Breathing Disturbances Research Articles

Exacerbation of sleep apnoea by frequent central events in patients with the obstructive sleep apnoea syndrome at altitude: a randomised trial

BackgroundMany patients with the obstructive sleep apnoea syndrome (OSA) travel to the mountains for recreational and professional activities while temporarily discontinuing continuous positive airway pressure (CPAP) treatment. A study was...

Associations Between Secondhand Smoke Exposure and Sleep Patterns in Children

The objective of this study was to investigate the relationship between exposure to secondhand smoke (SHS) and child sleep patterns among a group of children with asthma who were exposed regularly to tobacco smoke at home. We studied 219 children who were enrolled in an asthma intervention trial and were exposed regularly to SHS. Serum cotinine levels were used to measure exposure to tobacco smoke, and sleep patterns were assessed through parent reports using the Children's Sleep Habits Questionnaire. Covariates in adjusted analyses included gender, age, race, maternal marital status, education, and income, prenatal tobacco exposure, maternal depression, Home Observation for Measurement of the Environment total score, household density, asthma severity, and use of asthma medications. Exposure to SHS was associated with sleep problems, including longer sleep-onset delay (P = .004), sleep-disordered breathing (P = .02), parasomnias (P = .002), daytime sleepiness (P = .022), and overall sleep disturbance (P = .0002). We conclude that exposure to SHS is associated with increased sleep problems among children with asthma.

Sleep-related breathing and sleep-wake disturbances in ischemic stroke

Sleep-related breathing and sleep-wake disturbances in ischemic stroke

Sleep Disorders -Overview-

Sleep disorders include sleep disturbance and sleep-disordered breathing (SDB). Especially, SDB has been gathering much attention as sleep apnea syndrome (SAS) in clinical physicians last three decades. SAS is characterized with heavy snoring, excessive daytime sleepiness, and obesity. Pathophysiology of SAS is repeated obstructions of upper airway (pharyngeal sites) during sleep, so that marked hypoxemia and arousals occur. When SAS is severe and hypoxemia continues for long time, cardiovascular systems are much affected. Recent studies demonstrate that SAS is directly associated with hypertension, stroke, cardiac failure, and cardiac death. Another important clinical problem in patients with SAS is excessive daytime sleepiness that occurs due to repeated arousals during sleep. It has been reported that patients with SAS have more traffic car accidents. SAS impairs not only physical conditions but also mental and social conditions. Sleep disturbances, such as sleep loss, insomnia, and hypersomnia are also major health problem. Recent epidemiological studies demonstrated that sleep disturbances are common in general population. To understand the pathophysiology, diagnosis and treatment of sleep disturbances are clinically important and useful for general physicians.

Sleep-related breathing and sleep-wake disturbances in ischemic stroke

Sleep-related breathing disturbances (SDB) and sleep-wake disturbances (SWD) are often neglected in stroke patients. Recent studies suggest that they are frequent and have an impact on stroke outcome. We review current knowledge about frequency, clinical presentation, and consequences of poststroke SDB and SWD, and discuss treatment options. SDB, presenting with obstructive, central, or mixed apneas, is present in 50%-70% of stroke patients. We recommend screening for SDB in all stroke patients by respirography. Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive SDB, which reverses the vascular risk of the patients. In the absence of controlled trials, CPAP treatment should be reserved for patients with severe obstructive SDB, daytime symptoms (e.g., sleepiness), or high cardiovascular risk profile. Oxygen and adaptive servoventilation may be used for central SDB. SWD including insomnia, disturbances of wakefulness (hypersomnia, excessive daytime sleepiness, fatigue), sleep-related movement disorders (restless legs syndrome, periodic limb movements during sleep), and parasomnias (REM sleep behavior disorder) are found in 10%-50% of patients. SWD are associated with cognitive disturbances and may compromise neurologic recovery. Hypnotics and sedative antidepressants may aggravate SDB and neurologic recovery and should be used with caution. For disturbances of wakefulness, dopaminergic drugs, modafinil, or activating antidepressants may be considered. Poststroke sleep-related movement disorders can be treated with dopaminergic drugs; REM sleep behavior disorder with clonazepam. Sleep-related breathing disturbances and sleep-wake disturbances are frequent conditions that affect stroke outcome. In view of existing treatment options, these conditions deserve the neurologist's awareness.

Clinical perspective: monitoring sodium oxybate-treated narcolepsy patients for the development of sleep-disordered breathing

PurposeWhile the symptoms of narcolepsy are often amenable to treatment with sodium oxybate (SXB), the respiratory effects of long-term SXB treatment have not been systematically studied. Recent reports have implicated SXB with several cases of worsening sleep-related breathing disturbances and accidental death. In addition, these patients are at risk for obesity, which may aggravate co-morbid obstructive sleep apnea.MethodsBased on a review of the literature and the clinical experience of the author, recommendations for the use of SXB in patients with sleep-disordered breathing have been developed.ResultsAmong narcolepsy patients with evidence of sleep disordered breathing during baseline polysomnography, SXB should be prescribed only to those patients who fully comply with nasal continuous positive airway pressure therapy. The respiratory status of other SXB-treated patients should be periodically evaluated with nocturnal oximetry.ConclusionsBased on the currently available data, physicians prescribing SXB should remain vigilant for the possible development of sleep-disordered breathing during long-term treatment with SXB.

Central sleep apnoea in Rett syndrome

Breathing disturbances in Rett syndrome were reported almost entirely during wakefulness, with normal respiration during sleep. We studied a case of a proven MECP2 mutation in a girl, whose videopolygraphic and polysomnographic monitoring suggested the evidence of central apnoeas not only during awake, but also during sleep. Apart from prevalent awake respiratory dysfunction, central apnoeas in Rett syndrome may be also present during sleep.

Nocturnal polysomnographic characteristics of habitually snoring children initially referred to pediatric ENT or sleep clinics

Objectives To determine clinical and polysomnographic characteristics of children initially referred by primary care physicians (PCP) to either otolaryngology or sleep clinics for a history of habitual snoring. Methods Retrospective review of clinical characteristics and nocturnal polysomnograms (PSG) of snoring children referred initially to otolaryngologists by PCP (i.e., ENT) compared to a cross matched population of snoring children initially referred to a pediatric sleep center (i.e., SLEEP). Results Sixty-eight ENT referred children were cross-matched to 68 SLEEP children. ENT referred children were found to have significantly larger tonsillar size compared to SLEEP children (tonsil size score 3.1 vs. 2.5, p value <0.01). Despite larger tonsillar size, there were no differences observed in the number of children with clinically significant obstructive sleep apnea syndrome (OSAS) with an obstructive apnea hypopnea index (OAHI) ⩾ 5/h TST (40 ENT vs. 38 SLEEP children). Furthermore, SLEEP children with OSAS exhibited more severe sleep related breathing disturbances compared to ENT children (obstructive apnea index: 5.0 vs. 1.5 /h TST, p value <0.01; mean oxygen saturation nadir [76.3% vs. 87.0%, p < 0.01]). Finally, in 28 ENT referred children vs. 30 SLEEP the OAHI was <5/h TST. Conclusions Children referred by ENT are not more likely to be diagnosed with OSAS than snoring children directly referred to a pediatric sleep clinic by their pediatricians. The only difference in the referral decision between ENT and SLEEP seems to be tonsil size. Furthermore, PSG revealed a large percentage of children in whom surgical indication for AT is not obvious, thus suggesting that PSG is useful in determining the management of snoring children initially referred to ENT. Finally, SLEEP referred children diagnosed with OSAS exhibited increased indices among selected parameters indicative of sleep-disordered breathing.

Laryngomalacia in a 12-year-old child after laryngeal mask use

We present an unusual case of a 12-year-old child with state-dependent laryngomalacia presenting after anaesthesia with a laryngeal mask airway. Current literature on state-dependent laryngomalacia and injury following laryngeal mask use is reviewed. A child who had previously suffered with laryngomalacia as an infant presented with disturbed breathing at night and during exercise. After anaesthesia using a laryngeal mask airway, these symptoms became more pronounced. Microlaryngoscopy revealed laryngomalacic type movement of the larynx. Our case seems to support a more complex, multifactorial aetiology for laryngomalacia, including both the neurological control of the larynx as well as its structure.

Sibutramine versus continuous positive airway pressure in obese obstructive sleep apnoea patients

The aim of the present study was to compare the efficacy of 1 yr of sibutramine-induced weight loss versus continuous positive airway pressure (CPAP) treatment on sleep-disordered breathing, cardiac autonomic function and systemic blood pressure in obese patients with obstructive sleep apnoea. Subjects with a body mass index of > or =30 kg.m(-2) without previous treatment for obstructive sleep apnoea underwent either sibutramine (n = 22) or CPAP (n = 18) treatment for 1 yr. Sibutramine induced a 5.4+/-1.4 kg decrease in body weight compared to the CPAP group, in which no changes in anthropometric variables were observed. The CPAP treatment improved all sleep and respiratory variables, whereas sibutramine-induced weight loss improved only nocturnal arterial oxygen saturation profile. Only CPAP treatment improved night-time systolic and diastolic blood pressure and 24-h and daytime ambulatory diastolic blood pressure. Sibutramine-induced weight loss had no impact on indices of heart rate variability, whereas CPAP treatment increased daytime time domain indices. CPAP treatment for 1 yr had beneficial impacts on nocturnal breathing disturbances, and improved nocturnal oxygenation, night-time systolic and diastolic blood pressure, and daytime cardiac parasympathetic modulation. Sibutramine did not improve sleep-disordered breathing, systemic blood pressure or heart rate variability. There were no adverse effects, such as increment in blood pressure or arrhythmias, associated with this treatment regimen.

Combined adaptive servo-ventilation and automatic positive airway pressure (anticyclic modulated ventilation) in co-existing obstructive and central sleep apnea syndrome and periodic breathing

Background The co-existence of obstructive and central sleep apnea/hypopnea syndrome (OSAS) and periodic breathing is common in patients with and without underlying heart diseases. While automatic continuous positive airway pressure (APAP) has proven to effectively treat OSAS, the adaptive servo-ventilation (ASV) sufficiently improves periodic breathing. This is the first trial on a device which combines both treatment modes. Methods Pilot study on a two-week treatment in patients with co-existing obstructive and central and periodic breathing disturbances during sleep. Twelve consecutive patients (9 male, 3 female, age 56.9 ± 10.6 years, BMI 32.4 ± 5.5 kg/m 2) were treated with a new algorithm which combines APAP and ASV (also called anticyclic modulated ventilation (ACMV), SOMNOventCR ®, Weinmann, Hamburg, Germany). Seven suffered from arterial hypertension, coronary heart disease and mitral regurgitation, none from congestive heart failure. Results The total apnea–hypopnea index (AHI) improved from 43.8 ± 24.0/h to 2.1 ± 2.4 ( p < 0.01), the obstructive AHI from 12.8 ± 14.3/h to 0.3 ± 0.6/h ( p < 0.01) and the central AHI from 31.0 ± 17.5/h to 1.7 ± 2.0/h ( p < 0.01). Moreover, there was a significant improvement in the total number of arousals, respiratory induced arousals, oxygen saturation and sleep profile. Conclusion The algorithm combining automatic continuous positive airway pressure (CPAP) and ASV normalizes all types of co-existing obstructive and central apnea/hypopnea and periodic breathing.

Therapeutical options for the treatment of Cheyne-Stokes respiration.

The awareness of Cheyne-Stokes respiration (CSR) and of the co-existence of the obstructive sleep apnoea syndrome and central breathing disturbances has rapidly grown in recent years. CSR is defined by a waxing and waning pattern of the breathing amplitude. Sleep related breathing disorders in patients with heart failure are associated with impaired clinical outcome and survival. While continuous positive airway pressure treatment (CPAP) is widely used to treat CSR, it has failed to improve overall survival of heart failure patients. Nevertheless, it has been shown that CPAP reduces mortality if breathing disturbances were sufficiently eliminated. Therefore, optimal suppression of CSR is critical. While CPAP reduces CSR by 50% on average, adaptive servoventilation (ASV) normalises CSR in most patients. ASV devices apply different levels of pressure support: during periods of hypoventilation the inspiratory pressure is increased while it is reduced to the lowest possible level during hyperventilation. The devices deliver an expiratory pressure to overcome upper airways obstruction. Pressure support is defined by the difference between expiratory and inspiratory pressure. Thus, while pressure support is fixed in bilevel devices, it varies under ASV. However, the hypothesis that ASV might improve survival in CSR patients has to be proved in prospective studies in CPAP nonresponders. There is a lack of evidence on the use of bilevel devices in CSR. However, ASV has proven both to effectively treat CSR and to be superior to CPAP in respiratory and sleep parameters in short term and medium term studies. Nevertheless, data on the long term use and the influence on cardiac parameters are necessary.

Therapeutical options for the treatment of Cheyne-Stokes respiration.

The awareness of Cheyne-Stokes respiration (CSR) and of the co-existence of the obstructive sleep apnoea syndrome and central breathing disturbances has rapidly grown in recent years. CSR is defined by a waxing and waning pattern of the breathing amplitude. Sleep related breathing disorders in patients with heart failure are associated with impaired clinical outcome and survival. While continuous positive airway pressure treatment (CPAP) is widely used to treat CSR, it has failed to improve overall survival of heart failure patients. Nevertheless, it has been shown that CPAP reduces mortality if breathing disturbances were sufficiently eliminated. Therefore, optimal suppression of CSR is critical. While CPAP reduces CSR by 50% on average, adaptive servoventilation (ASV) normalises CSR in most patients. ASV devices apply different levels of pressure support: during periods of hypoventilation the inspiratory pressure is increased while it is reduced to the lowest possible level during hyperventilation. The devices deliver an expiratory pressure to overcome upper airways obstruction. Pressure support is defined by the difference between expiratory and inspiratory pressure. Thus, while pressure support is fixed in bilevel devices, it varies under ASV. However, the hypothesis that ASV might improve survival in CSR patients has to be proved in prospective studies in CPAP nonresponders. There is a lack of evidence on the use of bilevel devices in CSR. However, ASV has proven both to effectively treat CSR and to be superior to CPAP in respiratory and sleep parameters in short term and medium term studies. Nevertheless, data on the long term use and the influence on cardiac parameters are necessary.

Markers of glycemic control and insulin resistance in non-diabetic patients with Obstructive Sleep Apnea Hypopnea Syndrome: Does adherence to CPAP treatment improve glycemic control?

Background and Aim Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) is associated with glucose dysmetabolism and insulin resistance, therefore the amelioration of breathing disturbances during sleep can allegedly modify the levels of markers of glucose regulation and insulin resistance, such as glycated hemoglobin, fasting glucose, insulin and HOMA IR. The aim of this study was to explore the association between these parameters and sleep characteristics in non-diabetic OSAHS patients, as well as the effect of 6 months CPAP therapy on these markers, according to adherence to CPAP treatment. Methods Euglycemic patients ( n = 56; mean age ± SD: 46.07 ± 10.67 years) with newly diagnosed OSAHS were included. Glycated hemoglobin, fasting glucose, insulin levels and HOMA IR were estimated at baseline and 6 months after CPAP application. According to CPAP adherence, patients were classified as follows: group 1 (mean CPAP use ⩾ 4 h/night), group 2 (mean CPAP use < 4 h/night) and group 3 (refused CPAP treatment), and comparisons of levels of the examined parameters were performed. Results At baseline, average SpO 2 during sleep was negatively correlated with insulin levels and HOMA IR while minimum SpO 2 during sleep was also negatively correlated with insulin levels. After 6 months, only group 1 patients demonstrated a significant decrease in glycated hemoglobin ( p = 0.004) accompanied by a decrease in hs-CRP levels ( p = 0.002). No other statistically significant change was observed. Conclusions Nighttime hypoxia can affect fasting insulin levels in non-diabetic OSAHS patients. Good adherence to long-term CPAP treatment can significantly reduce HbA 1C levels, but has no effect on markers of insulin resistance.

Behavioral Correlates of Sleep-Disordered Breathing in Older Men

To examine the association between sleep-disordered breathing (SDB) and subjective measures of daytime sleepiness, sleep quality, and sleep-related quality of life in a large cohort of community-dwelling older men and to determine whether any association remained after adjustment for sleep duration. Cross-sectional. The functional outcome measures of interest were daytime sleepiness (Epworth Sleepiness Scale, ESS), sleep-related symptoms (Pittsburgh Sleep Quality Index, PSQI), and sleep-related quality of life (Functional Outcomes of Sleep Questionnaire, FOSQ). Analysis of variance and adjusted regression analyses examined the association between these outcome measures and SDB severity and actigraphy-determined total sleep time (TST). We then explored whether associations with SDB were confounded by sleep duration by adjusting models for TST. Community-based sample in home and research clinic settings. Two-thousand eight-hundred forty-nine older men from the multicenter Osteoporotic Fractures in Men Study that began in 2000. All participants underwent in-home polysomnography for 1 night and wrist actigraphy for a minimum of 5 consecutive nights. N/A. Participants were aged 76.4 + 5.5 years and had an apnea-hypopnea index (AHI) of 17.0 + 15.0. AHI and TST were weakly correlated. ESS scores individually were modestly associated with AHI and TST, but the association with AHI was attenuated by adjustment for TST. PSQI and FOSQ scores were largely not associated with measures of SDB severity but were modestly associated with TST. Daytime sleepiness, nighttime sleep disturbances, and sleep-related quality of life were modestly associated with TST. After adjustment for TST, there was no independent association with SDB severity. These results underscore the potential differences in SDB functional outcomes in older versus young and middle-aged adults.

Screening adults for obstructive sleep apnea

Obstructive sleep apnea (OSA) is the most prevalent breathing disturbance during sleep [1], affecting 2% to 6% of the general population, depending on age, sex, and the defi nition of criteria [2]. An estimated 82% of men and 92% of women with moderate to severe OSA have not been diagnosed [3]. Sleep apnea events are defi ned as a complete cessation of breathing (apnea) or a marked reduction in airfl ow (hypopnea) during sleep, and are considered clinically relevant if they last more than 10 seconds. The episodes of apneas and hypopneas may persist for 30 to 60 seconds in some individuals. OSA is characterized by repetitive obstruction of the upper airway, often resulting in oxygen desaturation and arousals from sleep. The classic daytime manifestation is excessive sleepiness, and other symptoms such as non-refreshing sleep, poor concentration, and fatigue are commonly reported [4]. OSA is a serious condition that diminishes the quality of life [5] and is also associated with many common comorbidities. Studies have documented an increased incidence of coronary artery disease, hypertension, congestive heart failure, cerebrovascular accidents, and gastroesophageal refl ux disease in OSA patients [6,7]. It is estimated that the average life span of an untreated OSA patient is 58 years, much shorter than the average life spans of 78 years for men and 83 years for women [8]. The signs and symptoms of OSA are shown in Table 1.

Central Alveolar Hypoventilation Syndrome Due to Surgical Resection for Bulbar Hemangioblastoma

A 29-year-old man with a history of resected bulbar hemangioblastoma was admitted to hospital with nighttime breathing disturbance, but with apparently normal breathing while awake. After diagnostic work-up, including polysomnographic testing, he was diagnosed as having central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma. Non-invasive positive pressure ventilation (NIPPV) via oronasal facemask was given for nocturnal ventilatory support. Two months after leaving our hospital, he was readmitted because of aspiration pneumonia. The pneumonia was successfully treated with antibiotics, but the desaturation during sleep worsened despite non-invasive ventilatory support. Higher bi-level positive pressure using a full facemask successfully alleviated sleep hypoventilation and apnea. To the best of our knowledge, this is the first case report of central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma.

Effects of obstructive sleep apnea on autonomic cardiac control during sleep

The present study investigated whether autonomic control of the heart for persons with low and high levels of sleep apnea/hypopnea differed between sleep stages and across the sleep period. Electrocardiography and impedance cardiography of 24 patients referred to polysomnography were recorded through the night. A mixed repeated-measures and between-subjects, quasi-experimental design was utilized. Heart period, high frequency heart rate variability, and pre-ejection period were computed, respectively, as measure of heart rate and estimates of parasympathetic and sympathetic control. The cardiac and autonomic measures for participants with low apnea-hypopnea indices were compared to those of patients with high rates of apnea-hypopnea across the sleep period and sleep stages. Cardiac rates of the two groups decreased incrementally through the sleep period. Cardiovascular measures during sleep from the group with high rates of apnea-hypopnea indicated larger parasympathetic activation in relation to wake baseline for epochs without arousals than from the group with low apnea-hypopnea rates. Parasympathetic activation during nonrapid-eye movement (non-REM) sleep (sleep stage 2) was significantly greater than during REM sleep. Higher levels of apnea-hypopnea seem to be associated with increased parasympathetic control, especially during lighter, non-REM sleep. A possible explanation for this phenomenon is a compensatory response to oxygen desaturation caused by disturbed breathing.

Adaptive Servoventilation (ASV) in Patients with Sleep Disordered Breathing Associated with Chronic Opioid Medications for Non-Malignant Pain

Adaptive servoventilation (ASV) can be effective therapy for specific types of central apnea such as Cheyne-Stokes respiration (CSR). Patients treated chronically with opioids develop central apneas and ataxic breathing patterns (Biot's respiration), but therapy with CPAP is usually unsuccessful. There are no published studies of ASV in patients with sleep apnea complicated by chronic opioid therapy. Retrospective analysis of 22 consecutive patients referred for evaluation and treatment of sleep apnea who had been using opioid medications for at least 6 months, had an apnea-hypopnea index (AHI) > or = 20/h, and had been tested with ASV. Baseline polysomnography was compared with CPAP and ASV. AHI, central apnea index (CAI), obstructive apnea index (OAI), hypopnea index (HI), desaturation index, mean SpO2, lowest SpO2, time SpO2 < 90%, and degree of Biot's respiration. Mean (SD) AHI measured 66.6/h (37.3) at baseline, 70.1/h (32.6) on CPAP, and 54.2/h (33.0) on ASV. With ASV, the mean OAI was significantly decreased to 2.4/h (p < 0.0001), and the mean HI increased significantly to 35.7/h (p < 0.0001). The decrease of CAI from 26.4/h to 15.6/h was not significant (p = 0.127). Biot's breathing persisted, and oxygenation parameters were unimproved with ASV. Due to residual respiratory events and hypoxemia, ASV was considered insufficient therapy in these patients. Persistence of obstructive events could be due to suboptimal pressure settings (end expiratory and/or maximal inspiratory). Residual central events could be related to fundamental differences in the pathophysiology of CSR compared to opioid induced breathing disturbances.

Dose-related patterns of glucocorticoid-induced side effects

Objective:To identify patterns of self-reported health problems relating to dose and duration of glucocorticoid intake in unselected patients with rheumatoid arthritis from routine practice.Methods:Data from 1066 patients were analysed. The...