Repetitive Pharyngeal Collapse Research Articles

Controversies in Obstructive Sleep Apnea Surgery.

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

Controversies in Obstructive Sleep Apnea Surgery.

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

Obstructive sleep apnoea-hypopnoea and arrhythmias: new updates.

Obstructive sleep apnoea-hypopnoea (OSAH) is a prevalent condition characterized by repetitive pharyngeal collapse during sleep, leading to hypoxemia, hypercapnia, and persistent inspiratory efforts against an occluded airway until arousal. Several studies demonstrated that OSAH exerts acute and chronic effects on the cardiovascular system. Thus, although being a respiratory problem, the most important consequences of OSAH are cardiovascular, among which there are arrhythmias. The purpose of this review is to systematically analyse what has been recently published about the relationship between OSAH and every cardiac arrhythmia separately. We searched Pubmed, Scopus, Web of Science and Cochrane Collaboration databases for 'OSAHS arrhythmias', 'OSAH arrhythmias' and 'OSA arrhythmias'. We analyse 1298 articles and meta-analyses, excluding already edited reviews. Arrhythmias, especially of ventricular origin, are frequent in OSAH. Ventricular premature beats, couplets and ventricular tachycardia runs are even more frequent in patients suffering from heart failure. They may be due to left heart remodelling, overwork and ischaemia and can explain at least some sudden deaths occurring between midnight and 6 a.m. Sinus pauses and atrioventricular blocks are increased according to the severity of the disturbance and may be reduced by continuous positive airway pressure therapy, preventing pace-maker implantation. Finally, atrial fibrillation, resistance against antiarrhythmic drugs and recurrences after surgical procedures are strongly related to OSAH. Arrhythmias are frequent in OSAH. Treatment of OSAH may reduce some of them. An implantable cardioverter-defibrillator and continuous positive airway pressure should be considered in some patients.

Tube Law of the Pharyngeal Airway in Sleeping Patients with Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is characterized by repetitive pharyngeal collapse during sleep. However, the dynamics of pharyngeal narrowing and re-expansion during flow-limited breathing are not well described. The static pharyngeal tube law (end-expiratory area versus luminal pressure) has demonstrated increasing pharyngeal compliance as luminal pressure decreases, indicating that the airway would be sucked closed with sufficient inspiratory effort. On the contrary, the airway is rarely sucked closed during inspiratory flow limitation, suggesting that the airway is getting stiffer. Therefore, we hypothesized that during inspiratory flow limitation, as opposed to static conditions, the pharynx becomes stiffer as luminal pressure decreases. Upper airway endoscopy and simultaneous measurements of airflow and epiglottic pressure were performed during natural nonrapid eye movement sleep. Continuous positive (or negative) airway pressure was used to induce flow limitation. Flow-limited breaths were selected for airway cross-sectional area measurements. Relative airway area was quantified as a percentage of end-expiratory area. Inspiratory airway radial compliance was calculated at each quintile of epiglottic pressure versus airway area plot (tube law). Eighteen subjects (14 males) with OSA (apnea-hypopnea index = 57 ± 27 events/h), aged 49 ± 8 y, with a body mass index of 35 ± 6 kg/m(2) were studied. A total of 163 flow limited breaths were analyzed (9 ± 3 breaths per subject). Compliances at the fourth (2.0 ± 4.7 % area/cmH2O) and fifth (0.0 ± 1.7 % area/cmH2O) quintiles were significantly lower than the first (12.2 ± 5.5 % area/cmH2O) pressure quintile (P < 0.05). The pharyngeal tube law is concave (airway gets stiffer as luminal pressure decreases) during respiratory cycles under inspiratory flow limitation.

Obstructive sleep apnea: an experience

Background: Obstructive sleep apnea (OSA) is a common disorder of repetitive pharyngeal collapse during sleep. It is more common among middle-aged adults. Obesity leads to and intensifies OSA. Epidemiologic studies have recorded relations of OSA with hypertension. The Berlin Questionnaire may find persons at high possibility for OSA and hence can evade costly polysomnography (PSG) studies, especially in resource-limited settings. This study is about our experience of Berlin Questionnaire and clinical characteristics of patients with OSA. Objective: To reveal our experience of OSA in terms of (i) age/sex distribution; (ii) Berlin Questionnaire utility; (iii) clinical features; (iv) polysomnograhic findings; and (v) association with obesity and hypertension. Materials and Methods: This prospective observational study was done in the Department of Chest Medicine and Department of ENT, Head and Neck Surgery of Government Medical College, Srinagar, Jammu and Kashmir. Outpatient department/inpatient department patients who showed positive scoring on Berlin Questionnaire were enrolled in the study. PSG was done in all of these patients. Clinical features, blood pressure, and body mass index (BMI) were noted in patients who showed positive PSG. Result: This study included a total of 120 Berlin Questionnaire positive patients, of which 96 were positive on PSG. Positive predictability value of Berlin Questionnaire was 80% for both low- and high-risk cases. Majority of PSG positive cases were female subjects (68.75%) while males comprised 31.25% of PSG positive cases. Most common age group was 51–65 years. Of PSG positive OSA patients, 41 (42.7%) showed mild disease, 30 (31.2%) moderate disease, and 25 (26%) severe disease. Most patients were grouped as per BMI into obese class II, and majorities were subjects with hypertension. In addition to snoring, other clinical features were dry mouth, excessive daytime sleepiness, and irritability. Conclusion: Berlin Questionnaire is an important screening tool to detect suspected OSA patients. Although male subjects are more commonly seen to be affected in literature, we found female predominance. Most of these patients are middle-aged. Obesity is an important risk factor, and most of these patients show BMI > 30 kg/m2. Most of these patients present hypertension as a comorbidity.

Obstructive sleep apnea and cardiac arrhythmias

Sleep-disordered breathing (SDB), which includes obstructive sleep apnea (OSA) as its most extreme variant, is characterized by intermittent episodes of partial or complete obstruction of the upper airway, leading to cessation of breathing while asleep. Cardiac arrhythmias are common problems in OSA patients, although the true prevalence and clinical relevance of cardiac arrhythmias remains to be determined. The presence and complexity of tachyarrhythmias and bradyarrhythmias may influence morbidity, mortality and quality of life for patients with OSA. Although the exact mechanisms underlying the link between OSA and cardiac arrhythmias are not well established, they could be some of the same proposed mechanisms relating OSA to different cardiovascular diseases, such as repetitive pharyngeal collapse during sleep, which leads to markedly reduced or absent airflow, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against an occluded airway and termination by arousal from sleep. These mechanisms elicit a variety of autonomic, hemodynamic, humoral and neuroendocrine responses that evoke acute and chronic changes in cardiovascular function. However, despite substantial research effort, the goals of determining in advance which patients will respond most favorably to certain treatment options (such as continuous positive airway pressure, tracheostomy or cardioversion) and the developing alternative treatments remain largely elusive. Therefore, this literature review aims to summarize a broad array of the pathophysiological mechanisms underlying the relationship between OSA and cardiac arrhythmias and the extent of this association from an epidemiological perspective, thereby attempting to assess the effects of OSA treatment on the presence of cardiac arrhythmias.

Obstructive Sleep Apnea and its Relationship to Cardiac Arrhythmias

Obstructive sleep apnea (OSA) affects approximately 4% of middle-aged men and 2% of middle-aged women. Cardiac arrhythmias are common problems in patients with OSA, even though the true prevalence and clinical relevance of cardiac arrhythmias remains to be determined. The presence and complexity of both tachyarrhythmias and bradyarrhythmias may influence morbidity, mortality, and the quality of life for OSA patients. Although the exact mechanisms underlying the link between OSA and cardiac arrhythmias are not well established, they could be partially the same proposed mechanisms relating OSA to different cardiovascular diseases. OSA is characterized by repetitive pharyngeal collapse during sleep that leads to markedly reduced or absent airflow, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against an occluded airway, and termination by arousal from sleep. These mechanisms elicit a variety of autonomic, hemodynamic, humoral, and neuroendocrine responses that by themselves evoke acute and chronic changes in cardiovascular function. These effects may lead to the development of cardiac arrhythmias and any other form of cardiovascular disease linked to OSA. The aims of this review are to describe the essential cardiovascular pathophysiological aspects of OSA, to outline the relationship between OSA and both tachyarrhythmias and bradyarrhythmias and their possible influence in the natural history of OSA patients, and to assess the effects of OSA treatment on the presence of cardiac arrhythmias.

Obstructive sleep apnea syndrome as an uncommon cause of fibromyalgia: a case report

Fibromyalgia syndrome (FMS) is characterized by chronic widespread musculoskeletal pain, stiffness and tenderness at multiple points. Sleep disturbances are common in FMS and patients usually complain about nonrestorative sleep. Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive pharyngeal collapse during sleep. Recurrent arousals from sleep occurs to restore pharyngeal patency in OSAS and this results in increased sympathetic activity and fragmentation of sleep. Sleep disturbances may lead to musculoskeletal pain and some studies suggest a relation between OSAS and FMS. Since OSAS is strongly associated with increased risk of myocardial infarction, cerebrovascular accidents and congestive heart failure, its diagnosis and treatment are of particular importance. Herein we present a female patient with diagnosis of FMS for 10 years who had complaints of morning fatigue, restless sleep, sleepiness during day and snoring besides musculoskeletal symptoms. Severe OSAS was diagnosed after polysomnographic analysis and FMS symptoms were totally improved with nasal continuous positive airway pressure treatment.

Aging Influences on Pharyngeal Anatomy and Physiology: The Predisposition to Pharyngeal Collapse

Obstructive sleep apnea is a common disorder with important sequelae.1–7 Aging substantially increases the risk of obstructive apnea,8–11 although the mechanisms underlying this predisposition remain unclear.8,12–15 Most current evidence suggests that obstructive apnea results from an interaction of the anatomy of the upper airway with the control of pharyngeal dilator muscles.4 Afflicted patients have compromised pharyngeal anatomy with reduced airway lumen.16–19,20 Through reflex mechanisms that drive activation of dilator muscles, pharyngeal patency is well maintained during wakefulness.21–23 However, these protective reflexes are diminished during sleep, thereby leading to collapse of the pharyngeal airway in anatomically predisposed people.24 Thus, aging could predispose to apnea via changes in pharyngeal anatomy and biomechanics or via deterioration in the function of pharyngeal dilator muscles.25–31 By combining magnetic resonance imaging techniques with pharyngeal physiological assessments, we sought to determine the structural and functional basis for the increased propensity for airway collapse among older persons. We included normal and near-normal controls to avoid the confounding influences of repetitive pharyngeal collapse as might occur with sleep apnea.

Prevalence of obstructive sleep apnoea following head and neck cancer treatment: A cross-sectional study

The obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a sleep-related breathing disorder characterised by repetitive pharyngeal collapse. OSAHS is associated with a reduced quality of life. A high OSAHS prevalence has been reported in patients treated for head and neck cancer (HNC). The aim of the present study was to identify the prevalence of OSAHS within a Dutch population of patients treated for HNC. Consecutive HNC patients with a follow-up of 6 months to 5 years after treatment of an oral or oropharynx carcinoma were eligible for inclusion. Two questionnaires were used to assess the presence of OSAHS-related complaints. Subsequently, polysomnography was used in patients with OSAHS-related complaints to confirm the diagnosis of OSAHS. Four out of 33 included patients were diagnosed with OSAHS, yielding a prevalence of 12%. Since recognition and treatment of OSAHS might play an important role in improving quality of life of HNC patients, we suggest screening all patients with an oral or oropharynx carcinoma for the presence of OSAHS-related complaints prior to and following HNC treatment.

Association of Serotonin Transporter Gene Polymorphism with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common condition characterized by repetitive pharyngeal collapse during sleep and daytime sleepiness. There is genetic predisposition to sleep disorders. Serotonin is involved in the regulation of sleep. The synaptic 5-hydroxytryptamine (HT) is inactivated by presynaptic reuptake, which is mediated by the serotonin transporter. Blockage of the serotonin transporter leads to increased extracellular 5-HT. Polymorphism of the serotonin transporter gene (STG) leads to alterations in serotonin level and may be important in OSAS. In this study, we aimed to assess the role of STG polymorphism in OSAS. Twenty-seven OSAS patients and 162 healthy volunteers were involved in the study. STG polymorphism was investigated using leukocytes obtained from peripheral blood. There was no difference between the genotypes and allele frequencies of the patients and controls regarding VNTR and HTTLPR polymorphisms (P > .05). The VNTR and HTTLPR variants and the frequencies of 12/12, 12/10, L, and S alleles were not significantly different between male and female control subjects (P > .05). The 12/12 and SS genotypes were over-represented in the female patients, whereas 12/10 and LL genotypes were over-represented in the male patients (P < .05). The genotypes 12 to 12 were over-represented in the male controls, whereas the genotypes 12 to 10 and L/S were over-represented in the male patients (P < .05). The alleles 10 and L were more frequent in the male patients than male controls (P < .05). The genotypes of female patients and female controls were not significantly different (P > .05). The allele 10 and L were less frequent in the female patients than female controls with Fisher's exact testing (P < .05). There was no relation between genotypes and clinical data of the patients (P > .05). STG polymorphism appears to be associated with the occurrence of OSAS, especially in male patients. Absence of association of between genetic variants and polysomnography findings may suggest that some mechanisms other than STG polymorphism are involved in OSAS pathophysiology. Our results need confirmation in a larger group of patients with OSAS.

Obstructive sleep apnoea.

Obstructive sleep apnoea is a disease of increasing importance because of its neurocognitive and cardiovascular sequelae. Abnormalities in the anatomy of the pharynx, the physiology of the upper airway muscle dilator, and the stability of ventilatory control are important causes of repetitive pharyngeal collapse during sleep. Obstructive sleep apnoea can be diagnosed on the basis of characteristic history (snoring, daytime sleepiness) and physical examination (increased neck circumference), but overnight polysomnography is needed to confirm presence of the disorder. Repetitive pharyngeal collapse causes recurrent arousals from sleep, leading to sleepiness and increased risk of motor vehicle and occupational accidents. The surges in hypoxaemia, hypercapnia, and catecholamine associated with this disorder have now been implicated in development of hypertension, but the association between obstructive sleep apnoea and myocardial infarction, stroke, and congestive heart failure is not proven. Continuous positive airway pressure, the treatment of choice for obstructive sleep apnoea, reduces sleepiness and improves hypertension.

Upper-Airway Collapsibility: Measurements and Sleep Effects

Obstructive sleep apnea (OSA) is characterized by repetitive pharyngeal collapse during sleep. Several techniques have been proposed to assess the collapsibility of the upper airway in awake humans, but sleep-wake comparisons have rarely been attempted and there are few studies comparing OSA patients to control subjects. We sought to compare two collapsibility measurement techniques between normal and apneic subjects, and between wakefulness and sleep. We conducted three studies. First, we examined whether collapsibility assessed by negative pressure pulses (NPPs) during wakefulness reflected values during sleep in 21 normal subjects. Second, we determined in these normal subjects whether collapsibility during sleep assessed by NPPs was predictive of collapsibility measured by inspiratory resistive loading (IRL). Finally, we compared upper-airway collapsibility between apnea patients (n = 22) and normal volunteers (n = 38) during wakefulness by NPPs. Clinical and research laboratories at the Brigham and Women's Hospital. Two populations of normal subjects (n = 21 and n = 38) and OSA patients (n = 22). Collapsibility during wakefulness, as measured by NPPs, correlated significantly with collapsibility during sleep (r = 0.62; p = 0.003). There was also a significant correlation between the two measures of collapsibility (IRL and NPP) during sleep (r = 0.53; p = 0.04). Both measures revealed a significant increase in pharyngeal collapsibility during sleep as compared to wakefulness. Finally, apnea patients had significantly greater pharyngeal collapsibility than control subjects during wakefulness (p = 0.017). These data suggest that upper-airway collapsibility measured during wakefulness does provide useful physiologic information about pharyngeal mechanics during sleep and demonstrates clear differences between individuals with and without sleep apnea.