|
1
|
Kryger M. Serendipity. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2023; 4:zpad029. [PMID: 37744181 PMCID: PMC10516468 DOI: 10.1093/sleepadvances/zpad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Meir Kryger
- Professor Emeritus, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
|
2
|
Belli-Marin JFC, Bocchi EA, Ayub-Ferreira S, Junior NC, Guimarães GV. Effects of β-blocker therapy on exercise oscillatory ventilation in reduced ejection fraction heart failure patients: A case series study. Biomed Pharmacother 2022; 152:113106. [PMID: 35665667 DOI: 10.1016/j.biopha.2022.113106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is an abnormal breathing pattern that occurs in ~20% of patients with heart failure (HF) and is associated with poor prognosis and exercise intolerance. β-blockers (βb) are prescribed for most HF patients; however, their effect on EOV remains unclear. We evaluated the effect of βb on EOV in HF patients with reduced ejection fraction (HFrEF). METHODS Fifteen patients diagnosed with HF, ejection fraction < 45%, aged from 18 to 65 years, were included before starting βb therapy. Patients underwent clinical evaluation, cardiopulmonary exercise testing, echocardiography, laboratory exams (norepinephrine levels, B type natriuretic peptide) at baseline and after βb therapy optimized for six months. Presence of exercise oscillatory breathing was determined by two experienced observers who were blinded to the moment of the test (pre or post). RESULTS Fifteen patients (1 female), aged 49.5 ± 2.5 years, with HFrEF, NYHA I-III enrolled in the study. The etiologies of the HFrEF were idiopathic (n = 8) and hypertensive (n = 7). LVEF increased after βb therapy from 25.9 ± 2.5% to 33 ± 2.6%, P = 0.02; peak VO2 did not significantly change (21.8 ± 1.7 vs 24.7 ± 1.9, P = 0.4); VE/VCO2 slope changed from 32.1 ± 10.6-27.5 ± 9.1, P = 0.03. Before βb initiation, nine patients (60%) had EOV, but only two (13%) did after optimized therapy. McNemar test was used to evaluate the significance of the association between the two moments (P = 0.02). CONCLUSION In patients with HF, medical therapy with βb can reverse EOV. This may explain why these patients experience symptom improvement after βb therapy.
Collapse
Affiliation(s)
| | - Edimar Alcides Bocchi
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Silvia Ayub-Ferreira
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Nelson Carvas Junior
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Guilherme Veiga Guimarães
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
| |
Collapse
|
|
3
|
Pinna GD, Maestri R. Computer-Assisted Assessment of the Interaction Between Arousals, Breath-by-Breath Ventilation, and Chemical Drive During Cheyne-Stokes Respiration in Heart Failure Patients. Front Physiol 2022; 13:815352. [PMID: 35222084 PMCID: PMC8867072 DOI: 10.3389/fphys.2022.815352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
Abstract
Transient increases in ventilation induced by arousal from sleep during Cheyne-Stokes respiration in heart failure patients are thought to contribute to sustaining and exacerbating the ventilatory oscillation. The only possibility to investigate the validity of this notion is to use observational data. This entails some significant challenges: (i) accurate identification of both arousal onset and offset; (ii) detection of short arousals (<3 s); (iii) breath-by-breath analysis of the interaction between arousals and ventilation; (iv) careful control for important confounding factors. In this paper we report how we have tackled these challenges by developing innovative computer-assisted methodologies. The identification of arousal onset and offset is performed by a hybrid approach that integrates visual scoring with computer-based automated analysis. We use a statistical detector to automatically discriminate between dominant theta–delta and dominant alpha activity at each instant of time. Moreover, a statistical detector is used to validate visual scoring of K complexes, delta waves or artifacts associated with an EEG frequency shift, as well as frequency shifts to beta activity. A high-resolution (250 ms) state-transition diagram providing continuous information on the sleep-wake state of the subject is finally obtained. Based on this information, arousals are automatically identified as any state change from sleep to wakefulness lasting ≥2 s. The assessment of the interaction between arousals and ventilation is performed using a breath-by-breath, case-control approach. The arousal-associated change in ventilation is measured as the normalized difference between minute ventilation in the case breath (i.e., with arousal) and that in the control breath (i.e., without arousal), controlling for sleep stage and chemical drive. The latter is estimated by using information from pulse oximetry at the finger. In the last part of the paper, we discuss main potential sources of error inherent in the described methodologies.
Collapse
|
|
4
|
Pinna GD, Robbi E, Bruschi C, La Rovere MT, Maestri R. Interaction Between Arousals and Ventilation During Cheyne-Stokes Respiration in Heart Failure Patients: Insights From Breath-by-Breath Analysis. Front Med (Lausanne) 2022; 8:742458. [PMID: 34977056 PMCID: PMC8717813 DOI: 10.3389/fmed.2021.742458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Study Objectives: Arousals from sleep during the hyperpneic phases of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA) in patients with heart failure are thought to cause ventilatory overshoot and a consequent longer apnea, thereby sustaining and exacerbating ventilatory instability. However, data supporting this model are lacking. We investigated the relationship between arousals, hyperpnea and post-hyperpnea apnea length during CSR-CSA. Methods: Breath-by-breath changes in ventilation associated with the occurrence of arousal were evaluated in 18 heart failure patients with CSR-CSA, apnea-hypopnea index ≥15/h and central apnea index ≥5/h. The change in apnea length associated with the presence of arousal during the previous hyperpnea was also evaluated. Potential confounding variables (chemical drive, sleep stage) were controlled for. Results: Arousals were associated with a large increase in ventilation at the beginning of the hyperpnea (+76 ± 35%, p < 0.0001), that rapidly declined during its crescendo phase. Around peak hyperpnea, the change in ventilation was -8 ± 26% (p = 0.14). The presence of arousal during the hyperpnea was associated with a median increase in the length of the subsequent apnea of +4.6% (Q1, Q2: -0.7%, 20.5%; range: -8.5%, 36.2%) (p = 0.021). The incidence of arousals occurring at the beginning of hyperpnea and mean ventilation in the region around its peak were independent predictors of the change in apnea length (p = 0.004 and p = 0.015, respectively; R2 = 0.78). Conclusions: Arousals from sleep during CSR-CSA in heart failure patients are associated with a rapidly decreasing ventilatory overshoot at the beginning of the hyperpnea, followed by a tendency toward a slight ventilatory undershoot around its peak. On average, arousals are also associated with a modest increase in post-hyperpnea apnea length; however, large increases in apnea length (>20%) occur in about a quarter of the patients.
Collapse
Affiliation(s)
- Gian Domenico Pinna
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Elena Robbi
- Sleep and Respiratory Function Unit, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy.,Laboratory for the Study of the Autonomic Nervous System, Department of Cardiology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Claudio Bruschi
- Department of Pneumology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Maria Teresa La Rovere
- Laboratory for the Study of the Autonomic Nervous System, Department of Cardiology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Roberto Maestri
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| |
Collapse
|
|
5
|
Pinna GD, La Rovere MT, Robbi E, Tavazzi L, Maestri R. CARDIAC chronotropic effects of sleep-disordered breathing in patients with heart failure. J Sleep Res 2020; 30:e13160. [PMID: 32791565 DOI: 10.1111/jsr.13160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
It is still not known whether the oscillation in heart rate (HR) induced by sleep-disordered breathing (SDB) in patients with heart failure entails significant chronotropic effects. We hypothesised that since cyclical changes in ventilation and arterial blood gases during SDB affect HR through multiple and complexly interacting mechanisms characterised by large inter-subject variability, chronotropic effects may change from patient to patient. A total of 42 patients with moderate-to-severe chronic heart failure with systolic dysfunction underwent an in-hospital sleep study. Chronotropic effects of SDB were quantified by comparing the distribution of instantaneous HR during SDB with that during periods without SDB (noSDB) within the same night in each patient. Based on distribution changes from noSDB to SDB, 12, nine, 11, and 10 patients showed a significant tachycardic, bradycardic, tachycardic and bradycardic, and neither significant tachycardic nor significant bradycardic effect, respectively. Tachycardic and bradycardic effects were primarily due to an increase in the rate rather than in the magnitude of cyclical HR elevations and reductions, and were more prevalent and severe in patients with dominant obstructive and central events, respectively. The apnea-hypopnea index did not differ between groups. Conversely, the time spent with an oxygen saturation of <90% was greater in the tachycardic and tachycardic-bradycardic groups compared to the bradycardic group. These findings indicate that HR distribution changes induced by SDB can vary from patient to patient revealing four distinct and well-characterised chronotropic effects. These effects are related to the degree of hypoxic burden brought about by SDB and are affected by the type of sleep apnea (central/obstructive).
Collapse
Affiliation(s)
- Gian Domenico Pinna
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| | - Maria Teresa La Rovere
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| | - Elena Robbi
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy.,Sleep Laboratory, Department of Pneumology, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Roberto Maestri
- Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS Montescano, Montescano, Italy
| |
Collapse
|
|
6
|
Pinna GD, Robbi E, Terzaghi M, Corbellini D, La Rovere MT, Maestri R. Temporal relationship between arousals and Cheyne-Stokes respiration with central sleep apnea in heart failure patients. Clin Neurophysiol 2018; 129:1955-1963. [DOI: 10.1016/j.clinph.2018.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/11/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
|
|
7
|
Clinical associations with immature breathing in preterm infants: part 2-periodic breathing. Pediatr Res 2016; 80:28-34. [PMID: 27002984 PMCID: PMC4929034 DOI: 10.1038/pr.2016.58] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 01/19/2016] [Indexed: 11/13/2022]
Abstract
BACKGROUND Periodic breathing (PB) is a normal immature breathing pattern in neonates that, if extreme, may be associated with pathologic conditions. METHODS We used our automated PB detection system to analyze all bedside monitor chest impedance data on all infants <35 wk' gestation in the University of Virginia Neonatal Intensive Care Unit from 2009-2014 (n = 1,211). Percent time spent in PB was calculated hourly (>50 infant-years' data). Extreme PB was identified as a 12-h period with PB >6 SDs above the mean for gestational age (GA) and postmenstrual age and >10% time in PB. RESULTS PB increased with GA, with the highest amount in infants 30-33 wk' GA at about 2 wk' chronologic age. Extreme PB was identified in 76 infants and in 45% was temporally associated with clinical events including infection or necrotizing enterocolitis (NEC), immunizations, or caffeine discontinuation. In 8 out of 28 cases of septicemia and 10 out of 21 cases of NEC, there was a >2-fold increase in %PB over baseline on the day prior to diagnosis. CONCLUSION Infants <35 wk GA spend, on average, <6% of the time in PB. An acute increase in PB may reflect illness or physiological stressors or may occur without any apparent clinical event.
Collapse
|
|
8
|
Dhakal BP, Lewis GD. Exercise oscillatory ventilation: Mechanisms and prognostic significance. World J Cardiol 2016; 8:258-266. [PMID: 27022457 PMCID: PMC4807314 DOI: 10.4330/wjc.v8.i3.258] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Alteration in breathing patterns characterized by cyclic variation of ventilation during rest and during exercise has been recognized in patients with advanced heart failure (HF) for nearly two centuries. Periodic breathing (PB) during exercise is known as exercise oscillatory ventilation (EOV) and is characterized by the periods of hyperpnea and hypopnea without interposed apnea. EOV is a non-invasive parameter detected during submaximal cardiopulmonary exercise testing. Presence of EOV during exercise in HF patients indicates significant impairment in resting and exercise hemodynamic parameters. EOV is also an independent risk factor for poor prognosis in HF patients both with reduced and preserved ejection fraction irrespective of other gas exchange variables. Circulatory delay, increased chemosensitivity, pulmonary congestion and increased ergoreflex signaling have been proposed as the mechanisms underlying the generation of EOV in HF patients. There is no proven treatment of EOV but its reversal has been noted with phosphodiesterase inhibitors, exercise training and acetazolamide in relatively small studies. In this review, we discuss the mechanistic basis of PB during exercise and the clinical implications of recognizing PB patterns in patients with HF.
Collapse
|
|
9
|
Abstract
Neurophysiologically, central apnea is due to a temporary failure in the pontomedullary pacemaker generating breathing rhythm. As a polysomnographic finding, central apneas occur in many pathophysiological conditions. Depending on the cause or mechanism, central apneas may not be clinically significant, for example, those that occur normally at sleep onset. In contrast, central apneas occur in a number of disorders and result in pathophysiological consequences. Central apneas occur commonly in high-altitude sojourn, disrupt sleep, and cause desaturation. Central sleep apnea also occurs in number of disorders across all age groups and both genders. Common causes of central sleep apnea in adults are congestive heart failure and chronic use of opioids to treat pain. Under such circumstances, diagnosis and treatment of central sleep apnea may improve quality of life, morbidity, and perhaps mortality. The mechanisms of central sleep apnea have been best studied in congestive heart failure and hypoxic conditions when there is increased CO2 sensitivity below eupnea resulting in lowering eupneic PCO2 below apneic threshold causing cessation of breathing until the PCO2 rises above the apneic threshold when breathing resumes. In many other disorders, the mechanism of central sleep apnea (CSA) remains to be investigated.
Collapse
Affiliation(s)
- S Javaheri
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | | |
Collapse
|
|
10
|
McGee S. Cheyne-stokes breathing and reduced ejection fraction. Am J Med 2013; 126:536-40. [PMID: 23541375 DOI: 10.1016/j.amjmed.2013.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 01/08/2013] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND The accuracy of Cheyne-Stokes breathing as a sign of left ventricular dysfunction and its overall prognostic significance are unknown. METHODS Between 2001 and 2006, the author examined 386 inpatients at a Department of Veterans Affairs Medical Center and compared the finding of Cheyne-Stokes breathing and its cycle length with the patients' echocardiographic ejection fraction (EF) and 5-year survival. RESULTS A total of 45 of 386 patients (11.7%) had Cheyne-Stokes breathing. Two variables were independently associated with Cheyne-Stokes breathing: reduced EF (P<.001) and age>80 years (P=.006). The presence of Cheyne-Stokes breathing increased the probability of a markedly reduced EF (ie, EF<40%; likelihood ratio, 5.3; 95% confidence interval, 3.1-9), especially in patients aged≤80 years (likelihood ratio, 7.8; 95% confidence interval, 3.9-15.5). The finding was present in 1 of 3 affected patients (sensitivity=34%). The correlation between cycle length and EF was poor (r=0.23, P=.14). The 5-year survival of patients with Cheyne-Stokes breathing (37.2%) was similar to that of patients without the finding (42.9%, P=.18, log-rank test). CONCLUSIONS In hospitalized patients, Cheyne-Stokes breathing increases the probability of left ventricular dysfunction. It is present in 1 of 3 patients with markedly reduced EF. When detected during physical examination, Cheyne-Stokes breathing does not indicate worse prognosis.
Collapse
Affiliation(s)
- Steven McGee
- General Medical Service, Department of Veterans Affairs Medical Center, Seattle, WA 98108, USA.
| |
Collapse
|
|
11
|
Abstract
Irregular breathing characterized by cyclic variation of ventilation with a period of approximately 1 min has been recognized in patients with heart failure for almost two centuries. Periodic breathing during exercise is a noninvasive parameter that is easily recognizable during submaximal cardiopulmonary exercise testing. Recent studies have established that periodic breathing during exercise not only signals significant impairment in resting and exercise hemodynamic parameters but also potently predicts adverse events in heart failure patients. This article reviews the mechanistic basis of periodic breathing and the clinical utility of discerning patterns of irregular breathing in patients with heart failure.
Collapse
Affiliation(s)
- Bishnu P Dhakal
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | | | | |
Collapse
|
|
12
|
Murphy RM, Shah RV, Malhotra R, Pappagianopoulos PP, Hough SS, Systrom DM, Semigran MJ, Lewis GD. Exercise oscillatory ventilation in systolic heart failure: an indicator of impaired hemodynamic response to exercise. Circulation 2011; 124:1442-51. [PMID: 21875912 DOI: 10.1161/circulationaha.111.024141] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is a noninvasive parameter that potently predicts outcomes in systolic heart failure (HF). However, mechanistic insights into EOV have been limited by the absence of studies relating EOV to invasive hemodynamic measurements and blood gases performed during exercise. METHODS AND RESULTS Fifty-six patients with systolic HF (mean±SEM age, 59±2 years; left ventricular ejection fraction, 30±1%) and 19 age-matched control subjects were studied with incremental cardiopulmonary exercise testing. Fick cardiac outputs, filling pressures, and arterial blood gases were measured at 1-minute intervals during exercise. We detected EOV in 45% of HF (HF+EOV) patients and in none of the control subjects. The HF+EOV group did not differ from the HF patients without EOV (HF-EOV) in age, sex, body mass index, left ventricular ejection fraction, or origin of HF. Univariate predictors of the presence of EOV in HF, among measurements performed during exercise, included higher right atrial pressure and pulmonary capillary wedge pressure and lower cardiac index (CI) but not Paco2 or Pao2. Multivariate logistic regression identified that low exercise CI is the strongest predictor of EOV (odds ratio, 1.39 for each 1.0-L · min(-1) · m(-2) decrement in CI; 95% confidence interval, 1.14-1.70; P=0.001). Among HF patients with EOV, exercise CI was inversely related to EOV cycle length (R=-0.71) and amplitude (R=-0.60; both P<0.001). In 11 HF+EOV subjects treated with 12 weeks of sildenafil, EOV cycle length and amplitude decreased proportionately to increases in CI. CONCLUSION Exercise oscillatory ventilation is closely related to reduced CI and elevated filling pressures during exercise and may be an important surrogate for exercise-induced hemodynamic impairment in HF patients. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00309790.
Collapse
Affiliation(s)
- Ryan M Murphy
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | | | | | | | | | | | | | | |
Collapse
|
|
13
|
Abstract
Central apnea is caused by temporary failure in the pontomedullary pacemaker generating breathing rhythm, which results in the loss of ventilatory effort, and if it lasts 10 seconds or more it is defined as central apnea. This article reviews current knowledge on central sleep apnea.
Collapse
Affiliation(s)
- S Javaheri
- Department of Medicine, University of Cincinnati College of Medicine, 4780 Socialville Fosters Road, Mason, OH 45040, USA.
| |
Collapse
|
|
14
|
Garcia-Touchard A, Somers VK, Olson LJ, Caples SM. Central sleep apnea: implications for congestive heart failure. Chest 2008; 133:1495-1504. [PMID: 18574295 PMCID: PMC2774238 DOI: 10.1378/chest.07-0871] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Congestive heart failure (HF), an exceedingly common and costly disease, is frequently seen in association with central sleep apnea (CSA), which often manifests as a periodic breathing rhythm referred to as Cheyne-Stokes respiration. CSA has historically been considered to be a marker of heart disease, since improvement in cardiac status is often associated with the attenuation of CSA. However, this mirroring of HF and CSA may suggest bidirectional importance to their relationship. In fact, observational data suggest that CSA, associated with repetitive oxyhemoglobin desaturations and surges in sympathetic neural activity, may be of pathophysiologic significance in HF outcomes. In light of the disappointing results from the first large trial assessing therapy with continuous positive airway pressure in patients with CSA and HF, further large-scale interventional trials will be needed to assess the role, if any, of CSA treatment on the outcomes of patients with HF. This review will discuss epidemiologic, pathophysiologic, diagnostic, and therapeutic considerations of CSA in the setting of HF.
Collapse
Affiliation(s)
| | - Virend K Somers
- Divisions of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Lyle J Olson
- Divisions of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Sean M Caples
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
|
15
|
Agostoni P, Apostolo A, Albert RK. Mechanisms of periodic breathing during exercise in patients with chronic heart failure. Chest 2008; 133:197-203. [PMID: 18187746 DOI: 10.1378/chest.07-1439] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Periodic breathing (PB) in heart failure (HF) is attributed to many factors, including low cardiac output delaying the time it takes pulmonary venous blood to reach the central and peripheral chemoreceptors, low lung volume, lung congestion, augmented chemoreceptor sensitivity, and the narrow difference between eupneic carbon dioxide tension and apneic/hypoventilatory threshold. METHODS AND RESULTS We measured expired gases, ventilation, amplitude, and duration of PB in 23 patients with PB during progressive exercise tests done with 0 mL, 250 mL, or 500 mL of added dead space. Periodicity of PB remained constant despite heart rate, oxygen consumption, and minute ventilation increasing. Within each PB cycle, starting from the beginning of exercise, the largest (peak) tidal volume approached maximum observed tidal volume, while the smallest (nadir) tidal volume increased as exercise power output increased. PB ceased when nadir tidal volume reached peak tidal volume. End-tidal carbon dioxide increased with added dead space, and PB ceased progressively earlier during the exercise done with increased dead space. CONCLUSION Circulatory delay does not contribute to the PB observed in exercising HF patients. The pattern of gradually increasing nadir tidal volume during exercise and the effect of dead space on both PB ceasing and end-tidal carbon dioxide suggest that low tidal volume and carbon dioxide apnea threshold are important contributors to PB that occurs during exercise in HF.
Collapse
Affiliation(s)
- Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Istituto di Cardiologia, Università di Milano, Via Parea 4, 20138 Milan, Italy.
| | | | | |
Collapse
|
|
16
|
Brack T, Jubran A, Laghi F, Tobin MJ. Fluctuations in end-expiratory lung volume during Cheyne-Stokes respiration. Am J Respir Crit Care Med 2005; 171:1408-13. [PMID: 15778489 DOI: 10.1164/rccm.200503-409oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We hypothesized that patients with Cheyne-Stokes respiration exhibit periodic increases in end-expiratory lung volume, mediated by changes in breath components, postinspiratory inspiratory muscle activity, or both. Calibrated inductive plethysmography revealed that 12 of 12 patients with Cheyne-Stokes respiration experienced increases in end-expiratory volume during hyperpnea: maximum 412 +/- 112 (SE) ml (range 75-1,543 ml). Compared with quiet breathing, the breath with largest increase in end-expiratory volume had larger tidal volume (867 +/- 107 vs. 567 +/- 38 ml, p < 0.01) and shorter expiratory time (1.25 +/- 0.11 vs. 1.66 +/- 0.15 seconds, p < 0.05). During decrescendo, the breath with largest decrease in end-expiratory volume had smaller tidal volume (p < 0.01) and longer expiratory time (p < 0.01). Cross-correlation of time series revealed that end-expiratory volume was related to both breath components (p < 0.0001). Bipolar needle electrodes revealed that scalene muscle activity at end-expiration was 50.7 +/- 14.0% higher at highest increase in lung volume than during preceding apnea (p < 0.05). Time series for scalene activity and end-expiratory volume were cross-correlated (p < 0.008). Increase in tonic scalene activity at end-expiration, however, was equivalent during crescendo and decrescendo phases: 50.6 +/- 22.1 versus 42.0 +/- 12.9% (p = 0.48). In conclusion, patients with Cheyne-Stokes respiration exhibit fluctuations in end-expiratory lung volume, primarily because of alterations in tidal volume and expiratory time rather than postinspiratory inspiratory muscle activity.
Collapse
Affiliation(s)
- Thomas Brack
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. VA Hospital, 111N, 5th Avenue and Roosevelt Road, Hines, IL 60141, USA
| | | | | | | |
Collapse
|
|
17
|
Kryger M. Oximeter performance and diagnostic accuracy of sleep studies. Chest 2003; 123:2160; author reply 2160. [PMID: 12796211 DOI: 10.1378/chest.123.6.2160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
|
18
|
Thalhofer S, Dorow P. Sleep-Breathing Disorders and Heart Failure. Sleep Breath 2002; 4:103-112. [PMID: 11868127 DOI: 10.1007/s11325-000-0103-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cheyne-Stokes respiration is known to be associated with severe left heart failure. Because of severe desaturation, sleep fragmentation, arousals, and an increase in sympathetic activity, Cheyne-Stokes respiration may lead to a further impairment of cardiac function and to a worsening of quality of life. Although the pathology of Cheyne-Stokes respiration is not fully understood, enhanced chemoreceptor sensitivity, prolonged circulation time, as well as decreased pulmonary gas stores and increased ventilatory drive may be contributing factors. Therapeutic options include the improvement of cardiac failure; medical treatment, such as using theophylline; continous positive airway pressure ventilation; and low-flow oxygen supply. Because of severe cardiac insufficiency, change of endothoracic pressure may worsen the hemodynamic situation in some patients. Therefore, this form of treatment has to be used carefully. Another possible treatment is a low-flow oxygen supply, which will prevent severe desaturations. This therapeutic approach might be a good alternative to noninvasive ventilation. However, it is controversial whether oxygen supply will improve quality of sleep of the patients, even in long-term treatment.
Collapse
Affiliation(s)
- Stefan Thalhofer
- Department of Respiratory and Intensive Care Medicine, DRK-Hospital Mark Brandenburg, Humboldt University of Berlin, Berlin, Germany
| | | |
Collapse
|
|
19
|
Solin P, Roebuck T, Swieca J, Walters EH, Naughton MT. Effects of cardiac dysfunction on non-hypercapnic central sleep apnea. Chest 1998; 113:104-10. [PMID: 9440576 DOI: 10.1378/chest.113.1.104] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Non-hypercapnic central sleep apnea (CSA) commonly occurs during nonrapid eye movement (non-REM) sleep in adults with congestive heart failure (CHF) and in some subjects without signs or symptoms of CHF. Hyperventilation, reduced lung volume, and circulatory delay are known to contribute to CSA, but to differing degrees depending on presence or absence of CHF. AIM To determine whether the pattern of ventilation during sleep could be used to determine the presence of CHF. METHODS Full polysomnographs demonstrating CSA were examined in 10 consecutive subjects with CHF and in 10 without CHF. Ventilatory, apnea, and cycle lengths, and circulation time (from the onset of ventilatory effort to the nadir of oximeter trace) were measured from cyclic apneas during non-REM sleep. RESULTS The non-CHF group had a greater left ventricular ejection fraction (LVEF) (59.7+/-1.9% vs 19.2+/-2.2%). Circulation time (11.8+/-0.5 s vs 24.9+/-1.7 s; p < 0.001) and cycle length (35.1+/-2.8 s vs 69.5+/-4.5 s; p < 0.001) were significantly greater in the CHF group compared with the non-CHF group, but not apnea length (21.3+/-1.8 s vs 26.8+/-2.0 s; p=0.06). Ventilatory length to apnea length ratio (VL:AL) was uniformly > 1.0 in the CHF group (mean, 1.65; range, 1.02 to 2.33), and in the non-CHF group < 1.0 (mean, 0.66; range, 0.54 to 0.89). LVEF correlated negatively with both circulation time (r=-0.86; p < 0.001) and cycle length (r=-0.79; p < 0.001). CONCLUSION The VL:AL ratio > 1.0, as well as both circulation time > 15 s and cycle length > 45 s, can be used to recognize the presence of CHF in subjects with CSA.
Collapse
Affiliation(s)
- P Solin
- Department of Respiratory Medicine, Alfred Hospital, Monash University Medical School, Melbourne, Victoria, Australia
| | | | | | | | | |
Collapse
|
|
20
|
Khoo MC, Anholm JD, Ko SW, Downey R, Powles AC, Sutton JR, Houston CS. Dynamics of periodic breathing and arousal during sleep at extreme altitude. RESPIRATION PHYSIOLOGY 1996; 103:33-43. [PMID: 8822221 DOI: 10.1016/0034-5687(95)00057-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To determine whether nocturnal periodic breathing (PB) at altitude is due primarily to unstable control of ventilation or the inability to maintain stable sleep states, we performed visual and computer analyses of the electroencephalographic and respiratory records of healthy volunteers at simulated altitudes of 4572, 6100 and 7620 m. Transient arousals were associated with < 52% of the apneas identified; thus, the PB cycle was not always associated with transient arousal. Following the termination of oxygen breathing, the reinitiation of PB was not dependent on the occurrence of arousal as the primary event. The transition from apnea to breathing preceded the appearance of arousal by approximately 1 to 4 sec. Ventilatory drive in the breaths immediately following arousal was significantly larger than corresponding control breaths, matched for SaO2. Our findings suggest that altitude-induced PB is unlikely to result from primary fluctuations in state. Arousals promote the development of PB with apnea and help to sustain these episodes, but are not necessary for their initiation.
Collapse
Affiliation(s)
- M C Khoo
- Biomedical Engineering Dept., University of Southern California, Los Angeles, USA
| | | | | | | | | | | | | |
Collapse
|
|
21
|
Shepard JW. HYPERTENSION, CARDIAC ARRHYTHMIAS, MYOCARDIAL INFARCTION, AND STROKE IN RELATION TO OBSTRUCTIVE SLEEP APNEA. Clin Chest Med 1992. [DOI: 10.1016/s0272-5231(21)00873-x] [Citation(s) in RCA: 189] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
|
22
|
Kryger MH, Millar T. Cheyne-Stokes respiration: Stability of interacting systems in heart failure. CHAOS (WOODBURY, N.Y.) 1991; 1:265-269. [PMID: 12779924 DOI: 10.1063/1.165839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Cheyne-Stokes respiration, a breathing pattern found in patients with heart failure, is characterized by periodic changes in ventilation. This pattern of breathing is also associated with oscillations in the arousal state, blood oxygen level, carbon dioxide blood level, and the blood pressure. Although originally described as an irregular breathing pattern or an unstable breathing pattern, Cheyne-Stokes respiration may be quite stable for prolonged periods of time. This breathing pattern may represent a clinical disorder in which disease results in a low-frequency oscillation of the system. Treatment that either reduces or abolishes the oscillation results in clinical improvement because of reduced oscillation of the systems whose function is linked to the changes in ventilation.
Collapse
Affiliation(s)
- M. H. Kryger
- University of Manitoba, St. Boniface Research Centre, Sleep Laboratory, 351 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada
| | | |
Collapse
|