbraecken; Wilfried De Backer; Paul Van de Heyning
BACKGROUND: Hypoxemia, hypertension, airway obstruction, and death have been associated with surgery for obstructive sleep apnea syndrome (OSAS). Patient analysis was undertaken to identify potential factors that could affect risk-management outcome.METHODS: One hundred eighty-two consecutively treated patients with OSAS undergoing 210 procedures were evaluated. Fifty-four factors were analyzed.RESULTS: Group characteristics included a mean age of 48.2 years, a mean respiratory
ROBERT W. RILEY; NELSON B. POWELL; CHRISTIAN GUILLEMINAULT; RAFAEL PELAYO; ROBERT J. TROELL; KASEY K. LI
Obstructive sleep apnea (OSA) is a leading public health problem in both developed and developing nations. However, awareness\\u000a regarding diagnostic options, management, and consequences of untreated OSA remains inadequate in the perioperative period.\\u000a Adverse surgical outcomes appear to be more frequent in OSA patients. Immediate postoperative complications may be partially\\u000a attributed to the negative effects of sedative, analgesic, and anesthetic
Jahan Porhomayon; Ali El-Solh; Sanjeev Chhangani; Nader D. Nader
Obstructive sleep apnea (OSA) is accompanied by neurocognitive impairment, likely mediated by injury to various brain regions. We evaluated brain morphological changes in patients with OSA and their relationship to neuropsychological and oximetric data. Sixteen patients affected by moderate-severe OSA (age: 55.8±6.7years, 13 males) and fourteen control subjects (age: 57.6±5.1years, 9 males) underwent 3.0 Tesla brain magnetic resonance imaging (MRI)
Federico Torelli; Nicola Moscufo; Girolamo Garreffa; Fabio Placidi; Andrea Romigi; Silvana Zannino; Marco Bozzali; Fabrizio Fasano; Giovanni Giulietti; Ina Djonlagic; Atul Malhotra; Maria Grazia Marciani; Charles R. G. Guttmann
Background—Obstructive sleep apnea (OSA) is associated with recurrent atrial fibrillation (AF) after electrocardioversion. OSA is highly prevalent in patients who are male, obese, and\\/or hypertensive, but its prevalence in patients with AF is unknown. Methods and Results—We prospectively studied consecutive patients undergoing electrocardioversion for AF (n151) and consecutive patients without past or current AF referred to a general cardiology practice
Apoor S. Gami; Gregg Pressman; Sean M. Caples; Ravi Kanagala; Joseph J. Gard; Diane E. Davison; Joseph F. Malouf; Naser M. Ammash; Paul A. Friedman; Virend K. Somers
Introduction Obstructive sleep apnea (OSA) and obesity are serious, widespread public health issues.\\u000a \\u000a \\u000a \\u000a Objective To localize and quantify geometric morphometric differences in facial soft tissue morphology in adults with and without OSA.\\u000a \\u000a \\u000a \\u000a Materials and methods Eighty adult Malays, consisting of 40 patients with OSA and 40 non-OSA controls, were studied. Both groups were evaluated\\u000a by the attending physician and through ambulatory sleep studies.
Saeed M. Banabilh; A. H. Suzina; Sidek Dinsuhaimi; A. R. Samsudin; G. D. Singh
Obstructive sleep apnea (OSA) is characterized by recurrent upper airway obstruction occurring at the level of the pharynx during sleep. Although cephalometric analysis is an important method in the diagnosis of craniofacial deformities, CT and magnetic resonance imaging have been highlighted as the major imaging methods to investigate the possible causes of OSA, which, in most cases, is multifactorial. Magnetic resonance and CT both allow an excellent evaluation of the various anatomical planes of the site of obstruction, which enables better clinical assessment and surgical approach. This pictorial essay aims to describe the aspects that must be evaluated in the diagnostic imaging of patients presenting with the major predisposing factors for OSA.
de Mello, Carlos Fernando; Guimaraes, Helio Antonio; Gomes, Camila Albuquerque de Brito; Paiva, Camila Caroline de Amorim
Cardiovascular diseases are the main source of morbidity and mortality in the United States with costs of more than $170 billion. Repetitive respiratory disorders during sleep are assumed to be a major cause of these diseases. Therefore, the understanding of the cardio-respiratory regulation during these events is of high public interest. One of the governing mechanisms is the mutual influence of the cardiac and respiratory oscillations on their respective onsets, the cardio-respiratory coordination (CRC). We analyze this mechanism based on nocturnal measurements of 27 males suffering from obstructive sleep apnea syndrome. Here we find, by using an advanced analysis technique, the coordigram, not only that the occurrence of CRC is significantly more frequent during respiratory sleep disturbances than in normal respiration (p-value<10?51) but also more frequent after these events (p-value<10?15). Especially, the latter finding contradicts the common assumption that spontaneous CRC can only be observed in epochs of relaxed conditions, while our newly discovered epochs of CRC after disturbances are characterized by high autonomic stress. Our findings on the connection between CRC and the appearance of sleep-disordered events require a substantial extension of the current understanding of obstructive sleep apneas and hypopneas.
Riedl, Maik; Muller, Andreas; Kraemer, Jan F.; Penzel, Thomas; Kurths, Juergen; Wessel, Niels
Cardiovascular diseases are the main source of morbidity and mortality in the United States with costs of more than $170 billion. Repetitive respiratory disorders during sleep are assumed to be a major cause of these diseases. Therefore, the understanding of the cardio-respiratory regulation during these events is of high public interest. One of the governing mechanisms is the mutual influence of the cardiac and respiratory oscillations on their respective onsets, the cardio-respiratory coordination (CRC). We analyze this mechanism based on nocturnal measurements of 27 males suffering from obstructive sleep apnea syndrome. Here we find, by using an advanced analysis technique, the coordigram, not only that the occurrence of CRC is significantly more frequent during respiratory sleep disturbances than in normal respiration (p-value<10-51) but also more frequent after these events (p-value<10-15). Especially, the latter finding contradicts the common assumption that spontaneous CRC can only be observed in epochs of relaxed conditions, while our newly discovered epochs of CRC after disturbances are characterized by high autonomic stress. Our findings on the connection between CRC and the appearance of sleep-disordered events require a substantial extension of the current understanding of obstructive sleep apneas and hypopneas. PMID:24718564
Riedl, Maik; Müller, Andreas; Kraemer, Jan F; Penzel, Thomas; Kurths, Juergen; Wessel, Niels
Study Objectives: Sleep apnea has been implicated as an independent risk factor for atherosclerotic coronary artery disease (CAD). An association between the severity of sleep apnea and total cholesterol levels has previously been reported. However, the association with small dense low density lipoprotein (LDL) cholesterol concentration (subclass B), one of the strongest predictors of atherosclerosis, is unknown. We examined the relationship between sleep apnea and LDL subclass B, considering body size. Methods: This is a cross-sectional observational cohort of participants enrolled in a cardiovascular health study. Sleep apnea was assessed with a validated portable monitor. Lipid panels included total cholesterol, triglycerides, high density lipoprotein cholesterol, LDL cholesterol, and LDL subclasses A, B, and A/B. Sleep apnea was analyzed categorically using the apnea hypopnea index (AHI). Results: A total of 519 participants were evaluated. Mean age was 58.7 ± 7.4 years; BMI was 29.6 ± 5.7; 65% were female; 59% were Caucasian, and 37% were African American. Among participants with abnormal waist circumference by ATP III criteria, moderate to severe sleep apnea (AHI ? 25) was not independently associated with LDL subclass B. In contrast, among participants with normal waist circumference, moderate to severe sleep apnea was associated with 4.5-fold odds of having LDL subclass B. Conclusions: Sleep apnea is independently associated with an atherogenic phenotype (LDL subclass B) in non-obese individuals. The association between sleep apnea and LDL subclass B in those with normal waist circumference may account, in part, for the increased risk of atherosclerosis and subsequent vascular events. Citation: Luyster FS; Kip KE; Drumheller OJ; Rice TB; Edmundowicz D; Matthews K; Reis SE; Strollo PJ. Sleep apnea is related to the atherogenic phenotype, lipoprotein subclass B. J Clin Sleep Med 2012;8(2):155-161.
Luyster, Faith S.; Kip, Kevin E.; Drumheller, Oliver J.; Rice, Thomas B.; Edmundowicz, Daniel; Matthews, Karen; Reis, Steven E.; Strollo, Patrick J.
Obstructive Sleep Apnea (OSA) is a disease in which airways involuntarily collapse during sleep, leading to serious consequences. About 1O% of snorers suffer from OSA, unknown to their, nevertheless requiring medical attention. The current standard of dia...
U. R. Abeyratne C. K. Patabandi K. Puvanendran
Sleep disordered breathing is a term which includes simple snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA). Simple snoring is a common complaint affecting 45% of adults occasionally and 25% of adults habitually and is a sign of upper airway obstruction. Snoring has also been identified as a possible risk factor for hypertension, ischemic heart disease, and stroke. The role of dentistry in sleep disorders is becoming more significant, especially in co-managing patients with simple snoring and mild to moderate OSA. The practicing dental professional has the opportunity to assist patients at a variety of levels, starting with the recognition of a sleep-related disorder, referring patients to a physician for evaluation, and assisting in the management of sleep disorders. Obesity is the main predisposing factor for OSA. In nonobese patients, craniofacial anomalies like micrognathia and retrognathia may also predispose to OSA. Diagnosis of OSA is made on the basis of the history and physical examination and investigations such as polysomnography, limited channel testing, split-night testing, and oximetry. Nocturnal attended polysomnography, which requires an overnight stay in a sleep facility, is the standard diagnostic modality in determining if a patient has OSA. As far as treatment is concerned, the less invasive procedures are to be preferred to the more invasive options. The first and simplest option would be behavior modification, followed by insertion of oral devices suited to the patient, especially in those with mild to moderate OSA. Continuous positive airway pressure (CPAP) and surgical options are chosen for patients with moderate to severe OSA. The American Academy of Sleep Medicine (AAOSM) has recommended oral appliances for use in patients with primary snoring and mild to moderate OSA. It can also be used in patients with a lesser degree of oxygen saturation, relatively less day time sleepiness, lower frequency of apnea, those who are intolerant to CPAP, or those who refuse surgery. Oral appliances improve the blood oxygen saturation levels as they relieve apnea in 20-75% of patients. They reduce the apnea-hypopnea index (AHI) by 50% or to < 10 events per h. Oral appliances also reduce the AHI to normal in 50-60% patients. PMID:17938499
Padma, Ariga; Ramakrishnan, N; Narayanan, Vinod
The objective of this study was to examine heart rate variability (HRV) among sleep stages in obstructive sleep apnea (OSA) patients. The study was retrospective within subjects and examined the sleep stages and HRV in relation to OSA, age, body mass index (BMI), and sex. Data collected during diagnostic polysomnograms were used in this study. There were 105 clinical patients undergoing polysomnography for suspected OSA. We sampled the electrocardiogram (ECG) from wakefulness, stage 2, and REM sleep and analyzed for frequency domain HRV. Sampled epochs were free of apnea and arousals. Heart rate variability decreased with age. Total frequency variability (TF) and low frequency variability (LF) in wakefulness and REM sleep increased as apnea severity increased. Measures of TF, LF, and the LF/HF ratio were greatest in REM sleep. There was less LF and TF in Stage REM sleep in patients with higher BMI. In conclusion, the decrease in HRV with aging is a robust finding that occurs even in a clinical sleep apnea population. However, apnea does not mimic aging effects on the heart because HRV increased as apnea severity increased. The decrease in HRV during REM sleep in the obese apnea patients suggests the possibility of an autonomic dysfunction in this subgroup. PMID:17171554
Reynolds, Erica B; Seda, Gilbert; Ware, J C; Vinik, Aaron I; Risk, Marcelo R; Fishback, Nancy F
Statement of problem. The efficiency of an appliance for treatment of sleep apnea shows inordinate interindividual difference. The mechanism of its therapeutic effects remains unresolved. Purpose. This study examined the effect of the device on sleep apnea, and masticatory and tongue muscles. Material and methods. Fifteen patients with sleep apnea syndrome were evaluated polysomno-graphically, with and without the appliance. Electromyograms
Study Objectives: Sleep disturbances in cirrhosis are assumed to be due to hepatic encephalopathy (HE). The interaction between cirrhosis, prior HE, and obstructive sleep apnea (OSA) has not been evaluated. We aimed to evaluate the additional effect of cirrhosis with and without prior HE on the sleep architecture and perceived sleep disturbances of OSA patients. Methods: A case-control review of OSA patients who underwent polysomnography (PSG) in a liver-transplant center was performed. OSA patients with cirrhosis (with/without prior HE) were age-matched 1:1 with OSA patients without cirrhosis. Sleep quality, daytime sleepiness, sleep quality, and sleep architecture was compared between groups. Results: Forty-nine OSA cirrhotic patients (age 57.4 ± 8.3 years, model for end-stage liver disease (MELD) 8.3 ± 5.4, 51% HCV, 20% prior HE) were age-matched 1:1 to OSA patients without cirrhosis. Apnea-hypopnea index, arousal index, sleep efficiency, daytime sleepiness, and effect of sleepiness on daily activities were similar between OSA patients with/ without cirrhosis. Sleep architecture, including %slow wave sleep (SWS), was also not different between the groups. MELD was positively correlated with time in early (N1) stage (r = 0.4, p = 0.03). All prior HE patients (n = 10) had a shift of the architecture towards early, non-restorative sleep (higher % [N2] stage [66 vs 52%, p = 0.005], lower % SWS [0 vs 29%, p = 0.02], lower REM latency [95 vs 151 minutes, p = 0.04]) compared to the rest. Alcoholic etiology was associated with higher latency to N1/N2 sleep, but no other effect on sleep architecture was seen. Conclusions: OSA can contribute to sleep disturbance in cirrhosis and should be considered in the differential of sleep disturbances in cirrhosis. Prior HE may synergize with OSA in worsening the sleep architecture. Citation: Kappus MR; Leszczyszyn DJ; Moses L; Raman S; Heuman DM; Bajaj JS. Effect of obstructive sleep apnea on the sleep architecture in cirrhosis. J Clin Sleep Med 2013;9(3):247-251.
Kappus, Matthew R.; Leszczyszyn, David J.; Moses, Leonard; Raman, Shekar; Heuman, Douglas M.; Bajaj, Jasmohan S.
We studied 50 consecutive patients to test the hypothesis that successful treatment of obstructive sleep apnea with nasal continuous positive airway pressure (nasal CPAP) will decrease automobile ac- cidents in patients with sleep apnea. Thirty-six (72%) of the patients reported using nasal CPAP reg- ularly during 2 yr. Fourteen patients reported they had not used CPAP during 2 yr. The
LARRY FINDLEY; CAROL SMITH; JOANNA HOOPER; MICHAEL DINEEN; PAUL M. SURATT
A recognized complication of vagal nerve stimulation is new or worsening sleep apnea. Its pathophysiology is not clearly understood. We report a patient with obstructive sleep apnea that was directly associated with vagal nerve stimulation causing recurring vocal cord adduction. Adjusting the stimulator settings resolved the problem. PMID:22364850
Aron, Margaret; Vlachos-Mayer, Helen; Dorion, Dominique
Sleep apnea patients and obese subjects are overexposed to cardiovascular diseases. These two health conditions may be associated with hemorheological alterations which could increase the cardiovascular risk. The present study investigated the hemorheological characteristics in patients with overweight and/or sleep apnea to identify the main predictor of red blood cell (RBC) abnormalities in sleep apnea patients. Ninety-seven patients were subjected to one night sleep polygraphy to determine their sleep apnea status. Body mass index (BMI) and the apnea/hypopnea index (AHI) were determined for categorization of obesity and sleep apnea status. Blood was sampled for hematocrit, blood viscosity, RBC deformability, aggregation and disaggregation threshold measurements. BMI and AHI were positively associated and were both positively associated with RBC aggregation. Analyses of covariance and multiple regression analyses revealed that BMI was more predictive of RBC aggregation than AHI. No association of BMI classes and AHI classes with RBC deformability or blood viscosity was observed. This study shows that increased RBC aggregation in sleep apnea patients is caused by overweight. Therapies to improve blood rheology in sleep apnea patients, and therefore reduce the risk for cardiovascular disorders, should focus on weight-loss. PMID:23271197
Sinnapah, Stéphane; Cadelis, Gilbert; Waltz, Xavier; Lamarre, Yann; Connes, Philippe
Objective: To evaluate the prevalence of obstructive sleep apnea in a large population of children with achondroplasia and to evaluate the effectiveness of adenoidectomy and\\/or tonsillectomy as treatment. Methods: Retrospective review of 95 children with achondroplasia. Results: Thirty –six patients (38%) had clinical evidence of obstructive sleep apnea. Thirty-four patients underwent surgery, with more than 1 procedure required in 10
ELIZABETH A. SISK; DIANE G. HEATLEY; BRET J. BOROWSKI; GLEN E. LEVERSON; RICHARD M. PAULI
Purpose: Persons with obstructive sleep apnea syndrome (OSAS) suffer cerebrovascular accidents at three to six times the rate of other Americans. Atherosclerosis of the cervical portion of the carotid artery has been suggested as a possible cause of these strokes. Lateral cephalometric radiographs used to determine the site of upper airway obstruction in sleep apnea patients can also image calcified
Arthur H Friedlander; Ronald Yueh; Michael R Littner
Rationale: Impaired endothelium-dependent vasodilation has been documented in patients with sleep apnea. This impairment may result in blood flow dysregulation during apnea-induced fluctuations in arterial blood gases. Objectives: To test the hypothesis that hypoxic and hypercapnic vasodilation in the forearm and cerebral circulation are impaired in patients with sleep apnea. Methods: We exposed 20 patients with moderate to severe sleep apnea and 20 control subjects, to isocapnic hypoxia and hyperoxic hypercapnia. A subset of 14 patients was restudied after treatment with continuous positive airway pressure. Measurements and Main Results: Cerebral flow velocity (transcranial Doppler), forearm blood flow (venous occlusion plethysmography), arterial pressure (automated sphygmomanometry), oxygen saturation (pulse oximetry), ventilation (pneumotachograph), and end-tidal oxygen and carbon dioxide tensions (expired gas analysis) were measured during three levels of hypoxia and two levels of hypercapnia. Cerebral vasodilator responses to hypoxia (?0.65 ± 0.44 vs. ?1.02 ± 0.72 [mean ± SD] units/% saturation; P = 0.03) and hypercapnia (2.01 ± 0.88 vs. 2.57 ± 0.89 units/mm Hg; P = 0.03) were smaller in patients versus control subjects. Hypoxic vasodilation in the forearm was also attenuated (?0.05 ± 0.09 vs. ?0.10 ± 0.09 unit/% saturation; P = 0.04). Hypercapnia did not elicit forearm vasodilation in either group. Twelve weeks of continuous positive airway pressure treatment enhanced hypoxic vasodilation in the cerebral circulation (?0.83 ± 0.32 vs. ?0.46 ± 0.29 units/% saturation; P = 0.01) and forearm (?0.19 ± 0.15 vs. ?0.02 ± 0.08 units/% saturation; P = 0.003), and hypercapnic vasodilation in the brain showed a trend toward improvement (2.24 ± 0.78 vs. 1.76 ± 0.64 units/mm Hg; P = 0.06). Conclusions: Vasodilator responses to chemical stimuli in the cerebral circulation and the forearm are impaired in many patients with obstructive sleep apnea. Some of these impairments can be improved with continuous positive airway pressure.
Reichmuth, Kevin J.; Dopp, John M.; Barczi, Steven R.; Skatrud, James B.; Wojdyla, Piotr; Hayes, Don; Morgan, Barbara J.
Obstructive sleep apnea syndrome (OSAS) is thought to be closely related to nasal airway resistance, which accounts for approximately one half of total upper airway resistance. This retrospective study aimed at elucidating the effect of endoscopic endonasal surgery on OSAS. Nine consecutive patients with OSAS complaining of nasal obstruction who underwent endoscopic endonasal surgery were enrolled. They were 8 men and 1 woman ranging from 34-73 years of age with an average of 53.2 years. All patients had chronic hypertrophic rhinitis and nasal septal deviation, and underwent septoplasty and submucous turbinectomy. The severity of OSAS was assessed by 8 sleep apnea indices of polysomnography before and after surgery. The indices included the apnea-hypopnea index (AHI), maximum apnea time, mean apnea time, minimum blood oxygen saturation, mean blood oxygen saturation, blood oxygen saturation decline index, awakening response index, and ratio of snoring time to sleep time. Significant decrease in the AHI (27.6 +/- 5.3 vs. 20.7 +/- 5.5/hr; p = 0.033), in the awakening response index (30.5 +/- 3.3 vs. 21.2 +/- 5.3/hr; p = 0.028), and increase in the mean blood oxygen saturation (95.1 +/- 0.7 vs. 96.0 +/- 0.7%; p = 0.023) were observed postoperatively. There was no significant change in the other 5 indices. In addition, nasal airflow resistance measured by acoustic rhinometry had significantly reduced during the periods of both inhalation (474.4 +/- 49.0 vs. 842.7 +/- 50.2cm3/s; p = 0.002) and exhalation (467.3 +/- 57.3 vs. 866.0 +/- 80.6 cm3/s; p = 0.004). The pre- and postoperative body mass indices did not differ statistically from each other. These results indicate that endoscopic endonasal surgery alone has a potential effect on sleep-disordered breathing in OSAS patients with nasal obstruction. We should be aware of such a positive impact of endonasal surgery upon the management of OSAS. PMID:23980484
Takahashi, Risa; Ohbuchi, Toyoaki; Hohchi, Nobusuke; Takeuchi, Shoko; Ohkubo, Jun-ichi; Ikezaki, Shoji; Suzuki, Hideaki
Study Objectives: The aim of this study was to evaluate cardiopulmonary exercise performance in lean and obese patients with obstructive sleep apnea (OSA) compared with controls. Design: Case-control study. Setting: The study was carried out in Sao Paulo Sleep Institute, Sao Paulo, Brazil. Patients and Participants: Individuals with similar ages were allocated into groups: 22 to the lean OSA group, 36 to the lean control group, 31 to the obese OSA group, and 26 to the obese control group. Interventions: The participants underwent a clinical evaluation, polysomnography, a maximum limited symptom cardiopulmonary exercise test, two-dimensional transthoracic echocardiography, and spirometry. Measurements and Results: The apnea-hypopnea index, arousal index, lowest arterial oxygen saturation (SaO2) and time of SaO2 < 90% were different among the groups. There were differences in functional capacity based on the following variables: maximal oxygen uptake (VO2max), P < 0.01 and maximal carbon dioxide production (VCO2max), P < 0.01. The obese patients with OSA and obese controls presented significantly lower VO2max and VCO2max values. However, the respiratory exchange ratio (RER) and anaerobic threshold (AT) did not differ between groups. Peak diastolic blood pressure (BP) was higher among the obese patients with OSA but was not accompanied by changes in peak systolic BP and heart rate (HR). When multiple regression was performed, body mass index (P < 0.001) and male sex in conjunction with diabetes (P < 0.001) independently predicted VO2max (mL/kg/min). Conclusions: The results of this study suggest that obesity alone and sex, when associated with diabetes but not OSA, influenced exercise cardiorespiratory function. Citation: Rizzi CF; Cintra F; Mello-Fujita L; Rios LF; Mendonca ET; Feres MC; Tufik S; Poyares D. Does obstructive sleep apnea impair the cardiopulmonary response to exercise? SLEEP 2013;36(4):547-553.
Rizzi, Camila F.; Cintra, Fatima; Mello-Fujita, Luciane; Rios, Lais F.; Mendonca, Elisangela T.; Feres, Marcia C.; Tufik, Sergio; Poyares, Dalva
Objective: The aim of this study was to investigate the effects of obstructive sleep apnea (OSA) on procedural and declarative memory encoding in the evening prior to sleep, on memory consolidation during subsequent sleep, and on retrieval in the morning after sleep. Methods: Memory performance (procedural mirror-tracing task, declarative visual and verbal memory task) and general neuropsychological performance were assessed before and after one night of polysomnographic monitoring in 15 patients with moderate OSA and 20 age-, sex-, and IQ-matched healthy subjects. Results: Encoding levels prior to sleep were similar across groups for all tasks. Conventional analyses of averaged mirror tracing performance suggested a significantly reduced overnight improvement in OSA patients. Single trial analyses, however, revealed that this effect was due to significantly flattened learning curves in the evening and morning session in OSA patients. OSA patients showed a significantly lower verbal retention rate and a non-significantly reduced visual retention rate after sleep compared to healthy subjects. Polysomnography revealed a significantly reduced REM density, increased frequency of micro-arousals, elevated apnea-hypopnea index, and subjectively disturbed sleep quality in OSA patients compared to healthy subjects. Conclusions: The results suggest that moderate OSA is associated with a significant impairment of procedural and verbal declarative memory. Future work is needed to further determine the contribution of structural or functional alterations in brain circuits relevant for memory, and to test whether OSA treatment improves or normalizes the observed deficits in learning. Citation: Kloepfer C; Riemann D; Nofzinger EA; Feige B; Unterrainer J; O'Hara R; Sorichter S; Nissen C. Memory before and after sleep in patients with moderate obstructive sleep apnea. J Clin Sleep Med 2009;5(6):540-548.
Kloepfer, Corinna; Riemann, Dieter; Nofzinger, Eric A.; Feige, Bernd; Unterrainer, Josef; O'Hara, Ruth; Sorichter, Stephan; Nissen, Christoph
Background Obstructive sleep apnea is a common sleep disorder that can cause excessive daytime sleepiness and impairment of cognition. These symptoms may lead to the occurrence of occupational accidents in workers with obstructive sleep apnea. Case presentation A 36-year-old man who worked as a dimensional control surveyor caused a vehicle accident while he was driving at the work site. Although he experienced loss of consciousness at the time of the accident, he had no other symptoms. His brain computed tomography and laboratory test did not show any specific findings. Medical tests were conducted to evaluate his fitness for work. Decreased sleep latency was observed on the electroencephalography image, which is suggestive of a sleep disorder. He frequently experienced daytime sleepiness and his Epworth sleepiness score was 13. The polysomnography showed a markedly increased apnea-hypopnea index of 84.3, which led to a diagnosis of severe obstructive sleep apnea. The patient was advised to return to work only when his obstructive sleep apnea improved through proper treatment. Conclusion Proper screening for obstructive sleep apnea among workers is important for preventing workplace accidents caused by this disorder, but screening guidelines have not yet been established in Korea. An effort toward preparing practical guidelines for obstructive sleep apnea is needed.
Study Objectives: Although periodic limb movements in sleep (PLMS) have been described in multiple pediatric publications, periodic limb movement disorder (PLMD) has not. The aims of this study were to describe the prevalence, sleep-related correlates, and polysomnographic correlates of PLMD in a large pediatric case series, and compare these to pediatric obstructive sleep apnea (OSA). Methods: All PLMD cases (defined by International Classification of Sleep Disorders, 2nd edition criteria + respiratory disturbance index [RDI] < 3) and OSA cases (defined by RDI ? 3 + PLMS < 5), from a single pediatric sleep practice, over a 2-year time span, were included. Chart, questionnaire, and polysomnographic data were compiled. Of 468 referred children, 66 PLMD cases were identified (14%). Results: The PLMD cases, mean age 8.1 years (range 1-17), were clinically characterized by frequent sleep onset and maintenance problems, difficulty awakening, restless sleep, leg pain/discomfort at night, and parasomnias. Compared to 90 OSA children, those with PLMD had a history of significantly more sleep onset and maintenance problems, leg pain/discomfort at night, parasomnias, getting out of bed at night, and family history of restless legs syndrome. Polysomnographically, PLMD cases had more awakenings, stage 1 sleep, stage shifts, and spontaneous arousals. Conclusions: These data indicate that pediatric PLMD has important clinical and polysomnographic correlates. In addition, PLMD has many characteristics that are different from pediatric OSA, suggesting that PLMD is a distinct pediatric sleep disorder, of which clinicians should be aware. Citation: Gingras JL; Gaultney JF; Picchietti DL. Pediatric periodic limb movement disorder: sleep symptom and polysomnographic correlates compared to obstructive sleep apnea. J Clin Sleep Med 2011;7(6):603-609.
Gingras, Jeannine L.; Gaultney, Jane F.; Picchietti, Daniel L.
This report seeks to establish the prevalence of sleep apnea in patients with the FMR1 premutation with and without FXTAS and to determine any correlation between CGG repeat and FMR1 mRNA levels with sleep apnea prevalence. Demographic and medical data from 430 (229 males, 201 females) participants were used in this analysis. Participants included premutation carriers with (n=118) and without FXTAS (n=174) as well as controls without the premutation (n=123). Logistic regression models were employed to estimate the odds ratio of sleep apnea relative to controls, adjusted for age and gender, and also to examine potential association with CGG size and FMR1 mRNA expression level. The observed proportion of sleep apnea in premutation carriers with and without FXTAS and controls are 31.4% (37/118), 8.6% (15/174), and 13.8% (17/123), respectively. The adjusted odds of sleep apnea for premutation carriers with FXTAS is about 3.4 times that compared to controls (odds ratio, OR=3.4, 95% CI 1.8 to 7.4; p=0.001), and similarly relative to premutation carriers without FXTAS (OR=2.9, 95% CI 1.2 to 6.9; p=0.014). The risk of sleep apnea was not different between controls and premutation carriers without FXTAS. The presence of sleep apnea is not associated with CGG repeat numbers nor FMR1 mRNA expression level among premutation carriers. Our data supports a higher prevalence and risk of sleep apnea in patients with FXTAS. We recommend that all patients diagnosed with FXTAS be screened for sleep apnea given the negative and perhaps accelerative impact sleep apnea may have on their FXTAS progression.
Hamlin, Alyssa; Liu, Ying; Nguyen, Danh V.; Tassone, Flora; Zhang, Lin; Hagerman, Randi J.
Untreated patients with obstructive sleep apnea (OSA) are at increased risk for motor vehicle collisions; however, it is unclear how this should be translated into fitness-to-drive recommendations. Accordingly, the Canadian Thoracic Society (CTS) Sleep Disordered Breathing Clinical Assembly and the Canadian Sleep Society (CSS) assembled a CTS-CSS working group to propose recommendations with regard to driving in patients with OSA. Recommendations for assessing fitness to drive in noncommercial drivers: 1. Severity of OSA alone is not a reliable predictor of collision risk and, therefore, should not be used in isolation to assess fitness to drive; 2. The severity of sleep apnea should be considered in the context of other factors to assess fitness to drive; 3. The decision to restrict driving is ultimately made by the motor vehicle licensing authority; however, they should take into account the information and recommendations provided by the sleep medicine physician and should follow provincial guidelines; 4. For patients prescribed continuous positive airway pressure (CPAP) therapy, objective CPAP compliance should be documented. Efficacy should also be documented in terms of reversing the symptoms and improvement in sleep apnea based on physiological monitoring; 5. For patients treated with surgery or an oral appliance, verification of adequate sleep apnea treatment should be obtained; and 6. A driver diagnosed with OSA may be recertified as fit to drive based on assessment of symptoms and demonstrating compliance with treatment. The assessment should be aligned with the provincial driver's license renewal period. Commercial vehicles: Assessment of fitness to drive should be more stringent for patients operating commercial vehicles. In general, the CTS-CSS working group was in agreement with the Medical Expert Panel recommendations to the Federal Motor Carrier Safety Administration in the United States; these recommendations were adapted for Canadian practitioners. PMID:24724150
Ayas, Najib; Skomro, Robert; Blackman, Adam; Curren, Kristen; Fitzpatrick, Michael; Fleetham, John; George, Charles; Hakemi, Tom; Hanly, Patrick; Li, Christopher; Morrison, Debra; Series, Frédéric
Sleep disordered breathing does show different types of events. These are obstructive apnea events, central apnea events and mixed sleep apnea (MSA) which have a central component with a pause in airflow without respiratory effort followed by an obstructive component with respiratory effort. The esophageal pressure (Pes) is the accurate method to assess respiratory effort. The aim of the present study is to investigate whether the features extracted from photo-plethysmogram (PPG) could relate with the changes in Pes during MSA. Therefore, Pes and PPG signals during 65 pre-scored MSA events and 10 s preceding the events were collected from 8 patients. Pulse intervals (PPI), Pulse wave amplitudes (PWA) and wavelet decomposition (Wv) of PPG signals at level 8 (0.15-0.32 Hz) were derived from PPG signals. Results show that significant correlations (r = 0.63, p < 0.01; r = 0.42, p < 0.05; r = 0.8, p < 0.01 for OSA part) were found between reductions in Pes and that in PPG based surrogate respiratory signals PPI, PWA and Wv. Results suggest that PPG based relative respiratory effort signal can be considered as an alternative to Pes as a means of measuring changes in inspiratory effort when scoring OSA and CSA parts of MSA events. PMID:23695488
Khandoker, A H; Karmakar, C K; Penzel, T; Glos, M; Palaniswami, M
Purpose Sleep apnea is common in myotonic dystrophy (MD) and may cause respiratory failure. Most of the sleep studies have been performed\\u000a in patients with excessive daytime sleepiness (EDS), which is a characteristic and strong predictor of sleep apnea. Therefore,\\u000a we investigated the prevalence of sleep apnea in adult MD patients who have no EDS.\\u000a \\u000a \\u000a \\u000a \\u000a Materials and methods Epworth Sleepiness Scale was
Esen Kiyan; Gulfer Okumus; Caglar Cuhadaroglu; Feza Deymeer
OBJECTIVES: The aim of this study was to investigate neuropsychological performance and biomarkers of oxidative stress in patients with obstructive sleep apnea and the relationships between these factors. METHODS: This was an observational, cross-sectional study of 14 patients (36.0±6.5 years old) with obstructive sleep apnea and 13 controls (37.3±6.9 years old). All of the participants were clinically evaluated and underwent full-night polysomnography as well as neuropsychological tests. Blood samples were used to assay superoxide dismutase, catalase, glutathione and homocysteine, as well as vitamins E, C, B11 and B12. RESULTS: The patients performed poorly relative to the controls on several neuropsychological tests, such as the attention test and tests of long-term memory and working memory/executive function. They also had lower levels of vitamin E (p<0.006), superoxide dismutase (p<0.001) and vitamin B11 (p<0.001), as well as higher concentrations of homocysteine (p<0.02). Serum concentrations of vitamin C, catalase, glutathione and vitamin B12 were unaltered. Vitamin E levels were related to performance in the backward digit span task (F?=?15.9; p?=?0.002) and this correlation remained after controlling for age and body mass index (F?=?6.3, p?=?0.01). A relationship between superoxide dismutase concentrations and executive non-perseveration errors in the Wisconsin Card Sorting Test (F?=?7.9; p?=?0.01) was also observed. CONCLUSIONS: Decreased levels of antioxidants and lower performance on the neuropsychological tasks were observed in patients with obstructive sleep apnea. This study suggests that an imbalance between antioxidants and pro-oxidants may contribute to neuropsychological alterations in this patient population.
Sales, Leticia Viana; de Bruin, Veralice Meireles Sales; D'Almeida, Vania; Pompeia, Sabine; Bueno, Orlando Francisco Amodeo; Tufik, Sergio; Bittencourt, Lia
Rationale: Despite emerging evidence that obstructive sleep apnea (OSA) may cause metabolic disturbances independently of other known risk factors, it remains unclear whether OSA is associated with incident diabetes. Objectives: To evaluate whether risk of incident diabetes was related to the severity and physiologic consequences of OSA. Methods: A historical cohort study was conducted using clinical and provincial health administrative data. All adults without previous diabetes referred with suspected OSA who underwent a diagnostic sleep study at St. Michael's Hospital (Toronto, Canada) between 1994 and 2010 were followed through health administrative data until May 2011 to examine the occurrence of diabetes. All OSA-related variables collected from the sleep study were examined as predictors in Cox regression models, controlling for sex, age, body mass index, smoking status, comorbidities, and income. Measurements and Main Results: Over a median follow-up of 67 months, 1,017 (11.7%) of 8,678 patients developed diabetes, giving a cumulative incidence at 5 years of 9.1% (95% confidence interval, 8.4-9.8%). In fully adjusted models, patients with apnea-hypopnea index (AHI) greater than 30 had a 30% higher hazard of developing diabetes than those with AHI less than 5. Among other OSA-related variables, AHI in rapid eye movement sleep and time spent with oxygen saturation less than 90% were associated with incident diabetes, as were heart rate, neck circumference, and sleep time. Conclusions: Among people with OSA, and controlling for multiple confounders, initial OSA severity and its physiologic consequences predicted subsequent risk for incident diabetes. PMID:24897551
Kendzerska, Tetyana; Gershon, Andrea S; Hawker, Gillian; Tomlinson, George; Leung, Richard S
The aim of the study - to investigate which of the following clinical (age, gender and weight) and polysomnographic data (respiratory disturbance index, duration of slow sleep, mean and maximum desaturation percent, arousal index) the most important for the daytime sleepiness in patients with obstructive sleep apnea syndrome. Obstructive sleep apnea was confirmed by polisomnography (ALICE 4 system). Daytime sleepiness was investigated using Epworth sleepiness scale (ESS). One hundred eight consecutive patients with obstructive sleep apnea were included in the study: 77 men (age 52.4+/-12.84 years) and 31 women (age 59.5+/-9.58 years). Correlation of ESS value and patients' weight was 0.32, p=0.001, ESS and respiratory disturbance index was 0.493, p<0.001, ESS and slow sleep time was -0.39, p<0.001, ESS and arousal index was 0.509, p<0.001, ESS and mean desaturation value was -0.352, p=0.001, and ESS and maximal desaturation value was -0.398, p<0.001. Logistic regression model was used to determine the role of gender, age, obesity degree (according to the body-mass index) and polysomnographic data for severe daytime sleepiness (ESS more than 10). In the univariate analysis male had odds ratio 3.52 (95% CI 1.35-9.16, p=0.01). In case of respiratory disturbance index is more than 34 - odds ratio was 4.25 (95% CI 1.85-9.76, p=0.001), slow sleep less than 38 minutes - odds ratio 3.08 (95% CI 1.38-6.9, p=0.006), mean desaturation less than 90% - odds ratio 4.09 (95% CI 1.68-9.96, p=0.002), maximal desaturation less than 80% 3.06 (95% CI 1.29-7.22, p=0.011), arousal index more than 30 - odds ratio 6.12 (95% CI 2.57-14.78, p<0.001). Only arousal index was statistically significant for the high daytime sleepiness in the multivariate analysis: odds ratio - 6.16 (95% CI 2.6-14.8, p<0.001). PMID:12695635
Miliauskas, Skaidrius; Sakalauskas, Raimundas
Obstructive sleep apnea (OSA) is highly prevalent sleep disorder of breathing in both adults and children that is fraught with substantial cardiovascular morbidities, the latter being attributable to a complex interplay between intermittent hypoxia (IH), episodic hypercapnia, recurrent large intra-thoracic pressure swings, and sleep disruption. Alterations in autonomic nervous system function could underlie the perturbations in cardiovascular, neurocognitive, immune, endocrine and metabolic functions that affect many of the patients suffering from OSA. Although these issues have received substantial attention in adults, the same has thus far failed to occur in children, creating a quasi misperception that children are protected. Here, we provide a critical overview of the evidence supporting the presence of autonomic nervous system (ANS) perturbations in children with OSA, draw some parallel assessments to known mechanisms in rodents and adult humans, particularly, peripheral and central chemoreceptor and baroreceptor pathways, and suggest future research directions.
Gozal, David; Hakim, Fahed; Kheirandish-Gozal, Leila
There is a high incidence of atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA). Whether this represents a causative relationship or is merely an association remains to be determined. This review describes the current understanding of pathophysiologic links supporting a causative relationship between OSA and AF. The management of AF with antiarrhythmics, cardioversion and ablation success depends on compliance with OSA treatment. OSA worsens every risk factor resulting in a higher stroke risk in AF patients. Strategies for early screening and compliance with OSA treatment are the need of the hour. PMID:24731146
Oza, Nishaki; Baveja, Swati; Khayat, Rami; Houmsse, Mahmoud
The effect of sleep apnea on the reproductive function of obese men is not entirely elucidated. The objective of this study was to define the effect of sleep apnea on the reproductive hormones and sexual function in obese men. This study included 89 severely obese men with BMI ?35 kg/m2 considering gastric bypass surgery. Anthropometrics (weight, and BMI), reproductive hormones, and sleep studies were measured. The sexual quality of life was assessed using the Impact of Weight on Quality of Life-Lite questionnaire (IWQOL-Lite). The mean age of our patients was 46.9 ± 11.0 years, the mean BMI was 47.8 ± 8.7 kg/m2 and the mean weight was 337.7 ± 62.4 lb. After correction for age and BMI, means of free testosterone per severity group of sleep apnea were as follows: no or mild sleep apnea 74.4 ± 3.8 pg/ml, moderate sleep apnea 68.6 ± 4.2 pg/ml, and severe sleep apnea 60.2 ± 2.92 pg/ml, P = 0.014. All other parameters of sleep apnea including hypopnea index, percent time below a SpO2 of 90%, and percent time below a SpO2 of 80% were also negatively correlated with testosterone levels after correction for age and BMI. BMI and presence of coronary artery disease decreased the sexual quality of life. Sleep apnea was associated with reduced sexual quality of life. In summary, sleep apnea negatively affects testosterone levels independent of BMI. Severely obese men had decreased sexual quality of life.
Hammoud, Ahmad O.; Walker, James M.; Gibson, Mark; Cloward, Tom V.; Hunt, Steven C.; Kolotkin, Ronette L.; Adams, Ted D.; Meikle, A. Wayne
Obstructive sleep apnea (OSA) is a common disorder in which individuals stop breathing during their sleep. These episodes last 10 seconds or more and cause oxygen levels in the blood to drop. Most of sleep apnea cases are currently undiagnosed because of expenses and practicality limitations of overnight polysomnography (PSG) at sleep labs, where an expert human observer is required.
Miad Faezipour; Khaled Elleithy
Obstructive sleep apnea (OSA) is an important clinical problem in the chronic kidney disease (CKD) population. OSA is associated with hypoxemia and sleep fragmentation, which activates the sympathetic nervous system, the renin-angiotensin-aldosterone system, alters cardiovascular hemodynamics, and results in free radical generation. In turn, a variety of deleterious processes such as endothelial dysfunction, inflammation, platelet aggregation, atherosclerosis, and fibrosis are triggered, predisposing individuals to adverse cardiovascular events and likely renal damage. Independent of obesity, OSA is associated with glomerular hyperfiltration and may be an independent predictor of proteinuria, a risk factor for CKD progression. OSA is also associated with hypertension, another important risk factor for CKD progression, particularly proteinuric CKD. OSA may mediate renal damage via several mechanisms, and there is a need to better elucidate the impact of OSA on incident renal disease and CKD progression. PMID:20676805
Adeseun, Gbemisola A; Rosas, Sylvia E
Obstructive sleep apnea (OSA) has become an important public health concern. Polysomnography (PSG) is traditionally considered an established and effective diagnostic tool providing information on the severity of OSA and the degree of sleep fragmentation. However, the numerous steps in the PSG test to diagnose OSA are costly and time consuming. This study aimed to apply the multiclass Mahalanobis-Taguchi system (MMTS) based on anthropometric information and questionnaire data to predict OSA. Implementation results showed that MMTS had an accuracy of 84.38% on the OSA prediction and achieved better performance compared to other approaches such as logistic regression, neural networks, support vector machine, C4.5 decision tree, and rough set. Therefore, MMTS can assist doctors in prediagnosis of OSA before running the PSG test, thereby enabling the more effective use of medical resources. PMID:22545062
Su, Chao-Ton; Chen, Kun-Huang; Chen, Li-Fei; Wang, Pa-Chun; Hsiao, Yu-Hsiang
Obstructive sleep apnea (OSA) has become an important public health concern. Polysomnography (PSG) is traditionally considered an established and effective diagnostic tool providing information on the severity of OSA and the degree of sleep fragmentation. However, the numerous steps in the PSG test to diagnose OSA are costly and time consuming. This study aimed to apply the multiclass Mahalanobis-Taguchi system (MMTS) based on anthropometric information and questionnaire data to predict OSA. Implementation results showed that MMTS had an accuracy of 84.38% on the OSA prediction and achieved better performance compared to other approaches such as logistic regression, neural networks, support vector machine, C4.5 decision tree, and rough set. Therefore, MMTS can assist doctors in prediagnosis of OSA before running the PSG test, thereby enabling the more effective use of medical resources.
Su, Chao-Ton; Chen, Kun-Huang; Chen, Li-Fei; Wang, Pa-Chun; Hsiao, Yu-Hsiang
Impaired endothelium-dependent vascular relaxation is a prognostic marker of atherosclerosis and cardiovascular disease. We evaluated endothelium-dependent flow-mediated dilation (FMD) and endothelium-independent nitroglycerin (NTG)-induced dilation of the brachial artery with Doppler ultrasound in 28 men with obstructive sleep apnea (OSA) and 12 men without OSA. Subjects with OSA (apnea-hypopnea index; mean +/- SD, 46.0 +/- 14.5) had lower FMD compared with subjects without OSA (5.3 +/- 1.7% vs. 8.3 +/- 1.0%, p < 0.001), and major determinants of FMD were the apnea-hypopnea index and age. There was no significant difference in NTG-induced dilation. Subjects with OSA were randomized to nasal continuous positive airway pressure (nCPAP) or observation for 4 weeks. Subjects on nCPAP had significant increase in FMD, whereas those on observation had no change (4.4% vs. -0.8%, difference of 5.2%, p < 0.001). Neither group showed significant change in NTG-induced vasodilation. Eight subjects who used nCPAP for over 3 months were reassessed on withdrawing treatment for 1 week. On nCPAP withdrawal, FMD became lower than during treatment (p = 0.02) and were similar to baseline values. Our findings demonstrated that men with moderate/severe OSA have endothelial dysfunction and treatment with nCPAP could reverse the dysfunction; the effect, however, was dependent on ongoing use. PMID:14551167
Ip, Mary S M; Tse, Hung-Fat; Lam, Bing; Tsang, Kenneth W T; Lam, Wah-Kit
Background: Evidence evaluating the risk of pneumonia in patients with obstructive sleep apnea is limited and mostly focuses on patients who receive continuous positive airway pressure (CPAP) therapy or on pediatric patients. We aimed to explore the risk of incident pneumonia among adults with sleep apnea, either with or without the need of CPAP therapy. Methods: From Jan. 1, 2000, we identified adult patients with sleep apnea from the Taiwan National Health Insurance Research Database. A control cohort without sleep apnea, matched for age, sex and comorbidities, was selected for comparison. The 2 cohorts were followed until Dec. 31, 2010, and observed for occurrence of pneumonia. Results: Of the 34 100 patients (6816 study patients and 27 284 matched controls), 2757 (8.09%) had pneumonia during a mean follow-up period of 4.50 years, including 638 (9.36%) study patients and 2119 (7.77%) controls. Kaplan–Meier analysis showed a higher incidence of pneumonia among patients with sleep apnea (log rank test, p < 0.001). After multivariate adjustment, patients with sleep apnea experienced a 1.20-fold (95% confidence interval 1.10–1.31) increase in incident pneumonia. The risk was even higher among patients who received CPAP therapy. Interpretation: Sleep apnea appeared to confer a higher risk for future pneumonia, possibly in a severity-dependent manner.
Su, Vincent Yi-Fong; Liu, Chia-Jen; Wang, Hsin-Kai; Wu, Li-An; Chang, Shi-Chuan; Perng, Diahn-Warng; Su, Wei-Juin; Chen, Yuh-Min; Lin, Elizabeth Ya-Hsuan; Chen, Tzeng-Ji; Chou, Kun-Ta
We attempted to validate a two-stage strategy to screen for severe obstructive sleep apnea syndrome (s-OSAS) among hypertensive outpatients, with polysomnography (PSG) as the gold standard. Using a prospective design, we recruited outpatients with hypertension from medical outpatient clinics. Interventions included: 1) assessment of clinical data; 2) home sleep testing (HST); and 3) 12-channnel, in-laboratory PSG. We developed models using clinical or HST data alone (single-stage models) or clinical data in tandem with HST (two-stage models) to predict s-OSAS. For each model, we computed area-under-receiver-operating-characteristic curves (AUC), sensitivity, specificity, negative likelihood ratio, and negative post-test probability (NPTP). Models were then rank-ordered based upon AUC values and NPTP. HST used alone had limited accuracy (AUC=0.727, ,NPTP = 2.9%). However, models that used clinical data in tandem with HST were more accurate in identifying s-OSAS, with lower NPTP: 1) facial morphometrics (AUC=0.816, NPTP=0.6%); 2) neck circumference (AUC=0.803, NPTP=1.7%); and Multivariable Apnea Prediction Score (AUC = 0.799, NPTP =1.5%) where sensitivity, specificity and NPTP were evaluated at optimal thresholds. Therefore, HST combined with clinical data can be useful in identifying s-OSAS in hypertensive outpatients, without incurring greater cost and patient burden associated with in-laboratory PSG. These models were less useful in identifying OSAS of any severity.
Gurubhagavatula, Indira; Fields, Barry G.; Morales, Christian R; Hurley, Sharon; Pien, Grace W; Wick, Lindsay C.; Staley, Bethany A.; Townsend, Raymond R; Maislin, Greg
Obstructive sleep apnea syndrome (OSAS) is a widespread disorder characterized by recurrent, partial, or complete episodes of apnea due to upper airway tract obstruction during sleep. OSAS frequency is likely to increase in hypothyroidism because of obesity, macroglossia, dysfunctional upper respiratory tractus (URT) musculature, deposition of mucopolysaccharides in URT tissues, and decreased ventilatory control. This study examines the relationship between OSAS and thyroid disease in OSAS subjects. This study includes 150 polysomnographically diagnosed OSAS patients (50 mild, 50 moderate, 50 severe OSAS cases) treated at Endocrinology and Metabolism Department of Ankara Numune Training and Research Hospital between January 2010 and May 2011 and 32 non-OSAS control subjects. All patients were given serum TSH, free T3 (fT3), free T4 (fT4), anti thyroid peroxidase (Anti-TPO), and anti-thyroglobulin (anti-TG) tests, as well as thyroid ultrasounds. We did not find any difference in prevalence of hypothyroidism, numbers of nodules and parenchyma heterogenicity determined by ultrasound, between OSAS subgroups and controls (p > 0,05). In this study, functional and ultrasonographic examination of the thyroid gland did not reveal any relationship between OSAS and thyroid disease. We believe hence that long-term follow-up studies can establish the possible significance of routine evaluation of OSAS patients for thyroid disease. PMID:23564558
Mete, Turkan; Yalcin, Yavuz; Berker, Dilek; Ciftci, Bulent; Guven Firat, Selma; Topaloglu, Oya; Cinar Yavuz, Halise; Guler, Serdar
Background. Obstructive sleep apnea (OSA) syndrome is one of the most common respiratory disorders in humans. There is emerging evidence linking OSA to vascular disease, particularly hypertension. The underlying pathophysiological mechanisms that link OSA to cardiovascular diseases such as hypertension, congestive heart failure, and atrial fibrillation are not entirely understood. The aim of this study was to investigate the association of obstructive sleep apnea hypopnea syndrome (OSAHS) with coronary atherosclerotic disease (CAD). Methods. A questionnaire survey based on Berlin questionnaire and Epworth Sleepiness Scale (ESS) was conducted among 406 patients to assess demographic data and the symptoms, such as excessive daytime sleepiness and snoring. Epworth Sleepiness Scale and Berlin questionnaire were completed by all of the patients. Venous blood samples were obtained for biochemical tests. Characteristics of coronary arteries were collected from angiographies' reports. All patients were divided into two groups based on results from Berlin questionnaire: low risk patients for OSA and high risk patients for OSA. Data were analyzed by SPSS software version 13. Results. Mean age of patients was 61.8 ± 10.5. 212 (52.2%) patients were categorized as high risk group for apnea. Also, excessive daytime sleepiness was reported in 186 patients (45.8%). The severity of coronary artery involvement, daytime sleepiness, and electrocardiogram abnormalities was significantly higher in high risk patients for OSA compared with low risk patients. High risk patients had higher level of FBS and LDL and lower level of HDL cholesterol (P < 0.05). Conclusion. Our study found a strong correlation between the number of stenotic vessels and OSA. Based on our findings, OSA can be a predisposing factor for cardiac diseases. PMID:24701348
Javadi, Hamid Reza; Jalilolghadr, Shabnam; Yazdi, Zohreh; Rezaie Majd, Zeinab
Background. Obstructive sleep apnea (OSA) syndrome is one of the most common respiratory disorders in humans. There is emerging evidence linking OSA to vascular disease, particularly hypertension. The underlying pathophysiological mechanisms that link OSA to cardiovascular diseases such as hypertension, congestive heart failure, and atrial fibrillation are not entirely understood. The aim of this study was to investigate the association of obstructive sleep apnea hypopnea syndrome (OSAHS) with coronary atherosclerotic disease (CAD). Methods. A questionnaire survey based on Berlin questionnaire and Epworth Sleepiness Scale (ESS) was conducted among 406 patients to assess demographic data and the symptoms, such as excessive daytime sleepiness and snoring. Epworth Sleepiness Scale and Berlin questionnaire were completed by all of the patients. Venous blood samples were obtained for biochemical tests. Characteristics of coronary arteries were collected from angiographies' reports. All patients were divided into two groups based on results from Berlin questionnaire: low risk patients for OSA and high risk patients for OSA. Data were analyzed by SPSS software version 13. Results. Mean age of patients was 61.8 ± 10.5. 212 (52.2%) patients were categorized as high risk group for apnea. Also, excessive daytime sleepiness was reported in 186 patients (45.8%). The severity of coronary artery involvement, daytime sleepiness, and electrocardiogram abnormalities was significantly higher in high risk patients for OSA compared with low risk patients. High risk patients had higher level of FBS and LDL and lower level of HDL cholesterol (P < 0.05). Conclusion. Our study found a strong correlation between the number of stenotic vessels and OSA. Based on our findings, OSA can be a predisposing factor for cardiac diseases.
Javadi, Hamid Reza; Jalilolghadr, Shabnam; Yazdi, Zohreh; Rezaie Majd, Zeinab
Obesity, sleep apnea, diabetes and cardiovascular diseases are some of the most common diseases encountered by the worldwide population, with high social and economic burdens. Significant emphasis has been placed on obtaining blood pressure, body mass index, and placing importance on screening for signs and symptoms pointing towards cardiovascular disease. Symptoms related to sleep, or screening for sleep apnea has been overlooked by cardiac, diabetic, pulmonary and general medicine clinics despite recommendations for screening by several societies. In recent years, there is mounting data where obesity and obstructive sleep apnea sit at the epicenter and its control can lead to improvement and prevention of diabetes and cardiovascular complications. This editorial raises questions as to why obstructive sleep apnea screening should be included as yet another vital sign during patient initial inpatient or outpatient visit.
Surani, Salim R
Obesity, sleep apnea, diabetes and cardiovascular diseases are some of the most common diseases encountered by the worldwide population, with high social and economic burdens. Significant emphasis has been placed on obtaining blood pressure, body mass index, and placing importance on screening for signs and symptoms pointing towards cardiovascular disease. Symptoms related to sleep, or screening for sleep apnea has been overlooked by cardiac, diabetic, pulmonary and general medicine clinics despite recommendations for screening by several societies. In recent years, there is mounting data where obesity and obstructive sleep apnea sit at the epicenter and its control can lead to improvement and prevention of diabetes and cardiovascular complications. This editorial raises questions as to why obstructive sleep apnea screening should be included as yet another vital sign during patient initial inpatient or outpatient visit. PMID:24936259
Surani, Salim R
On a busy day at the pediatric office, child health care practitioners may see children of different ages present with symptoms such as inattentiveness, hyperactivity, aggression, behavioral problems, excessive sleepiness, difficulty waking up in the morning, learning problems, frequent awakening at night, restless sleep, morning headaches, and nocturnal enuresis. Children with these symptoms may be underweight or morbidly obese; healthy; or suffering from asthma, seasonal allergies, or other ailments. What they will likely have in common is a fairly well-known and yet under-recognized condition - obstructive sleep apnea syndrome (OSA). The American Academy of Pediatrics first published "Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome" in 2002. However, with the increase in obstructive sleep apnea syndrome research, they revised these guidelines in 2012. These new guidelines evaluate obstructive sleep apnea syndrome diagnostic techniques, describe available treatment options, and provide follow-up recommendations. This article explores those revisions. PMID:24126981
Obstructive sleep apnea has been a concern for commercial vehicle drivers for several decades. An increasing body of knowledge supports the idea that insufficient sleep can affect drivers' abilities to react efficiently and expediently, leading to motor vehicle accidents. Insufficient sleep can be described as short sleep periods, prolonged driving time, and dysfunctional sleep breathing. Commercial motor vehicle drivers are required to undergo physical examinations at least once every 2 years to maintain certification. Medical examiners are encouraged to screen for obstructive sleep apnea during these biannual examinations. Current literature identifies four frequently used screening tools for obstructive sleep apnea: STOP Questionnaire, STOP-Bang Questionnaire, Berlin Questionnaire, and Epworth Sleepiness Scale. Medical examiners must determine which screening method is valid, reliable, and has sufficient evidence to support its use. PMID:24811697
A 3-month-old baby was diagnosed with obstructive sleep apnea (OSA) on polysomnography (PSG) with a high apnea hypopnea index (AHI). On further investigations he was found to have a vallecular cyst that was successfully treated. We discuss the clinical presentation of vallecular cysts and the importance of polysomnography in identifying this rare condition. Citation: De A; Don DM; Magee III W; Ward SLD. Vallecular cyst as a cause of obstructive sleep apnea in an infant. J Clin Sleep Med 2013;9(8):825-826.
De, Aliva; Don, Debra M.; Magee, William; Ward, Sally L. Davidson
We derived descriptive characteristics related to habitual sleep duration and insomnia for individuals newly diagnosed with sleep apnea/hypopnea syndrome and evaluated how sleep apnea/hypopnea syndrome, insomnia, depression, and sleep duration relate to sleepiness and fatigue. In total, 100 participants were divided into three sleep groups: short (<7 hours), long (? 8 hours), and midrange (7-7.9 hours). Polysomnography, insomnia, sleepiness, fatigue, depression, and gender were assessed. Half of the participants were short sleepers. They were more likely to have insomnia than midrange or long sleepers and they were more likely to be sleepy than midrange or long sleepers, regardless of insomnia. PMID:23345390
Fichten, Catherine S; Creti, Laura; Rizzo, Dorrie; Bailes, Sally; Baltzan, Marc; Amsel, Rhonda; Libman, Eva
Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep disorder, characterized by repeated disruptions of breathing during sleep. This disease has many potential consequences including excessive daytime sleepiness, neurocognitive deterioration, endocrinologic and metabolic effects, and decreased quality of life. Patients with OSAS experience repetitive episodes of hypoxia and reoxygenation during transient cessation of breathing that provoke systemic effects. Furthermore, there may be increased levels of biomarkers linked to endocrine-metabolic and cardiovascular alterations. Epidemiological studies have identified OSAS as an independent comorbid factor in cardiovascular and cerebrovascular diseases, and physiopathological links may exist with onset and progression of heart failure. In addition, OSAS is associated with other disorders and comorbidities which worsen cardiovascular consequences, such as obesity, diabetes, and metabolic syndrome. Metabolic syndrome is an emerging public health problem that represents a constellation of cardiovascular risk factors. Both OSAS and metabolic syndrome may exert negative synergistic effects on the cardiovascular system through multiple mechanisms (e.g., hypoxemia, sleep disruption, activation of the sympathetic nervous system, and inflammatory activation). It has been found that CPAP therapy for OSAS provides an objective improvement in symptoms and cardiac function, decreases cardiovascular risk, improves insulin sensitivity, and normalises biomarkers. OSAS contributes to the pathogenesis of cardiovascular disease independently and by interaction with comorbidities. The present review focuses on indirect and direct evidence regarding mechanisms implicated in cardiovascular disease among OSAS patients.
Zamarron, Carlos; Valdes Cuadrado, Luis; Alvarez-Sala, Rodolfo
Background Obstructive sleep apnea (OSA) is a common disease, affecting approximately 2% of women and 4% of men residing in Western communities. No systematically reviewed data are available about the prevalence of this disease in Asia, the most heavily populated continent. Methods PubMed/Medline, Scopus and Google Scholar were searched for articles published from 1993 to May 2012 that reported the prevalence of OSA diagnosed via sleep monitoring and the prevalence of patients at risk for OSA as assessed by symptomatology and/or sleep questionnaires. We have also searched abstract database of major pulmonary and sleep scientific societies for relevant abstracts presented from 2010 to 2012. The following inclusion criteria were used: articles published in English, age???18 years, ??100 participants in studies using sleep monitoring for the diagnosis of OSA, ??300 participants in studies using questionnaires to detect patients at high risk for OSA. Exclusion criteria: duplicate publications, studies reporting the prevalence of central sleep apnea only, hospital based studies as well as studies assessing OSA prevalence among patients with resistant arterial hypertension, chronic kidney disease, heart failure and in patients with concomitant neurological disease. Results Twenty four articles were found to meet the inclusion criteria, covering 47,957 subjects (26,042 men and 21,915 women) and four relevant abstracts were noted. OSA prevalence ranged from 3.7% to 97.3%. Male gender, older age, a higher BMI and waist to hip ratio, greater neck circumference, arterial hypertension, smoking, snoring and daytime sleepiness were associated with OSA. Sample size, difference between the populations studied and the fact that some works included patients with a high pre-test probability of OSA explain the difference in prevalence rates. Conclusion This systematic review highlights the lack of data regarding the prevalence of OSA in Asians. Only a few studies provide an approximate estimate of the OSA burden in some Asian communities.
The diagnosis and management of insomnia relies primarily on clinical history. However, patient self-report of sleep-wake times may not agree with objective measurements. We hypothesized that those with shallow or fragmented sleep would under-report sleep quantity, and that this might account for some of the mismatch. We compared objective and subjective sleep-wake times for 277 patients who underwent diagnostic polysomnography. The group included those with insomnia symptoms (n = 92), obstructive sleep apnea (n = 66) or both (n = 119). Mismatch of wake duration was context dependent: all three groups overestimated sleep latency but underestimated wakefulness after sleep onset. The insomnia group underestimated total sleep time by a median of 81 min. However, contrary to our hypothesis, measures of fragmentation (N1, arousal index, sleep efficiency, etc.) did not correlate with the subjective sleep duration estimates. To unmask a potential relationship between sleep architecture and subjective duration, we tested three hypotheses: N1 is perceived as wake; sleep bouts under 10 min are perceived as wake; or N1 and N2 are perceived in a weighted fashion. None of these hypotheses exposed a match between subjective and objective sleep duration. We show only modest performance of a Naïve Bayes Classifier algorithm for predicting mismatch using clinical and polysomnographic variables. Subjective-objective mismatch is common in patients reporting insomnia symptoms. We conclude that mismatch was not attributable to commonly measured polysomnographic measures of fragmentation. Further insight is needed into the complex relationships between subjective perception of sleep and conventional, objective measurements. PMID:23521019
Bianchi, Matt T; Williams, Kathryn L; McKinney, Scott; Ellenbogen, Jeffrey M
Clinical studies have suggested that sleep apnea is associated with impaired brachial artery flow-mediated dilation, a surrogate of endothelial dysfunction. We examined this question among older participants in the baseline examination of the Sleep Heart Health/Cardiovascular Health Study cohort (n = 1,037, age 68 years or older, 56% female). Indices of sleep apnea, derived from 12-channel home polysomnography, were the apnea-hypopnea index (average number of apneas/hypopneas per hour) and the hypoxemia index (percentage of time below 90% O2 saturation). Baseline arterial diameter and percentage of flow-mediated dilation were measured by ultrasound. Sleep apnea measures were associated with baseline diameter and the percentage of flow-mediated dilation, although these associations were weakened after adjustment for other cardiovascular risk factors, particularly body mass index. However, a statistically significant linear association between the hypoxemia index and baseline diameter was observed even after adjustment for body mass index and other confounders (p < 0.01). The associations were stronger among participants who were younger than 80 years and among those who with hypertension. This study adds to the growing body of evidence linking sleep apnea with vascular dysfunction in older subjects. Whether these relationships are entirely independent of obesity is unclear. This association might be one of the mechanisms explaining the relationship between sleep apnea, hypertension, and cardiovascular disease. PMID:14551166
Nieto, F Javier; Herrington, David M; Redline, Susan; Benjamin, Emelia J; Robbins, John A
Rationale: Hypoglossal nerve stimulation (HGNS) recruits lingual muscles, reduces pharyngeal collapsibility, and treats sleep apnea. Objectives: We hypothesized that graded increases in HGNS relieve pharyngeal obstruction progressively during sleep. Methods: Responses were examined in 30 patients with sleep apnea who were implanted with an HGNS system. Current (milliampere) was increased stepwise during non-REM sleep. Frequency and pulse width were fixed. At each current level, stimulation was applied on alternating breaths, and responses in maximal inspiratory airflow (VImax) and inspiratory airflow limitation (IFL) were assessed. Pharyngeal responses to HGNS were characterized by the current levels at which VImax first increased and peaked (flow capture and peak flow thresholds), and by the VImax increase from flow capture to peak (?VImax). Measurements and Main Results: HGNS produced linear increases in VImax from unstimulated levels at flow capture to peak flow thresholds (215 ± 21 to 509 ± 37 ml/s; mean ± SE; P < 0.001) with increasing current from 1.05 ± 0.09 to 1.46 ± 0.11 mA. VImax increased in all patients and IFL was abolished in 57% of patients (non-IFL subgroup). In the non-IFL compared with IFL subgroup, the flow response slope was greater (1241 ± 199 vs. 674 ± 166 ml/s/mA; P < 0.05) and the stimulation amplitude at peak flow was lower (1.23 ± 0.10 vs. 1.80 ± 0.20 mA; P < 0.05) without differences in peak flow. Conclusions: HGNS produced marked dose-related increases in airflow without arousing patients from sleep. Increases in airflow were of sufficient magnitude to eliminate IFL in most patients and IFL and non-IFL subgroups achieved normal or near-normal levels of flow, suggesting potential HGNS efficacy across a broad range of sleep apnea severity.
Barnes, Maree; Hillman, David; Malhotra, Atul; Kezirian, Eric; Smith, Philip L.; Hoegh, Thomas; Parrish, Daniel; Eastwood, Peter R.
Numerous medical disorders, including obstructive sleep apnea, may cause nocturnal diaphoresis. Previous work has associated severe obstructive sleep apnea with nocturnal diaphoresis. This case report is of import as our patient with severe nocturnal diaphoresis manifested only mild sleep apnea, and, for years, his nocturnal diaphoresis was ascribed to other causes, i.e., first prostate cancer and then follicular B-cell lymphoma. Additionally, it was the nocturnal diaphoresis and not more common symptoms of obstructive sleep apnea, such as snoring, that led to the definitive diagnosis of his sleep apnea and then to treatment with a gratifying resolution of his onerous symptom. Citation: Vorona RD; Szklo-Coxe M; Fleming M; Ware JC. Nocturnal diaphoresis secondary to mild obstructive sleep apnea in a patient with a history of two malignancies. J Clin Sleep Med 2013;9(7):717-719.
Vorona, Robert Daniel; Szklo-Coxe, Mariana; Fleming, Mark; Ware, J. Catesby
Background: Obstructive sleep apnea (OSA) is an important and common comorbidity in patients with chronic kidney disease (CKD). However, few studies have addressed how OSA presents in this patient population and whether it is clinically apparent. Objective: The objectives of this study were to determine if the prevalence and severity of sleep related symptoms distinguished CKD patients with OSA from those without apnea, and whether the clinical presentation of OSA in CKD patients differed from the general OSA population. Methods: One hundred nineteen patients were recruited from outpatient nephrology clinics. All patients completed a sleep history questionnaire, the Epworth Sleepiness Scale (daytime sleepiness, ESS > 10), the Pittsburgh Sleep Quality Index (poor sleep quality, PSQI > 5), and underwent overnight cardiopulmonary monitoring for determination of sleep apnea (respiratory disturbance index ? 15). CKD patients with OSA (n = 46) were compared to (1) CKD patients without OSA (n = 73) and (2) OSA patients without CKD (n = 230) who were referred to the sleep centre. Results: The prevalence of OSA symptoms and PSQI scores did not differ between CKD patients with OSA and CKD patients without apnea. Although the prevalence of daytime sleepiness was higher in CKD patients with OSA compared to CKD patients without apnea (39% vs. 19%, p = 0.033), both daytime sleepiness and other symptoms of sleep apnea were considerably less frequent than in OSA patients without a history of kidney disease. Conclusions: The presence of OSA in patients with CKD is unlikely to be clinically apparent. Consequently, objective cardiopulmonary monitoring during sleep is required to reliably identify this comorbidity. Citation: Nicholl DDM; Ahmed SB; Loewen AHS; Hemmelgarn BR; Sola DY; Beecroft JM; Turin TC; Hanly PJ. Clinical presentation of obstructive sleep apnea in patients with chronic kidney disease. J Clin Sleep Med 2012;8(4):381-387.
Nicholl, David D. M.; Ahmed, Sofia B.; Loewen, Andrea H. S.; Hemmelgarn, Brenda R.; Sola, Darlene Y.; Beecroft, Jaime M.; Turin, Tanvir C.; Hanly, Patrick J.
The association between nocturnal apneas and transient pulmonary hypertension (PHT) has been well documented. However, there is controversy over the frequency and pathophysiological mechanisms of daytime pulmonary hypertension in patients with obstructive sleep apnea (OSAS). The present study sought to evaluate frequency and mechanisms of pulmonary hypertension in patients with OSAS. It included 49 consecutive patients with polysomnographically proven OSAS
M. Hetzel; M. Kochs; N. Marx; H. Woehrle; I. Mobarak; V. Hombach; J. Hetzel
Objectives: To examine the efficacy of various therapeutic modalities for mild obstructive sleep apnea using cardiopulmonary coupling variables of sleep quality. Methods: A 67-year-old Caucasian subject's sleep was recorded at home for 10 nights using a type 3 sleep recording device that measured ECG and body position, followed by generation of the cardiopulmonary sleep spectrogram. Three baseline nights, one night with a sleep jacket containing 3 tennis balls to restrict sleep in the supine position, 2 nights with oxygen only delivered via a nasal cannula at a flow rate of 2 L/minute, 2 nights with a mandible advancing appliance (MAA) only, and 2 nights using oxygen at 2 L/minute with the MAA were compared. Results: Baseline sleep quality estimated using the ratio of high-frequency and low-frequency coupling (1.03) was below the expected normal adult values ranging from 1.67-4.0. The sleep quality ratio was significantly higher (2.08) using the MAA alone compared to baseline, sleep position restriction (1.61), oxygen therapy (0.81), and the combination of MAA with oxygen (1.66). Conclusion: Sleep quality measured objectively using cardiopulmonary coupling variables differentiated the efficacy of therapeutic options for mild obstructive sleep apnea. Such an approach may have practical utility. Citation: Schramm PJ; Thomas RJ. Assessment of therapeutic options for mild obstructive sleep apnea using cardiopulmonary coupling measures. J Clin Sleep Med 2012;8(3):315-320.
Schramm, Preetam J.; Thomas, Robert J.
In response to a request from the public regarding obstructive sleep apnea (OSA), a common disorder associated with serious morbidity and mortality, a review was undertaken to examine the comparative effectiveness of approaches for screening, diagnosing, ...
Obstructive sleep apnea (OSA) is recurrent obstruction of the upper airway leading to sleep fragmentation and intermittent hypoxia (IH) during sleep. There is growing evidence from animal models of OSA that IH is independently associated with metabolic dysfunction, including dyslipidemia and insulin resistance. The precise mechanisms by which IH induces metabolic disturbances are not fully understood. Over the last decade, several groups of investigators developed a rodent model of IH, which emulates the oxyhemoglobin profile in human OSA. In the mouse model, IH induces dyslipidemia, insulin resistance and pancreatic endocrine dysfunction, similar to those observed in human OSA. Recent reports provided new insights in possible mechanisms by which IH affects lipid and glucose metabolism. IH may induce dyslipidemia by up-regulating lipid biosynthesis in the liver, increasing adipose tissue lipolysis with subsequent free fatty acid flux to the liver, and inhibiting lipoprotein clearance. IH may affect glucose metabolism by inducing sympathetic activation, increasing systemic inflammation, increasing counter-regulatory hormones and fatty acids, and causing direct pancreatic beta cell injury. IH models of OSA have improved our understanding of the metabolic impact of OSA, but further studies are needed before we can translate recent basic research findings to clinical practice.
Drager, Luciano F.; Jun, Jonathan C.; Polotsky, Vsevolod Y.
The aim of the present study was to examine the prevalence of metabolic syndrome (MS) and its components among obstructive sleep apnea (OSA) patients vs controls, as well as to investigate which of these components are strongly associated with the presence of OSA in subjects reporting symptoms indicating sleep-disordered breathing. Included were 83 consecutive male subjects, without known concomitant diseases, who visited an outpatient clinic of obesity, diabetes and metabolism. Based on polysomnography, these were divided into two groups: OSA patients (n = 53) and controls (n = 30). Parameters indicating MS, according to the NCEP ATP III criteria (blood pressure, waist circumference, glucose, triglycerides, and HDL-cholesterol levels) were evaluated in both groups. The criteria for MS were fulfilled in 49 participants. Presence of MS was significantly correlated with the presence of OSA. However, after adjustment for BMI, only serum glucose was significantly associated with the presence of OSA (P = 0.002). Conversely, the presence of MS was associated with a significant reduction in percentage of slow-wave sleep (P = 0.030). In conclusion, these results provide further evidence for the association between OSA and MS. Between subjects with MS, elevated serum glucose levels indicate a higher probability for the presence of OSA.
Papanas, Nikolaos; Steiropoulos, Paschalis; Nena, Evangelia; Tzouvelekis, Argyris; Skarlatos, Athanasios; Konsta, Maria; Vasdekis, Vasileios; Maltezos, Efstratios; Bouros, Demosthenes
Obstructive apneas produce high negative intrathoracic pressure that imposes an afterload burden on the left ventricle. Such episodes might produce structural changes in the left ventricle over time. Doppler echocardiograms were obtained within 2 months of attended polysomnography. Patients were grouped according to apnea-hypopnea index (AHI): mild/no obstructive sleep apnea (OSA; AHI <15) and moderate/severe OSA (AHI ?15). Mitral valve tenting height and area, left ventricular (LV) long and short axes, and LV end-diastolic volume were measured in addition to tissue Doppler parameters. Comparisons of measurements at baseline and follow-up between and within groups were obtained; correlations between absolute changes (?) in echocardiographic parameters were also performed. After a mean follow-up of 240 days mitral valve tenting height increased significantly (1.17 ± 0.12 to 1.28 ± 0.17 cm, p = 0.001) in moderate/severe OSA as did tenting area (2.30 ± 0.41 to 2.66 ± 0.60 cm(2), p = 0.0002); ?tenting height correlated with ?LV end-diastolic volume (rho 0.43, p = 0.01) and ?tenting area (rho 0.35, p = 0.04). In patients with mild/no OSA there was no significant change in tenting height; there was a borderline significant increase in tenting area (2.20 ± 0.44 to 2.31 ± 0.43 cm(2), p = 0.05). Septal tissue Doppler early diastolic wave decreased (8.04 ± 2.49 to 7.10 ± 1.83 cm/s, p = 0.005) in subjects with moderate/severe OSA but not in in those with mild/no OSA. In conclusion, in patients with moderate/severe OSA, mitral valve tenting height and tenting area increase significantly over time. This appears to be related, at least in part, to changes in LV geometry. PMID:22264596
Pressman, Gregg S; Figueredo, Vincent M; Romero-Corral, Abel; Murali, Ganesan; Kotler, Morris N
The response to chemical stimuli (chemical responsiveness) and the increases in respiratory drive required for arousal (arousal threshold) and for opening the airway without arousal (effective recruitment threshold) are important determinants of ventilatory instability and, hence, severity of obstructive apnea. We measured these variables in 21 obstructive apnea patients (apnea-hypopnea index 91 +/- 24 h(-1)) while on continuous-positive-airway pressure. During sleep, pressure was intermittently reduced (dial down) to induce severe hypopneas. Dial downs were done on room air and following approximately 30 s of breathing hypercapneic and/or hypoxic mixtures, which induced a range of ventilatory stimulation before dial down. Ventilation just before dial down and flow during dial down were measured. Chemical responsiveness, estimated as the percent increase in ventilation during the 5(th) breath following administration of 6% CO(2) combined with approximately 4% desaturation, was large (187 +/- 117%). Arousal threshold, estimated as the percent increase in ventilation associated with a 50% probability of arousal, ranged from 40% to >268% and was <120% in 12/21 patients, indicating that in many patients arousal occurs with modest changes in chemical drive. Effective recruitment threshold, estimated as percent increase in pre-dial-down ventilation associated with a significant increase in dial-down flow, ranged from zero to >174% and was <110% in 12/21 patients, indicating that in many patients reflex dilatation occurs with modest increases in drive. The two thresholds were not correlated. In most OSA patients, airway patency may be maintained with only modest increases in chemical drive, but instability results because of a low arousal threshold and a brisk increase in drive following brief reduction in alveolar ventilation. PMID:17823298
Younes, Magdy; Ostrowski, Michele; Atkar, Raj; Laprairie, John; Siemens, Andrea; Hanly, Patrick
Purpose: This study compares craniofacial measurements of lateral cephalometric radiographs of young obstructive sleep apnea patients with those of nonapneic snorers and controls.Patients and Methods: Forty-eight patients (BMI = 28.0 ± 3.8) with obstructive sleep apnea, 25 patients (BMI = 26.3 ± 3.5) with nonapneic snoring, and 54 controls (BMI = 24.8 ± 2.7) were evaluated. All subjects were between
Francis R Johns; Patrick J Strollo; Michael Buckley; Joseph Constantino
Obesity is a strong risk factor for the development and progression of sleep apnea. Responses to exercise by patients with\\u000a obstructive sleep apnea syndrome (OSAS) are clinically relevant to reducing body weight and cardiovascular risk factors. This\\u000a study aimed to clarify the aerobic and anaerobic exercise capacities and their possible relationships with other findings\\u000a in patients with OSAS. Forty patients
Kagan Ucok; Abdullah Aycicek; Murat Sezer; Abdurrahman Genc; Muzaffer Akkaya; Veli Caglar; Fatma Fidan; Mehmet Unlu
Obstructive sleep apnea syndrome (OSAS) is an important disease that affects both the right and the left cardiac ventricle.\\u000a This paper presents a novel classification method called pairwise ANFIS based on Adaptive Neuro-Fuzzy Inference System (ANFIS)\\u000a and one against all method for detecting the obstructive sleep apnea syndrome. In order to extract the features related with\\u000a OSAS, we have used
Kemal Polat; Sebnem Yosunkaya; Salih Günes
Background Vaspin and lipocalin-2 are less-known recent members of adipocytokine family. There are ongoing studies investigating the role of vaspin ve lipocalin-2 in metabolic syndrome (MS). Obstructive sleep apnea syndrome (OSAS) is independently associated with an increased prevalence of MS. We aimed to measure the levels of vaspin and lipocalin-2 which are secreted from adipocytes in patients with severe OSAS and examine the relationship between these two adipocytokines and OSAS. Methods The study consisted of two groups: severe OSAS patients with an apnea-hypopnea index (AHI) of >30/h (OSAS group, 34 subjects) and age-matched healthy volunteers with a AHI <5/h (control group, 25 subjects) Serum levels of vaspin and lipocalin-2 in these two groups were compared. Results Serum levels of vaspin were significantly lower in OSAS group; patients with severe OSAS compared with control group; healthy volunteers (OSAS group: 0.69±0.5 vs. control group: 1.24±1.13; P=0.034). The difference between the two groups in terms of serum levels of lipocalin-2 has not reached statistical significance (OSAS group: 61.6±18.2 vs. control group: 68.5±20.1; P=0.17). Conclusions We found that serum vaspin levels were significantly lower in patients with severe OSAS compared with healthy controls. Lipocalin-2 levels were similar. The decrease in serum vaspin levels in severe OSAS patients may be important in diagnosis and follow-up of these patients.
Zorlu, Mehmet; Akkoyunlu, Muhammed Emin; Kilic, Elif; Karatoprak, Cumali; Cakirca, Mustafa; Yavuz, Erdinc; Ardic, Cuneyt; Camli, Ahmet Adil; Cikrikcioglu, Mehmetali; Kart, Levent
Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management. Citation: Vasu TS; Grewal R; Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature. J Clin Sleep Med 2012;8(2):199-207.
Vasu, Tajender S.; Grewal, Ritu; Doghramji, Karl
Over the last decade, there has been an emerging interest in the link between obstructive sleep apnea (OSA) and ocular health. Though the evidence for OSA playing a role in cerebrovascular disease risk seems clear, the same cannot be said for optic neuropathies. The association between OSA and glaucoma or non-arteritic anterior ischemic optic neuropathy (NAION) has been postulated to be secondary to direct hypoxia or mechanisms of optic nerve head vascular dysregulation. Papilledema and increased intracranial pressure have also been reported in OSA and are thought to be due to increased cerebral perfusion pressure and cerebral venous dilation secondary to hypoxia and hypercapnia. This article reviews the evidence for possible pathophysiological links between OSA and optic nerve pathology. The epidemiologic and clinical evidence for an association, direct or indirect, between OSA and glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), and papilledema or idiopathic intracranial hypertension is presented. PMID:24942500
L Fraser, Clare
Several types of apnea are described in premature infants and in infants who have survived breathing-stoppage episodes which may be related to the sudden infant death syndrome. Upper airway apnea appears to induce the greatest changes: oxygen desaturation is more pronounced than in a central apnea of similar duration, and secondary cardiac changes are observed earlier and are more severe.
Christian Guilleminault; Rosa Peraita; Marianne Souquet; William C. Dement
The inflammatory state caused by obesity increases the level of adipokines, such as leptin, with a direct impact on the central respiratory regulation. The present study addresses this problem by evaluation of the association of sleep apnea diagnosis in relation to body fat measured by dual-energy X-ray absorptiometry (DXA), anthropometric parameters and biochemical variables. All patients carried out overnight polysomnography, anthropometric evaluations [Body Mass Index (BMI), neck and waist circumference], body composition analyzed by DXA and blood sample collection (lipid profile, fasting glycemia, insulin, glycated hemoglobin, C-reactive protein and serum leptin levels). Obstructive sleep apnea-hypopnea syndrome (OSAHS) was defined by the apnea-hypopnea index (AHI) from the overnight polysomnography. According to the AHI, the women were divided into two groups: with and without apnea. Twenty-seven of them had OSAHS (AHI = 22.04 ± 17.55). The main results are the following: (a) BMI was not capable of predicting OSAHS in this study (p = 0.204); (b) for each 1 % increase in TBF %, the probability of having sleep apnea increased by 12.8 %; (c) comparing all variables (anthropometrics, DXA and blood sample), serum leptin was the only variable with a significant difference between the groups (p = 0.0257). The results reinforce the role of total body fat and leptin in the etiology of OSAHS and the need to include the evaluation of corporal composition measures by DXA in studies of sleep apnea. PMID:23183853
Bezerra, Patrícia Costa; do Prado, Mirley; Gaio, Eduardo; Franco, Octavio Luiz; Tavares, Paulo
A 4-yr-old girl has exhibited severe snoring, restless sleep and increasing daytime sleepiness over the last 3 months. The physical examination showed that she was not obese but had kissing tonsils. Polysomnography demonstrated increased apnea-hypopnea index (AHI) of 5.2, and multiple sleep latency tests (MSLT) showed shortened mean sleep latency and one sleep-onset REM period (SOREMP). She was diagnosed with obstructive sleep apnea (OSA) and underwent tonsillectomy and adenoidectomy. After the surgery, her sleep became much calmer, but she was still sleepy. Another sleep test showed normal AHI of 0.2, the mean sleep latency of 8 min, and two SOREMPs. Diagnosis of OSA to be effectively treated by surgery and narcolepsy without cataplexy was confirmed. Since young children exhibiting both OSA and narcolepsy can fail to be diagnosed with the latter, it's desirable to conduct MSLT when they have severe daytime sleepiness or fail to get better even with good treatment.
Kwon, Soonhak; Jang, Kyungmi; Hwang, Sukyung; Cho, Minhyun
Detection of sleep apnea using electrocardiographic (ECG) parameters is noninvasive and inexpensive. Our approach is based on the hypothesis that the patient's sleep-wake cycle during episodes of sleep apnea modulates heart rate (HR) oscillations. These HR oscillations appear as low-frequency fluctuations of instantaneous HR (IHR) and can be detected using HR variability analysis in the frequency domain. The purpose of this study was to evaluate the efficacy of our ECG-based algorithm for sleep apnea detection and quantification. The algorithm first detects normal QRS complexes and R-R intervals used to derive IHR and to estimate its spectral power in several frequency ranges. A quadratic classifier, trained on the learning set, uses 2 parameters to classify the 1-minute epoch in the middle of each 6-minute window as either apneic or normal. The windows are advanced by 1-minute steps, and the classification process is repeated. As a measure of quantification, the algorithm correctly classified 84.7% of all the 1-minute epochs in the evaluation database; and as a measure of the accuracy of apnea classification, the algorithm correctly classified all 30 test recordings in the evaluation database either as apneic or normal. Our sleep apnea detection algorithm based on analysis of a single-lead ECG provides accurate apnea detection and quantification. Because of its noninvasive and low-cost nature, this algorithm has the potential for numerous applications in sleep medicine. PMID:20719334
Babaeizadeh, Saeed; White, David P; Pittman, Stephen D; Zhou, Sophia H
Study Objectives: Heart rate increases after obstructive events in patients with obstructive sleep apnea (OSA). This response is generally attributed to arousal from sleep. Opening of the obstructed airway, however, is associated with ventilatory and hemodynamic changes that could result in physiologic responses unrelated to arousal. Our objective was to determine the contribution of these physiologic responses to postevent tachycardia. Design: Analysis of data obtained during previous research protocols. Setting: Academic sleep laboratory. Participants: Twenty patients with severe OSA. Interventions: Patients were placed on a continuous positive airway pressure (CPAP) device. CPAP was reduced during sleep to different levels (dial-downs), producing obstructive events of varying severity. Some dial-downs with severe obstruction were maintained until spontaneous airway opening. In others, CPAP was increased after three obstructed breaths, terminating the events approximately 10 sec before spontaneous termination in long dial-downs. Measurement and Results: Beat-by-beat heart rate (HR) was measured for 20 sec following airway opening. Spontaneous opening during sustained dial-downs occurred 21.9 ± 8.4 sec after dial-down, was associated with arousal, and resulted in the greatest postevent tachycardia (7.8 ± 4.0 min-1). However, deliberate termination of events (12.2 ± 2.6 sec after dial-down) was also followed by tachycardia that, in the absence of cortical arousal, showed a dose-response behavior, increasing with severity of obstruction and without apparent threshold. ?HR following deliberately brief, severe obstruction (3.8 ± 3.0 min-1) was approximately half the ?HR that followed spontaneous opening of equally severe obstructions despite the shorter duration and absence of cortical arousal. Conclusions: Postevent tachycardia is due in large part to physiologic (arousal-unrelated) responses that occur upon relief of obstruction. Citation: Azarbarzin A; Ostrowski M; Moussavi Z; Hanly P; Younes M. Contribution of arousal from sleep to postevent tachycardia in patients with obstructive sleep apnea. SLEEP 2013;36(6):881-889.
Azarbarzin, Ali; Ostrowski, Michele; Moussavi, Zahra; Hanly, Patrick; Younes, Magdy
Introduction Obstructive sleep apnea (OSA) is characterized by intermittent hypoxemia, arousals from sleep, and daytime sleepiness. Accumulating\\u000a evidence indicates that hypoxemia and sleep disruption contribute to the development of cardiovascular abnormalities in OSA.\\u000a OSA is effectively treated with continuous positive airway pressure (CPAP) therapy that splints open the airway during sleep.\\u000a Studies have shown that CPAP therapy improves daytime sleepiness and
John M. Dopp; Barbara J. Morgan
The spectrum of sleep disordered breathing (SDB) encompasses habitual snoring at the low end of severity all the way to frank obstructive sleep apnea (OSA), with upper airway resistance syndrome (UARS) and obstructive alveolar hypoventilation being considered as less severe variants of this condition. SDB occurs in children of all ages, from neonates to adolescents, and is characterized by repeated events of increased upper airway resistance as well as with either partial or complete upper airway obstruction during sleep, all of which may result in disruption of normal gas exchange and sleep integrity . SDB was initially described over a century ago  and was then rediscovered in children by Guilleminault in 1976 . However, this complex and relatively prevalent disorder is only now being recognized as a major public health problem. During the initial years since the seminal paper by Guilleminault et al , it became apparent that the classic clinical syndrome of OSA in children markedly differed from the OSA seen in adults, in particular with respect to gender distribution, clinical manifestations, polysomnographic findings, and treatment approaches [4,5]. However in more recent years, the epidemic of obesity that affects the pediatric population all over the world has led, in our opinion, to the emergence of a phenotypic variant of OSA in children that closely resembles that of adults with the disease. In this paper, we will review the pathophysiological mechanisms of OSA in children, delineate the clinical manifestations associated with the disease, and provide arguments for our novel and hopefully useful proposition that aims to define 2 types of OSA in children. For the sake of convenience, and in analogy with type I and type II diabetes, we propose to divide pediatric OSA as types I and II. PMID:18769509
Dayyat, Ehab; Kheirandish-Gozal, Leila; Gozal, David
Background: Airway patency in both children and adults depends on the tonic and phasic activation of muscles of the tongue and pharynx supplied by the hypoglossal nerve arising at the medullary level Methods/Patient: We report a case of a 2-year-old who after resection of fourth ventricle anaplastic ependymoma developed severe sleep disordered breathing and tongue fasciculation. Results: Polysomnography showed severe obstructive sleep apnea with oxygen desaturation to 33%. Magnetic resonance imaging of the brain showed post-surgical effacement of the dorsal lateral medulla. Conclusions: We postulate that damage to the hypoglossal nerve at the level of the medulla contributed to the patient's severe obstructive sleep apnea. Patient was treated with tracheostomy. Citation: DelRosso LM; Hoque R; Gonzalez-Toledo E. Two-year-old with post-surgical hypoglossal nerve injury and obstructive sleep apnea. J Clin Sleep Med 2014;10(1):97-98.
DelRosso, Lourdes M.; Hoque, Romy; Gonzalez-Toledo, Eduardo
We report two cases of obstructive sleep apnea (OSA) that presented during infantry field exercises as snoring so loud as to risk betraying the unit's position. Both patients exceeded the height-weight standards of the Army Weight Control Program (AWCP). Since high body mass is a strong risk factor for OSA, we asked whether the AWCP reduces the risk of OSA. We found that it should for women in all age groups and for men over 40, but it is less protective for younger men (who constitute a large portion of Army personnel). In light of this and of previous estimates that up to 1.5% of all Army personnel exceed the AWCP standards, we conclude that there may be a significant number of unrecognized cases of OSA in the Army. Additionally, tightening of the AWCP standards may be warranted for women under 30 and men under 50, who currently are permitted to significantly exceed ideal body weight. PMID:8700336
Sonna, L A; Smith, P L; Schwartz, A R
Study Objectives: Obstructive sleep apnea (OSA), common in Parkinson disease (PD), contributes to sleep disturbances and daytime sleepiness. We assessed the effect of continuous positive airway pressure (CPAP) on OSA, sleep, and daytime sleepiness in patients with PD. Design: This was a randomized placebo-controlled, crossover design. Patients with PD and OSA were randomized into 6 w of therapeutic treatment or 3 w of placebo followed by 3 w of therapeutic treatment. Patients were evaluated by polysomnography (PSG) and multiple sleep latency test (MSLT) pretreatment (baseline), after 3 w, and after 6 w of CPAP treatment. Analyses included mixed models, paired analysis, and within-group analyses comparing 3 w to 6 w of treatment. Setting: Sleep laboratory. Participants: Thirty-eight patients with PD (mean age = 67.2 ± 9.2 y; 12 females). Intervention: Continuous positive airway pressure. Measurements: PSG outcome measures: sleep efficiency, %sleep stages (N1, N2, N3, R), arousal index, apnea-hypopnea index (AHI), and % time oxygen saturation < 90% (%time SaO2 < 90%). MSLT outcome measures: mean sleep-onset latency (MSL). Results: There were significant group-by-time interactions for AHI (P < 0.001), % time SaO2 < 90% (P = 0.02), %N2 (P = 0.015) and %N3 (P = 0.014). Subjects receiving therapeutic CPAP showed significant decrease in AHI, %time SaO2 < 90%, %N2, and significant increase in %N3 indicating effectiveness of CPAP in the treatment of OSA, improvement in nighttime oxygenation, and in deepening sleep. The paired sample analyses revealed that 3 w of therapeutic treatment resulted in significant decreases in arousal index (t = 3.4, P = 0.002). All improvements after 3 w were maintained at 6 w. Finally, 3 w of therapeutic CPAP also resulted in overall decreases in daytime sleepiness (P = 0.011). Conclusions: Therapeutic continuous positive airway pressure versus placebo was effective in reducing apnea events, improving oxygen saturation, and deepening sleep in patients with Parkinson disease and obstructive sleep apnea. Additionally, arousal index was reduced and effects were maintained at 6 weeks. Finally, 3 weeks of continuous positive airway pressure treatment resulted in reduced daytime sleepiness measured by multiple sleep latency test. These results emphasize the importance of identifying and treating obstructive sleep apnea in patients with Parkinson disease. Citation: Neikrug AB; Liu L; Avanzino JA; Maglione JE; Natarajan L; Bradley L; Maugeri A; Corey-Bloom J; Palmer BW; Loredo JS; Ancoli-Israel S. Continuous positive airway pressure improves sleep and daytime sleepiness in patients with Parkinson disease and sleep apnea. SLEEP 2014;37(1):177-185.
Neikrug, Ariel B.; Liu, Lianqi; Avanzino, Julie A.; Maglione, Jeanne E.; Natarajan, Loki; Bradley, Lenette; Maugeri, Alex; Corey-Bloom, Jody; Palmer, Barton W.; Loredo, Jose S.; Ancoli-Israel, Sonia
Summary Background The diagnostic process and the surgical procedures in patients with snoring and obstructive sleep apnea syndrome (OSAS) are crucial. The aim of this study was to assess the efficacy of surgical treatment in snoring and OSAS patients. Material/Methods A precise laryngological examination and screening polysomnography (Poly-Mesam) were performed in all patients with mild, moderate and severe OSAS before and 6 months after surgery. The patients completed questionnaires concerning their complaints. We included patients qualified to septoplasty, laser-assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP) and radiofrequency-induced thermotherapy of the tongue base (RITT). Outcome evaluation of surgery was performed on the basis of data received from follow-up laryngological examinations, selected parameters obtained from the Poly-Mesam test and follow-up questionnaires. Results In most cases we observed improvement, defined as decreasing some sleep parameters, such as a respiratory disturbance index (RDI), by more than 50%, decreasing the loudness of snoring, decreasing the number of hypopneas, and obtaining better blood saturation values. After UPPP we noticed changes in retropalatal space, soft palate dimensions and uvula-posterior pharyngeal wall distance. In the postoperative period we did not observe severe complications. In some cases we found short-lived palatal deficiency after UPPP. Patients after RITT experienced discomfort and throat pain lasting from 2 to 4 days. In 2 patients we observed swelling of the tongue base, which decreased after few days. Conclusions Surgery in OSAS contributes to normalization of some sleep parameters. The majority of patients experienced improvement after surgery.
Olszewska, Ewa; Rutkowska, Justyna; Czajkowska, Aneta; Rogowski, Marek
Asthma has been identified as a possible risk factor for Obstructive Sleep Apnea (OSA) in children. It is not known whether parent-reported asthma increases the likelihood of the diagnosis of OSA in snoring children. We hypothesized that snoring children with asthma are more likely to have OSA than snoring children without asthma. This study is a 1-year retrospective review of polysomnogram and questionnaire data collected on 236 patients referred to the University of Maryland Pediatric Sleep laboratory for evaluation of snoring. Of the 236 patients, 58% (137/236) were boys, and 79% (173/219 reporting race) were African-American (AA). The age at referral was 7.2 +/- 3.7 years (mean +/- S.D.). Mean body mass index (BMI) percentile was 73.4 +/- 32.3%, with 43.2% (54/125) >95th percentile. A history of asthma was reported by 31.4% (74/236); no subject was symptomatic on the night of the study. We found no increased risk for polysomnographically diagnosed OSA for asthmatics. To the contrary, by logistic regression analysis, a parent/guardian report of asthma decreased the odds of having OSA by 34% (p = 0.027), controlling for individual and socioeconomic factors and assessment results. Polysomnographic (PSG) differences between asthmatic and non-asthmatic children were found in only the arousal index (11.0 vs.9.3 +/- 6.5/h, p = 0.099) and total sleep time (337.1 +/- 64.3 vs. 347 +/- 65.2 min, p = 0.1) In a referral-based group of predominantly AA inner-city snoring children, asymptomatic asthma decreased the likelihood of OSA. PMID:18421491
Ramagopal, Maya; Scharf, Steven M; Roberts, Darryl W; Blaisdell, Carol J
Study Objectives: To assess the relative roles and interaction of obstructive sleep apnea (OSA) severity and obesity on interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Design: Cross-sectional cohort. Setting: The Icelandic Sleep Apnea Cohort. Participants: 454 untreated OSA patients (380 males and 74 females), mean ± standard deviation age 54.4 ± 10.6 yr. Interventions: N/A. Measurements and Results: Participants underwent a sleep study, abdominal magnetic resonance imaging to measure total abdominal and visceral fat volume, and had fasting morning IL-6 and CRP levels measured in serum. A significantly higher correlation was found for BMI than visceral fat volume with CRP and IL-6 levels. Oxygen desaturation index, hypoxia time, and minimum oxygen saturation (SaO2) significantly correlated with IL-6 and CRP levels, but apnea-hypopnea index did not. When stratified by body mass index (BMI) category, OSA severity was associated with IL-6 levels in obese participants only (BMI > 30 kg/m2). A multiple linear regression model with interaction terms showed an independent association of OSA severity with IL-6 levels and an interaction between OSA severity and BMI, i.e., degree of obesity altered the relationship between OSA and IL-6 levels. An independent association of OSA severity with CRP levels was found for minimum SaO2 only. A similar interaction of OSA severity and BMI on CRP levels was found for males and postmenopausal women. Conclusions: OSA severity is an independent predictor of levels of IL-6 and CRP but interacts with obesity such that this association is found only in obese patients. Citation: Arnardottir ES; Maislin G; Schwab RJ; Staley B; Benediktsdottir B; Olafsson I; Juliusson S; Romer M; Gislason T; Pack AI. The interaction of obstructive sleep apnea and obesity on the inflammatory markers c-reactive protein and interleukin-6: the Icelandic Sleep Apnea Cohort. SLEEP 2012;35(7):921-932.
Arnardottir, Erna S.; Maislin, Greg; Schwab, Richard J.; Staley, Bethany; Benediktsdottir, Bryndis; Olafsson, Isleifur; Juliusson, Sigurdur; Romer, Micah; Gislason, Thorarinn; Pack, Allan I.
Phrenic nerve stimulation can reproduce during wakefulness the dissociation between upper airway and inspiratory muscles that is associated with obstructive sleep-related breathing disorders. This could provide a useful management tool in the study of passive upper airway (UA) dynamics during wakefulness in patients with the obstructive sleep apnea-hypopnea syndrome (OSAHS). To as- sess the feasibility of the technique in this
CHRISTIAN STRAUS; ALEXANDRE DEMOULE; VALÉRIE ATTALI; ISABELLE ARNULF; JEAN-PHILIPPE DERENNE; THOMAS SIMILOWSKI
The objective of this study was to compare the frequency of some sociocultural, clinical, and anthropometric data between men and women in a sample of 1745 patients referred to a Sleep Unit for symptoms of obstructive sleep apnea (OSA). A standardized questionnaire was administered and anthropometric data were measured. Patients underwent a polysomnography (during a night or a nap) or
Esther Quintana-Gallego; Carmen Carmona-Bernal; Francisco Capote; Ángeles Sánchez-Armengol; Georgina Botebol-Benhamou; Juan Polo-Padillo; José Castillo-Gómez
Obstructive sleep apnea (OSA) consists of repetitive choking spells due to sleep-induced reduction of upper airway muscle tone. Millions of adults and children live unaware of this condition, which can have a profound affect on their health and quality of...
D. E. Watenpaugh R. Carter
Although the incidence of sudden infant death syndrome (SIDS) has been decreased by education programs to avoid sleeping in prone position, the pathological mechanisms of SIDS have not fully been understood. Basic research on sleep apnea using experimental animals may help further understanding and prevention of SIDS because the syndrome is thought as inability to wake up from respiratory arrest
Akira Nakamura; Tomoyuki Kuwaki
Although the incidence of sudden infant death syndrome (SIDS) has been decreased by education programs to avoid sleeping in prone position, the pathological mechanisms of SIDS have not fully been understood. Basic research on sleep apnea using experimental animals may help further understanding and prevention of SIDS because the syndrome is thought as inability to wake up from respiratory arrest
Akira Nakamura; Tomoyuki Kuwaki
Obstructive sleep apnea syndrome (OSAS), which is a highly prevalent breathing disorder in sleep, is an independent risk factor for cardiovascular morbidity and mortality. Results from clinical studies as well as animal models and cell culture studies utilizing intermittent hypoxia implicate oxidative stress and inflammation in the pathogenesis of OSAS. However, the underlying mechanisms are not entirely understood. Both oxidative
Lena Lavie; Vsevolod Polotsky
This paper presents an application of data mining to the medical domain sleep research, i.e. an approach for automatic sleep stage scoring and apnea-hypopnea detection. By several combined techniques (Fourier and wavelet transform, DDTW and waveform recognition), our approach extracts meaningful features (frequencies and special patterns) from EEG, ECG, EOG and EMG data, on which a decision trees classifier is
Tim Schlüter; Stefan Conrad
We established and tested an unconstrained sleep apnea monitoring method using a polyvinylidene (PVDF) film-based sensor for continuous and accurate monitoring of apneic events occurred during sleep. Twenty-six sleep apnea patients and six normal subjects participated in this study. Subjects' respiratory signals were measured using the PVDF-based sensor during polysomnography. The PVDF sensor comprised a 4 × 1 array, and a thin silicon pad was placed over the sensor to prevent damage. Total thickness of the merged system was approximately 1.1 mm which was thin enough to prevent the subject from being consciously aware of its presence. It was designed to be placed under subjects' backs and installed between a bed cover and mattress. The proposed method was based on the standard deviation of the PVDF signals, and it was applied to a test set for detecting apneic events. The method's performance was assessed by comparing the results with a sleep physician's manual scoring. The correlation coefficient for the apnea-hypopnea index (AHI) values between the methods was 0.94 (p < 0.001). The areas under the receiver operating curves at three AHI threshold levels (>5, >15, and >20) for sleep apnea diagnosis were 0.98, 0.99, and 0.98, respectively. For min-by-min apnea detection, the method classified sleep apnea with an average sensitivity of 72.9%, specificity of 90.6%, accuracy of 85.5%, and kappa statistic of 0.60. The developed system and method can be applied to sleep apnea detection in home or ambulatory monitoring. PMID:24718565
Hwang, Su Hwan; Lee, Hong Ji; Yoon, Hee Nam; Jung, Da Woon; Lee, Yu-Jin G; Lee, Yu Jin; Jeong, Do-Un; Park, Kwang Suk
Muscle nerve sympathetic activity (MSA), the interval between two R-waves in the ECG, or the interbeat interval (RR-interval), and blood pressure (BP) were recorded in 10 awake patients with obstructive sleep apnea (OSA) and in nine sex- and age-matched controls. Changes in RR-interval and MSA, evoked by sodium nitroprusside-induced reduction of BP, were used to quantitate baroreflex sensitivity. Both the cardiac (expressed as the RR-interval versus mean arterial BP slope) and the muscle sympathetic (mean MSA area versus diastolic BP slope) baroreflex sensitivity were depressed in patients as compared with controls. Cardiac baroreflex slope sensitivity (expressed as a regression coefficient) was 5.5 +/- 1.2 (mean +/- SEM) in patients and 9.6 +/- 0.96 in controls (p < 0.05). The corresponding figures for the sympathetic slope sensitivity were -4.9 +/- 0.9 and -13.1 +/- 2.3, respectively (p < 0.05). Differences remained after stepwise correction for age, body mass index (BMI), and to some extent BP. Resting MSA correlated with cardiac (r = 0.67, p < 0.003) and sympathetic (r = 0.56, p < 0.025) baroreflex sensitivity in the entire study group. We conclude that OSA patients exhibit an impaired baroreflex sensitivity to a hypotensive stimulus, which may represent an adaptive response to changes in BP or hypoxemia occurring in association with nocturnal apneas. Baroreflex adaptation may also contribute to the augmentation of resting MSA observed in OSA patients in this as well as in a previous study. PMID:8912770
Carlson, J T; Hedner, J A; Sellgren, J; Elam, M; Wallin, B G
We hypothesized that impaired performance on driving simulation and EEG defined attention lapses are greater in obstructive sleep apnea patients than in the normal population. Participants completed a 60-minute driving simulation with continuous EEG monitoring. Sleep apnea patients demonstrated increased lane position variability, crashes, and attention lapses throughout the task. Attention lapses appeared to underlie the poorer driving performance. Because sleepiness can occur in other populations, e.g. shift workers and on call physicians, these results support the need for the development of countermeasures, highway safety education programs, and the recognition and treatment of sleep disorders.
Risser, M.R.; Ware, J.C.
Chronic posttraumatic sleep disturbance may include sleep-disordered breathing (SDB), but this disorder of sleep respiration is usually not suspected in trauma survivors. Sleep breathing signs and symptoms were studied in 178 adults-all with SDB-including typical sleep clinic patients (N = 89) reporting classic snoring and sleepiness and crime victims (N = 89) with insomnia and posttraumatic stress. Significant differences (p < 0.0001) were common between groups. Sleep breathing complaints, loud snoring, marked obesity, and obstructive sleep apnea were prevalent in sleep clinic patients; crime victims reported more insomnia, nightmares, poor sleep quality, leg jerks, cognitive-affective symptoms, psychotropic medication usage, and less snoring but more upper airway resistance syndrome. Both groups reported high rates of fatigue or sleepiness, nocturia, morning dry mouth, and morning headaches. Awareness of these clinical features might enhance detection of SDB among trauma survivors. PMID:16772861
Krakow, Barry; Melendrez, Dominic; Warner, Teddy D; Clark, Jimmy O; Sisley, Brandy N; Dorin, Richard; Harper, Ronald M; Leahigh, Lisa K; Lee, Samuel A; Sklar, David; Hollifield, Michael
The objective was to establish the evidence base for diagnosing sleep apnea (SA) in adult patients using systematic review methods. Tests covered were sleep monitoring devices, radiologic imaging, laboratory assays, and clinical signs and symptoms posited...
S. D. Ross I. E. Allen K. J. Harrison M. Kvasz J. Connelly I. A. Sheinhait
Study Objectives: The purpose of this study was to determine if subjects with moderate-to-severe obstructive sleep apnea would experience increasing treatment effect when a tongue retention component was added to a mandibular repositioning appliance. Design: Cohort study. Setting: Sleep clinic. Patients: Forty-four sequentially recruited patients with moderate-to-severe obstructive sleep apnea. Interventions: Subjects were sleep tested at 4 treatment stages of oral appliance therapy. The 4 stages were: 6-mm mandibular protrusion, 8-mm protrusion, 6-mm protrusion with a tongue retention bulb, and 8-mm protrusion with a tongue retention bulb. Measurements and Results: Forty-one of 44 subjects completed the protocol. There was a decrease in mean respiratory disturbance index from 33.5 events/h at baseline to 18.1 events/h at stage 4 (p = 0.001). Mean Epworth Sleepiness Scale (ESS) decreased from 12.3 at baseline to 9.0 at stage 4 (p = 0.0001. Conclusions: A combined approach utilizing both mandibular protrusion and tongue retention can provide effective treatment for moderate-to-severe obstructive sleep apnea. The addition of a tongue bulb may provide further treatment effect when mandibular protrusion is limited. Appliance designs that allow for convenient combination therapy need to be developed for this purpose. Citation: Dort L; Remmers J. A combination appliance for obstructive sleep apnea: the effectiveness of mandibular advancement and tongue retention. J Clin Sleep Med 2012;8(3):265-269.
Dort, Leslie; Remmers, John
Background Disturbed sleep and nocturnal altered breathing are related to disturbances of glucose metabolism. The present uncontrolled observational study explores the role of these factors on the variability of fasting glycemia. Methods The number and duration of nocturnal awakenings and the fasting glycemia of 97 patients with type 2 diabetes treated with diet, metformin, or gliptins were recorded over seven consecutive days. During the same time period, the main respiratory indexes—oxygen disturbance index, apnea/hypopnea index, and respiratory disturbance index—were recorded for one night. Results The three respiratory indexes and the number of nocturnal awakenings are highly correlated with the coefficient of variation of the fasting blood glucose recorded over the 7-day period at p <.005 level. A multiple regression analysis showed that the variables in the model explained 86% of the variability. Results Respiratory/sleep disturbances appear to be modulators superimposed on blood glucose levels determined by other factors.
Tatti, Patrizio; Strollo, Felice; Passali, Desiderio
We studied the effects of modafinil, a vigilance-enhancing drug, on excessive daytime sleepiness, memory, night sleep and respiration in 6 patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) using a double-blind random cross-over design with 24-hour polysomnography, verbal memory test and a 5-week sleep-wake diary kept by the patients. There were two 2-week treatment periods in which either modafinil or placebo
Isabelle Arnulf; Pascale Homeyer; Lucile Garma; William A. Whitelaw; Jean-Philippe Derenne
The relationship between health-related quality of life (HRQOL) and sleep apnea was examined in a sample of elderly African-Americans\\u000a screened for snoring and daytime sleepiness. Seventy African-Americans over the age of 65 years completed a comprehensive\\u000a sleep questionnaire, the Quality of Well-Being Scale (QWB), and the Medical Outcomes Study (MOS) Core Measures of HRQOL (116-item\\u000a Long Version) and had sleep
Carl Stepnowsky; Sherella Johnson; Joel Dimsdale; Sonia Ancoli-Israel
Background Postoperative delirium, a common complication in the elderly, can occur following any type of surgery and is associated with increased morbidity and mortality; it may also be associated with subsequent cognitive problems. Effective therapy for postoperative delirium remains elusive because the causative factors of delirium are likely multiple and varied. Methods Patients ? 65 years old undergoing elective knee arthroplasty were prospectively evaluated for postoperative Diagnostic and Statistical Manual of Mental Disorders-IV delirium. Exclusion criteria included dementia, mini-mental state exam score<24, delirium, clinically significant CNS/neurological disorder, current alcoholism, or any serious psychiatric disorder. Delirium was assessed on postoperative days 2 and 3 using standardized scales. Patients’ pre-existing medical conditions were obtained from medical charts. The occurrence of obstructive sleep apnea (OSA) was confirmed by contacting patients to check their polysomnography records. Data were analyzed using Pearson Chi-Square or Wilcoxon Rank Sum tests and multiple logistic regressions adjusted for effects of covariates. Results Of 106 enrolled patients, 27 (25%) developed postoperative delirium. Of the 15 patients with obstructive sleep apnea, 8 (53%) experienced postoperative delirium, compared to 19 (20%) of the patients without obstructive sleep apnea (p=0.0123, OR: 4.3). Obstructive sleep apnea was the only statistically significant predictor of postoperative delirium in multivariate analyses. Conclusions This is the first prospective study employing validated measures of delirium to identify an association between pre-existing obstructive sleep apnea and postoperative delirium.
Flink, Benjamin J.; Rivelli, Sarah K.; Cox, Elizabeth A.; White, William D.; Falcone, Grace; Vail, Thomas P.; Young, Christopher C.; Bolognesi, Michael P.; Krystal, Andrew D.; Trzepacz, Paula T.; Moon, Richard E.; Kwatra, Madan M.
Purpose Attempts to understand the causes of cognitive impairment in Obstructive Sleep Apnea (OSA) are complicated by the overlap among clinical and demographic factors that may impact cognition. The goal of the current study was to isolate the contribution of hypoxemia to cognitive impairment in OSA. Methods Two groups of 20 patients with newly diagnosed OSA were compared. The groups differed on severity of hypoxemia but not other demographic (e.g., age, gender, education, estimated premorbid IQ) or clinical (e.g., sleep related respiratory disturbances, daytime sleepiness, depressive symptoms) variables. Participants completed polysonmography and cognitive assessment. Results We compared patients with high and low hypoxemia on measures of memory, attention, executive functioning, and motor coordination using independent samples t-tests. The high hypoxemia group performed significantly better on immediate recall (HVLT-R; t=?2.50, p<.02) than the low hypoxemia group. No group differences were observed on other neuropsychological measures. Conclusions This study is one of the first to compare the cognitive performance of patients with high and low hypoxemia after controlling for demographic factors and aspects of OSA severity that could confound the relationship. In our carefully matched sample we observed an unexpected advantage of higher hypoxemia on memory. These preliminary findings are discussed in the context of basic science literature on the protective effects of adaptation to intermittent hypoxemia. Our data suggest that the association between hypoxemia and cognition may not straightforward. Future research targeting the effects of hypoxemia on cognition controlling for other clinical factors in large groups of patients with OSA will be important.
Hoth, Karin F.; Zimmerman, Molly E.; Meschede, Kimberly A.; Arnedt, J. Todd; Aloia, Mark S.
Rationale: Cross-sectional association has been reported between sleep-disordered breathing (SDB) and insulin resistance, but no prospective studies have been performed to determine whether SDB is causal in the development of diabetes. Objectives: The purpose of our study was to investigate the prevalence and incidence of type II diabetes in subjects with SDB and whether an independent relationship exists between them. Methods: A cross-sectional and longitudinal analysis was performed in 1,387 participants of the Wisconsin Sleep Cohort. Full polysomnography was used to characterize SDB. Diabetes was defined in two ways: (1) physician-diagnosis alone or (2) for those with glucose measurements, either fasting glucose ? 126 mg/dl or physician diagnosis. Measurements and Main Results: There was a greater prevalence of diabetes in subjects with increasing levels of SDB. A total of 14.7% of subjects with an apnea–hypopnea index (AHI) of 15 or more had a diagnosis of diabetes compared with 2.8% of subjects with an AHI of less than 5. The odds ratio for having a physician diagnoses of diabetes mellitus with an AHI of 15 or greater versus an AHI of less than 5 was 2.30 (95% confidence interval, 1.28–4.11; p = 0.005) after adjustment for age, sex, and body habitus. The odds ratio for developing diabetes mellitus within 4 yr with an AHI of 15 or more compared with an AHI of less than 5 was 1.62 (95% confidence interval, 0.67–3.65; p = 0.24) when adjusting for age, sex, and body habitus. Conclusions: Diabetes is more prevalent in SDB and this relationship is independent of other risk factors. However, it is not clear that SDB is causal in the development of diabetes.
Reichmuth, Kevin J.; Austin, Diane; Skatrud, James B.; Young, Terry
Obstructive sleep apnea (OSA) is a common condition of childhood, and is associated with significant morbidity. Prevalence of the condition peaks during early childhood, due in part to adenoidal and tonsillar enlargement within a small pharyngeal space. The lymphoid tissues regress after 10 years of age, in the context of ongoing bony growth, and there is an associated fall in the prevalence of OSA. Obstruction of the nasopharynx by adenoidal enlargement promotes pharyngeal airway collapse during sleep, and the presence of large tonsils contributes to airway obstruction. Administration of systemic corticosteroids leads to a reduction in the size of lymphoid tissues due to anti-inflammatory and lympholytic effects. However, a short course of systemic prednisone has been demonstrated not to have a significant effect on adenoidal size or the severity of OSA, and adverse effects preclude the long-term use of this therapy. Intranasal corticosteroids are effective in relieving nasal obstruction in allergic rhinitis, and allergic sensitization is more prevalent among children who snore than among those who do not snore. Intranasal corticosteroids have also been demonstrated to reduce adenoidal size, independent of the individual's atopic status. There is preliminary evidence of an improvement in the severity of OSA in children treated with intranasal corticosteroids, but further studies are needed before such therapy can be routinely recommended. Prescribing clinicians should take into account the potential benefits to the patient, the age of the child, the presence of comorbidities such as allergic rhinitis, the agent used, and the dose and duration of treatment when considering such therapy. PMID:14720053
Nixon, Gillian M; Brouillette, Robert T
Purpose of review The aim of this review is to summarize current evidence about the impact of Obstructive Sleep Apnea (OSA) and Intermittent Hypoxia (IH) on dyslipidemia and provide future perspectives in this area. Recent findings IH, a hallmark of OSA, induces hyperlipidemia in lean mice. Hyperlipidemia of IH occurs, at least in part, due to activation of the transcription factor sterol regulatory element–binding protein-1 (SREBP-1) and an important downstream enzyme of triglyceride and phospholipid biosynthesis, stearoyl-coenzyme A desaturase-1 (SCD-1). Furthermore, IH may regulate SREBP-1 and SCD-1 via the transcription factor hypoxia-inducible factor 1. In contrast, key genes involved in cholesterol biosynthesis, SREBP-2 and 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase, are unaffected by IH. In humans, there is no definitive evidence regarding the effect of OSA on dyslipidemia. Several cross-sectional studies suggest that OSA is independently associated with increased levels of total cholesterol, LDL and triglycerides, whereas others report no such relationship. Some non-randomized and randomized studies show that OSA treatment with continuous positive airway pressure may have a beneficial effect on lipid profile. Summary There is increasing evidence that IH is independently associated with dyslipidemia. However, the role of OSA in causality of dyslipidemia remains to be established.
Drager, Luciano F.; Jun, Jonathan; Polotsky, Vsevolod Y.
Purpose of review To provide an update on the connection between obstructive sleep apnea (OSA) and cardiovascular disease. Recent findings Large prospective studies have established that OSA is associated with an increased incidence of hypertension and, in men, of coronary disease, stroke, and heart failure. Advances in understanding the pathophysiologic basis for these associations include identification of a role for OSA in inducing abnormalities in hepatic lipid-metabolizing enzymes, endothelial dysfunction, and upregulation of pro-inflammatory and pro-thrombotic mediators. A large body of data implicates OSA as playing a significant role in the occurrence and resistance to treatment of atrial fibrillation. Clinical trials have shown small to modest improvements in blood pressure associated with continuous positive airway pressure (CPAP) use, with smaller or uncontrolled studies suggesting that CPAP may improve cardiovascular outcomes or intermediate markers. Summary OSA and cardiovascular disease commonly co-aggregate. Multiple studies indicate that OSA contributes to or exacerbates cardiovascular disease, and thus may be a novel target for cardiovascular risk reduction. While the evidence supports screening and treatment of OSA in patients at risk for cardiovascular disease, it also underscores a need for well powered clinical trials to examine the role of CPAP and other therapies in these populations.
Monahan, Ken; Redline, Susan
Recent studies suggest a higher than expected prevalence of obstructive sleep apnea (OSA) in patients with refractory epilepsy. In some cases, treatment of OSA improves seizure control. We report a case in which clinically significant OSA disappeared after left frontal lobe resection that produced a near seizure free state. This occurred in the absence of the usual factors, such as weight or medication change or variation in polysomnography (PSG) recording methodology, that often confound the comparison of sequential PSGs over time. Our patient underwent PSG with 18-channel EEG recording pre- and postoperatively using standardized scoring techniques. Baseline testing revealed an apnea-hypopnea index (AHI) of 24 with severe oxygen desaturations reaching a nadir of 62%. Postoperative testing found both the AHI and oxygen saturation normalized as well as a marked reduction in spike rate. We hypothesize that the pathophysiology of OSA in patients with epilepsy may be impacted by frequent, extensive interictal epileptiform discharges (IEDs) and/or seizures altering upper airway control during sleep. PMID:18503557
Foldvary-Schaefer, Nancy; Stephenson, Lisa; Bingaman, William
Objectives: Emergence of central sleep apnea has been described in the setting of continuous positive airway pressure (CPAP) initiation. The underlying mechanism is unclear; however, we postulate that air leak washing out anatomical dead space is a contributing factor. Design: Data were obtained from 310 patients with obstructive sleep apnea (OSA) who underwent either split-night or full-night CPAP titration during January to July of 2009. The majority (n = 245) underwent titration with a nasal mask. Average total leak and maximum total leak were measured at therapeutic CPAP level. Unintentional leak was calculated by subtracting manufacturer-defined intentional leak from maximum leak. Results: Subjects were divided into two groups: central apnea index (CAI) during titration < 5/hour and ? 5/hour. The groups were similar in terms of gender, age, BMI, and AHI. The CAI < 5 group had a median average leak of 45.5 L/min (IQR 20.8 L/min) versus 51.0 L/min (IQR 21.0 L/min) with CAI ? 5 (p = 0.056). Maximum leak was 59.5 L/min (IQR 27.0 L/min) with CAI < 5 and 75.0 L/min (IQR 27.8 L/min) with CAI ? 5 (p = 0.003). In the subset of subjects titrated using a nasal mask, median average leak was 42.0 L/min (IQR 17.0) in the CAI < 5 group and 50.0 L/min (IQR 16.8) in the CAI ? 5 group (p = 0.001). In the CAI < 5 group, median maximum leak was 57.0 L/min (IQR 23.0) versus 74.5 L/min (IQR 24.3) in the CAI ? 5 group (p < 0.001). Conclusions: Leak during CPAP titration is associated with the development of acute central apnea; these data may have mechanistic and therapeutic implications for complex apnea. Commentary: A commentary on this article appears in this issue on page 1193. Citation: Montesi SB; Bakker JP; Macdonald M; Hueser L; Pittman S; White DP; Malhotra A. Air leak during CPAP titration as a risk factor for central apnea. J Clin Sleep Med 2013;9(11):1187-1191.
Montesi, Sydney B.; Bakker, Jessie P.; Macdonald, Mary; Hueser, Lauren; Pittman, Stephen; White, David P.; Malhotra, Atul
Background The gender-specific influences of various confounding factors, including apnea, age, BMI, and cigarette consumption, on the function of the parasympathetic nerve system (PNS) during sleep in OSA patients has never been investigated. Methods One hundred ninety-seven males and 63 females with OSA were subjected to full PSG examinations including assessment of R-R intervals (RRIs) during an overnight ECG. The PNS-derived modulatory effect on the RRIs and the variability of this effect were quantified during REM and NREM using instantaneous time-frequency analysis with complex demodulation. The spectral domain with the maximum instantaneous amplitude in the high-frequency band between 0.15 and 0.4 Hz was defined as the main HF peak and used as a surrogate marker of PNS discharge. Based on density-spectrum-array maps of the main HF peaks (HF-DSA map), shifts in the central frequency of the main HF peak over time were continuously observed. When the main HF peaks on the HF-DSA maps maintained the same central frequency for more than 20 sec or 5 min, the PNS functions were considered to be “stable” or “very stable”, respectively. Results Apneas enhanced PNS-derived cardiac-modulation during REM in males, but more importantly, they made PNS-function unstable during both REM and NREM in males and during NREM in females. Aging blunted the PNS-derived cardiac-modulation during both REM and NREM regardless of gender, but aging had no impact on the stability of PNS-function. BMI blunted PNS-eliciting cardiac-modulation during REM in males and during NREM in both males and females. BMI made the PNS unstable during REM in females. Neither height nor cigarette consumption influenced any PNS-related parameter. Conclusions The PNS-derived cardiac-modulation was generally inhibited by aging and obesity, in which the effect of obesity was gender-specific. The PNS instability at nighttime was mainly induced by apneas but by obesity particularly during REM in females.
Yamaguchi, Kazuhiro; Inoue, Yuji; Ohki, Noboru; Satoya, Natsumi; Inoue, Fukumi; Maeda, Yoshiko; Sekiguchi, Haruki; Suzuki, Mayumi; Tsuji, Takao; Aoshiba, Kazutetsu; Nagai, Atsushi
... Medicine . Shelby Freedman Harris, director of the Behavioral Sleep Medicine Program and the Sleep-Wake Disorders Center at ... Toronto; Shelby Freedman Harris, Psy.D., director, Behavioral Sleep Medicine Program and Sleep-Wake Disorders Center, Montefiore Medical ...
Detection of desaturations on the pulse oximetry signal is of great importance for the diagnosis of sleep apneas. Using the counting of desaturations, an index can be built to help in the diagnosis of severe cases of obstructive sleep apnea-hypopnea syndrome. It is important to have automatic detection methods that allows the screening for this syndrome, reducing the need of the expensive polysomnography based studies. In this paper a novel recognition method based on the empirical mode decomposition of the pulse oximetry signal is proposed. The desaturations produce a very specific wave pattern that is extracted in the modes of the decomposition. Using this information, a detector based on properly selected thresholds and a set of simple rules is built. The oxygen desaturation index constructed from these detections produces a detector for obstructive sleep apnea-hypopnea syndrome with high sensitivity (0.838) and specificity (0.855) and yields better results than standard desaturation detection approaches. PMID:24931493
Schlotthauer, Gastón; Di Persia, Leandro E; Larrateguy, Luis D; Milone, Diego H
Sleep apnea is a common respiratory disorder during sleep, which is described as a cessation of airflow to the lungs that lasts at least for 10 s and is associated with at least 4% drop in blood's oxygen saturation level (S(a)O(2)). The current gold standard method for sleep apnea assessment is full-night polysomnography (PSG). However, its high cost, inconvenience for patients, and immobility have persuaded researchers to seek simple and portable devices to detect sleep apnea. In this article, we report on developing a new method for sleep apnea detection and monitoring, which only requires two data channels: tracheal breathing sounds and the pulse oximetry (S(a)O(2) signal). It includes an automated method that uses the energy of breathing sounds signals to segment the signals into sound and silent segments. Then, the sound segments are classified into breath, snore, and noise segments. The S(a)O(2) signal is analyzed automatically to find its rises and drops. Finally, a weighted average of different features extracted from breath segments, snore segments and S(a)O(2) signal are used to detect apnea and hypopnea events. The performance of the proposed approach was evaluated on the data of 66 patients recorded simultaneously with their full-night PSG study, and the results were compared with those of the PSG. The results show high correlation (0.96, P < 0.0001) between the outcomes of our system and those of the PSG. Also, the proposed method has been found to have sensitivity and specificity values of more than 91% in differentiating simple snorers from obstructive sleep apnea patients. PMID:20734154
Yadollahi, Azadeh; Giannouli, Eleni; Moussavi, Zahra
Sleep-disordered breathing (SDB), commonly known as sleep apnea, is associated with an increased risk of cancer mortality, according to a new study. While previous studies have associated SDB with increased risks of hypertension, cardiovascular disease, depression, and early death, this is the first human study to link apnea with higher rate of cancer mortality, showing a nearly five times higher incidence of cancer deaths in patients with severe SDB compared to those without the disorder, a result that echoes previous findings in animal studies.
While patients with obstructive sleep apnea (OSA) or multiple sclerosis (MS) are at high risk of developing postoperative complications, both of them have special anesthetic considerations in intraoperative and postoperative periods. A careful preoperative evaluation, use of the optimal anesthetic regimen and close postoperative care is essential for these patients. Rarity of coexistence of both obstructive sleep apnea and multiple sclerosis in a surgical patient necessitates careful anesthetic management. We here report anesthetic management of a female patient with OSA and MS who underwent anesthesia three times for surgery and review the literature.
Ceyhan, Aysegul; Uyar, Esra Turkyilmaz; Gencay, Isin Yazici; Gunal, Solmaz Eruyar
Obstructive sleep apnea (OSA), is a common clinical condition affecting at least 2–4% of the adult population. Hypertension is found in about half of all OSA patients, and about one-third of all patients with essential hypertension have OSA. There is growing evidence that successful treatment of OSA can reduce systemic blood pressure (BP). Body position appears to have an important
M Berger; A Oksenberg; DS Silverberg; E Arons; H Radwan; A Iaina
Context: Epidemiological studies reported an inverse or U-shaped relationship between sleep duration and weight. The relationship between sleep and resting energy expenditure (REE) has not been well characterized. Objective: The aim of the study was to determine the relationship between sleep, REE, and stress hormones. Design and Setting: We conducted a cross-sectional evaluation of a prospective cohort study at a tertiary referral research clinical center. Subjects: Subjects included 126 obese individuals (30 males, 96 females; age, 40.5 ± 6.9 yr; body mass index, 38.6 ± 6.5 kg/m2; sleep duration, 360 ± 50 min/night; and sleep efficiency, 79.5 ± 7.5%). Main Outcome Measure(s): REE and respiratory quotient (RQ) were assessed by indirect calorimetry. Sleep duration and sleep efficiency were assessed by actigraphy. Sleep quality was estimated by questionnaires, and sleep apnea was evaluated by respiratory disturbance index (RDI). Morning plasma ACTH, serum cortisol, and 24-h urinary free cortisol and catecholamines were also measured. Results: RDI was positively correlated with REE adjusted by fat-free mass (r = 0.307; P = 0.003) and RQ (r = 0.377; P < 0.001). Sleep efficiency was inversely correlated with RQ (r = ?0.200; P = 0.033). The relationship of RDI score and REE was stronger in men than women (P = 0.03). In women, serum cortisol was positively correlated (r = 0.407; P < 0.001), and Epworth sleepiness score tended to be inversely (r = ?0.190; P = 0.086) correlated with adjusted REE. The RQ was positively related to RDI in women, whereas subjective sleep time was related to RQ in men. In a multiple regression model, RDI, serum cortisol, and urinary norepinephrine were directly related to REE, whereas serum cortisol also directly related to adjusted REE. Conclusion: Poor sleep quality was associated with increased REE, a higher RQ indicating a shift from fat toward carbohydrate oxidation, and activation of the stress system.
de Jonge, Lilian; Zhao, Xiongce; Mattingly, Megan S.; Zuber, Samuel M.; Piaggi, Paolo; Csako, Gyorgy
Evidence has consistently supported the association of obstructive sleep apnea syndrome (OSAS) with an increased prevalence of hypertension. It has also been shown that the severity of OSAS is directly correlated with the degree of blood pressure (BP) elevation and that hypertension occurring in subjects with OSAS is more likely to be severe, resistant to antihypertensive treatment and associated with alterations in day-to-night BP changes. Proposed mechanisms for the pathogenesis of OSAS-related hypertension include the activation of the sympathetic nervous system, alterations in autonomic cardiovascular (CV) modulation, the activation of the renin-angiotensin-aldosterone system, endothelial dysfunction, systemic and vascular inflammation, oxidative stress, metabolic abnormalities, arterial stiffness and alterations in cardiac function and structure. Given the adverse prognostic implications of OSAS-related hypertension for CV morbidity and mortality, the confirmation of resistant hypertension by using ambulatory BP monitoring (ABPM) and the identification of alterations in day-to-night BP changes is of the utmost importance to implement more aggressive strategies for achieving BP control. In turn, the proper identification and implementation of specific treatment strategies for OSAS (that is, continuous positive airway pressure) in subjects with resistant hypertension may promote BP control and optimize CV protection. The present paper will review the evidence supporting the association of OSAS with resistant hypertension and the proposed mechanisms for this association. It will also address the role of ABPM in the confirmation of resistant hypertension in subjects with OSAS and whether the proper identification and management of OSAS in subjects with resistant hypertension will improve BP control. PMID:24804613
Parati, Gianfranco; Ochoa, Juan Eugenio; Bilo, Grzegorz; Mattaliano, Paola; Salvi, Paolo; Kario, Kazuomi; Lombardi, Carolina
Objective To determine the effects of obstructive sleep apnea (OSA) on visual vigilance during simulated automobile driving. Methods Twenty-five drivers with OSA and 41 comparison drivers participated in an hour-long drive in a high fidelity driving simulator. Drivers responded to light targets flashed at seven locations across the forward horizon. Dependent measures were percent correct (hit rate, HR), and reaction time (RT). Self-assessment of sleepiness used the Stanford Sleepiness Scale (SSS) before and after the drive and the Epworth Sleepiness Scale (ESS). Results OSA drivers showed reduced vigilance based on lower HR than comparison drivers, especially for peripheral targets (80.7 +/? 14.8% vs. 86.7 +/? 8.8%, p = 0.03). OSAS drivers were sleepier at the end of the drive than comparison drivers (SSS = 4.2 +/? 1.2 vs. 3.6 +/? 1.2, p = 0.03), and increased sleepiness correlated with decreased HR only in those with OSA (r = ?0.49, p = 0.01). Lower HR and higher post-drive SSS predicted greater numbers of driving errors in all subjects. Yet, ESS, pre-drive SSS, and most objective measures of disease severity failed to predict driving and vigilance performance in OSA. Conclusions Reduced vigilance for peripheral visual targets indicates that OSA drivers have restriction of their effective field of view, which may partly explain their increased crash risk. This fatigue-related decline in attention is predicted by increased subjective sleepiness during driving. These findings may suggest a means of identifying and counseling high-risk drivers, and aid in the development of in-vehicle alerting and warning devices.
Tippin, Jon; Sparks, JonDavid; Rizzo, Matthew
Although previous studies demonstrated that patients with obstructive sleep apnea syndrome (OSAS) may present subclinical manifestations of dysphagia, in not one were different textures and volumes systematically studied. The aim of this study was to analyze the signs and symptoms of oropharyngeal dysphagia using fiberoptic endoscopic evaluation of swallowing (FEES) with boluses of different textures and volumes in a large cohort of patients with OSAS. A total of 72 OSAS patients without symptoms of dysphagia were enrolled. The cohort was divided in two groups: 30 patients with moderate OSAS and 42 patients with severe OSAS. Each patient underwent a FEES examination using 5, 10 and 20 ml of liquids and semisolids, and solids. Spillage, penetration, aspiration, retention, and piecemeal deglutition were considered. The penetration-aspiration scale (PAS), pooling score (PS), and dysphagia outcome and severity scale (DOSS) were used for quantitative analysis. Each patient completed the SWAL-QOL questionnaire. Forty-six patients (64 %) presented spillage, 20 (28 %) piecemeal deglutition, 26 (36 %) penetration, and 30 (44 %) retention. No differences were found in the PAS, PS, and DOSS scores between patients with moderate and severe OSAS. Patients with severe OSAS scored higher General Burden and Food selection subscales of the SWAL-QOL. Depending on the DOSS score, the cohort of patients was divided into those with and those without signs of dysphagia. Patients with signs of dysphagia scored lower in the General Burden and Symptoms subscales of the SWAL-QOL. OSAS patients show signs of swallowing impairment in about half of the population; clinicians involved in the management of these patients should include questions on swallowing when taking the medical history. PMID:23817806
Schindler, Antonio; Mozzanica, Francesco; Sonzini, Giulia; Plebani, Daniela; Urbani, Emanuele; Pecis, Marica; Montano, Nicola
Untreated and long-lasting obstructive sleep apnea (OSA) may lead to important vascular abnormalities, including endothelial cell (EC) dysfunction, hypertension, and atherosclerosis. We observed a correlation between microcirculatory reactivity and endothelium-dependent release of nitric oxide in OSA patients. Therefore, we hypothesized that OSA affects (micro)vasculature and we aimed to identify vascular gene targets of OSA that could possibly serve as reliable biomarkers of severity of the disease and possibly of vascular risk. Using quantitative RT-PCR, we evaluated gene expression in skin biopsies of OSA patients, mouse aortas from animals exposed to 4-week intermittent hypoxia (IH; rapid oscillations in oxygen desaturation and reoxygenation), and human dermal microvascular (HMVEC) and coronary artery endothelial cells (HCAEC) cultured under IH. We demonstrate a significant upregulation of endothelial nitric oxide synthase (eNOS), tumor necrosis factor-alpha-induced protein 3 (TNFAIP3; A20), hypoxia-inducible factor 1 alpha (HIF-1??? and vascular endothelial growth factor (VEGF) expression in skin biopsies obtained from OSA patients with severe nocturnal hypoxemia (nadir saturated oxygen levels [SaO2]<75%) compared to mildly hypoxemic OSA patients (SaO2 75%-90%) and a significant upregulation of vascular cell adhesion molecule 1 (VCAM-1) expression compared to control subjects. Gene expression profile in aortas of mice exposed to IH demonstrated a significant upregulation of eNOS and VEGF. In an in vitro model of OSA, IH increased expression of A20 and decreased eNOS and HIF-1? expression in HMVEC, while increased A20, VCAM-1 and HIF-1?expression in HCAEC, indicating that EC in culture originating from distinct vascular beds respond differently to IH stress. We conclude that gene expression profiles in skin of OSA patients may correlate with disease severity and, if validated by further studies, could possibly predict vascular risk in OSA patients. PMID:23923005
Kaczmarek, Elzbieta; Bakker, Jessie P; Clarke, Douglas N; Csizmadia, Eva; Kocher, Olivier; Veves, Aristidis; Tecilazich, Francesco; O'Donnell, Christopher P; Ferran, Christiane; Malhotra, Atul
Untreated and long-lasting obstructive sleep apnea (OSA) may lead to important vascular abnormalities, including endothelial cell (EC) dysfunction, hypertension, and atherosclerosis. We observed a correlation between microcirculatory reactivity and endothelium-dependent release of nitric oxide in OSA patients. Therefore, we hypothesized that OSA affects (micro)vasculature and we aimed to identify vascular gene targets of OSA that could possibly serve as reliable biomarkers of severity of the disease and possibly of vascular risk. Using quantitative RT-PCR, we evaluated gene expression in skin biopsies of OSA patients, mouse aortas from animals exposed to 4-week intermittent hypoxia (IH; rapid oscillations in oxygen desaturation and reoxygenation), and human dermal microvascular (HMVEC) and coronary artery endothelial cells (HCAEC) cultured under IH. We demonstrate a significant upregulation of endothelial nitric oxide synthase (eNOS), tumor necrosis factor-alpha-induced protein 3 (TNFAIP3; A20), hypoxia-inducible factor 1 alpha (HIF-1??? and vascular endothelial growth factor (VEGF) expression in skin biopsies obtained from OSA patients with severe nocturnal hypoxemia (nadir saturated oxygen levels [SaO2]<75%) compared to mildly hypoxemic OSA patients (SaO2 75%–90%) and a significant upregulation of vascular cell adhesion molecule 1 (VCAM-1) expression compared to control subjects. Gene expression profile in aortas of mice exposed to IH demonstrated a significant upregulation of eNOS and VEGF. In an in vitro model of OSA, IH increased expression of A20 and decreased eNOS and HIF-1? expression in HMVEC, while increased A20, VCAM-1 and HIF-1?expression in HCAEC, indicating that EC in culture originating from distinct vascular beds respond differently to IH stress. We conclude that gene expression profiles in skin of OSA patients may correlate with disease severity and, if validated by further studies, could possibly predict vascular risk in OSA patients.
Kaczmarek, Elzbieta; Bakker, Jessie P.; Clarke, Douglas N.; Csizmadia, Eva; Kocher, Olivier; Veves, Aristidis; Tecilazich, Francesco; O'Donnell, Christopher P.; Ferran, Christiane; Malhotra, Atul
Introduction We hypothesized that the size of the hyoid bone itself may affect the severity of sleep apnea. The aim of this study was to identify the relationship between hyoid bone dimensions and the severity of sleep apnea using computerized tomography (CT) axial images. Methods We retrospectively measured the hyoid bone in axial images of neck CTs and correlated these measurements with results of polysomnography in a total of 106 male patients. The new hyoid bone parameters studied in this study were as follows: distance between bilateral lesser horns (LH-d), distance between bilateral greater horns (GH-d), distance from the most anterior end of the hyoid arch to GH-d (AP), distance from the greater to the lesser horn on right and left sides (GH-LH), and the anterior angle between bilateral extensive lines from the greater to the lesser horn (H-angle). Data was analyzed using univariate and multivariate logistic regression, and Pearson correlation tests. Results We found a significant inverse correlation between the apnea-hypopnea index (AHI) and GH-d or AP. Neither the LH-d, GH-LH, nor H-angle were associated with the AHI. The patient group that met the criteria of both GH-d<45.4 and AP<33.4 demonstrated the most severe AHI. Conclusion The lateral width or antero-posterior length of hyoid bone was associated with AHI and predicted the severity of sleep apnea in male patients. This finding supports the role of expansion hyoidplasty for treatment of sleep apnea. Pre-operative consideration of these parameters may improve surgical outcomes in male patients with sleep apnea.
Ahn, Sang Hyeon; Kim, Chang-Hoon; Yoon, Joo-Heon; Lee, Jeung-Gweon; Cho, Hyung-Ju
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder with periodic reduction or cessation of airflow during sleep. It is associated with loud snoring, disrupted sleep, and witnessed apneas. Treatment of OSA varies from simple measures such as oral appliances and nasal continuous positive airway pressure (CPAP) to surgical procedures like uvulopalatopharyngoplasty and tracheostomy. Oral appliances are a viable nonsurgical treatment alternative in patients with OSA, of which mandibular advancement devices are most common. Edentulism which contributes to the worsening of OSA reduces the number of available therapeutic strategies and is considered a contraindication to oral appliance therapy. This clinical report describes the treatment of a 63-year-old edentulous OSA patient for whom a mandibular advancement device was designed.
Keyf, Filiz; Ciftci, Bulent; F?rat Guven, Selma
... a statement provided by the American Academy of Sleep Medicine. The study subjects were 47 adults with an ... Medical Center, New York City; American Academy of Sleep Medicine, press release, June 4, 2014. Sleep 2014, annual ...
Background—Enhanced nocturnal heart rate variability (HRV) has been evoked in sleep-related breathing disorders. However, its capacity to detect obstructive sleep apnea syndrome (OSAS) has not been systematically determined. Thus, we evaluated the discriminant power of HRV parameters in a first group of patients (G1) and validated their discriminant capacity in a second group (G2). Methods and Results—In G1, 39 of
Frederic Roche; Jean-Michel Gaspoz; Isabelle Court-Fortune; Pascal Minini; Vincent Pichot; David Duverney; Frederic Costes; Jean-Claude Barthelemy
Purpose The transduction mechanism of the inner ear and the transmission of nerve impulses along the auditory way are highly dependent\\u000a upon the cochlear oxygen supply. Several studies have considered the possibility that obstructive sleep apnea–hypopneas during\\u000a sleep can interfere with these processes, and the results are not uniform. The aim of the study is to evaluate the auditory\\u000a function in
Manuele Casale; Emanuela Vesperini; Massimiliano Potena; Marco Pappacena; Federica Bressi; Peter Jarden Baptista; Fabrizio Salvinelli
Study Objectives: The purpose of this pilot study was to evaluate a group of children with mild to moderate Obstructive Sleep Apnea\\u000a Syndrome (OSAS) for baseline neurocognitive deficits and behavioral dysfunction. A subset of the sample were also reassessed,\\u000a using the same test battery, after treatment with adenotonsillectomy.Design: Baseline and post-treatment neuropsychological and behavioral assessment.Setting: Pediatric sleep disorders clinic at
Judith Owens; Anthony Spirito; Ann Marcotte; Melissa McGuinn; Leslie Berkelhammer
Study Objectives: To review studies examining the cooccurrence of insomnia and obstructive sleep apnea (OSA), explore evidence for the effect of OSA therapy on insomnia symptoms and the effect of insomnia treatments on breathing and sleep in patients with OSA, and discuss challenges in the evaluation and treatment of comorbid insomnia and OSA. Methods/Results: Seven pertinent studies were identified that assessed the prevalence of comorbid insomnia and OSA or sleep disordered breathing. Four studies were identified that examined the effects of OSA treatment in patients with insomnia, and 8 studies were found that examined hypnotic use in patients with OSA or sleep disordered breathing. A high prevalence (39%-58%) of insomnia symptoms have been reported in patients with OSA, and between 29% and 67% of patients with insomnia have an apnea-hypopnea index of greater than 5. Combination therapy, including both cognitive behavior therapy and OSA treatment, resulted in greater improvements in insomnia than did either cognitive behavior therapy or OSA treatment alone. The use of GABAergic nonbenzodiazepine agents has been associated with improvements in sleep and has little to no effect on the apnea-hypopnea index in patients with OSA. Conclusions: Insomnia and OSA frequently cooccur. The optimal strategy for adequately treating comorbid insomnia and OSA remains unclear. Future research examining the impact of insomnia on continuous positive airway pressure therapy is needed. Given the substantial overlap in symptoms between insomnia and OSA, evaluation and treatment of these 2 conditions can be challenging and will require multidisciplinary collaboration among sleep specialists. Citation: Luyster FS; Buysse DJ; Strollo PJ. Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med 2010;6(2):196-204.
Luyster, Faith S.; Buysse, Daniel J.; Strollo, Patrick J.
Background Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by repeated breathing pauses during sleep and is closely associated with obesity. Body fat is known to be a predictive factor for OSAHS and its severity. Aim To study the correlation between the severity of OSAHS and body composition measurements. Methods 30 patients with OSAHS (21 men, 9 women, mean age 45.1 years, mean apnea-hypopnea index = 29.6/hour) were included in the study after full polysomnography. They were divided into 3 groups according to the apnea-hypopnea index (AHI): mild OSAHS (mean AHI 10.9/h), moderate OSAHS (mean AHI 23.9/h) and severe OSAHS (mean AHI 53.9/h). Body composition (body fat, body water and dry lean mass) was assessed using bioelectric impedance assay (BIA). Other measurements included neck and abdominal circumferences and body mass index (BMI). Pearson's coefficient (r) was used to express correlations between AHI and the following parameters: BMI, neck and abdominal circumferences, body fat, dry lean mass, and body water. Wilcoxon Sum-of-Ranks (Mann-Whitney) test for comparing unmatched samples was used to compare anthropometric and body composition measurements between groups. Results The correlation between AHI and BMI was weak (r = 0.38). AHI correlated moderately with neck circumference (r = 0.54), with neck circumference corrected by height (r = 0.60), and more strongly with body fat (r = 0.67), with body water (r = 0.69) and with abdominal circumference (r = 0.75). There was a strong negative correlation between AHI and dry lean mass (r = - 0.92). There were significant differences in body fat, body water, neck circumference corrected by height and abdominal circumference (Wilcoxon Sum-of-Ranks, p < 0.01), between mild and severe OSASH groups, but not in BMI (Wilcoxon Sumof-Ranks, W = 86.5; p = 0.17). Conclusions In our study, the severity of OSAHS correlated with body fat and with body water more strongly than with general and cervical obesity. Abdominal adiposity may predict OSAHS severity better than neck circumference.
To determine how the obstructive sleep apnea (OSA) patient's pathophysiological traits predict the success of the treatment aimed at stabilization or increase in respiratory motor outputs, we studied 26 newly diagnosed OSA patients [apnea-hypopnea index (AHI) 42 ± 5 events/h with 92% of apneas obstructive] who were treated with O2 supplementation, an isocapnic rebreathing system in which CO2 was added only during hyperpnea to prevent transient hypocapnia, and a continuous rebreathing system. We also measured each patient's controller gain below eupnea [change in minute volume/change in end-tidal Pco2 (?V?e/?PetCO2)], CO2 reserve (eupnea-apnea threshold PetCO2), and plant gain (?PetCO2/?V?e), as well as passive upper airway closing pressure (Pcrit). With isocapnic rebreathing, 14/26 reduced their AHI to 31 ± 6% of control (P < 0.01) (responder); 12/26 did not show significant change (nonresponder). The responders vs. nonresponders had a greater controller gain (6.5 ± 1.7 vs. 2.1 ± 0.2 l·min?1·mmHg?1, P < 0.01) and a smaller CO2 reserve (1.9 ± 0.3 vs. 4.3 ± 0.4 mmHg, P < 0.01) with no differences in Pcrit (?0.1 ± 1.2 vs. 0.2 ± 0.9 cmH2O, P > 0.05). Hypercapnic rebreathing (+4.2 ± 1 mmHg PetCO2) reduced AHI to 15 ± 4% of control (P < 0.001) in 17/21 subjects with a wide range of CO2 reserve. Hyperoxia (SaO2 ?95–98%) reduced AHI to 36 ± 11% of control in 7/19 OSA patients tested. We concluded that stabilizing central respiratory motor output via prevention of transient hypocapnia prevents most OSA in selected patients with a high chemosensitivity and a collapsible upper airway, whereas increasing respiratory motor output via moderate hypercapnia eliminates OSA in most patients with a wider range of chemosensitivity and CO2 reserve. Reducing chemosensitivity via hyperoxia had a limited and unpredictable effect on OSA.
Teodorescu, Mihaela; Pegelow, David F.; Teodorescu, Mihai C.; Gong, Yuansheng; Fedie, Jessica E.; Dempsey, Jerome A.
Obstructive Sleep Apnea (OSA), a highly prevalent, under-diagnosed disorder, is an important preventable cause of accidents at work and on the road. Commercial drivers are predominantly middle-aged men with high levels of obesity and hypertension, increasing their risk for OSA. Although Department of Transportation (DOT) physicals are conducted to certify drivers, physicians have no accurate and convenient methods for identifying
Chris Berka; Philip Westbrook; Daniel J. Levendowski; Michelle N. Lumicao; Caitlin K. Ramsey; Timothy Zavora; Travis Offner
The aim of this study was to assess the effect of bite opening induced to derive a placebo effect from the treatment (6); hence, by a mandibular advancement splint (MAS) on efficacy and side it is important to follow patients carefully using objective effects in the treatment of obstructive sleep apnea. In a randomized techniques. crossover fashion, 23 adult patients
Andrew J. Pitsis; M. Ali Darendeliler; Helen Gotsopoulos; Peter Petocz; Peter A. Cistulli
Background: The use of portable respiratory monitoring (PM) has been proposed for the diagnosis of obstructive sleep apnea syndrome (OSAS), but most studies that validate PM accuracy have not followed the best standards for diagnostic test validation. The objective of the present study was to evaluate the accuracy of PM performed at home to diagnose OSAS and its outcomes after
Ana Claudia; Tonelli de Oliveira; Denis Martinez; Luiz Felipe; T. Vasconcelos; Sandro Cadaval Goncalves; Maria do Carmo Lenz; Sandra Costa Fuchs; Miguel Gus; Erlon Oliveira de Abreu-Silva; Leila Beltrami Moreira; Flavio Danni Fuchs
Obstructive sleep apnea-hypopnea syndrome is associated independently with an increase in cardiovascular risk factors and is associated with self-reported lack of exercise. We aimed to investigate the utility of the incremental shuttle walk test in routine clinical practice to monitor physical capacity of patients with obstructive sleep apnea-hypopnea syndrome and explore whether continuous positive airway pressure therapy alters exercise capacity. Participants with symptomatic moderate/severe obstructive sleep apnea-hypopnea syndrome attending for a trial of continuous positive airway pressure therapy completed questionnaires assessing sleepiness and physical activity and underwent an incremental shuttle walk test. Subjects compliant or partially compliant with continuous positive airway pressure therapy underwent reassessment at 2 weeks, 3 months and 6 months post-initiation of therapy. Participants unable to tolerate continuous positive airway pressure therapy completed a single reassessment 6 months after their initial visit. Continuous positive airway pressure therapy resulted in an increased distance walked during the incremental shuttle walk test. Improvements in cardiovascular responses to exercise were identified. Compliant patients reported increased daily activity. The incremental shuttle walk test is a simple, reproducible and safe test that is responsive to continuous positive airway pressure treatment. Our findings support the use of the incremental shuttle walk test for monitoring the effects of continuous positive airway pressure treatment and may suggest its use in rehabilitation programmes designed to reduce obesity and cardiovascular risk factors in patients with obstructive sleep apnea-hypopnea syndrome. PMID:23425321
Billings, Catherine G; Aung, Thida; Renshaw, Stephen A; Bianchi, Stephen M
OBJECTIVES. Positive airway pressure therapy (PAP) is frequently used to treat chil- dren who have obstructive sleep apnea syndrome and do not respond to adeno- tonsillectomy. However, no studies have evaluated objectively adherence to PAP in children, and few studies have evaluated objectively the effectiveness of PAP. The objective of this study was to determine adherence and effectiveness of PAP
Carole L. Marcus; Gerald Rosen; Sally L. Davidson Ward; Ann C. Halbower; Laura Sterni; Janita Lutz
Obstructive sleep apnea (OSA) is a relatively common disorder in the United States that affects people of all ages, but is most prevalent among the middle-aged and elderly. Affected individuals experience repeated collapse and obstruction of the upper air...
D. Moorthy E. M. Balk G. D. Kitsios K. Patel M. Chang N. O. Obadan R. C. Iovin R. R. Bannuru S. Ip S. Sen
Background: Cardiovascular complications are common in patients with obstructive sleep apnea (OSA). Blood rheology is a major determent of coagulation and an established risk factor for cardiovascular events. Since nocturnal hypoxemia could influence parameters of blood rheology, we hypothesized that OSA alters blood rheology independent of other cardiovascular risk factors. Methods: One hundred and ten consecutive patients admitted to the
Stephan Steiner; Thomas Jax; Stefanie Evers; Marcus Hennersdorf; Andreas Schwalen; Bodo E. Strauer
Many people with obstructive sleep apnea syndrome (OSAS) are treated well with continuous positive airway pressure (CPAP) but an important number cannot tolerate it or have ongoing symptoms despite good compliance.Alternative therapies are needed for these patients.Weight loss should be encouraged in all obese subjects since this may reduce or even cure the OSAS and the risks from associated disorders
Previous studies of craniofacial risk factors for obstructive sleep apnea (OSA) have been based predominantly on cephalometry. However, differences in head form (measured by the cranial index (CI)) and facial form (measured by the facial index (FI)) are consid- ered by anthropologists to provide a basis for structural variation in craniofacial anatomy. We assessed the association of head and facial
BANU CAKIRER; MARK G. HANS; GREG GRAHAM; JOAN AYLOR; PETER V. TISHLER; SUSAN REDLINE
Obstructive sleep apnea syndrome (OSAS) is associated with cardiovascular morbidity as well as excessive daytime sleepiness and poor quality of life. In this study, we apply a machine learning technique [support vector machines (SVMs)] for automated recognition of OSAS types from their nocturnal ECG recordings. A total of 125 sets of nocturnal ECG recordings acquired from normal subjects (OSAS- )
Ahsan H. Khandoker; Marimuthu Palaniswami; Chandan K. Karmakar
Objectives Obstructive sleep apnea, a common indication for adenotonsillectomy in children, has been linked to behavioral morbidity. We assessed psychiatric diagnoses in children before and after adenotonsillectomy and examined whether baseline sleep apnea predicted improvement after surgery. Method Subjects of this prospective cohort study were children aged 5.0–12.9 years-old who had been scheduled for adenotonsillectomy (n = 79), or care for unrelated surgical conditions (n=27, among whom 13 had surgery after baseline assessment). Prior to intervention and one year later, subjects underwent structured diagnostic interviews and polysomnography. The main outcome measure was frequency of DSM-IV attention and disruptive behavior disorder diagnoses (A&DBDs) at baseline and follow-up. Results At baseline, A&DBDs were diagnosed in 36.7% of adenotonsillectomy subjects and 11.1% of controls (p<.05); attention-deficit/hyperactivity disorder was found in 27.8% and 7.4%, respectively (p<.05). One year later, group differences were non-significant, A&DBDs were diagnosed in only 23.1% (p<.01), and 50% of subjects with baseline attention-deficit/hyperactivity disorders no longer met diagnostic criteria. Obstructive sleep apnea on polysomnography at baseline did not predict concurrent psychiatric morbidity or later improvement. Conclusions Attention and disruptive behavior disorders, diagnosed by DSM-IV criteria, were more common before clinically-indicated adenotonsillectomy than one year later. Surgery may be associated with reduced morbidity even among subjects lacking polysomnographic evidence of obstructive sleep apnea.
Dillon, James E.; Blunden, Sarah; Ruzicka, Deborah L.; Guire, Kenneth E.; Champine, Donna; Weatherly, Robert A.; Hodges, Elise K.; Giordani, Bruno J.; Chervin, Ronald D.
The purpose of this study was to compare two groups of adult men from different ethnic backgrounds and with obstructive sleep apnea; they were selected by matching age, gender, skeletal pattern, body mass index, and respiratory disturbance index. Pretreatment cephalometric radiographs and overnight polysomnograms of 30 Chinese and 43 Caucasian patients with Class II, Division 1 malocclusions were analyzed to
Yuehua Liu; Alan A. Lowe; Xianglong Zeng; Minkui Fu; John A. Fleetham
Rationale: Studies of the genetics of obstructive sleep apnea may be facilitated by identifying intermediate traits with high heritability that quantify etiological pathways, such as those related to respiratory control. Electrocardiogram (ECG)-based sleep spectrograms, measuring the coupling between respiratory modulation of ECG QRS-wave amplitude and heart rate variability, may provide measures of sleep state and ventilatory dynamics during sleep. We evaluated the familial aggregation of distinctive spectrographic biomarkers of unstable sleep, related to elevated-low frequency cardiopulmonary coupling (e-LFC), to assess their utility in genetic studies. Methods: 622 participants from 137 families from the Cleveland Family Study underwent standardized polysomnography (PSG). From the ECG signal on the PSG, the interbeat interval time series and the corresponding ECG-derived respiratory signal were extracted, and the low frequency (0.01-0.1 Hz) component of their coupling was computed using a fully automated method. Narrow sense heritability of e-LFC was calculated using variance component methods. Results: A spectral marker of abnormal low frequency cardiopulmonary coupling (e-LFC) demonstrated moderate correlation with apnea hypopnea index (AHI; r = 0.35, P < 0.0001). The heritability estimate for e-LFC, after adjusting for age and sex was 0.32 (P < 10-5) and remained unchanged after additionally adjusting for body mass index or AHI. In biological relatives of those with sleep apnea, a related marker of e-LFC was more prevalent than in controls (P = 0.05). Conclusions: Approximately 30% of the variability of e-LFC, measured from a continuous ECG during sleep, is explained by familial factors other than BMI. ECG-based spectrographic measures of cardiopulmonary coupling may provide novel phenotypes for characterizing subgroups of individuals with different propensities and genetic etiologies for sleep apnea or for other conditions associated with sleep fragmentation. Citation: Ibrahim LH; Jacono FJ; Patel SR; Thomas RJ; Larkin EK; Mietus JE; Peng CK; Goldberger AL; Redline S. Heritability of abnormalities in cardiopulmonary coupling in sleep apnea: use of an electrocardiogram-based technique. SLEEP 2010;33(5):643-646.
Ibrahim, Lamia H.; Jacono, Frank J.; Patel, Sanjay R.; Thomas, Robert J.; Larkin, Emma K.; Mietus, Joseph E.; Peng, Chung-Kang; Goldberger, Ary L.; Redline, Susan
Introduction: Chronic Obstructive Pulmonary Disease (COPD) and obstructive sleep apnea syndrome are two diseases, which often coexist in one person. The sleep apnea is often caused by an interruption to breath when sleeping, due to an obstruction of the upper airway during inhalation, causing chronic snoring, morning headaches, increased body weight, blood pressure and sleepiness during the day. Aim: The purpose of this study is to investigate the extend of this problem among a large group of elderly people living in the Attica Basin. Material and Methods: Material of the study was 500 people aged 70 and above years old, including 274 men and 226 women. Data collection was facilitated with the use of an anonymous questionnaire with the purpose to identify patients with apnea, after a personal interview with the researcher. Data analysis was performed with the use of the statistical package SPSS 17. Results: Based on their responses to the questionnaires, it was found that 98.0% of the participants have abnormal sleepiness during the day. The 35.4% of them show no apnea, while 36.0% of the sample suffer from mild sleep apnea. It is important though, the fact that about one out of three seniors, 28.6%, shows sleep apnea in a high risk level. Conclusions: COPD is a complex disease that occurs in a large proportion of the elderly. Emphasis should be given on early diagnosis and treatment of sleep apnea syndrome, in order to improve the quality of the elderly life.
Diomidous, Marianna; Marios, Nikas; Zikos, Dimitrios; Konstantinos, Gourgoulianis; Zoe, Daniil; Mpizopoulou, Zoe; Xrysi, Xatzoglou; Zoe, Roupa
Sleep Apnea is highly prevalent and may contribute to insulin resistance in patients with acromegaly. The primary aim of this study was to assess the impact of sleep apnea treatment with a continuous positive air pressure (CPAP) device on insulin resistance evaluated by hyperinsulinemic euglycemic clamp (HEC). A prospective, randomized, open label, placebo-controlled, crossover study was performed at a tertiary outpatient pituitary center. Twelve acromegalic subjects on somatostatin analogs (SA) with a recent diagnosis of moderate to severe sleep apnea were randomized to CPAP therapy or to nasal dilator adhesive (NDA) with placebo effect for 3 months and then crossed over for another 3 months period without washout. Assessment of HEC, mathematical insulin resistance indexes (HOMA, HOMA2 and QUICKI), GH, IGF-1, HbA1c and free fat acids were performed. A significant reduction on insulin resistance was demonstrated by HEC at the end of the study in patients on CPAP (HEC, pre- and post-CPAP: 4.27 vs. 6.10 mg/Kg/min, P = 0.032). This reduction was not observed in NDA group (HEC, pre- and post-adhesive: 5.53 vs. 5.19 mg/Kg/min, P = 0.455). There was no significant difference on HbA1c or on peripheral insulin resistance indexes in both treatments. CPAP promoted a significant increase on peripheral insulin sensitivity in acromegalic patients with moderate to severe sleep apnea on SA use. Our results support the concept that sleep apnea plays an important role on glucose metabolism. Insulin resistance indexes were unable to detect this finding. PMID:22983689
Duarte, Felipe Henning Gaia; Jallad, Raquel Soares; Amaro, Aline Cecília Soares; Drager, Luciano Ferreira; Lorenzi-Filho, Geraldo; Bronstein, Marcello Delano
Background: Patients with obstructive sleep apnea/hypopnea syndrome (OSAHS), even those generally compliant with CPAP therapy, often intermittently discontinue CPAP. Study Objective: Examine the impact of CPAP withdrawal on sleep, sleep disordered breathing (SDB), and daytime function in subjects with varying severity of OSAHS. Patients and Interventions: Forty-two subjects (26M/16 F) with OSAHS (AHI4% = 45.2 ± 35.5/h pretreatment) on CPAP for 4 months were evaluated on the second night of CPAP withdrawal. Sleep architecture, SDB indices, and subjective/objective daytime function were assessed pretreatment, on CPAP therapy, and after CPAP withdrawal. Comparisons were made between pretreatment and CPAP withdrawal for the entire group, and for subgroups of mild/moderate (AHI4% < 30/h, n = 22) and severe (AHI4% > 30/h, n = 20) SDB. Results: Overall, and for mild/moderate subjects, SDB indices returned to pretreatment values on CPAP withdrawal but with fewer apneas and more hypopneas/RERAs. For severe SDB, the event frequency (AI, AHI4%, and RDI) was lower and O2 desaturation was improved on CPAP withdrawal. Across SDB severity, sleep architecture showed lower %REM (15.6% vs 12.9%, P = 0.009) on the CPAP withdrawal compared to pretreatment. Stanford Sleepiness Score, MSLT, and PVT measures were not significantly different between pretreatment and CPAP withdrawal. Conclusions: Over a wide range of SDB severity CPAP withdrawal results in recurrence of SDB, albeit with less severe O2 desaturation. Subjective/objective daytime function returned to pretreatment levels. Sleep architecture changes on CPAP withdrawal (acute SDB) may reflect reduced sleep pressure compared to pretreatment chronic SDB. Our data suggest detrimental effects of even brief withdrawal of CPAP in subjects with both mild and severe OSAHS. Citation: Young LR; Taxin ZH; Norman RG; Walsleben JA; Rapoport DM; Ayappa I. Response to CPAP withdrawal in patients with mild versus severe obstructive sleep apnea/hypopnea syndrome. SLEEP 2013;36(3):405-412.
Young, Laura R.; Taxin, Zachary H.; Norman, Robert G.; Walsleben, Joyce A.; Rapoport, David M.; Ayappa, Indu
Study Objectives: To evaluate the sensitivity and specificity of a portable single-channel (intra-nasal pressure) sleep apnea device (ApneaLink) in both the laboratory and at home for assessment of sleep apnea risk in comparison with standard polysomnography (PSG). Methods: Fifty-five participants underwent simultaneous recordings of standard PSG and ApneaLink in the laboratory. Of these, 38 participants also used the ApneaLink device in their own homes for one night. PSG respiratory events were scored using standard criteria. Intra-nasal pressure signals were analyzed using the ApneaLink automated computerized algorithm provided to yield estimates of airflow for detection of apneas and hypopneas. Apnea-hypopnea indices (AHI) were compared. Results: There was high sensitivity and specificity for the ApneaLink AHI when compared to simultaneous PSG at comparable AHI levels (AHI ? 15 events/h; sensitivity 100%, specificity 92%; positive and negative predictive values 70% and 100%, respectively). Home-measured ApneaLink AHI sensitivity and specificity were also reliable when compared with PSG (AHI ? 5, 81% and 77%, respectively; AHI ? 15, 67% and 91%), and improved slightly when two nights' data were used (AHI ? 5, 88% and 85%; AHI ? 15, 67% and 93%). Conclusions: The ApneaLink demonstrated good sensitivity and specificity in quantifying AHI when compared to PSG in a population with and without confirmed OSA. This simple, easy-to-use device may be useful in de novo large-scale occupational or underserved community OSA diagnostic programs to identify those with unambiguous disease who need immediate treatment or indicate those who may be at increased risk of OSA. Citation: Crowley KE; Rajaratnam SMW; Shea SA; Epstein LJ; Czeisler CA; Lockley SW. Evaluation of a single-channel nasal pressure device to assess obstructive sleep apnea risk in laboratory and home environments. J Clin Sleep Med 2013;9(2):109–116.
Crowley, Kate E.; Rajaratnam, Shantha M.W.; Shea, Steven A.; Epstein, Lawrence J.; Czeisler, Charles A.; Lockley, Steven W.
Study Objectives: The ApneaLink Plus is a portable recording device that measures air flow, respiratory effort, heart rate, and pulse oximetry. In the current study, we asked whether this device could be used to screen for obstructive sleep apnea in the pediatric population. Methods: Sleep-laboratory polysomnography (PSG) was performed simultaneously with measurements using the portable device on obese pediatric patients referred for snoring. The obstructive apnea hypopnea index (OAHI) was calculated automatically by the device (autoscore) and manually by the investigators. Sensitivity, specificity, correlation, and receiver operating curves (ROC) were used to compare the portable device to PSG. Results: Twenty-five subjects (60% male, mean age 13.6 ± 3.0 years, OAHI on PSG 11.8 ± 27.1) were studied. We identified a significant correlation between the OAHI of the ApneaLink autoscore and PSG (Spearman Rho = 0.886 [p < 0.001]). Using the PSG results as standard, ROC curves comparing the ApneaLink OAHI with the PSG OAHI demonstrated high congruence. The autoscore agreement was very good at PSG OAHI > 1.5 (area under the receiver operating curve [AUC] 0.965, OAHI > 5 [AUC 0.937], and OAHI > 10 [AUC 1.00]). The agreement of the manual score and autoscore were essentially equivalent. The device's autoscore demonstrated high sensitivity at all cutoffs examined (100% at OAHI > 1.5, 85.7% at OAHI > 5, and 100% at OAHI > 10). The specificity increased with increasing cutoffs (46.2% at OAHI > 1.5, 83.3% at OAHI > 5, and 90.0% at OAHI > 10). Conclusion: he ApneaLink Plus is a sensitive screening tool for evaluation of suspected OSAS in obese pediatric patients aged 9-18 years. The specificity improves with increasing OAHI cutoffs. The device detects OSAS when tested in a sleep laboratory on obese adolescents referred for symptoms of sleep related breathing disorder. Citation: Lesser DJ; Haddad GG; Bush RA; Pian MS. The utility of a portable recording device for screening of obstructive sleep apnea in obese adolescents. J Clin Sleep Med 2012;8(3):271-277.
Lesser, Daniel J.; Haddad, Gabriel G.; Bush, Ruth A.; Pian, Mark S.
Introduction In 70 consecutive male patients with obstructive sleep apnea (OSA) diagnosed at the Northport VA Medical Center Sleep Disorders\\u000a Center, we have characterized the association between obesity, OSA, and pulmonary hypertension (PH).\\u000a \\u000a \\u000a \\u000a \\u000a Materials and methods By including anthropometric, pulmonary function, and sleep study parameters in a multivariate logistic regression model, we\\u000a found that a BMI of >40 kg\\/m2 and the minimum oxygen
Daniel J. O’Hearn; Avram R. Gold; Morris S. Gold; Paul Diggs; Steven M. Scharf
The association of sleep apnea with daytime hypersomnolence without obesity, and its potentially lethal cardiopulmonary sequelae, make it crucial that this condition be distinguished from narcolepsy. A patient with retrognathia who had been diagnosed as a narcoleptic for 15 years had the primary complaint of excessive daytime sleepiness. Sleep laboratory evaluation showed severe hypoxemia and a mean of 366 upper airway obstructions per night. The patient was treated with a tracheotomy; this resulted in relief of the sleep-related upper airway obstructions, hypoxemia, and hypersomnolence. PMID:576659
Imes, N K; Orr, W C; Smith, R O; Rogers, R M
Obstructive sleep apnea (OSA) is a highly prevalent medical condition in obese children and is associated with significant neurocognitive, cardiovascular and metabolic derangements. Monogenic forms of obesity resulting from disruption of the leptin-melanocortin pathways have become more notable in recent years and distinguish between various obese phenotypes. However, the association of such disorders with OSA is not well established in children or adults. In this report, we describe a 23-month-old female with morbid obesity and OSA, who was found to carry a defect in the melanocortin-4 receptor (MC4R) pathway. This report emphasizes the genetic basis of obesity related to MC4R deficiency and OSA in children. Citation: Pillai S; Nandalike K; Kogelman Y; Muzumdar R; Balk SJ; Arens R. Severe obstructive sleep apnea in a child with melanocortin-4 receptor deficiency. J Clin Sleep Med 2014;10(1):99-101.
Pillai, Sophia; Nandalike, Kiran; Kogelman, Yelena; Muzumdar, Radhika; Balk, Sophie J.; Arens, Raanan
BACKGROUND: The aim of this study was to evaluate epidemiological relationship between chronic obstructive pulmonary disease and sleep apnea syndrome in a sample of Persian population. METHODS: As a part of a population-based cross-sectional study, 3900 randomly selected individuals aged 15 years or older were invited to take part in the survey; 3770 individuals (96.6%) agreed to fill out the respiratory and sleep questionnaire. Those subjects suspected to have either chronic obstructive pulmonary disease and/or obstructive sleep apnea underwent spirometry and polysomnography test if indicated. Spirometric measurements were performed on 420 invited responders. Polysomnography measurements were performed on 25 of the responders. RESULTS: Prevalence rates for sleep apnea, chronic obstructive pulmonary disease and current asthma were 4.98%, 5.7% and 3.1%, respectively. Logistic regression showed independent associations between sleep apnea and chronic obstructive pulmonary disease. There was no significant independent association between sleep apnea symptoms and current asthma and wheeze ever. CONCLUSIONS: These observations indicated relationship between chronic obstructive pulmonary disease and obstructive sleep apnea. These observations indicated the necessity of further studies to explain the possible common pathogenic mechanisms involved in two disease entities.
Amra, Babak; Golshan, Mohammad; Fietze, Ingo; Penzel, Thomas; Welte, Tobias
Sleep-related breathing disorders (SRBD) are disorders of breathing during sleep characterized by prolonged partial upper airway obstruction, intermittent complete or partial obstruction (obstructive apnea or hypopnea), or both prolonged and intermittent obstruction that disrupts normal ventilation during sleep, normal sleep patterns, or both. Children with OSAS may sleep in unusual positions, such as seated or with neck hyperextended, even if the neck position is not the only unusual posture or the special sleeping positions that is possible to detect in children with SRBD. We have hypothesized that the assumption of unusual posture during sleep, in particular legs retracting or crossing during sleep, could be a way to enlarge the diaphragmatic excursion and promoting the alveolar gas exchanges avoiding the stress of the antero-lumbar and prevertebral muscular chains in SRBD subjects. We have hypothesized that the assumption of unusual posture during sleep, in particular legs retracting or crossing during sleep, could be a way to enlarge the diaphragmatic excursion and promoting the alveolar gas exchanges avoiding the stress of the antero-lumbar and prevertebral muscular chains in SRBD subjects. We can postulate that the prevertebral and antero-lumbar muscular chains could be oversolicited during the apnoic events, and the assumption of abnormal posture could be interpreted as a way to relax or diminish the strain or muscular stress caused by the apneas. The consequence of this hypothesis could be summarized in the concept that a specific rehabilitation or muscular program to improve the tone of this kinetic chain, could be useful to limit the effect nocturnal or diurnal of this so impacting syndrome. PMID:23660129
Carotenuto, Marco; Gimigliano, Francesca; Fiordelisi, Giovanni; Ruberto, Maria; Esposito, Maria
Study Objectives: Recurrent apneas and hypoxemia during sleep in obstructive sleep apnea (OSA) are associated with profound changes in cerebral blood flow to the extent that cerebral autoregulation may be insufficient to protect the brain. Since the brain is sensitive to hypoxia, the cerebrovascular morbidity seen in OSA could be due to chronic, cumulative effects of intermittent hypoxia. Near-infrared spectroscopy (NIRS) has the potential to noninvasively monitor brain tissue oxygen saturation (SO2), and changes in concentration of oxyhemoglobin [O2Hb], deoxyhemoglobin [HHb] and total hemoglobin [tHb] with real-time resolution. We hypothesized that brain tissue oxygenation would be worse during sleep in OSA relative to controls and sought to determine the practical use of NIRS in the sleep laboratory. Design: We evaluated changes in brain tissue oxygenation using NIRS during overnight polysomnography. Setting: Studies were conducted at University of Illinois, Chicago and Carle Hospital, Urbana, Illinois. Patients: Nineteen subjects with OSA and 14 healthy controls underwent continuous NIRS monitoring during polysomnography. Measurements and Results: We observed significantly lower indexes of brain tissue oxygenation (SO2: 57.1 ± 4.9 vs. 61.5 ± 6.1), [O2Hb]: 22.8 ± 7.7 vs. 31.5 ± 9.1, and [tHb]: 38.6 ± 11.2 vs. 48.6 ±11.4 ?mol/L) in OSA than controls (all P <0.05). However, multivariate analysis showed that the differences might be due to age disparity between the two groups. Conclusions: NIRS is an effective tool to evaluate brain tissue oxygenation in OSA. It provides valuable data in OSA assessment and has the potential to bridge current knowledge gap in OSA. Citation: Olopade CO; Mensah E; Gupta R; Huo D; Picchietti DL; Gratton E; Michalos A. Noninvasive determination of brain tissue oxygenation during sleep in obstructive sleep apnea: a near-infrared spectroscopic approach. SLEEP 2007;30(12):1747-1755.
Olopade, Christopher O.; Mensah, Edward; Gupta, Rajarsi; Huo, Dezheng; Picchietti, Daniel L.; Gratton, Enrico; Michalos, Antonios
Objective Although blacks are at higher risk for obstructive sleep apnea (OSA), they are not as likely as their white counterparts to receive OSA evaluation and treatment. This study assessed knowledge, beliefs, and attitudes towards OSA evaluation and treatment among blacks residing in Brooklyn, New York. Methods Five focus groups involving 39 black men and women (aged ?18 years) were conducted at the State University of New York (SUNY) Downstate Medical Center in Brooklyn to ascertain barriers preventing or delaying OSA evaluation and treatment. Results Misconceptions about sleep apnea were a common theme that emerged from participants’ responses. Obstructive sleep apnea was often viewed as a type of insomnia, an age-related phenomenon, and as being caused by certain bedtime activities. The major theme that emerged about barriers to OSA evaluation was unfamiliarity with the study environment. Barriers were categorized as: problems sleeping in a strange and unfamiliar environment, unfamiliarity with the study protocol, and fear of being watched while sleeping. Barriers to continuous positive airway pressure (CPAP) treatment adoption were related to the confining nature of the device, discomfort wearing a mask while they slept, and concerns about their partner’s perceptions of treatment. Conclusion Results of this study suggest potential avenues for interventions to increase adherence to recommended evaluation and treatment of OSA. Potential strategies include reducing misconceptions about OSA, increasing awareness of OSA in vulnerable communities, familiarizing patients and their partners with laboratory procedures used to diagnose and treat OSA. We propose that these strategies should be used to inform the development of culturally and linguistically tailored sleep apnea interventions to increase awareness of OSA among blacks who are at risk for OSA and associated comorbidities.
Shaw, Raphael; McKenzie, Sharon; Taylor, Tonya; Olafiranye, Oladipupo; Boutin-Foster, Carla; Ogedegbe, Gbenga; Jean-Louis, Girardin
In-laboratory polysomnography is the 'gold standard' for diagnosing obstructive sleep apnea syndrome, but is time consuming and costly, with long waiting lists in many sleep laboratories. Therefore, the search for alternative methods to detect respiratory events is growing. In this prospective study, we compared attended polysomnography with two other methods, with or without mandible movement automated analysis provided by a distance-meter and added to airflow and oxygen saturation analysis for the detection of respiratory events. The mandible movement automated analysis allows for the detection of salient mandible movement, which is a surrogate for arousal. All parameters were recorded simultaneously in 570 consecutive patients (M/F: 381/189; age: 50±14 years; body mass index: 29±7 kg m(-2) ) visiting a sleep laboratory. The most frequent main diagnoses were: obstructive sleep apnea (344; 60%); insomnia/anxiety/depression (75; 13%); and upper airway resistance syndrome (25; 4%). The correlation between polysomnography and the method with mandible movement automated analysis was excellent (r: 0.95; P<0.001). Accuracy characteristics of the methods showed a statistical improvement in sensitivity and negative predictive value with the addition of mandible movement automated analysis. This was true for different diagnostic thresholds of obstructive sleep severity, with an excellent efficiency for moderate to severe index (apnea-hypopnea index ?15h(-1) ). A Bland & Altman plot corroborated the analysis. The addition of mandible movement automated analysis significantly improves the respiratory index calculation accuracy compared with an airflow and oxygen saturation analysis. This is an attractive method for the screening of obstructive sleep apnea syndrome, increasing the ability to detect hypopnea thanks to the salient mandible movement as a marker of arousals. PMID:22835145
Maury, Gisele; Cambron, Laurent; Jamart, Jacques; Marchand, Eric; Senny, Frédéric; Poirrier, Robert
Background: Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have a high prevalence of obstructive sleep apnea (OSA) that can have significant clinical implications. An accurate clinical screening tool for OSA that identifies patients for further diagnostic testing would assist in the identification of this comorbidity. The Berlin Questionnaire (BQ), Adjusted Neck Circumference (ANC), and STOP-BANG questionnaire are 3 such instruments that have been validated in patients with normal kidney function. Objective: The objective of this study was to determine the validity of these screening instruments in patients with CKD and ESRD, using overnight cardiopulmonary monitoring to diagnose OSA. Methods: One hundred seventy-two patients were recruited from nephrology clinics and hemodialysis units (CKD: n = 109; ESRD: n = 63). All patients completed the BQ, ANC, STOP-BANG, and overnight cardiopulmonary monitoring to diagnose OSA (respiratory disturbance index [RDI] ? 15). Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for the BQ, ANC, and STOP-BANG. Results: Obstructive sleep apnea was present in 41 CKD patients (38%) and 32 ESRD patients (51%). All screening instruments had satisfactory sensitivity (56% to 94%) but poor specificity (29% to 77%) and low accuracy (51% to 69%) in both CKD and ESRD patients with RDI ? 15. Using an RDI ? 30 yielded similar results. Conclusions: Current screening questionnaires do not accurately identify patients at high risk for OSA or rule out the presence of OSA in patients with CKD and ESRD. Consequently, objective monitoring during sleep is required to reliably identify sleep apnea in these patient populations. Citation: Nicholl DDM; Ahmed SB; Loewen AHS; Hemmelgarn BR; Sola DY; Beecroft JM; Turin TC; Hanly PJ. Diagnostic value of screening instruments for identifying obstructive sleep apnea in kidney failure. J Clin Sleep Med 2013;9(1):31-38.
Nicholl, David D. M.; Ahmed, Sofia B.; Loewen, Andrea H. S.; Hemmelgarn, Brenda R.; Sola, Darlene Y.; Beecroft, Jaime M.; Turin, Tanvir C.; Hanly, Patrick J.
Study Objectives: To determine the effect of the drug combination domperidone and pseudoephedrine on nocturnal oximetry measurements and daytime sleepiness in patients with obstructive sleep apnea. Methods: We recruited patients with severe snoring and apneic episodes willing to undergo repeated nocturnal oximetry testing. Following baseline clinical history, Epworth Sleepiness Scale administration, and home overnight nocturnal oximetry, patients were started on weight-adjusted doses of domperidone and pseudoephedrine. Follow-up oximetry studies were performed at the patient's convenience. On the final visit, a repeat clinical history, Epworth score, and oximetry were obtained. Results: Sixteen of 23 patients noted disappearance of snoring and apneic episodes. Another 3 patients reported improvement in snoring and no apneic episodes. All but one patient had a decrease in Epworth scores (mean decrease 9.9 (95% CI, 7.2-12.6, p < 0.0001). Mean oxygen saturation (2.5; 95% CI, 0.66-4.41, p = 0.008), percent time with oxygen saturation < 90% (14.8; 95% CI, 24.4 to 5.2, p = 0.003), and the 4% oxygen desaturation index (18.2; 95% CI, 27.3 to 9.1, p < 0.0001) improved significantly. No adverse effects of treatment were noted. Conclusions: The combination of domperidone and pseudoephedrine improved self reported snoring and sleepiness, and may have improved apneic episodes and sleep-related nocturnal oxygen desaturation in patients with obstructive sleep apnea provided the proportion of time spent asleep did not diminish. This drug combination warrants further study as a treatment for obstructive sleep apnea. Citation: Larrain A; Kapur VK; Gooley TA; Pope CE. Pharmacological treatment of obstructive sleep apnea with a combination of pseudoephedrine and domperidone. J Clin Sleep Med 2010;6(2):117-123.
Larrain, Augusto; Kapur, Vishesh K.; Gooley, Ted A.; Pope, Charles E.
Background Hypothyroidism and obstructive sleep apnea (OSA) are both common health problems and can be seen together. Each of these 2 diseases can cause pulmonary hypertension (PH). We aimed to determine whether hypothyroidism with OSA has a significant effect on the frequency and severity of PH. Material/Methods A total of 236 patients were included in the study. Patients were divided into 3 groups: Group I, Obstructive Sleep Apnea (n=149); Group II, Hypothyroidism (n=56); and Group III, Obstructive Sleep Apnea-Hypothyroidism (n=31). All patients underwent polysomnography and echocardiography and serum levels of thyroid-stimulating hormone (TSH) and free thyroxine 4 (FT4) were analyzed. Results There were 167 male and 69 female participants, and the mean age was 47.8±11.5 (Group I: 81.9% male, 18.1% female; Group II: 44.6% male, 55.4% female; Group III: 64.6% male, 35.4% female). Distribution of mean pulmonary arterial pressure on echocardiography was statistically different among the 3 groups (x2=14.99, p=0.006). When adjusted according to the apnea-hypopnea index (AHI), age, and body mass index (BMI), a significant relation with PH was determined (p=0.002). Conclusions The combination of hypothyroidism with OSA is associated with an increased frequency and severity of PH. When PH is found out of line with the severity of OSA, thyroid dysfunction should be investigated.
Araz, Omer; Ucar, Elif Yilmazel; Yalcin, Asl?han; Pulur, Didem; Acemoglu, Hamit; Tas, Hakan; Saglam, Leyla; Akgun, Metin; Mirici, Arzu
Background: Obstructive sleep apnea (OSA) is a common sleep disorder associated with several adverse health outcomes. Given the close association between OSA and obesity, lifestyle and dietary interventions are commonly recommended to patients, but the evidence for their impact on OSA has not been systematically examined. Objectives: To conduct a systematic review and meta-analysis to assess the impact of weight loss through diet and physical activity on measures of OSA: apnea-hypopnea index (AHI) and oxygen desaturation index of 4% (ODI4). Methods: A systematic search was performed to identify publications using Medline (1948-2011 week 40), EMBASE (from 1988-2011 week 40), and CINAHL (from 1982-2011 week 40). The inverse variance method was used to weight studies and the random effects model was used to analyze data. Results: Seven randomized controlled trials (519 participants) showed that weight reduction programs were associated with a decrease in AHI (-6.04 events/h [95% confidence interval -11.18, -0.90]) with substantial heterogeneity between studies (I2 = 86%). Nine uncontrolled before-after studies (250 participants) showed a significant decrease in AHI (-12.26 events/h [95% confidence interval -18.51, -6.02]). Four uncontrolled before-after studies (97 participants) with ODI4 as outcome also showed a significant decrease in ODI4 (-18.91 episodes/h [95% confidence interval -23.40, -14.43]). Conclusions: Published evidence suggests that weight loss through lifestyle and dietary interventions results in improvements in obstructive sleep apnea parameters, but is insufficient to normalize them. The changes in obstructive sleep apnea parameters could, however, be clinically relevant in some patients by reducing obstructive sleep apnea severity. These promising preliminary results need confirmation through larger randomized studies including more intensive weight loss approaches. Citation: Araghi MH; Chen YF; Jagielski A; Choudhury S; Banerjee D; Hussain S; Thomas GN; Taheri S. Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. SLEEP 2013;36(10):1553-1562.
Araghi, Marzieh Hosseini; Chen, Yen-Fu; Jagielski, Alison; Choudhury, Sopna; Banerjee, Dev; Hussain, Shakir; Thomas, G. Neil; Taheri, Shahrad
Background: The “Diagnosis and Treatment of Sleep Apnea in Cerebrovascular Disease” (GoToSleep) study is evaluating a strategy to improve the diagnosis and treatment of sleep apnea among veterans with stroke or transient ischemic attack (TIA) who also have hypertension. Specifically, the GoToSleep study was designed to overcome some of the barriers that exist within the Veterans Health Administration (VHA) to the timely diagnosis and treatment of sleep apnea by using ambulatory home-based polysomnography and auto-titrating continuous positive airway pressure (CPAP) to reduce the reliance on laboratory-based sleep studies. Methods: The GoToSleep study is a prospective, multi-site, randomized, controlled strategy trial among an expected 318 veterans with cerebrovascular disease and hypertension who are assigned to an intervention group or a control group. Patients in the intervention group receive unattended polysomnography at baseline, and those with sleep apnea receive auto-titrating CPAP therapy for up to one year. Patients in the control group receive usual care and unattended polysomnography at the end of the study to identify the rate of undiagnosed sleep apnea. The primary objectives of the GoToSleep study are to determine whether a diagnostic and therapeutic intervention strategy among veterans with cerebrovascular disease and hypertension improves: (1) detection of sleep apnea; (2) appropriate treatment for sleep apnea; and (3) control of hypertension. Twenty-four-hour blood pressure assessments are made at baseline and at the end of the one-year study period for both groups. Antihypertensive medications and their doses are recorded at the time of the 24-hour blood pressure measurements. Discussion: This manuscript provides the rationale for 4 key components of the design of the GoToSleep trial: the inclusion of patients with cerebrovascular disease and hypertension without the use of a measure of daytime sleepiness as an eligibility criterion; the use of portable polysomnography and auto-titrating CPAP in patients' homes rather than using sleep laboratory polysomnography with fixed pressure CPAP; the analytic approach to evaluating change in blood pressure in the context of change in antihypertensive medications; and the use of a usual care control group. Citation: Bravata DM; Ferguson J; Miech EJ; Agarwal R; McClain V; Austin C; Struve F; Foresman B; Li X; Wang Z; Williams LS; Dallas MI; Couch CD; Sico J; Fragoso C; Matthias MS; Chumbler N; Myers J; Burrus N; Dube A; French DD; Schmid AA; Concato J; Yaggi HK. Diagnosis and treatment of sleep apnea in patients' homes: the rationale and methods of the “GoToSleep” randomized-controlled trial. J Clin Sleep Med 2012;8(1):27–35.
Bravata, Dawn M.; Ferguson, Jared; Miech, Edward J.; Agarwal, Rajiv; McClain, Vincent; Austin, Charles; Struve, Frederick; Foresman, Brian; Li, Xinli; Wang, Zhu; Williams, Linda S.; Dallas, Mary I.; Couch, Cody D.; Sico, Jason; Fragoso, Carlos; Matthias, Marianne S.; Chumbler, Neale; Myers, Jennifer; Burrus, Nicholas; Dube, Archana; French, Dustin D.; Schmid, Arlene A.; Concato, John; Yaggi, H. Klar
Introduction The aim of the study was to investigate the effectiveness of combined bipolar radiofrequency surgery of the tongue base (RFBT) and uvulopalatopharyngoplasty (UPPP) in a single session for obstructive sleep apnea and whether this combination is safe and well tolerated. Material and methods Seventy-nine patients with obstructive sleep apnea and both palatal and retroglossal obstruction underwent UPPP with bipolar RFBT. The control group consisted of 35 patients treated by UPPP alone. Results The apnea-hypopnea index significantly decreased from 28.7 to 14.1. The oxygen desaturation index decreased from 15.1 to 10.3. Mean oxygen saturation was unchanged. Subjectively, the Epworth Sleepiness Scale was significantly improved from 10.6 to 7.3, and the snoring level decreased from 8.4 to 6.0. The overall treatment success rate increased from 41.9% for UPPP alone to 51.7% for UPPP + RFBT. No serious adverse events occurred. Two patients had postoperative bleeding from the tonsillar bed after UPPP. Four patients had ulceration of the base of the tongue after RFBT with spontaneous cure. One patient had a taste change in half of the tongue that resolved within two months. Conclusions Combined bipolar RFBT and UPPP in a single session is well tolerated and safe surgery in the treatment of obstructive sleep apnea. It is effective in reducing respiratory parameters and subjective symptoms of obstructive sleep apnea. Further advantages are a single session, simple feasibility, bipolar technique and short time of the procedure.
Zabrodsky, Michal; Kastner, Jan; Betka, Jaroslav; Klozar, Jan
Background T-Wave Alternans (TWA) activity is known to be a function of heart rate and condition, as well as perhaps physiological state. A recently published non-parametric non-stationary TWA analysis method has been shown to reject nonstationary noise accurately using phase randomized surrogates and has been shown to estimate TWA accurately. This new method was evaluated on multiple databases over a range of heart rates and in healthy subjects, cardiac patients, and obstructive sleep apnea (OSA) patients. We hypothesized that TWA would be lower than previously reported when measured with our new technique and that higher levels of TWA would be observed in OSA patients when compared to normals. Methods Five databases were analyzed: 1) Healthy subjects from PhysioNet’s Normal Sinus Rhythm Database (NSRDB), 2) Arrhythmia patients from PhysioNet’s Chronic Heart Failure Database (CHFDB) and 3) PhysioNet’s Sudden Cardiac Death Database (SCDDB), 4) OSA patients from PhysioNet’s MIT-BIH Polysomnographic Database (SLPDB), and 5) a private Sleep Apnea Database (SADB) of 85 subjects. TWA magnitudes were calculated for 7 heart rate decades [intervals of 10 beats per minute (BPM) between 40 and 110 BPM] for each database. The Mann-Whitney U-test and the two-sample Kolmogorov-Smirnov test were applied to test for significant differences between data from each database in each heart rate decade interval. Results In the healthy population TWA activity level tended to increase with heart rate. Moreover, there appeared to be an unexpected nadir in TWA activity around 60–70 BPM, and a small but significant rise in TWA above and below these heart rates. The rise in TWA at lower heart rates has not been previously reported to our knowledge. We also observed that TWA is unexpectedly lower in OSA patients and did not increase with heart rate. Conclusion Although the physiological mechanisms underlying our observations are unclear, there may be clinical implications for TWA testing, particularly at low heart rates, a previously overlooked aspect of TWA.
Nemati, Shamim; Malhotra, Atul; Clifford, Gari D.
Study Objectives: Red blood cell distribution width (RDW) is a newly recognized risk marker for various diseases. We evaluated the value of RDW in predicting the severity of obstructive sleep apnea syndrome (OSAS). Methods: From retrospective analyses of 526 patients admitted to our sleep laboratory for polysomnography between January 2010 and July 2011, 108 patients with complete medical records and hemogram analyses were evaluated. Results: The study population consisted of 108 patients (age: 49.16 ± 11.1 [range 16-76] years; 72 [66.7%] males). In the overall population, the mean RDW was 14.04 (± 2.37), and 31 patients (28.7%) had RDW > 15. RDW increased significantly with increased severity of OSAS (p = 0.046) and was positively correlated with the apnea-hypopnea index (p = 0.002, r = 0.300), even in the non-anemic group (p = 0.013, r = 0.291). The apnea-hypopnea index was significantly higher in the group with high RDW (> 15; p = 0.046). RDW was negatively correlated with sleep time (p = 0.028, r = 0.217), average oxygen saturation of hemoglobin (p = 0.003, r = -0.239), and minimum desaturation value (p = 0.016, r = -0.235). Conclusions: In patients referred with a clinical diagnosis of OSAS, RDW may be a marker for the severity of the condition. As RDW is usually included in a complete blood count, it could provide an inexpensive tool for triaging OSAS patients for polysomnography evaluation. Citation: Sökücü SN; Karasulu L; Dalar L; Seyhan EC; Alt?n S. Can red blood cell distribution width predict severity of obstructive sleep apnea syndrome? J Clin Sleep Med 2012;8(5):521-525.
Sokucu, Sinem Nedime; Karasulu, Levent; Dalar, Levent; Seyhan, Ekrem Cengiz; Alt?n, Sedat
Study Objectives: Upper airway sensory deficit has been reported to be associated with snoring or obstructive sleep apnea. There are limited data on the correlation between disease severity and upper airway sensation. In this study, we investigated the relationship between clinical parameters and standardized palatal sensory threshold (SPST) using Semmes Weinstein monofilaments. Methods: We recruited 40 snorers and 19 control subjects. Palatal sensory threshold was measured in all study subjects, using Semmes Weinstein monofilaments. Standardized palatal sensory threshold was determined by subtraction of hard palate sensation from uvular sensation. All subjects with snoring underwent a modified Muller maneuver during wakefulness before polysomnography. Results: SPST was higher in snorers than in control subjects, but did not differ according to the severity of obstructive sleep apnea. Patients with higher SPST (? 0.45 g/mm2) were older and had more severe hypoxemia indices: lower nadir oxyhemoglobin saturation (SpO2) and higher percentage of sleep time at < 90% SpO2. Adjusted for age, sex, neck circumference, and body mass index, SPST was correlated with the apnea-hypopnea index and hypoxemia indices. With a cutoff value ? 0.45 g/mm2, the sensitivity of SPST for nocturnal hypoxemia (nadir SpO2, < 80%) was 81.3%. Patients with higher SPST (? 0.45 g/mm2) showed more airway occlusion in modified Muller maneuver, than those with lower values. Conclusions: The SPST measured using Semmes Weinstein monofilaments reflects nocturnal hypoxemia and airway occlusion. This test provides a potential tissue marker of the severity of hypoxemia in patients who snore. Citation: Kim SW; Park HW; Won SJ; Jeon SY; Jin HR; Lee SJ; Chang DY; Kim DW. Palatal sensory threshold reflects nocturnal hypoxemia and airway occlusion in snorers and obstructive sleep apnea patients. J Clin Sleep Med 2013;9(11):1179-1186.
Kim, Sang-Wook; Park, Hyun Woo; Won, Sung Jun; Jeon, Sea-Yuong; Jin, Hong Ryul; Lee, So-Jin; Chang, Dong-Yeop; Kim, Dae Woo
Stroke is not only more prevalent but is also associated with more severe adverse functional outcomes among patients with sleep apnea. Monocarboxylate transporters (MCT) are important regulators of cellular bioenergetics, have been implicated in brain susceptibility to acute severe hypoxia (ASH), and could underlie the unfavorable prognosis of cerebrovascular accidents in sleep apnea patients. Rodents were exposed to either intermittent hypoxia (IH) during sleep, a characteristic feature of sleep apnea, or to sustained hypoxia (SH), and expression of MCT1 and MCT2 was assessed. In addition, the functional recovery to MCAO in rats and hMCT2 transgenic mice and of hippocampal slices subjected to ASH was assessed, as well as the effects of MCT blocker and MCT2 antisense oligonucleotides and siRNAs. IH, but not SH, induced significant reductions in MCT2 expression over time at both the mRNA and protein levels, and in the functional recovery of hippocampal slices subjected to ASH. Similarly, MCAO-induced infarcts were significantly greater in IH-exposed rats and mice, and over-expression of hMCT2 in mice markedly attenuated the adverse effects of IH. Exogenous pyruvate treatment reduced infarct volumes in normoxic rats but not in IH-exposed rats. Administration of he MCT2 blocker 4CN, but not the MCT1 antagonist pCMBS, increased infarct size. Thus, prolonged exposures to IH mimicking sleep apnea are associated with increased CNS vulnerability to ischemia that is mediated, at least in part, by concomitant decreases in the expression and function of MCT2. Efforts to develop agonists of MCT2 should provide opportunities to ameliorate the overall outcome of stroke.
Wang, Yang; Guo, Shang-Z; Bonen, Arend; Li, Richard C.; Kheirandish-Gozal, Leila; Zhang, Shelley X.L.; Brittian, Kenneth R.; Gozal, David
Background: Obstructive sleep apnea (OSA) is a major problem in need of new treatment approaches. The present pilot study tests the hypothesis that the application of expiratory resistance via a nasal valve device would improve breathing during sleep in subjects with OSA and in primary snorers. Methods: Thirty men and women were recruited from the community and from the Stanford University Sleep Disorders Clinic. Twenty-four had at least mild OSA (AHI >5), and 6 were primary snorers. Subjects underwent 2 nights of polysomnographic evaluation, one with and one without a new nasal resistance device with the order of nights counterbalanced across participants. The device consisted of a small valve inserted into each nostril calibrated to provide negligible inspiratory resistance, but increased expiratory resistance with a back pressure between 60 and 90 cm H2O*sec/Liter (at 100 mL/sec flow). Standard polysomnography was conducted to compare participants' sleep both with and without the device, with the scoring conducted blind to treatment condition. Results: The apnea-hypopnea (AHI) (p < 0.001) and oxygen desaturation (O2DI) (p < 0.01) indices both significantly decreased, and the percentage of the night spent above 90% saturation (p < 0.05) significantly increased with device use. The observed amount of snoring (p < 0.001) was significantly decreased with device use, and there were no significant changes in measures of sleep architecture. Conclusions: The results of this pilot study are suggestive of a therapeutic effect of expiratory nasal resistance for some OSA patients and indicate that this technique is worthy of further clinical study. Citation: Colrain IM; Brooks S; Black J. A pilot evaluation of a nasal expiratory resistance device for the treatment of obstructive sleep apnea. J Clin Sleep Med 2008;4(5):426–433.
Colrain, Ian M.; Brooks, Stephen; Black, Jed
A significant number of patients with obstructive sleep apnea neither tolerate positive airway pressure (PAP) therapy nor achieve suc- cessful outcomes from either upper airway surgeries or use of an oral appliance. The purpose of this paper, therefore, was to systematically evaluate available peer-reviewed data on the effectiveness of adjunctive medical therapies and summarize findings from these studies. A review
Sigrid C. Veasey; Christian Guilleminault; Kingman P. Strohl; Mark H. Sanders; Robert D. Ballard; Ulysses J. Magalang
The diagnosis of sleep apnea syndrome (SAS) has a significant importance in clinic for preventing diseases of hypertention, coronary heart disease, arrhythmia and cerebrovascular disorder, etc. This study presents a novel method for SAS detection based on single-channel electrocardiogram (ECG) signal. The method preprocessed ECG and detected QRS waves to get RR signal and ECG-derived respiratory (EDR) signal. Then 40 time- and spectral-domain features were extracted to normalize the signals. After that support vector machine (SVM) was used to classify the signals as "apnea" or "normal". Finally, the performance of the method was evaluated by the MIT-BIH Apnea-ECG database, and an accuracy of 95% in train sets and an accuracy of 88% in test sets were achieved. PMID:24459959
Yu, Xiaomin; Tu, Yuewen; Huang, Chao; Ye, Shuming; Chen, Hang
Obesity has a negative effect on male reproductive function. It is associated with low testosterone levels and alteration in gonadotropin secretion. Male obesity has been linked to reduced male fertility. Data regarding the relation of obesity to sperm parameters are conflicting in terms of the nature and magnitude of the effect. New areas of interest are emerging that can help explain the variation in study results, such as genetic polymorphism and sleep apnea. Sleep disorders have been linked to altered testosterone production and hypogonadism in men. It was also correlated to erectile dysfunction. The relation of sleep disorders to male fertility and sperm parameters remains to be investigated. Men with hypogonadism and infertility should be screened for sleep apnea. Treatment of obesity and sleep apnea improves testosterone levels and erectile function.
Hammoud, Ahmad O; Carrell, Douglas T; Gibson, Mark; Matthew Peterson, C; Wayne Meikle, A
ABSTRACT Objectives The present retrospective study analyzes sagittal cephalometric changes in patients affected by obstructive sleep apnea syndrome submitted to maxillomandubular advancement. Material and Methods 15 adult sleep apnea syndrome (OSAS) patients diagnosed by polysomnography (PSG) and treated with maxillomandubular advancement (MMA) were included in this study. Pre- (T1) and postsurgical (T2) PSG studies assessing the apnea/hypopnea index (AHI) and the lowest oxygen saturation (LSAT) level were compared. Lateral cephalometric radiographs at T1 and T2 measuring sagittal cephalometric variables (SNA, SNB, and ANB) were analyzed, as were the amount of maxillary and mandibular advancement (Co-A and Co-Pog), the distance from the mandibular plane to the most anterior point of the hyoid bone (Mp-H), and the posterior airway space (PAS). Results Postoperatively, the overall mean AHI dropped from 58.7 ± 16 to 8.1 ± 7.8 events per hour (P < 0.001). The mean preoperative LSAT increased from 71% preoperatively to 90% after surgery (P < 0.001). All the patients in our study were successfully treated (AHI < 20 or reduced by 50%). Cephalometric analysis performed after surgery showed a statistically significant correlation between the mean SNA variation and the decrease in the AHI (P = 0.01). The overall mean SNA increase was 6°. Conclusions Our findings suggest that the improvement observed in the respiratory symptoms, namely the apnea/hypopnea episodes, is correlated with the SNA increase after surgery. This finding may help maxillofacial surgeons to establish selective criteria for the surgical approach to sleep apnea syndrome patients.
Ronchi, Paolo; Ambrosoli, Alessandro; Caprioglio, Alberto
Objectives We identified the primary symptoms leading to Chinese patients presenting at hospital with suspected obstructive sleep apnea (OSA) and studied the prevalence and characteristics of OSA in confirmed cases. Methods We collected data on 350 consecutive patients (302 males and 43±11 years old) with suspected OSA who underwent overnight polysomnography (PSG). Results Among all patients, rankings of primary symptoms that led to the patients presenting at hospital for PSG were observed apnea (33%), snoring alone (29%), choking/gasping (13%), daytime sleepiness (5%) and other (20%). For severe OSA, prevalence rate was 61%, apnea hypopnea index (AHI) was 64±18, age was 44±10 years old, body mass index (BMI) was 28±3.5 kg/m2, and hypertension rate was 28%. Conclusions Self-awareness of symptoms led a majority of the patients to present at hospital in China. Compared to currently available case series studies, our results suggest that OSA patients in East Asian countries are characterized by higher prevalence and more severe apnea, younger age, poorer sleep quality, but less obesity and less comorbidity with hypertension, relative to countries in North America, South America and Europe.
Li, Zhe; Du, Lina; Li, Yun; Huang, Lili; Lei, Fei; Yang, Linghui; Li, Tao
A 66-year-old man with hypertension presented with complaints of excessive daytime sleepiness (Epworth Sleepiness Score 14/24), dyspnea upon exertion, and episodes of noninjurious dream-enacting behavior. He reported tongue biting when sleeping in the right lateral decubitus position. Medications included atenolol 12.5 mg, lovastatin 20 mg, doxazosin 2 mg, amlodipine 5 mg, isosorbide mononitrate 60 mg, and aspirin 81 mg. He denied headaches, visual changes, dysarthria, dysphagia, or localized weakness. He denied use of alcohol, tobacco, or drugs. PMID:23136263
DelRosso, Lourdes; Gonzalez-Toledo, Eduardo; Chesson, Andrew L; Hoque, Romy
Study Objectives: To identify and prioritize future research needs (FRN) topics for diagnosis and treatment of obstructive sleep apnea (OSA). Methods: Twenty-one panel members represented six stake-holder categories: patients and the public, providers; purchasers of health care, payers, policymakers, and principal investigators. Building on a recently completed comparative effectiveness review, stakeholders nominated and discussed potential FRN topics. Stakeholders then nominated their top priority FRN topics based on the Agency for Healthcare Research and Quality Effective Health Care Program Selection Criteria. From these nominations, the highest priority FRN topics were determined and were elaborated upon to include possible study designs to address the topics. Results: Thirty-seven topics were discussed and prioritized. The nine highest priority FRN topics included: cost-effectiveness of management strategies, defining age- and sex-specific criteria for OSA, evaluating routine preoperative screening for OSA, evaluating involvement of a sleep medicine specialist in diagnosis of OSA, evaluating clinical prediction rules, assessing the effect of treating sleep disordered breathing and long-term clinical outcomes, comparing treatments for patients who do not tolerate positive airway pressure, evaluating strategies to improve treatment compliance, and evaluating the association between sleep apnea severity and long-term clinical outcomes. Conclusions: While there are numerous specific research questions with low or insufficient strength of evidence for OSA management, OSA patients, their healthcare providers, and society at large would benefit from refocusing research efforts into the prioritized research questions and away from simple comparisons of short-term outcomes between specific interventions. Citation: Patel K; Moorthy D; Chan JA; Concannon TW. High priority future research needs for obstructive sleep apnea diagnosis and treatment. J Clin Sleep Med 2013;9(4):395-402.
Patel, Kamal; Moorthy, Denish; Chan, Jeffrey A.; Concannon, Thomas W.; Ratichek, Sara J.; Chung, Mei; Balk, Ethan M.
Treatment of sleep apnea-hypopnea syndrome (SAHS) by fixed continuous positive airway pressure (CPAP) requires an in-labora- tory titration procedure to determine the effective pressure level (Peff). We recently reported that one auto-CPAP machine can be used without titration study allowing Peff determination. The aim of this study was to evaluate the accuracy of an auto CPAP trial at home. A
Study Objectives: Obstructive sleep apnea (OSA) has been associated with increased perioperative morbidity and mortality. We initiated a protocol designed to screen patients preoperatively and monitor them postoperatively. The goal was to identify patients who were at risk for oxygen desaturation after discharge from the postanesthesia recovery room (PACU). Methods: Patients without previously diagnosed OSA presenting to the preoperative evaluation clinic were assessed over a 10.5-month period using a validated prediction rule to identify patients thought to be at high risk of OSA (sleep apnea clinical score, SACS ? 15). Following surgery, patients were monitored in the PACU for significant respiratory events: apnea, increased FiO2 requirement, pain-sedation mismatch, or episodes of desaturation. Patients were placed in 3 groups based on their SACS and the presence or absence of recurrent PACU respiratory events (group 1: SACS < 15, no recurrent events; group 2: SACS ?15, no recurrent events; and group 3: SACS ? 15, recurrent events.) The number of oxygen desaturations ? 4% per hour, the oxygen desaturation index (ODI), was calculated for each patient for 24 to 48 hours after PACU discharge. An ODI > 10 was the threshold chosen to indicate a high frequency of oxygen desaturation. Results: The percentage of patients with ODI > 10 differed significantly across the 3 study groups (12%, 37%, and 57%, for groups 1–3, p = 0.005). Mean ODI in group 1 was significantly different from groups 2 and 3 (5.8 compared to 10.0 group 2 and 11.4 group 3 with p = 0.001). Conclusions: We have shown that combining preoperative screening is useful for identifying patients at risk for oxygen desaturation after PACU discharge. Citation: Gali B; Whalen FX; Gay PC; Olson EJ; Schroeder DR; Plevak DJ; Morgenthaler TI. Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. J Clin Sleep Med 2007;3(6):582-588.
Gali, Bhargavi; Whalen, Francis X.; Gay, Peter C.; Olson, Eric J.; Schroeder, Darrell R.; Plevak, David J.; Morgenthaler, Timothy I.
BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a recognized risk factor for cardiovascular morbidity and mortality, perhaps due to causative exacerbations of systemic oxidative stress. Putative oxidative stress related to numerous episodes of intermittent hypoxia, may be an oxidants chief driving force in OSAS patients. METHODS: We assessed the resting and n-formyl-methionyl-leucyl-phenylalanine (fMLP)- induced whole blood chemiluminescence (as a measure
Izabela Grabska-Kobylecka; Andrzej Kobylecki; Piotr Bialasiewicz; Maciej Krol; Golsa Ehteshamirad; Marek Kasielski; Dariusz Nowak
Obstructive sleep apnea (OSA) is a common, chronic disease asso- ciated with obesity. OSA and obesity are both prevalent in African Americans, who are also at increased risk for secondary complica- tions. To identify susceptibility loci for OSA, we undertook a 9-centi- morgans genome scan in 59 African-American pedigrees ascertained on the basis of either an affected individual with laboratory-con-
Lyle J. Palmer; Sarah G. Buxbaum; Emma K. Larkin; Sanjay R. Patel; Robert C. Elston; Peter V. Tishler; Susan Redline
Study Objectives: We performed a systematic review of the OSA-related risk of crash in commercial motor vehicle (CMV) drivers. The primary objective involved determining whether individuals with obstructive sleep apnea (OSA) are at an increased risk for a motor vehicle crash when compared to comparable individuals who do not have the disorder. A secondary objective involved determining what factors are associated with an increased motor vehicle crash risk among individuals with OSA. Design/Setting: Seven electronic databases (MEDLINE, PubMed (PreMEDLINE), EMBASE, PsycINFO, CINAHL, TRIS, and the Cochrane library) were searched (through May 27, 2009), as well as the reference lists of all obtained articles. We included controlled studies (case-control or cohort) that evaluated crash risk in individuals with OSA. We evaluated the quality of each study and the interplay between the quality, quantity, robustness, and consistency of the body of evidence, and tested for publication bias. Data were extracted by 2 independent analysts. When appropriate, data from different studies were combined in a fixed- or random-effects meta-analysis. Results: Individuals with OSA are clearly at increased risk for crash. The mean crash-rate ratio associated with OSA is likely to fall within the range of 1.21 to 4.89. Characteristics that may predict crash in drivers with OSA include BMI, apnea plus hypopnea index, oxygen saturation, and possibly daytime sleepiness. Conclusions: Untreated sleep apnea is a significant contributor to motor vehicle crashes. Citation: Tregear S; Reston J; Schoelles K; Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med 2009;5(6):573-581.
Tregear, Stephen; Reston, James; Schoelles, Karen; Phillips, Barbara
Background\\/Aims: We aimed to determine the effects of adenoidectomy and\\/or tonsillectomy (AT) on cardiac functions in children with adenoid and\\/or tonsillary hypertrophy and obstructive sleep apnea syndrome (OSAS) by using echocardiography with tissue Doppler imaging facility (TDI). Methods: Twenty-nine children with adenoid and\\/or tonsillary hypertrophy and OSAS and 26 children with primary snoring entered the study. Cardiac functions were assessed
Mehmet Birol Ugur; Sait Mesut Dogan; Ayhan Sogut; Lokman Uzun; Fikret Cinar; Remzi Altin; Mustafa Aydin
This study focuses on the analysis of blood oxygen saturation (SaO2) from nocturnal pulse oximetry (NPO) to help in the diagnosis of the obstructive sleep apnea (OSA) syndrome. A population of 148 patients suspected of suffering from OSA syndrome was studied. A wide set of 16 features was used to characterize changes in the SaO2 profile during the night. Our
D. A?lvarez; R. Hornero; J. V. Marcos; F. del Campo
Abstract Ginosar, Yehuda, Atul Malhotra, and Eli Schwartz. High altitude, continuous positive airway pressure, and obstructive sleep apnea: Subjective observations and objective data. High Alt Med Biol 14:186–189, 2013.—We report observations made by one of the authors who ascended to the Thorang La pass (5416?m) in the Nepal Himalaya in October 2010, despite moderate-severe obstructive sleep apnea. We report the first recorded use of nasal CPAP to treat high altitude pulmonary edema (progressively severe dyspnea at rest and severe orthopnea, with tachycardia and tachypnea) that occurred at 4400 meters, when snow and darkness made safe evacuation difficult. We also present objective longitudinal data of the effects of altitude on auto-adjusting CPAP delivered via a portable nasal CPAP device, and on the apnea hypopnea index measured during sleep while using the device. OSA may be a risk factor for the development of high altitude pulmonary edema and we suggest that a nasal CPAP device located in high altitude trekking stations may provide an additional or alternative treatment option for managing high altitude pulmonary edema until evacuation is possible.
Malhotra, Atul; Schwartz, Eli
Background: Rhinitis and obstructive sleep apnea (OSA) often coexist during childhood. To delineate this clinical association, we examined OSA severity and polysomnogram (PSG) features in children with rhinitis and OSA. Given that rapid-eye-movement (REM) sleep is characterized by nasal congestion, we hypothesized that children with rhinitis have more REM-related breathing abnormalities. Methods: We conducted a retrospective cross-sectional analysis of 145 children with PSG-diagnosed OSA. Outcomes included PSG parameters and obstructive apnea–hypopnea index (OAHI) during REM and non-REM. Linear multivariable models examined the joint effect of rhinitis and OSA parameters with control for potential confounders. Results: Rhinitis was present in 43% of children with OSA (n = 63) but overall OAHI severity was unaffected by the presence of rhinitis. In contrast, OAHI during REM sleep in children with moderate–severe OSA was significantly increased in subjects with rhinitis and OSA (44.1/hr; SE = 6.4) compared with those with OSA alone (28.2/hr; SE = 3.8). Conclusion: Rhinitis is highly prevalent in children with OSA. Although OSA is not more severe in children with rhinitis, they do have a distinct OSA phenotype characterized by more REM-related OSA. Further research is needed to delineate the link between REM-sleep and the physiology of the nose during health and disease.
Huseni, Shehlanoor; Gutierrez, Maria J.; Rodriguez, Carlos E.; Nino, Cesar L.; Perez, Geovanny F.; Pancham, Krishna
Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that can cause left ventricular (LV) dysfunction. In patients with OSA, the LV dysfunction is usually evaluated by echocardiography. The purpose of this study was to evaluate whether the use of breathhold cine MRI for the study of LV dysfunction would be feasible and well tolerated by patients with OSA. Six
Jan Mintorovitch; André J Duerinckxa; Michael D Goldman; Horst H Meissner
The National Institutes of Health (NIH) Sleep Disorders Research Plan expresses a need for methods that can non-invasively monitor sleep characteristics. Forty subjects were tested using a novel, passive ballistocardiography-based system during an overnight study. We examined our system's ability to measure heart rate as compared to EKG while we also investigated our system's apnea and arousal detection capabilities as
David C. Mack; Majd Alwan; Beverely Turner; Paul Suratt; Robin A. Felder
Background/Aims Obstructive sleep apnea is becoming more important in gastroesophageal reflux disease (GERD) patients. This study investigated the prevalence of high risk for obstructive sleep apnea in GERD patients in comparison with that in healthy controls using the Berlin Questionnaire. We also investigated the risk factors for obstructive sleep apnea in GERD patients. Methods We enrolled 1,007 subjects: 776 healthy controls, 115 individuals with erosive reflux disease, and 116 with non-erosive reflux disease. GERD was diagnosed and classified using endoscopy and a reflux questionnaire. The Berlin Questionnaire was used to evaluate obstructive sleep apnea. Results More patients in the GERD group (28.2%) had higher risk for obstructive sleep apnea than healthy controls (20.4%, P = 0.036). More patients with non-erosive disease (32.8%) had higher risk for obstructive sleep apnea (OSA) than patients with erosive disease (20.9%) and controls (20.4%, P = 0.010). On multivariate analysis, non-erosive disease was a high risk factor for obstructive sleep apnea (odds ratio [OR], 1.82; P = 0.011). Age ? 55 years (OR, 1.83; P < 0.001) and a high body mass index (? 25 kg/m2) (OR, 2.76; P < 0.001) were also identified as risk factors. Nocturnal GERD was related to high risk for OSA in non-erosive disease patients (OR, 2.97; P = 0.019), but not in erosive disease patients. Conclusions High risk for OSA is more prevalent in GERD patients than in controls. Non-erosive reflux disease, age ? 55, and a high BMI are associated with high risk for OSA.
You, Chan Ran; Oh, Jung Hwan; Seo, Minji; Lee, Hye Yeon; Joo, Hyonsoo; Jung, Sung Hoon; Lee, Sang Haak; Choi, Myung-Gyu
Background Obstructive sleep apnea is a common disorder acting as a risk factor for the development and progression of cardiometabolic derangements including non-alcoholic fatty liver disease. Recent research data suggest that non-alcoholic fatty pancreatic disease may be a more sensitive marker than non-alcoholic fatty liver disease for early subclinical metabolic risk and may contribute to the progression of subclinical disease to overt type 2 diabetes mellitus. Presentation of the hypothesis We postulate that obstructive sleep apnea may be a risk factor for non-alcoholic fatty pancreatic disease. It is well known that intermittent hypoxia related to obstructive sleep apnea leads to hormonal derangements. Excessive lipolysis, enhanced lipid synthesis and systemic and local inflammation may favor ectopic fat deposition similarly to non-alcoholic fatty liver disease. Furthermore, it is possible that obstructive sleep apnea can lead to pancreatic beta cell damage via intermittent hypoxia. Testing of the hypothesis Future research should focus on the following: first, whether non-alcoholic fatty pancreatic disease is an independent risk factor for the development of metabolic disease including diabetes mellitus or is a simple consequence of obesity; second, the prevalence of non-alcoholic fatty pancreatic disease among people with obstructive sleep apnea and vice versa, which should be compared to the prevalence of these diseases in general population; third, whether coexistence of these conditions is related to greater cardiometabolic risk than either disease alone; and fourth, whether the treatment of obstructive sleep apnea will translate into the resolution of non-alcoholic fatty pancreatic disease. Implications of the hypothesis If proven, this hypothesis will provide new knowledge on the complex interplay between various metabolic insults. Second, screening for NAFPD may identify individuals at risk for developing type 2 diabetes mellitus for targeted prevention. Third, screening for the presence of non-alcoholic fatty pancreatic disease in patients with obstructive sleep apnea may help to decrease the incidence of diabetes mellitus through a targeted prevention.
We investigated the role of daytime sleepiness and sleep quality in psychosocial outcomes of patients with obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP). Thirty-seven individuals with moderate to severe OSA and compliant with CPAP treatment for at least 3 months were compared to 27 age- and education-matched healthy controls. The OSA group and the control group were studied with overnight polysomnography (PSG) and compared on measures of daytime sleepiness (Epworth Sleepiness Scale), sleep quality (Pittsburg Sleep Quality Index), mood (Beck Depression Inventory, Profile of Mood States), and functional outcomes (Functional Outcomes of Sleep Questionnaire). After CPAP treatment, the OSA group improved on sleep quality and sleepiness. As a group, they did not differ from controls on sleep architecture after CPAP. The OSA group also showed significant improvements in functional outcomes and was comparable to controls on mood and functional outcomes. Persistent difficulties included lowered activity level and residual sleepiness in some individuals. Sleepiness was found to be a significant predictor of mood and affective states, while both sleepiness and sleep quality predicted functional outcomes. These results highlight the importance of assessment and intervention targeting psychosocial functioning and sleepiness in individuals with OSA after treatment.
Eskes, Gail A.; Morrison, Debra L.; Rajda, Malgorzata; Spurr, Kathleen F.
Seven morbidly obese patients with sleep-related upper airway obstruction (UAO) were studied before and during progesterone treatment. All subjects had severe daytime somnolence, and five of the seven had congestive heart failure. All subjects were studied for one or two consecutive baseline nights in the sleep laboratory. Six of the seven subjects showed a mean of greater than 100 UAOs. Patients were treated for two to four weeks with medroxyprogesterone acetate, 20 mg three times daily. At the end of the treatment period, the sleep studies were repeated. There was no significant difference in the incidence, mean duration, or rate per minute of apneic episodes occurring before and with progesterone treatment. Severe hypoxemia during sleep persisted with treatment, as did the occurrence of cardiac arrhythmias. There was a significant improvement in the waking Pao2 with progesterone treatment. PMID:216329
Orr, W C; Imes, N K; Martin, R J
Background Both obstructive sleep apnea syndrome (OSAS) and coronary artery calcification (CAC) are considered to be related with the presence of coronary artery disease (CAD). In this study we evaluate the association between OSAS and presence of subclinical atherosclerosis assessed by tomographic coronary calcium score in patients who had OSAS but no history of known CAD. Methods Seventy-three patients who were asymptomatic for CAD and had suspected OSAS were referred to overnight attended polysomnography. Patients were classified into 4 groups according to the Apnea-Hypopnea Index (AHI). All patients underwent computed tomographic examination for tomographic coronary calcification scoring. Physical examination, sleep study recordings, complete blood count and serum biochemistry were obtained from all patients. Results In the whole group, AHI levels were weakly correlated with coronary calcium score (r = 0.342, p = 0.003) and body mass index (r = 0.337, p = 0.004), moderately correlated with basal oxygen saturation (r = ?0.734, p < 0.001), and strongly correlated with oxygen desaturation index (r = 0.844, p < 0.001). In an univariate analysis, age, AHI, basal oxygen saturation, and oxygen desaturation index were associated with CAC in patients with OSAS. In a multiple logistic regression model, age (OR 1.108,%95 CI 1.031-1.191, p = 0.005) and AHI (OR 1.036,% 95 CI 1.003-1.070, p = 0.033) were only independent predictors of CAC in patients with OSAS with a sensitivity of 88.9% and 77.8% and a specificity of 54.3% and 56.5% respectively. Conclusions Our findings suggest that in patients with moderate or severe OSAS and advanced age, physicians should be alert for the presence of subclinical atherosclerosis.
Objective: Obstructive sleep apnea (OSA) is increasingly recognized as a public health concern. Definitive diagnosis is by overnight polysomnographic (PSG) examination. Identification of clinical predictors would be beneficial in helping prioritize high-risk patients for assessment. Practical application of morphometric predictive variables would require a high level of reproducibility in a clinical setting. In this study, our objective was to evaluate reliability between observers in measurements of candidate morphometric parameters in women. Design and Methods: This was a prospective study of 71 women who had been referred for PSG with suspected OSA. Selected morphometric parameters were measured independently in the sleep laboratory by two trained sleep physicians. Results: Neck circumference and truncal measurements for lower costal, midabdominal, and hip circumferences had higher reliability coefficients (intraclass correlation coefficients [ICC] of 0.78, 0.95, 0.95, and 0.81) than the smaller dimension measurements, including cricomental distance or retrognathia (ICC of 0.04 and 0.17). Of the women participating in this study, 50 of 71 had apnea-hypopnea indexes (AHI) ? 5. Body mass index (BMI), neck circumference, lower costal girth, midabdominal girth, and hip girth were all significantly higher (p < 0.001-0.004) in women with AHI ? 5. Conclusions: There was wide variation in inter-observer reliability for different physical dimensions. We propose that any clinical morphologic measurement employed in predictive modeling should be reliably reproducible in clinical setting conditions. Our findings support the use of several truncal measures, BMI, and neck circumference as predictive measures in women undergoing evaluation for OSA. Citation: Gjevre JA; Taylor-Gjevre RM; Reid JK; Skomro R; Cotton D. Inter-observer reliability of candidate predictive morphometric measurements for women with suspected obstructive sleep apnea. J Clin Sleep Med 2013;9(7):695-699.
Gjevre, John A.; Taylor-Gjevre, Regina M.; Reid, John K.; Skomro, Robert; Cotton, David
The sleep-related breathing disorders have been categorized in various ways. The most basic schema divides them into obstructive or central apneic events. An American Academy of Sleep Medicine (AASM) Task Force Report published in 1999 defined four separate syndromes associated with abnormal respiratory events during sleep among adults, namely, obstructive sleep apnea-hypopnea syndrome (OSAHS), central sleep apnea-hypopnea syndrome, Cheyne-Stokes breathing syndrome, and sleep hypoventilation syndrome. In this classification, the upper airway resistance syndrome was not regarded as a distinct syndrome; instead, respiratory event-related arousals (RERAs) were considered part of the syndrome of OSAHS. PMID:12800785
Lee-Chiong, Teofilo L
Study Objectives: To determine the effects of dronabinol on quantitative electroencephalogram (EEG) markers of the sleep process, including power distribution and ultradian cycling in 15 patients with obstructive sleep apnea (OSA). Methods: EEG (C4-A1) relative power (% total) in the delta, theta, alpha, and sigma bands was quantified by fast Fourier transformation (FFT) over 28-second intervals. An activation ratio (AR = [alpha + sigma] / [delta + theta]) also was computed for each interval. To assess ultradian rhythms, the best-fitting cosine wave was determined for AR and each frequency band in each polysomnogram (PSG). Results: Fifteen subjects were included in the analysis. Dronabinol was associated with significantly increased theta power (p = 0.002). During the first half of the night, dronabinol decreased sigma power (p = 0.03) and AR (p = 0.03), and increased theta power (p = 0.0006). At increasing dronabinol doses, ultradian rhythms accounted for a greater fraction of EEG power variance in the delta band (p = 0.04) and AR (p = 0.03). Females had higher amplitude ultradian rhythms than males (theta: p = 0.01; sigma: p = 0.01). Decreasing AHI was associated with increasing ultradian rhythm amplitudes (sigma: p < 0.001; AR: p = 0.02). At the end of treatment, lower relative power in the theta band (p = 0.02) and lower AHI (p = 0.05) correlated with a greater decrease in sleepiness from baseline. Conclusions: This exploratory study demonstrates that in individuals with OSA, dronabinol treatment may yield a shift in EEG power toward delta and theta frequencies and a strengthening of ultradian rhythms in the sleep EEG. Citation: Farabi SS; Prasad B; Quinn L; Carley DW. Impact of dronabinol on quantitative electroencephalogram (qEEG) measures of sleep in obstructive sleep apnea syndrome. J Clin Sleep Med 2014;10(1):49-56.
Farabi, Sarah S.; Prasad, Bharati; Quinn, Lauretta; Carley, David W.
Background The aim of this study was to assess the effects of continuous positive airway pressure (CPAP) on arterial stiffness, central blood pressure, and reflected pulse wave characteristics in patients with severe obstructive sleep apnea (OSA) and stage 2–3 arterial hypertension. Methods Forty-four patients with hypertension and severe OSA (apnea/hypopnea index > 30) received stepped dose titration of antihypertensive treatment, consisting of valsartan 160 mg + amlodipine 5–10 mg + hydrochlorothiazide 25 mg. CPAP therapy was added after 3 weeks of continuous antihypertensive treatment with BP < 140/90 mmHg or after adjusting triple treatment in patients with resistant arterial hypertension. The patients were randomized to effective CPAP (4–15 mm H2O) or placebo CPAP (pressure 4 mm H2O) for three weeks, then crossed over to the alternative treatment in a single-blind manner. Office blood pressure (BP), ambulatory BP monitoring, ambulatory arterial stiffness index (AASI), aortic BP, carotid-femoral pulse wave velocity (cfPWV), and systolic wave augmentation index were measured using a Sphygmocor® device at baseline, after antihypertensive treatment, placebo CPAP, and effective CPAP. Results Baseline cfPWV was above the normal range in 94% of patients. After reaching target BP, the cfPWV decreased by 1.9 ± 1.0 msec (P = 0.007). Effective CPAP achieved a further cfPWV reduction of 0.7 msec (P = 0.03). Increased arterial stiffness (pulse wave velocity > 12 msec) persisted in 35% of patients on antihypertensive treatment and effective CPAP, in 56% of patients on antihypertensive treatment alone, and in 53% of patients on placebo CPAP. Only the combination of antihypertensive treatment with effective CPAP achieved a significant reduction in augmentation index and AASI, along with a further reduction in aortic and brachial BP. Conclusion Effective CPAP for 3 weeks resulted in a significant additional decrease in office BP, ambulatory BP monitoring, central BP, and augmentation index, together with an improvement in arterial stiffness parameters, ie, cfPWV and AASI, in a group of hypertensive patients with OSA.
Litvin, AY; Sukmarova, ZN; Elfimova, EM; Aksenova, AV; Galitsin, PV; Rogoza, AN; Chazova, IE
Objectives This study investigated the outcomes of uvula-preserving palatopharyngoplasty (UPPPP) in patients with obstructive sleep apnea syndrome (OSAS). Methods Twenty men with obstructive sleep apnea syndrome received the UPPPP operation at our institution. We measured symptom changes after UPPPP using a visual analog scale (VAS), and all patients were examined with polysomnography pre- and post-operatively. 'Surgical success' was defined as reduction in apnea-hypopnea index (AHI) to below 20 events per hour and more than 50% post-operative reduction. Results Snoring decreased significantly (6.7±2.3 to 3.7±2.9 on VAS, P=0.002) but the postoperative globus sense did not differ from that preoperatively (2.0±2.4 to 2.1±2.7 on VAS, P=0.79). Apnea and apnea-hypopnea indices were significantly reduced after UPPPP (34.7±20 to 24.2±17.2 events/hour, P=0.029). The surgical success rate was 40% regardless of Friedman stage. There was significant reduction in the AHI on supine sleep in both surgically successful and unsuccessful patient groups. Conclusion UPPPP may minimize postoperative globus sense and other complications, with a success rate comparable to that of previously reported surgical methods in OSAS patients. In addition, it may reduce the apnea-hypopnea index in the supine sleep position.
Kwon, Minsu; Jang, Yong Ju; Lee, Bong-Jae
Obstructive sleep apnea (OSA), a condition in which the upper airway collapses during sleep, is strongly associated with metabolic and cardiovascular diseases. Little is known how OSA affects the cerebral circulation. The goals of this study were 1) to develop a rat model of chronic OSA that involved apnea and 2) to test the hypothesis that 4 wk of apneas during the sleep cycle alters endothelium-mediated dilations in middle cerebral arteries (MCAs). An obstruction device, which was chronically implanted into the trachea of rats, inflated to obstruct the airway 30 times/h for 8 h during the sleep cycle. After 4 wk of apneas, MCAs were isolated, pressurized, and exposed to luminally applied ATP, an endothelial P2Y2 receptor agonist that dilates through endothelial-derived nitric oxide (NO) and endothelial-dependent hyperpolarization (EDH). Dilations to ATP were attenuated ~30% in MCAs from rats undergoing apneas compared with those from a sham control group (P < 0.04 group effect; n = 7 and 10, respectively). When the NO component of the dilation was blocked to isolate the EDH component, the response to ATP in MCAs from the sham and apnea groups was similar. This finding suggests that the attenuated dilation to ATP must occur through reduced NO. In summary, we have successfully developed a novel rat model for chronic OSA that incorporates apnea during the sleep cycle. Using this model, we demonstrate that endothelial dysfunction occurred by 4 wk of apnea, likely increasing the vulnerability of the brain to cerebrovascular related accidents. PMID:23761641
Crossland, Randy F; Durgan, David J; Lloyd, Eric E; Phillips, Sharon C; Reddy, Anilkumar K; Marrelli, Sean P; Bryan, Robert M
Sleep apnea (SA) and excessive daytime sleepiness (EDS) are common sleep disorders among patients with end-stage renal disease (ESRD). This cross-sectional study, carried out in two dialysis centers in Saudi Arabia, assessed the prevalence of sleep apnea and sleepiness in Saudi patients with ESRD who are on maintenance dialysis with either peritoneal or hemodialysis. We used questionnaires to assess the prevalence of SA and EDS. The association between sleep apnea, EDS, and other sleep disorders, the underlying causes of renal failure, and other demographic data were also examined. Among 227 enrolled patients, the mean patient age was 55.7 years ± 17.2 years; 53.7% were male, and 46.3% were female. The overall prevalence of SA as defined by the Berlin questionnaire (BQ) was 37% in males and 34% in females, which was not a statistically significant difference (P = 0.459). Sleep apnea was significantly associated with age, neck size, afternoon and evening hemodialysis shift, obesity, diabetes, and hypertension (P-values, 0.001, 0.029, < 0.0001, < 0.0001, < 0.008, 0.002, and < 0.001, respectively). Sleep apnea was also significantly associated with other sleep disorders such as restless leg syndrome, insomnia, habitual snoring, and EDS (P-values, < 0.001, < 0.001, < 0.001, and < 0.001, respectively). The prevalence of EDS was 44%, and EDS was significantly more prevalent in patients undergoing peritoneal dialysis (P < 0.001); it was also associated with older age, diabetes mellitus, and other sleep disorders. SA and EDS are common in dialysis patients and are significantly associated with other sleep disorders. PMID:22382215
Study Objective: To determine the impact of continuous positive airway pressure (CPAP) on weight change in persons with obstructive sleep apnea (OSA). Design, Setting, and Participants: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) was a 6-month, randomized, double-blinded sham-controlled multicenter clinical trial conducted at 5 sites in the United States. Of 1,105 participants with an apnea hypopnea index ? 10 events/ hour initially randomized, 812 had body weight measured at baseline and after 6 months of study. Intervention: CPAP or Sham CPAP. Measurements: Body weight, height, hours of CPAP or Sham CPAP use, Epworth Sleepiness Scale score. Results: Participants randomized to CPAP gained 0.35 ± 5.01 kg, whereas those on Sham CPAP lost 0.70 ± 4.03 kg (mean ± SD, p = 0.001). Amount of weight gain with CPAP was related to hours of device adherence, with each hour per night of use predicting a 0.42 kg increase in weight. This association was not noted in the Sham CPAP group. CPAP participants who used their device ? 4 h per night on ? 70% of nights gained the most weight over 6 months in comparison to non-adherent CPAP participants (1.0 ± 5.3 vs. -0.3 ± 5.0 kg, p = 0.014). Conclusions: OSA patients using CPAP may gain a modest amount of weight with the greatest weight gain found in those most compliant with CPAP. Commentary: A commentary on this article appears in this issue on page 995. Citation: Quan SF; Budhiraja R; Clarke DP; Goodwin JL; Gottlieb DJ; Nichols DA; Simon RD; Smith TW; Walsh JK; Kushida CA. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea. J Clin Sleep Med 2013;9(10):989-993.
Quan, Stuart F.; Budhiraja, Rohit; Clarke, Denise P.; Goodwin, James L.; Gottlieb, Daniel J.; Nichols, Deborah A.; Simon, Richard D.; Smith, Terry W.; Walsh, James K.; Kushida, Clete A.
Sleep apnoea is a very common sleep disorder which can cause symptoms such as daytime sleepiness, irritability and poor concentration. To monitor patients with this sleeping disorder we measured the electrical activity of the heart. The resulting electrocardiography (ECG) signals are both non-stationary and nonlinear. Therefore, we used nonlinear parameters such as approximate entropy, fractal dimension, correlation dimension, largest Lyapunov exponent and Hurst exponent to extract physiological information. This information was used to train an artificial neural network (ANN) classifier to categorize ECG signal segments into one of the following groups: apnoea, hypopnoea and normal breathing. ANN classification tests produced an average classification accuracy of 90%; specificity and sensitivity were 100% and 95%, respectively. We have also proposed unique recurrence plots for the normal, hypopnea and apnea classes. Detecting sleep apnea with this level of accuracy can potentially reduce the need of polysomnography (PSG). This brings advantages to patients, because the proposed system is less cumbersome when compared to PSG. PMID:21285482
Acharya, U Rajendra; Chua, Eric Chern-Pin; Faust, Oliver; Lim, Teik-Cheng; Lim, Liang Feng Benjamin
This is the case report of a 32-year-old obese male with a history of agitation, hallucinations, and delirium, recently diagnosed with primary hypothyroidism; he gave a several month history of fatigue with nocturnal snoring and frequent awakening. Polysomnogram revealed severe OSA; initiation of CPAP and levothyroxine resulted in immediate improvement. The lack of a previous psychiatric history and acuteness of presentation was consistent with hypothyroid psychosis complicated by sleep deprivation cause by untreated OSA. Primary hypothyroidism is a common disorder often associated with depression. It is rarely associated with psychosis and was first described as “myxoedematous madness” in 1949. It has not been previously reported to cause psychosis when associated with obstructive sleep apnea. This case illustrates the need for examination of potential multiple organic causes in a patient who presents with psychosis in the critical care setting. Citation: Neal JM; Yuhico RJO. “Myxedema madness” associated with newly diagnosed hypothyroidism and obstructive sleep apnea. J Clin Sleep Med 2012;8(6):717-718.
Neal, J. Matthew; Yuhico, Rodney Joe O.
Background Lack of adherence to recommended treatment for obstructive sleep apnea remains an ongoing public health challenge. Despite evidence that continuous positive airway pressure (CPAP) is effective and improves overall quality of life, adherence with the use of CPAP in certain racial/ethnic groups, especially blacks, is suboptimal. Evidence indicates that the incidence and prevalence of obstructive sleep apnea are higher among blacks, relative to whites, and blacks are less likely to adhere to recommended treatment compared with other racial/ethnic groups. Methods Using a two-arm randomized controlled design, this study will evaluate the effectiveness of a culturally and linguistically tailored telephone-delivered intervention to promote adherence to physician-recommended sleep apnea assessment and treatment among blacks with metabolic syndrome, versus an attention-control arm. The intervention is designed to foster adherence to recommended sleep apnea care using the stages-of-change model. The intervention will be delivered entirely over the telephone. Participants in the intervention arm will receive 10 phone calls to address challenges and barriers to recommended care. Outcomes will be assessed at baseline, and at 6- and 12-months post-randomization. Discussion This tailored behavioral intervention will improve adherence to sleep apnea assessment and treatment among blacks with metabolic syndrome. We expect to demonstrate that this intervention modality is feasible in terms of time and cost and can be replicated in populations with similar racial/ethnic backgrounds. Trial registration The study is registered at clinicaltrials.gov NCT01946659 (February 2013)
Evaluation of sleep apnea-hypopnea syndrome (SAHS) is mainly based on the polysomnogram (PSG), which is considered as the golden diagnostic criteria. As a novel noninvasive and low cost alternative method to detect SAHS patients, the diagnostic power of ECG-derived respiration (EDR) hasn’t been well determined. In light of this, we tested whether EDR can be utilized as a feasible tool to diagnose SAHS in Chinese patients. Overnight sleep investigation was performed in 120 subjects using polysomnogram (PSG) and 24-hour ambulatory electrocardiogram (AECG). The apnea hypopnea index (AHI) was calculated from EDR and PSG respectively. With EDR assessments, 77 subjects were determined as SAHS (+), 43 were diagnosed as SAHS (-). The diagnostic accordance rate was 87.5% and the area under curve was 0.938. The coefficient correlation of AHI between EDR and PSG was 0.879 (P <0.001), while the correlation of maximum apnea and hypopnea time duration were 0.716 (P <0.001) and 0.281 (P <0.005), respectively. All correlations were statistically significant (P <0.01). EDR can be used as a practical tool for the diagnosis of SAHS.
Tong, Guang-Ming; Zhang, Hai-Cheng; Guo, Ji-Hong; Han, Fang
The objective of this study was to verify the effect of a mandibular repositioning device (MRD) on polysomnographic parameters and on the mean electromyographic activity of the masseter and temporal muscles in individuals with obstructive sleep apnea syndrome (OSAS). This is a prospective cohort study conducted at multidisciplinary OSAS center in a tertiary referral center. Nineteen individuals with mild or moderate OSAS associated with Mallampati 3-4 were treated with an MRD during sleep. The subjects underwent diurnal electromyography (EM) and nocturnal polysomnography (PSG) examinations both prior and after initial treatment (3 months with MRD for PSG and 6 and 12 months of treatment for EM). The examinations performed at different times were compared. Comparison of the initial and final polysomnography examination revealed a significant mean reduction of apnea-hypopnea index (AHI) from 13.8 to 7.8. The successful treatment rate with the MRD was 52.6%, and the improved treatment rate was 68.4%. Patients with lower pre-treatment AHI presented higher rates of cure. There was no statistically significant change in electromyography examination among different times. The MRD reduced the apnea-hypopnea index in individuals with enlarged base of tongue and mild and moderate OSAS without damaging the function of the masseter and temporal muscles as determined by electromyography. PMID:23880923
Leite, Fernando G J; Rodrigues, Renata C S; Ribeiro, Ricardo F; Eckeli, Alan L; Regalo, Simone C H; Sousa, Luiz G; Fernandes, Regina M F; Valera, Fabiana C P
Background. Obstructive sleep apnea (OSA) is associated with coronary artery disease. Intermittent hypoxia associated with OSA increases sympathetic activity and may cause systemic inflammation, which may contribute to atherosclerosis leading to an increase in the size of carotid intima media thickness (CIMT). Methods. PubMed and Cochrane library were reviewed by utilizing different combinations of key words: sleep apnea, carotid disease, intima media thickness, and carotid atherosclerosis. Inclusion criteria were English articles; studies with adult population with OSA and without OSA; CIMT recorded by ultrasound in mean and standard deviation or median with 95% confidence interval; and OSA defined as apnea hypopnea index of ?5/h. A total of 95 studies were reviewed for inclusion, with 16 studies being pooled for analysis. Results. Ninety-five studies were reviewed, while 16 studies were pooled for analysis; since some studies have more than one data set, there were 25 data sets with 1415 patients being pooled for meta-analysis. All studies used ultrasound to measure CIMT. CIMT standardized difference in means ranged from ?0.883 to 8.01. The pooled standardized difference in means was 1.40 (lower limit 0.996 to upper limit 1.803, (P < 0.0001). Conclusion. Patients with OSA appear to have increased CIMT suggestive of an atherosclerotic process.
Harvey, Michael; Khan, Ahmed Abdullah; Albustani, Mustafa; Baessler, Aaron; Madbouly, Essam M.; Navid, Nayab
Many sleep centres try to perform a reduced portable test in order to decrease the number of overnight polysomnographies that are expensive, time-consuming, and disturbing. With some limitations, heart rate variability (HRV) has been useful in this task. The aim of this investigation was to evaluate if inclusion of symbolic dynamics variables to a logistic regression model integrating clinical and physical variables, can improve the detection of subjects for further polysomnographies. To our knowledge, this is the first contribution that innovates in that strategy. A group of 133 patients has been referred to the sleep center for suspected sleep apnea. Clinical assessment of the patients consisted of a sleep related questionnaire and a physical examination. The clinical variables related to apnea and selected in the statistical model were age (p < 10-3), neck circumference (p < 10-3), score on a questionnaire scale intended to quantify daytime sleepiness (p < 10-3), and intensity of snoring (p < 10-3). The validation of this model demonstrated an increase in classification performance when a variable based on non-linear dynamics of HRV (p < 0.01) was used additionally to the other variables. For diagnostic rule based only on clinical and physical variables, the corresponding area under the receiver operating characteristic (ROC) curve was 0.907 (95% confidence interval (CI) = 0.848, 0.967), (sensitivity 87.10% and specificity 80%). For the model including the average of a symbolic dynamic variable, the area under the ROC curve was increased to 0.941 (95% = 0.897, 0.985), (sensitivity 88.71% and specificity 82.86%). In conclusion, symbolic dynamics, coupled with significant clinical and physical variables can help to prioritize polysomnographies in patients with a high probability of apnea. In addition, the processing of the HRV is a well established low cost and robust technique.
Ravelo-García, A. G.; Saavedra-Santana, P.; Juliá-Serdá, G.; Navarro-Mesa, J. L.; Navarro-Esteva, J.; Álvarez-López, X.; Gapelyuk, A.; Penzel, T.; Wessel, N.
Study Objectives: Children with the obstructive sleep apnea syndrome (OSAS) have impaired responses to hypercapnia, subatmospheric pressure, and inspiratory resistive loading during sleep. This may be due, in part, to an impairment in the afferent limb of the upper airway sensory pathway. Therefore, we hypothesized that children with OSAS had diminished upper airway sensation compared to controls. Design: Case-control Setting: Academic hospital Participants: Subjects with OSAS aged 6–16 years, and age- and BMI-matched controls. Interventions: Two-point discrimination (TPD) was measured during wakefulness with modified calipers in the anterior tongue, right interior cheek, and hard palate. Results: Thirteen children with OSAS and 9 controls were tested. The age (mean ± SD) for OSAS and controls was 11 ± 4 vs. 13 ± 2 years (NS); OSAS BMI Z score 2.4 ± 0.5, controls 2.2 ± 0.5 (NS); OSAS apnea hypopnea index 31 ± 48, controls 0.4 ± 0.5 events/hour (P < 0.001). Children with OSAS had impaired TPD in the anterior tongue (median [range]) = 9 [3–14] mm, controls 3 [1–7], P = 0.002) and hard palate (OSAS 6 [3–9] mm, controls 3 [1–4], P < 0.001). TPD in the cheek was similar between the groups (P = 0.12). Conclusion: TPD in the anterior tongue and hard palate was impaired in children with OSAS during wakefulness. We speculate that this impairment might be due to a primary sensory function abnormality or secondary to nerve damage and/or hypoxemia caused by OSAS. Further studies after treatment of OSAS are needed. Citation: Tapia IE; Bandla P; Traylor J; Karamessinis L; Huang J; Marcus CL. Upper airway sensory function in children with obstructive sleep apnea syndrome. SLEEP 2010;33(7):968–972.
Tapia, Ignacio E.; Bandla, Preetam; Traylor, Joel; Karamessinis, Laurie; Huang, Jingtao; Marcus, Carole L.
Study Objectives: Habitual snoring is a prevalent condition that is not only a marker of obstructive sleep apnea (OSA) but can also lead to vascular risk. However, it is not easy to check snoring status at home. We attempted to develop a snoring sound monitor consisting of a smartphone alone, which is aimed to quantify snoring and OSA severity. Methods: The subjects included 50 patients who underwent diagnostic polysomnography (PSG), of which the data of 10 patients were used for developing the program and that of 40 patients were used for validating the program. A smartphone was attached to the anterior chest wall over the sternum. It acquired ambient sound from the built-in microphone and analyzed it using a fast Fourier transform on a real-time basis. Results: Snoring time measured by the smartphone highly correlated with snoring time measured by PSG (r = 0.93). The top 1 percentile value of sound pressure level (L1) determined by the smartphone correlated with the ambient sound L1 during sleep determined by PSG (r = 0.92). Moreover, the respiratory disturbance index estimated by the smartphone (smart-RDI) highly correlated with the apnea-hypopnea index (AHI) obtained by PSG (r = 0.94). The diagnostic sensitivity and specificity of the smart-RDI for diagnosing OSA (AHI ? 15) were 0.70 and 0.94, respectively. Conclusions: A smartphone can be used for effectively monitoring snoring and OSA in a controlled laboratory setting. Use of this technology in a noisy home environment remains unproven, and further investigation is needed. Commentary: A commentary on this article appears in this issue on page 79. Citation: Nakano H; Hirayama K; Sadamitsu Y; Toshimitsu A; Fujita H; Shin S; Tanigawa T. Monitoring sound to quantify snoring and sleep apnea severity using a smartphone: proof of concept. J Clin Sleep Med 2014;10(1):73-78.
Nakano, Hiroshi; Hirayama, Kenji; Sadamitsu, Yumiko; Toshimitsu, Ayaka; Fujita, Hisayuki; Shin, Shizue; Tanigawa, Takeshi
Background: Patent foramen ovale (PFO) with right-to-left shunt has a prevalence of 10% to 34% in the general population. It can cause an ischemic stroke, transient ischemic attack, and paradoxical peripheral or coronary embolization. Its influence on migraine and several other diseases and conditions is currently under debate. Attention has recently been turned to the correlation between PFO and obstructive sleep apnea. Thus far, studies on the prevalence of right-to-left shunts as a surrogate for PFO in these patients were limited by small sample sizes and the results have been conflicting. Here, we evaluate the prevalence of right-to-left shunting (RLS) through transcranial Doppler ultrasound (TCD) in a large patient group with obstructive sleep apnea (OSA). Methods: One hundred consecutive patients (mean age 59.5 y) with OSA underwent TCD with intravenous injection of agitated saline. The grading of right-to-left-shunts was in accordance with the Spencer PFO Grading Scale. Results: RLS was detected in 72 of 100 patients (72%). Thirty-four out of these 72 patients (47%) had a shunt grade I or II; 15 (21%) had a shunt Grade III or IV; and 23 (32%) had a large shunt (Grade V or V+). In 47 of 72 patients (65%), a right-to-left shunt was detectable at rest without Valsalva maneuver. Conclusion: The prevalence of a RLS in patients with OSA is high. Provided other intracardiac or pulmonary shunts were absent, the high prevalence of a RLS suggests a high prevalence of PFO in patients with OSA. Citation: Guchlerner M; Kardos P; Liss-Koch E; Franke J; Wunderlich N; Bertog S; Sievert H. PFO and right-to-left shunting in patients with obstructive sleep apnea. J Clin Sleep Med 2012;8(4):375–380.
Guchlerner, Marina; Kardos, Peter; Liss-Koch, Eva; Franke, Jennifer; Wunderlich, Nina; Bertog, Stefan; Sievert, Horst
Study Objectives: Obstructive sleep apnea (OSA) has been linked to and is associated with increased cardiovascular and cerebrovascular morbidity. Ongoing inflammatory responses play an important role in this association. Multiple small size studies addressing the profile of the inflammatory markers in OSA are available therefore we performed a meta-analysis. Methods: Systematic review of medical literature was conducted using PubMed, Cochrane, and EMBASE databases from 1968 to 2011 by utilizing the key words obstructive sleep apnea, C-Reactive protein, tumor necrosis factor alpha (TNF-?), interleukin 6 (IL-6), interleukin 8 (IL-8), intercellular adhesion molecule (ICAM), vascular cell adhesion molecule (VCAM) and Selectins. Inclusion criteria were: full text English articles; studies with adult population; reported values for at least one of the markers of interest; with at least two separate groups (subjects with OSA and control group); OSA was defined as AHI of ? 5/h. Results: Five hundred and twelve studies were reviewed for inclusion with 51 studies pooled for analysis (30 studies for CRP, 19 studies for TNF-?, 8 studies for ICAM, 18 studies for IL-6, six studies for VCAM and 5 studies for Selectins). The levels of inflammatory markers were higher in patients with OSA compared to control group. Standardized pooled Mean differences were calculated to be 1.77 for CRP, 1.03 for TNF-?, 2.16 for IL-6, 4.22 for IL-8, 2.93 for ICAM, 1.45 for Selectins and 2.08 for VCAM. Conclusions: In this meta-analysis, the levels of systemic inflammatory markers were found to be higher in OSA patients compared to control subjects. Citation: Nadeem R; Molnar J; Madbouly EM; Nida M; Aggarwal S; Sajid H; Naseem J; Loomba R. Serum inflammatory markers in obstructive sleep apnea: a meta-analysis. J Clin Sleep Med 2013;9(10):1003-1012.
Nadeem, Rashid; Molnar, Janos; Madbouly, Essam M.; Nida, Mahwish; Aggarwal, Saurabh; Sajid, Hassan; Naseem, Jawed; Loomba, Rohit
Background The STOP-BANG is a simple obstructive sleep apnea (OSA) screening tool, part questionnaire (STOP) and part demographic or physical measures (BANG), developed for use in preoperative surgical clinics. This study assessed sensitivity and specificity of the instrument among patients referred to a sleep disorders laboratory, and also its performance characteristics when BANG physical measures are patient-reported rather than measured. Methods Adults referred for diagnostic polysomnography completed the STOP questions and answered four yes/no questions (BANG self-reported) about their body mass index (weight and height), age, neck circumference, and gender, which were also assessed by laboratory technologists (BANG-measured). Results Among N=219 subjects (mean age 46.3 ± 13.9 [s.d.] years; 98 [44.8%] males) the sensitivity of the STOP-BANG measured for an apnea/hypopnea index (AHI, events per hour of sleep) >5, >15, and >30 was 82, 93, and 97% respectively. Corresponding negative predictive values were 44, 87, and 96%. Specificities were comparatively low (48, 40, and 33%). The STOP-BANG measured and STOP-BANG self-reported scores showed essentially equivalent test characteristics against polysomnography. Conclusions The STOP-BANG appears to have limited utility in a referred, sleep laboratory setting. Negative results help to identify some individuals as unlikely to have moderate-to-severe apnea, and may thereby prove useful in identification of patients who would benefit more from laboratory studies than home studies. A STOP-BANG in which all information is self-reported may be as effective as the original version, and has potential to facilitate research or community screening where good negative predictive value is required for an effective screening tool.
Boynton, Grace; Vahabzadeh, Arshia; Hammoud, Sami; Ruzicka, Deborah L.; Chervin, Ronald D.
The relation between snoring and obstructive sleep apnea as well as hypothyroidism is the object of interest of many authors. The respiratory disturbances during sleep are often observed in patients suffering from hypothyroidism. The relation of snoring to overweight in those patients has not been taken into account. The aim of the study was to evaluate the relations between hypothyroidism and quantitative and qualitative respiratory disturbances during sleep. Additional aim was to establish the relations of sleep apnea syndrome, snoring, hypothyroidism and overweight. The subjects included 15 patients (11 females and 4 males) aged from 28 to 73 (mean 50.3) suffering from hypothyroidism. All of them underwent thyroid testing before and after the hormonal treatment. TSH and fT4 concentrations were determined. At the same time the sleep assessment (PolyMESAM) was performed twice. Data were obtained from sleep studies and questionnaires (Epworth sleepiness scale). After the thyroid hormones stabilization significant decrease of snoring severity was observed. On the contrary, the respiratory disturbance index (RDI), desaturation index (DI), the lowest saturation (LSAT) did not change significantly, however, the Epworth scale score showed significant improvement. The correlations showed the strong relation between loud snoring and TSH (r=0.73, p<0.01) and fT4 (r=-0.66, p<0.003) concentrations before the treatment. The analysis showed no correlation between body mass (BMI) and snoring. The hormonal stabilization in patients suffering from hypothyroidism causes improvement in snoring severity. Based on our investigation the relationship between hypothyroidism and severity of snoring and excessive daytime somnolence was confirmed. It indicates a possible connection between hypothyroidism and upper airway resistance syndrome. PMID:17443029
Misiolek, M; Marek, B; Namyslowski, G; Scierski, W; Zwirska-Korczala, K; Kazmierczak-Zagorska, Z; Kajdaniuk, D; Misiolek, H
Background: Substantial discrepancies exist in the type of sleep studies performed to diagnose pediatric obstructive sleep apnea (OSA) in different countries. Respiratory polygraphic (RP) recordings are primarily performed in sleep laboratories in Europe, whereas polysomnography (PSG) constitutes the majority in the US and Australia. Home RP show consistent apnea-hypopnea index (AHI) underscoring, primarily because the total recording time is used as the denominator when calculating the AHI compared to total sleep time (TST). However, laboratory-based RP are less likely affected, since the presence of sleep technicians and video monitoring may enable more accurate TST estimates. We therefore examined differences in AHI in PSG and in-lab RP, and whether RP-based AHI may impact clinical decision making. Methods: Of all the children assessed for possible OSA who underwent PSG evaluation, 100 were identified and divided into 4 groups: (A) those with AHI < 1/h TST (n = 20), (B) 1 ? AHI < 5/h TST (n = 40), (C) 5 ? AHI < 10/h TST (n = 20), and (D) AHI ? 10/h TST (n = 20). Electroencephalography, electrooculography, and electromyography channels were deleted from the original unscored recordings to transform them into RP, and then rescored in random sequence. AHI-RP were compared to AHI-PSG, and therapeutic decisions based on AHI-RP and AHI-PSG were formulated and analyzed using clinical details derived from the patient's clinic letter. Results: Bland Altman analysis showed that in lab RP underestimated the AHI despite more accurate estimates of TST. This underestimation was due to missed hypopneas causing arousals without desaturation. Basing the therapeutic management decision on RP instead of PSG results changed the clinical management in 23% of all patients. The clinical management for patients in groups A and D was unaffected. However, 27.5% of patients in group B would have been given no treatment, as they would be diagnosed as having no OSA (AHI < 1/h TST) when they should have received a trial of anti-inflammatory therapy or been referred for ear, nose, and throat (ENT) review. Sixty percent of patients in group C would have received either a trial of medical treatment to treat mild OSA or no treatment, instead of referral to ENT services or commencement of continuous positive airway pressure. Conclusion: Apnea-hypopnea index (AHI) is underestimated in respiratory polygraphy (RP), and the disparity in AHI-RP and AHI-polysomnography can significantly affect clinical management decisions, particularly in children with mild and moderate obstructive sleep apnea (1 < AHI < 10/h total sleep time). Citation: Tan HL; Gozal D; Ramirez HM; Bandla HPR; Kheirandish-Gozal L. Overnight polysomnography versus respiratory polygraphy in the diagnosis of pediatric obstructive sleep apnea. SLEEP 2014;37(2):255-260.
Tan, Hui-Leng; Gozal, David; Ramirez, Helena Molero; Bandla, Hari P. R.; Kheirandish-Gozal, Leila
Both working and immediate memories were assessed every 4h by specific short-term memory tasks over sustained wakefulness in 12 patients with obstructive sleep apnea and hypopnea syndrome (OSAHS) and 10 healthy controls. Results indicated that OSAHS patients exhibited lower working memory performances than controls on both backward digit span and complex Sternberg tasks. Speed and accuracy on Sternberg tasks were affected by memory load in both groups. However, immediate memory was not impaired in OSAHS patients. Diurnal and nocturnal SaO(2) were correlated with speed and accuracy high-speed memory scanning performance on Sternberg tasks in patients. These results suggest specific working memory deficits associated with OSAHS over sustained wakefulness with a possible deficiency in the central executive responsible for the higher information processing, in addition to a potentially insufficient storage capacity. Among OSAHS patients, working memory ability involved in high-speed memory scanning may be impaired by chronic hypoxemia. PMID:21041012
Grenèche, Jérôme; Krieger, Jean; Bertrand, Frédéric; Erhardt, Christine; Maumy, Myriam; Tassi, Patricia