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Kundel V, Ahn A, Arzt M, Asin J, Azarbarzin A, Collop N, Das A, Fang JC, Khayat R, Penzel T, Pépin JL, Sharma S, Suurna MV, Tallavajhula S, Malhotra A. Insights, recommendations, and research priorities for central sleep apnea: report from an expert panel. J Clin Sleep Med 2025; 21:405-416. [PMID: 39385622 PMCID: PMC11789259 DOI: 10.5664/jcsm.11424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 10/03/2024] [Accepted: 10/03/2024] [Indexed: 10/12/2024]
Abstract
Central sleep apnea (CSA) is commonly encountered among patients with sleep-disordered breathing; however, its clinical consequences are less well-characterized. The senior author (A.M.) therefore convened an expert panel to discuss the common presentations of CSA, as well as challenges and knowledge gaps in the diagnosis and management of CSA. The panel identified several key research priorities essential for advancing our understanding of the disorder. Within the diagnostic realm, panel members discussed the utility of multinight assessments and importance of the development and validation of novel metrics and automated assessments for differentiating central vs obstructive hypopneas, such that their impact on clinical outcomes and management may be better evaluated. The panel also discussed the current therapeutic landscape for the management of CSA and agreed that therapies should primarily aim to alleviate sleep-related symptoms, after optimizing treatment to address the underlying cause. Most importantly, the panel concluded that there is a need to further investigate the clinical consequences of CSA, as well as the implications of therapy on clinical outcomes, particularly among those who are asymptomatic. Future research should focus on endo-phenotyping central events for a better mechanistic understanding of the disease, validating novel diagnostic methods for implementation in routine clinical practice, as well as the use of combination therapy and comparative effectiveness trials in elucidating the most efficacious interventions for managing CSA. CITATION Kundel V, Ahn A, Arzt M, et al. Insights, recommendations, and research priorities for central sleep apnea: report from an expert panel. J Clin Sleep Med. 2025;21(2):405-416.
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Affiliation(s)
- Vaishnavi Kundel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anjali Ahn
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jerryll Asin
- Department of Pulmonary Medicine and Center for Sleep Medicine, Amphia Hospital, Breda, The Netherlands
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nancy Collop
- Emory Sleep Center, Emory University, Atlanta, Georgia
| | - Aneesa Das
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, The Ohio State University, Columbus, Ohio
| | - James C. Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Rami Khayat
- University of California-Irvine Comprehensive Sleep Center, Irvine, California
| | - Thomas Penzel
- Interdisciplinary Sleep Medicine Center, Charité University Hospital, Berlin, Germany
| | - Jean-Louis Pépin
- University Grenoble Alpes, INSERM, CHU Grenoble Alpes, HP2 Laboratory, Grenoble, France
| | - Sunil Sharma
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, West Virginia University, Morgantown, West Virginia
| | - Maria V. Suurna
- Otolaryngology-Head and Neck Surgery, University of Miami Health System, Miami, Florida
| | - Sudha Tallavajhula
- Department of Neurology, Epilepsy Division, University of Texas Health Sciences Center, Houston, Texas
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego, San Diego, California
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Kasai T, Kohno T, Shimizu W, Ando S, Joho S, Osada N, Kato M, Kario K, Shiina K, Tamura A, Yoshihisa A, Fukumoto Y, Takata Y, Yamauchi M, Shiota S, Chiba S, Terada J, Tonogi M, Suzuki K, Adachi T, Iwasaki Y, Naruse Y, Suda S, Misaka T, Tomita Y, Naito R, Goda A, Tokunou T, Sata M, Minamino T, Ide T, Chin K, Hagiwara N, Momomura S. JCS 2023 Guideline on Diagnosis and Treatment of Sleep Disordered Breathing in Cardiovascular Disease. Circ J 2024; 88:1865-1935. [PMID: 39183026 DOI: 10.1253/circj.cj-23-0489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Affiliation(s)
- Takatoshi Kasai
- Division of School of Health Science, Department of Pathobiological Science and Technology, Faculty of Medicine, Tottori University
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Shinichi Ando
- Sleep Medicine Center, Fukuokaken Saiseikai Futsukaichi Hospital
| | - Shuji Joho
- Second Department of Internal Medicine, University of Toyama
| | - Naohiko Osada
- Department of Cardiology, St. Marianna University School of Medicine
| | - Masahiko Kato
- Division of School of Health Science, Department of Pathobiological Science and Technology, Faculty of Medicine, Tottori University
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | | | | | - Akiomi Yoshihisa
- Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Science
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | | | - Motoo Yamauchi
- Department of Clinical Pathophysiology of Nursing and Department of Respiratory Medicine, Nara Medical University
| | - Satomi Shiota
- Department of Respiratory Medicine, Juntendo University Graduate School of Medicine
| | | | - Jiro Terada
- Department of Respiratory Medicine, Japanese Red Cross Narita Hospital
| | - Morio Tonogi
- 1st Depertment of Oral & Maxillofacial Surgery, Nihon Univercity School of Dentistry
| | | | - Taro Adachi
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yoshihisa Naruse
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Shoko Suda
- Department of Cardiovascular Medicine, Juntendo University School of Medicine
| | - Tomofumi Misaka
- Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Science
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Ryo Naito
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine
| | - Tomotake Tokunou
- Division of Cardiology, Department of Medicine, Fukuoka Dental College
| | - Makoto Sata
- Department of Pulmonology and Infectious Diseases, National Cerebral and Cardiovascular Center
| | | | - Tomomi Ide
- Faculty of Medical Sciences, Kyushu University
| | - Kazuo Chin
- Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Nobuhisa Hagiwara
- YUMINO Medical Corporation
- Department of Cardiology, Tokyo Women's Medical University
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Berik Safçi S. The prevalence and polysomnographic characteristics of treatment-emergent central sleep apnea with obstructive sleep apnea. Sleep Breath 2024; 28:1245-1250. [PMID: 38308750 DOI: 10.1007/s11325-024-02999-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE To investigate the prevalence of treatment-emergent central sleep apnea (TECSA) in individuals with obstructive sleep apnea syndrome (OSAS) during continuous positive airway pressure (CPAP) titration and assess their polysomnographic characteristics. METHODS A total of 116 patients with OSAS who underwent full-night CPAP titration at the Sleep Laboratory of Adana City Research and Education Hospital from September 2017 to January 2018 were recruited for the study. The patients' polysomnographic data related to respiratory events and sleep stages were reviewed in a retrospective manner. RESULTS While on CPAP titration, 20 of the 116 patients developed central sleep apnea (CSA). The prevalence of TECSA in the patients with OSAS was 17.2%, being separately determined as 16.3% and 2.2% for the male and female patients, respectively. In the baseline PSG, the groups did not statistically significantly differ in relation to the apnea hypopnea index (AHI), central apnea index (CAI), arousal index (AI), or oxygen desaturation index (ODI). However, the TECSA group had a significantly higher mean oxygen saturation value compared to the non-TECSA group (p = 0.01). The total AHI, CAI, and AI values of the TECSA group were significantly higher during the whole CPAP titration compared to the non-TECSA group. No significant difference was observed in the comparison of the two groups in relation to the titration pressure and ODI. CONCLUSION TECSA is a phenomenon that can occur with obstructive sleep apnea treatment and mostly regress spontaneously following appropriate CPAP treatment. TECSA is observed at different rates of prevalence. In this study, the prevalence of TECSA was higher than previously reported.
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Testelmans D, Kalkanis A, Papadopoulos D, Demolder S, Buyse B. Central sleep apnea: emphasizing recognition and differentiation. Expert Rev Respir Med 2024; 18:309-320. [PMID: 38878064 DOI: 10.1080/17476348.2024.2369256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/13/2024] [Indexed: 06/19/2024]
Abstract
INTRODUCTION Central sleep apnea (CSA) is a sleep-related breathing disorder in which the effort to breathe is intermittently diminished or absent. CSA is a common disorder among patients with different cardiovascular disorders, including heart failure. In addition, a growing number of medications have been shown to induce CSA and CSA can emerge after initiation of treatment for obstructive sleep apnea. Accumulating evidence shows that CSA is a heterogeneous disorder with individual differences in clinical and biological characteristics and/or underlying pathophysiological mechanisms. AREAS COVERED This narrative review offers an overview of the diagnostic aspects and classification of CSA, with an emphasis on heart failure patients, patients with CSA due to a medication and treatment-emergent CSA. The importance of evaluation of prognostic biomarkers in patients with different types of CSA is discussed. This narrative review synthesizes literature on CSA sourced from the PubMed database up to February 2024. EXPERT OPINION CSA presents a remarkably diverse disorder, with treatment modalities exhibiting potentially varied efficacy across its various phenotypes. This highlights the imperative for tailored management strategies that are rooted in phenotype classification.
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Affiliation(s)
- Dries Testelmans
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Alexandros Kalkanis
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Dimitrios Papadopoulos
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Saartje Demolder
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Bertien Buyse
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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Sakuma T, Shinomiya S, Takahara Y, Mizuno S. Awake Hypercapnic Ventilatory Response in Obstructive Sleep Apnea Syndrome. SLEEP MEDICINE RESEARCH 2022. [DOI: 10.17241/smr.2021.01172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Objective Decreased ventilatory response to carbon dioxide or hypercapnic ventilatory response (HCVR) is a feature of pediatric obstructive sleep apnea (OSA) and is also known to diminish during sleep in obese adolescents (age, 12–16 years) with OSA. It reduces minute ventilation, air flow, and tidal volume during inspiration, as well as upper airway obstruction. The purpose of this study was to investigate awake HCVR in adult patients with OSA and to elucidate its association with sleep apnea.Methods HCVR was measured before performing polysomnography (PSG). PSG is performed as the evaluation method during sleep, and the severity of apnea is evaluated by apnea hypopnea index. Patient background, PSG data and HCVR were examined.Results Awake HCVR was greater in patients with severe OSA than in patients with mild and moderate OSA, and in severe OSA patients, the HCVR during awaking was higher in patients with larger changes in saturation of percutaneous oxygen during sleep. Awake HCVR did not differ by age, but it was greater in morbidly obese patients with OSA than in thin patients with OSA. The most frequent apnea pattern of OSA was obstructive, regardless of severity; although with an increasing severity of OSA, the central pattern decreased and the mixed pattern increased in frequency. The appearance of the mixed pattern increased in the augmented HCVR group.Conclusions This study suggested that awake HCVR could be used as an index of progression and a factor to determine the effects of treatment in patients with OSA.
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Abstract
Central apnea syndrome is a disorder with protean manifestations and concomitant conditions. It can occur as a distinct clinical entity or as part of another clinical syndrome. The pathogenesis of central sleep apnea (CSA) varies depending on the clinical condition. Sleep-related withdrawal of the ventilatory drive to breathe is the common denominator among all cases of central apnea, whereas hypocapnia is the final common pathway leading to apnea in the majority of central apnea. Medical conditions most closely associated with CSA include heart failure, stroke, spinal cord injury, and opioid use, among others. Nocturnal polysomnography is the standard diagnostic method, including measurement of sleep and respiration. The latter includes detection of flow, measurement of oxyhemoglobin saturation and detection of respiratory effort. Management strategy incorporates clinical presentation, associated conditions, and the polysomnographic findings in an individualized manner. The pathophysiologic heterogeneity may explain the protean clinical manifestations and the lack of a single effective therapy for all patients. While research has enhanced our understanding of the pathogenesis of central apnea, treatment options are extrapolated from treatment of obstructive sleep apnea. Co-morbid conditions and concomitant obstructive sleep apnea influence therapeutic approach significantly. Therapeutic options include positive pressure therapy, pharmacologic therapy, and supplemental Oxygen. Continuous positive airway pressure (CPAP) is the initial standard of care, although the utility of other modes of positive pressure therapy, as well as pharmacotherapy and device-based therapies, are currently being investigated.
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Affiliation(s)
- Geoffrey Ginter
- Department of Internal Medicine, University Health Center and John D. Dingell VA Medical Center, Wayne State University School of Medicine, Detroit, MI, United States
| | - M Safwan Badr
- Department of Internal Medicine, University Health Center and John D. Dingell VA Medical Center, Wayne State University School of Medicine, Detroit, MI, United States.
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Mitchell GS, Baker TL. Respiratory neuroplasticity: Mechanisms and translational implications of phrenic motor plasticity. HANDBOOK OF CLINICAL NEUROLOGY 2022; 188:409-432. [PMID: 35965036 DOI: 10.1016/b978-0-323-91534-2.00016-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Widespread appreciation that neuroplasticity is an essential feature of the neural system controlling breathing has emerged only in recent years. In this chapter, we focus on respiratory motor plasticity, with emphasis on the phrenic motor system. First, we define related but distinct concepts: neuromodulation and neuroplasticity. We then focus on mechanisms underlying two well-studied models of phrenic motor plasticity: (1) phrenic long-term facilitation following brief exposure to acute intermittent hypoxia; and (2) phrenic motor facilitation after prolonged or recurrent bouts of diminished respiratory neural activity. Advances in our understanding of these novel and important forms of plasticity have been rapid and have already inspired translation in multiple respects: (1) development of novel therapeutic strategies to preserve/restore breathing function in humans with severe neurological disorders, such as spinal cord injury and amyotrophic lateral sclerosis; and (2) the discovery that similar plasticity also occurs in nonrespiratory motor systems. Indeed, the realization that similar plasticity occurs in respiratory and nonrespiratory motor neurons inspired clinical trials to restore leg/walking and hand/arm function in people living with chronic, incomplete spinal cord injury. Similar application may be possible to other clinical disorders that compromise respiratory and non-respiratory movements.
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Affiliation(s)
- Gordon S Mitchell
- Breathing Research and Therapeutics Center, Department of Physical Therapy and McKnight Brain Institute, University of Florida, Gainesville, FL, United States.
| | - Tracy L Baker
- Department of Comparative Biosciences, School of Veterinary Medicine, University of Wisconsin, Madison, WI, United States
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8
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Hutter T, Horvath C, Hefti JP, Brill AK. [Treatment-Emergent Central Sleep Apnea - Detection and Treatment]. PRAXIS 2022; 111:436-443. [PMID: 35673844 DOI: 10.1024/1661-8157/a003848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Treatment-Emergent Central Sleep Apnea - Detection and Treatment Abstract. In treatment-emergent central sleep apnea (TECSA), affected patients with obstructive sleep apnea newly develop central sleep apnea (AHI central ≥5/h) under therapy with positive pressure ventilation which cannot be explained by other causes. The pathophysiology of TECSA is incompletely understood. PaCO2 and the associated apnea threshold seem to play a central role. The incidence of TECSA varies (1.8-20%), and in about 2/3 of cases it is self-limiting in the course of the therapy. If persistence or new onset occurs later in the course of positive pressure therapy, a further evaluation (e.g., echocardiography, neurologic examination, medication history) is indicated. Effective treatment options include a change in ventilation therapy (adaptive servoventilation or bilevel ventilation with back-up frequency) or additional nocturnal oxygen supplementation; these options should be decided case by case.
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Affiliation(s)
- Tabea Hutter
- Universitätsklinik für Pneumologie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Christian Horvath
- Universitätsklinik für Pneumologie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
- Sleep Research Laboratories of the University Health Network Toronto Rehabilitation Institute (KITE) and Toronto General Hospital and Department of Medicine of the University of Toronto, Toronto, Kanada
| | | | - Anne-Kathrin Brill
- Universitätsklinik für Pneumologie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Abstract
Treatment-emergent central sleep apnea (TECSA) is a specific form of sleep-disordered breathing, characterized by the emergence or persistence of central apneas during treatment for obstructive sleep apnea. The purpose of this review was to summarize the definition, epidemiology, potential mechanisms, clinical characteristics, and treatment of TECSA. We searched for relevant articles up to January 31, 2020, in the PubMed database. The prevalence of TECSA varied widely in different studies. The potential mechanisms leading to TECSA included ventilatory control instability, low arousal threshold, activation of lung stretch receptors, and prolonged circulation time. TECSA may be a self-limited disorder in some patients and could be resolved spontaneously over time with ongoing treatment of continuous positive airway pressure (CPAP). However, central apneas persist even with the regular CPAP therapy in some patients, and new treatment approaches such as adaptive servo-ventilation may be necessary. We concluded that several questions regarding TECSA remain, despite the findings of many studies, and it is necessary to carry out large surveys with basic scientific design and clinical trials for TECSA to clarify these irregularities. Further, it will be vital to evaluate the baseline demographic and polysomnographic data of TECSA patients more carefully and comprehensively.
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Zeineddine S, Badr MS. Treatment-Emergent Central Apnea: Physiologic Mechanisms Informing Clinical Practice. Chest 2021; 159:2449-2457. [PMID: 33497650 DOI: 10.1016/j.chest.2021.01.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022] Open
Abstract
The purpose of this review was to describe our management approach to patients with treatment-emergent central sleep apnea (TECSA). The emergence of central sleep apnea during positive airway pressure therapy occurs in approximately 8% of titration studies for OSA, and it has been associated with several demographic, clinical, and polysomnographic factors, as well as factors related to the titration study itself. TECSA shares similar pathophysiology with central sleep apnea. In fact, central and OSA pathophysiologic mechanisms are inextricably intertwined, with ventilatory instability and upper airway narrowing occurring in both entities. TECSA is a "dynamic" process, with spontaneous resolution with ongoing positive airway pressure therapy in most patients, persistence in some, or appearing de novo in a minority of patients. Management strategy for TECSA aims to eliminate abnormal respiratory events, stabilize sleep architecture, and improve the underlying contributing medical comorbidities. CPAP therapy remains a standard therapy for TECSA. Expectant management is appropriate given its transient nature in most cases, whereas select patients would benefit from an early switch to an alternative positive airway pressure modality. Other treatment options include supplemental oxygen and pharmacologic therapy.
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Affiliation(s)
- Salam Zeineddine
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Detroit, MI; Department of Medicine, Wayne State University, Detroit, MI.
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11
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Ghadiri M, Grunstein RR. Clinical side effects of continuous positive airway pressure in patients with obstructive sleep apnoea. Respirology 2020; 25:593-602. [PMID: 32212210 DOI: 10.1111/resp.13808] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/05/2020] [Accepted: 03/03/2020] [Indexed: 12/14/2022]
Abstract
CPAP is considered the gold standard treatment in OSA and is highly efficacious in controlling OSA symptoms. However, treatment effectiveness is limited because of many factors including low adherence due to side effects. This review highlights the range of side effects associated with CPAP therapy in patients with OSA. This information is important for the initiation of patients onto CPAP as well as their continued care while on treatment, given the increase in non-medically supervised CPAP care models in use globally.
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Affiliation(s)
- Maliheh Ghadiri
- Woolcock Institute of Medical Research, Respiratory Technology Group, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,School of Biomedical Engineering, University of Technology Sydney, Sydney, NSW, Australia
| | - Ronald R Grunstein
- Woolcock Institute of Medical Research, Respiratory Technology Group, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Sydney, NSW, Australia
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12
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Sleep Apnea Treatment Considerations in Patients with Comorbidities. Otolaryngol Clin North Am 2020; 53:339-349. [PMID: 32199633 DOI: 10.1016/j.otc.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A wide range of sleep, psychiatric, and medical comorbidities can present with obstructive sleep apnea (OSA), complicating treatment because of intolerance or low adherence to traditional modalities of therapy. Providers must have heightened awareness of how these comorbidities can affect their patients' OSA and work together as a team to optimize health and well-being in this complex population.
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Abstract
Complex sleep apnea syndrome (Comp-SAS) is the term used to describe a specific form of sleep disordered breathing characterized by the arise of central sleep apnea in patient with previous obstructive sleep apnea syndrome (OSAS) treated with continuous positive airway pressure devices (CPAP). The mechanisms of its occurrence are not well understood, but partly it seems to be a consequence of increased carbon dioxide elimination under positive airway pressure treatment and related improvement of pulmonary ventilation. The prevalence of Comp-SAS ranges from 5% to 20% of OSAS patient getting CPAP therapy with no significant predictors in comparison with simple obstructive sleep apnea, but more likely to happened in older males with more severe OSAS and accompanying cardiovascular pathology such as ischemic heart disease, atrial fibrillation and heart failure. In most cases of Comp-SAS, central apnea events are transient and disappear after continuous CPAP therapy use for 1 to 2 months. Novel treatment options like adaptive servo-ventilation or BiPAP-ST are available for such non-responders to CPAP but contra-indicated to patients with systolic heart failure. From the other hand, still not clear is it mandatory to treat all affected individuals with Comp-SAS if the disease is uncomplicated and patient is asymptomatic.
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Affiliation(s)
- A D Palman
- Sechenov First Moscow State Medical University, Moscow, Russia
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14
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Bitter T, Özdemir B, Fox H, Horstkotte D, Oldenburg O. Cycle length identifies obstructive sleep apnea and central sleep apnea in heart failure with reduced ejection fraction. Sleep Breath 2018; 22:1093-1100. [PMID: 29637409 DOI: 10.1007/s11325-018-1652-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 11/24/2022]
Abstract
AIM To clarify whether unmasking of central sleep apnea during continuous positive airway pressure (CPAP) initiation can be identified from initial diagnostic polysomnography (PSG) in patients with heart failure with reduced ejection fraction (HFREF) and obstructive sleep apnea (OSA) MATERIALS AND METHODS: Forty-three consecutive patients with obstructive sleep apnea and central sleep apnea (OSA/CSA) in HFREF were matched with 43 HFREF patients with OSA and successful CPAP initiation. Obstructive apneas during diagnostic PSG were then analyzed for cycle length (CL), ventilation length (VL), apnea length (AL), time to peak ventilation (TTPV), and circulatory delay (CD). We calculated duty ratio (DR) as the ratio of VL/CL and mathematic loop gain (LG). RESULTS While AL was similar, CL, VL, TTPV, CD, and DR was significantly longer in patients with OSA/CSA compared to those with OSA, and LG was significantly higher. Receiver operator curves identified optimal cutoff values of 50.2 s for CL (area under the curve (AUC) 0.85, 29.2 s for VL (AUC 0.92), 11.5 s for TTPV (AUC 0.82), 26.4 s for CD (AUC 0.79), and 3.96 (AUC 0.78)) respectively for LG to identify OSA/CSA. CONCLUSION OSA/CSA in HFREF can be identified by longer CL, VL, TTPV, and CD from obstructive events in initial diagnostic PSG. The underlying mechanisms seem to be the presence of an increased LG.
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Affiliation(s)
- Thomas Bitter
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Burak Özdemir
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Dieter Horstkotte
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Olaf Oldenburg
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
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Pépin JL, Woehrle H, Liu D, Shao S, Armitstead JP, Cistulli PA, Benjafield AV, Malhotra A. Adherence to Positive Airway Therapy After Switching From CPAP to ASV: A Big Data Analysis. J Clin Sleep Med 2018; 14:57-63. [PMID: 29198291 DOI: 10.5664/jcsm.6880] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/03/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES There is a lack of data regarding adherence trajectories when switching from continuous positive airway pressure (CPAP) to adaptive servoventilation (ASV) in the context of persistent or treatment-emergent central sleep apnea (CSA). This study investigated 90-day adherence rates in patients with sleep apnea based on the type of positive airway pressure (PAP) device used and any switching of PAP modality over time. METHODS Telemonitoring data were obtained from a United States PAP database. Eligible patients were a 30% random sample who started PAP, plus all who started ASV, from January 1, 2015 to October 2, 2015. All received PAP and had at least one session with usage of 1 hour or more. Adherence and device usage were determined in three groups: started on CPAP and stayed on CPAP (CPAP only); started on ASV and stayed on ASV (ASV only); started on CPAP, switched to ASV (Switch). The United States Medicare definition of adherence was used. RESULTS The study included 198,890 patients; 189,724 (CPAP only), 8,957 (ASV only) and 209 (Switch). In the Switch group, average apnea-hypopnea index decreased significantly on ASV versus CPAP. At 90 days, adherence rates were 73.8% and 73.2% in the CPAP only and ASV only groups. In the Switch group, CPAP adherence was 62.7%, improving to 76.6% after the switch to ASV. Mean device usage at 90 days was 5.27, 5.31, and 5.73 h/d in the CPAP only, ASV only, and Switch groups, respectively. CONCLUSIONS Treatment-emergent or persistent CSA during CPAP reduced therapy adherence, but adherence improved early after switching from CPAP to ASV.
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Affiliation(s)
- Jean-Louis Pépin
- Institut National de la Santé et de la Recherche Médicale (INSERM), HP2 Laboratory (Hypoxia: Pathophysiology), Grenoble Alpes University, Grenoble, France
| | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany.,ResMed Science Center, Sydney, Australia
| | | | | | | | - Peter A Cistulli
- Charles Perkins Centre, University of Sydney, and Royal North Shore Hospital, Sydney, Australia
| | | | - Atul Malhotra
- University of California San Diego, La Jolla, California
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Nigam G, Riaz M, Chang ET, Camacho M. Natural history of treatment-emergent central sleep apnea on positive airway pressure: A systematic review. Ann Thorac Med 2018; 13:86-91. [PMID: 29675059 PMCID: PMC5892094 DOI: 10.4103/atm.atm_321_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION: Treatment-emergent central sleep apnea (TECSA) is observed in some patients when they are treated with positive airway pressure (PAP) after significant resolution of the preexisting obstructive events in patients with obstructive sleep apnea. The objective of this study was to systematically review the literature for studies describing the natural history of TECSA. METHODS: PubMed, Medline, Scopus, Web of Science, and Cochran Library databases were searched through June 29, 2017. RESULTS: Five studies were identified that discussed the natural history of TECSA. TECSA developed in 3.5%–19.8% of PAP-treated patients. Treatment-persistent central sleep apnea (TPCSA), representing protracted periods of PAP therapy-related central apneas, was noted in 14.3%–46.2% of patients with TECSA. Delayed-TECSA (D-TECSA) represents an anomalous TECSA entity appearing weeks to months after initial PAP therapy. D-TECSA was observed in 0.7%–4.2% of OSA patients undergoing PAP treatment (after at least 1 month). In patients with TECSA, a higher apnea–hypopnea index (AHI) and central apnea index at their baseline study or a higher residual AHI at their titration study may be associated with an increased likelihood of conversion to TPCSA. CONCLUSIONS: Overall, TECSA developed in 3.5%–19.8% of PAP-treated patients with OSA. The vast majority will experience complete resolution of central apneas over a few weeks to months. Unfortunately, about a third of patients with TECSA may continue to exhibit persistence of central sleep apnea on reevaluation. A small proportion may experience D-TECSA after few weeks to several months of initial exposure to PAP therapy.
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Affiliation(s)
- Gaurav Nigam
- Division of Sleep Medicine, Clay County Hospital, Flora, IL, USA
| | - Muhammad Riaz
- Division of Sleep Medicine, Astria Health Center, Grandview, WA, USA
| | - Edward T Chang
- Division of Otolaryngology, Sleep Surgery, and Sleep Medicine, Tripler Army Medical Center, HI, USA
| | - Macario Camacho
- Division of Otolaryngology, Sleep Surgery, and Sleep Medicine, Tripler Army Medical Center, HI, USA
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17
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Complex sleep apnea after full-night and split-night polysomnography: the Greek experience. Sleep Breath 2017; 22:713-719. [PMID: 29222618 DOI: 10.1007/s11325-017-1601-7] [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: 08/31/2017] [Revised: 11/18/2017] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Treatment-emergent central sleep apnea (TE-CSA) is defined as the emergence or persistence of central respiratory events during the initiation of positive airway pressure (PAP) without a back-up rate in obstructive sleep apnea (OSA) patients and after significant resolution of obstructive events. Previous studies have estimated a prevalence from 0.56 to 20.3%. The aim of this study was to establish the prevalence of TE-CSA in a Greek adult population. METHODS One thousand fifty nine patients with newly diagnosed OSA, who were referred to the Sleep Disorders Center of Evangelismos Hospital of Athens over an 18-month period, were included in this study. A split-night polysomnography (PSG), or two formal overnight PSGs (diagnostic and continuous PAP (CPAP) titration study), were performed. RESULTS Patients with OSA were divided in two groups; the first group included 277 patients, who underwent two separate studies (diagnostic and CPAP titration study), and the second group 782 patients, who underwent split-night studies. The prevalence of TE-CSA in the first group was 2.53% (7 patients), and in the second group was 5.63% (44 patients). CONCLUSIONS The prevalence of TE-CSA in Greece was lower compared to most previous reported studies. The significant variation in the prevalence of TE-CSA between different centers throughout the world is mainly associated with the used diagnostic criteria as well as methodological and technical aspects.
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18
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Lombardi C, Caravita S, Parati G. Central sleep apnea during continuous positive airway pressure therapy in obstructive sleep apnea patients: from the compliance to adaptation, maladaptation and reflexes. J Thorac Dis 2017; 9:4152-4156. [PMID: 29268457 DOI: 10.21037/jtd.2017.09.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Carolina Lombardi
- Sleep Disorders Center, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Gianfranco Parati
- Sleep Disorders Center, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
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Liu D, Armitstead J, Benjafield A, Shao S, Malhotra A, Cistulli PA, Pepin JL, Woehrle H. Trajectories of Emergent Central Sleep Apnea During CPAP Therapy. Chest 2017; 152:751-760. [PMID: 28629918 PMCID: PMC6026232 DOI: 10.1016/j.chest.2017.06.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 05/04/2017] [Accepted: 06/01/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The emergence of central sleep apnea (CSA) during positive airway pressure (PAP) therapy has been observed clinically in approximately 10% of obstructive sleep apnea titration studies. This study assessed a PAP database to investigate trajectories of treatment-emergent CSA during continuous PAP (CPAP) therapy. METHODS U.S. telemonitoring device data were analyzed for the presence/absence of emergent CSA at baseline (week 1) and week 13. Defined groups were as follows: obstructive sleep apnea (average central apnea index [CAI] < 5/h in week 1, < 5/h in week 13); transient CSA (CAI ≥ 5/h in week 1, < 5/h in week 13); persistent CSA (CAI ≥ 5/h in week 1, ≥ 5/h in week 13); emergent CSA (CAI < 5/h in week 1, ≥ 5/h in week 13). RESULTS Patients (133,006) used CPAP for ≥ 90 days and had ≥ 1 day with use of ≥ 1 h in week 1 and week 13. The proportion of patients with CSA in week 1 or week 13 was 3.5%; of these, CSA was transient, persistent, or emergent in 55.1%, 25.2%, and 19.7%, respectively. Patients with vs without treatment-emergent CSA were older, had higher residual apnea-hypopnea index and CAI at week 13, and more leaks (all P < .001). Patients with any treatment-emergent CSA were at higher risk of therapy termination vs those who did not develop CSA (all P < .001). CONCLUSIONS Our study identified a variety of CSA trajectories during CPAP therapy, identifying several different clinical phenotypes. Identification of treatment-emergent CSA by telemonitoring could facilitate early intervention to reduce the risk of therapy discontinuation and shift to more efficient ventilator modalities.
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Affiliation(s)
| | | | | | | | | | - Peter A Cistulli
- Charles Perkins Centre at University of Sydney, Sydney, Australia; Royal North Shore Hospital, Sydney, Australia
| | - Jean-Louis Pepin
- Institut National de la Santé et de la Recherche Médicale (INSERM) U 1042, HP2 Laboratory, Grenoble Alpes University, Grenoble, France
| | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany.
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Pawar KS, Goyal A, Khurana A, Kumar S, Sen AK. Case of postural complex sleep apnea: effect of gravitational forces. Lung India 2017; 34:386-389. [PMID: 28671174 PMCID: PMC5504900 DOI: 10.4103/lungindia.lungindia_374_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We report a case of an elderly male with predominant obstructive sleep apnea and who developed or complex sleep apnea (CxSA) at the start of continuous positive airway pressure (CPAP) titration. This CxSA was more prominent in supine position, and he was not settling with either CPAP/bilevel positive airway pressure (PAP) in supine position. He finally settled with CPAP along with position therapy. This case highlights the importance of treating CxSA with basic PAP modes like CPAP along with positional therapy before switching to costlier therapies such as adaptive servo-ventilation.
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Affiliation(s)
| | - Abhishek Goyal
- Department of Pulmonary Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Alkesh Khurana
- Department of Pulmonary Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Senthil Kumar
- Department of Pulmonary Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Amit Kumar Sen
- Department of Pulmonary Medicine, AIIMS, Bhopal, Madhya Pradesh, India
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21
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Whom are we treating with adaptive servo-ventilation? A clinical post hoc analysis. Clin Res Cardiol 2017; 106:702-710. [DOI: 10.1007/s00392-017-1112-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/07/2017] [Indexed: 12/12/2022]
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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23
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S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen – Kapitel „Schlafbezogene Atmungsstörungen“. SOMNOLOGIE 2016. [DOI: 10.1007/s11818-016-0093-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nigam G, Pathak C, Riaz M. A systematic review on prevalence and risk factors associated with treatment- emergent central sleep apnea. Ann Thorac Med 2016; 11:202-10. [PMID: 27512510 PMCID: PMC4966223 DOI: 10.4103/1817-1737.185761] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION: Treatment-emergent central sleep apnea (TECSA) is the appearance of central apneas and hypopneas after significant resolution of the obstructive events has been attained using positive airway pressure (PAP) therapy. The aim of the study was to determine the prevalence of TECSA and to understand what factors are associated with its development. METHODS: PubMed, MEDLINE, Scopus, Web of Science and Cochran Library databases were searched with Mesh headings to locate studies linking TECSA and obstructive sleep apnea (OSA). RESULTS: Nine studies were identified that reported the prevalence of TECSA ranging from 5.0% to 20.3%. Prevalence of TECSA for studies using only full night titration was between 5.0% and 12.1% where as it was between 6.5% and 20.3% for studies using split-night polysomnogram. The mean effective continuous PAP (CPAP) setting varied between 7.5 cm and 15.2 cm of water for patients in TECSA group and between 7.4 cm and 13.6 cm of water for the group without TECSA. CONCLUSIONS: The aggregate point prevalence of TECSA is about 8% with the estimated range varying from 5% to 20% in patients with untreated OSA. The prevalence tends to be higher for split-night studies compared to full night titration studies. TECSA can occur at any CPAP setting although extremely high CPAP settings could increase the likelihood. Male gender, higher baseline apnea-hypopnea index, and central apnea index at the time of diagnostic study could be associated with the development of TECSA at a subsequent titration study.
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Affiliation(s)
- Gaurav Nigam
- Department of Sleep Medicine, Clay County Hospital, Flora, IL, USA
| | - Charu Pathak
- Department of Obstetrics and Gynecology, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Muhammad Riaz
- Department of Hospital Medicine, Twin Cities Community Hospital, Templeton, CA, USA
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Braegelmann KM, Streeter KA, Fields DP, Baker TL. Plasticity in respiratory motor neurons in response to reduced synaptic inputs: A form of homeostatic plasticity in respiratory control? Exp Neurol 2016; 287:225-234. [PMID: 27456270 DOI: 10.1016/j.expneurol.2016.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/16/2016] [Accepted: 07/20/2016] [Indexed: 12/31/2022]
Abstract
For most individuals, the respiratory control system produces a remarkably stable and coordinated motor output-recognizable as a breath-from birth until death. Very little is understood regarding the processes by which the respiratory control system maintains network stability in the presence of changing physiological demands and network properties that occur throughout life. An emerging principle of neuroscience is that neural activity is sensed and adjusted locally to assure that neurons continue to operate in an optimal range, yet to date, it is unknown whether such homeostatic plasticity is a feature of the neurons controlling breathing. Here, we review the evidence that local mechanisms sense and respond to perturbations in respiratory neural activity, with a focus on plasticity in respiratory motor neurons. We discuss whether these forms of plasticity represent homeostatic plasticity in respiratory control. We present new analyses demonstrating that reductions in synaptic inputs to phrenic motor neurons elicit a compensatory enhancement of phrenic inspiratory motor output, a form of plasticity termed inactivity-induced phrenic motor facilitation (iPMF), that is proportional to the magnitude of activity deprivation. Although the physiological role of iPMF is not understood, we hypothesize that it has an important role in protecting the drive to breathe during conditions of prolonged or intermittent reductions in respiratory neural activity, such as following spinal cord injury or during central sleep apnea.
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Affiliation(s)
- K M Braegelmann
- Department of Comparative Biosciences, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, United States
| | - K A Streeter
- Department of Comparative Biosciences, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, United States
| | - D P Fields
- Department of Comparative Biosciences, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, United States
| | - T L Baker
- Department of Comparative Biosciences, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, United States.
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Clinical Use of Loop Gain Measures to Determine Continuous Positive Airway Pressure Efficacy in Patients with Complex Sleep Apnea. A Pilot Study. Ann Am Thorac Soc 2016. [PMID: 26214564 DOI: 10.1513/annalsats.201410-469bc] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Measures of unstable ventilatory control (loop gain) can be obtained directly from the periodic breathing duty ratio on polysomnography in patients with Cheyne-Stokes respiration/central sleep apnea and can predict the efficacy of continuous positive airway pressure (CPAP) therapy. OBJECTIVES In this pilot study, we aimed to determine if this measure could also be applied to patients with complex sleep apnea (predominant obstructive sleep apnea, with worsening or emergent central apneas on CPAP). We hypothesized that loop gain was higher in patients whose central events persisted 1 month later despite CPAP treatment versus those whose events resolved over time. METHODS We calculated the duty ratio of the periodic central apneas remaining on the CPAP titration (or second half of the split night) while patients were on optimal CPAP with the airway open (obstructive apnea index < 1/h). Loop gain was calculated by the formula: LG = 2π/[(2πDR - sin(2πDR)]. Patients were followed on CPAP for 1 month. Post-treatment apnea-hypopnea index and compliance data were recorded from smart cards. MEASUREMENTS AND MAIN RESULTS Thirty-two patients with complex sleep apnea were identified, and 17 patients had full data sets. Eight patients continued to have a total of more than five events per hour (11.8 ± 0.5/h) (nonresponders). The remaining nine patients had an apnea-hypopnea index less than 5/h (2.2 ± 0.4/h) (responders). Loop gain was higher in the nonresponders versus responders (2.0 ± 0.1 vs. 1.7 ± 0.2, P = 0.026). Loop gain and the residual apnea-hypopnea index 1 month after CPAP were associated (r = 0.48, P = 0.02). CPAP compliance was similar between groups. CONCLUSIONS In this pilot study, loop gain was higher for patients with complex sleep apnea in whom central apneas persisted after 1 month of CPAP therapy (nonresponders). Loop gain measurement may enable an a priori determination of those who need alternative modes of positive airway pressure.
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27
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Pathophysiology of central sleep apneas. Sleep Breath 2016; 20:467-82. [DOI: 10.1007/s11325-015-1290-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/10/2015] [Accepted: 11/23/2015] [Indexed: 11/26/2022]
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Moro M, Gannon K, Lovell K, Merlino M, Mojica J, Bianchi MT. Clinical predictors of central sleep apnea evoked by positive airway pressure titration. Nat Sci Sleep 2016; 8:259-66. [PMID: 27555802 PMCID: PMC4968988 DOI: 10.2147/nss.s110032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE Treatment-emergent central sleep apnea (TECSA), also called complex apnea, occurs in 5%-15% of sleep apnea patients during positive airway pressure (PAP) therapy, but the clinical predictors are not well understood. The goal of this study was to explore possible predictors in a clinical sleep laboratory cohort, which may highlight those at risk during clinical management. METHODS We retrospectively analyzed 728 patients who underwent PAP titration (n=422 split-night; n=306 two-night). Demographics and self-reported medical comorbidities, medications, and behaviors as well as standard physiological parameters from the polysomnography (PSG) data were analyzed. We used regression analysis to assess predictors of binary presence or absence of central apnea index (CAI) ≥5 during split-night PSG (SN-PSG) versus full-night PSG (FN-PSG) titrations. RESULTS CAI ≥5 was present in 24.2% of SN-PSG and 11.4% of FN-PSG patients during titration. Male sex, maximum continuous positive airway pressure, and use of bilevel positive airway pressure were predictors of TECSA, and rapid eye movement dominance was a negative predictor, for both SN-PSG and FN-PSG patients. Self-reported narcotics were a positive predictor of TECSA, and the time spent in stage N2 sleep was a negative predictor only for SN-PSG patients. Self-reported history of stroke and the CAI during the diagnostic recording predicted TECSA only for FN-PSG patients. CONCLUSION Clinical predictors of treatment-evoked central apnea spanned demographic, medical history, sleep physiology, and titration factors. Improved predictive models may be increasingly important as diagnostic and therapeutic modalities move away from the laboratory setting, even as PSG remains the gold standard for characterizing primary central apnea and TECSA.
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Affiliation(s)
| | | | | | | | - James Mojica
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matt T Bianchi
- Neurology Department; Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
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A Sleep-Disordered Breathing Pattern Related to Positive Airway Pressure Therapy. Ann Am Thorac Soc 2015; 12:1892-5. [DOI: 10.1513/annalsats.201505-280cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Muza RT. Central sleep apnoea-a clinical review. J Thorac Dis 2015; 7:930-7. [PMID: 26101651 DOI: 10.3978/j.issn.2072-1439.2015.04.45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/28/2015] [Indexed: 11/14/2022]
Abstract
Central sleep apnoea (CSA) is characterised by recurrent apnoeas during sleep with no associated respiratory effort. It mostly results from withdrawal of the wakefulness drive in sleep leaving ventilation under metabolic control. A detailed physiological understanding of the control of breathing in wakefulness and sleep is essential to the understanding of CSA. It encompasses a diverse group of conditions with differing aetiologies and pathophysiology. Likewise treatment varies according to underlying aetiology. Some of the conditions such as idiopathic (primary) CSA (ICSA) are relatively rare and benign. On the other hand Cheyne-Stokes breathing (CSB) pattern is quite common in patients with heart failure and might be a prognostic indicator of poor outcome. Unfortunately modern medical management of heart failure does not seem to have significantly reduced the prevalence of CSA in this group. Since the adoption of positive airway pressure (PAP) as a common treatment modality of obstructive sleep apnoea (OSA), complex CSA has been increasingly observed either as treatment emergent or persistent CSA. Depending on the particular condition, various treatment strategies have been tried in the past two decades which have included hypnotic therapy, respiratory stimulants, judicious administration of carbon dioxide, oxygen therapy, PAP and bi-level ventilatory support with a backup rate. In the past decade adaptive servo ventilation (ASV) has been introduced with much promise. Various studies have shown its superiority over other treatment modalities. Ongoing long term studies will hopefully shed more light on its impact on cardiovascular morbidity and mortality. Other rare forms are still poorly understood and treatments remain suboptimal.
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Affiliation(s)
- Rexford T Muza
- Sleep Disorders Centre, Nuffield House, Guy's & St Thomas' Hospital NHS Trust, London, UK
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Correia S, Martins V, Sousa L, Moita J, Teixeira F, Dos Santos JM. Clinical impact of adaptive servoventilation compared to other ventilatory modes in patients with treatment-emergent sleep apnea, central sleep apnea and Cheyne-Stokes respiration. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:132-137. [PMID: 25926251 DOI: 10.1016/j.rppnen.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 08/15/2014] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION Adaptive servoventilation is a recent ventilatory mode initially designed to treat Cheyne-Stokes respiration (CSR). Recently, the efficacy of ASV has been discussed for the treatment of central sleep apnea (CSA) and treatment-emergent central sleep apnea (treatment-emergent CSA) where other forms of traditional positive airway pressure (PAP) may be insufficient. OBJECTIVES To compare the clinical impact of ASV with other forms of PAP in treating patients with treatment-emergent CSA, CSA and CSR. METHODS Medical data of all the patients who underwent polysomnography (PSG) with ASV titration were evaluated. The patients were divided into two groups according to the mode of ventilation reimbursed: ASV and PAP (AutoCPAP/CPAP/BIPAP). All patients had a minimal follow-up of 6 months. Both groups were compared in terms of symptoms, apnea hypopnea index, compliance, cardiac function and cardiovascular events. RESULTS ASV titration was performed in 33 patients (30M/3F) with a mean age of 69±8 years. The majority (58%) present a treatment-emergent SA and 42% a CSA and or CSR. The median initial diagnostic AHI was 46±22events/h. After the initial diagnosis, 28 patients were treated with PAP and 5 with servoventilation. All of the patients treated with PAP were posteriorly submitted to PSG and ASV titration because of suboptimal response to PAP. Despite a clear indication for ASV, due to differences in reimbursement, 15 patients continued treatment with PAP (12 with AutoCPAP, 1 with BIPAP and 2 with CPAP) and 16 changed to ASV. Two patients were lost in follow-up. In both groups, most of patients present a treatment-emergent SA (53% in ASV group vs. 67% in PAP group) or a CSA/CSR (29.4% in ASV group vs. 20% in PAP). After ASV titration, the mean follow-up was 25±14 months. Both groups (ASV vs. PAP) were similar in terms of compliance (77±23% vs.88±14%) and in terms of Epworth sleepiness scale score (6±5 vs. 7±5). There was a statistical difference in terms of residual AHI: mean AHI was 4±3 in ASV group and 9±3 in PAP group (P=0.005). We found no differences in terms of left ventricular fractional shortening (ASV 33±10% vs. PAP 32±10%). Although no difference was observed between the 2 groups in terms of non-fatal cardiovascular events (3 events in each group), 2 fatal cardiovascular events occurred in the PAP group (sudden death). CONCLUSIONS These data confirm that ASV is an efficient treatment in patients with treatment-emergent CSA, CSA/CSR significantly decreasing residual AHI. In both groups, compliance rate was high and sleepiness improved. It is relevant that the 2 patients who died of sudden death were treated with PAP.
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Affiliation(s)
- Sílvia Correia
- Pneumology Department, ULS-Guarda, Sousa Martins Hospital, Guarda, Portugal.
| | - Vitória Martins
- Pneumology Department, HG-CHUC, Sleep Medicine Center, Coimbra, Portugal
| | - Liliana Sousa
- Neurophysiology Department, HG-CHUC, Sleep Medicine Center, Coimbra, Portugal
| | - Joaquim Moita
- Pneumology Department, HG-CHUC, Sleep Medicine Center, Coimbra, Portugal
| | - Fátima Teixeira
- Pneumology Department, HG-CHUC, Sleep Medicine Center, Coimbra, Portugal
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Prevalence of central sleep apnea during continous positive airway pressure (CPAP) titration in subjects with obstructive sleep apnea syndrome at an altitude of 2640 m. Sleep Med 2015; 16:343-6. [DOI: 10.1016/j.sleep.2014.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/15/2014] [Accepted: 09/19/2014] [Indexed: 12/28/2022]
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Tomita Y, Kasai T. Effectiveness of adaptive servo-ventilation. World J Respirol 2015; 5:112. [DOI: 10.5320/wjr.v5.i2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 04/16/2015] [Accepted: 06/11/2015] [Indexed: 02/06/2023] Open
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Javaheri S, Brown LK, Randerath WJ. Clinical Applications of Adaptive Servoventilation Devices. Chest 2014; 146:858-868. [DOI: 10.1378/chest.13-1778] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Morgenthaler TI, Kuzniar TJ, Wolfe LF, Willes L, McLain WC, Goldberg R. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. Sleep 2014; 37:927-34. [PMID: 24790271 DOI: 10.5665/sleep.3662] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Prior studies show that adaptive servoventilation (ASV) is initially more effective than continuous positive airway pressure (CPAP) for patients with complex sleep apnea syndrome (CompSAS), but choosing therapies has been controversial because residual central breathing events may resolve over time in many patients receiving chronic CPAP therapy. We conducted a multicenter, randomized, prospective trial comparing clinical and polysomnographic outcomes over prolonged treatment of patients with CompSAS, with CPAP versus ASV. METHODS Qualifying participants meeting criteria for CompSAS were randomized to optimized CPAP or ASV treatment. Clinical and polysomnographic data were obtained at baseline and after 90 days of therapy. RESULTS We randomized 66 participants (33 to each treatment). At baseline, the diagnostic apnea-hypopnea index (AHI) was 37.7 ± 27.8 (central apnea index [CAI] = 3.2 ± 5.8) and best CPAP AHI was 37.0 ± 24.9 (CAI 29.7 ± 25.0). After second-night treatment titration, the AHI was 4.7 ± 8.1 (CAI = 1.1 ± 3.7) on ASV and 14.1 ± 20.7 (CAI = 8.8 ± 16.3) on CPAP (P ≤ 0.0003). At 90 days, the ASV versus CPAP AHI was 4.4 ± 9.6 versus 9.9 ± 11.1 (P = 0.0024) and CAI was 0.7 ± 3.4 versus 4.8 ± 6.4 (P < 0.0001), respectively. In the intention-to-treat analysis, success (AHI < 10) at 90 days of therapy was achieved in 89.7% versus 64.5% of participants treated with ASV and CPAP, respectively (P = 0.0214). Compliance and changes in Epworth Sleepiness Scale and Sleep Apnea Quality of Life Index were not significantly different between treatment groups. CONCLUSION Adaptive servoventilation (ASV) was more reliably effective than CPAP in relieving complex sleep apnea syndrome. While two thirds of participants experienced success with CPAP, approximately 90% experienced success with ASV. Because both methods produced similar symptomatic changes, it is unclear if this polysomnographic effectiveness may translate into other desired outcomes. CLINICAL TRIALS Clinicaltrials.Gov NCT00915499.
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Affiliation(s)
- Timothy I Morgenthaler
- Mayo Clinic Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Lisa F Wolfe
- Northwestern University Feinberg School of Medicine, Chicago, IL
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Complex sleep apnea syndrome. SLEEP DISORDERS 2014; 2014:798487. [PMID: 24693440 PMCID: PMC3945285 DOI: 10.1155/2014/798487] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/10/2013] [Accepted: 11/23/2013] [Indexed: 12/16/2022]
Abstract
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.
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Ryu HU, Lee EM, Lee GH, Kim B, Lee SA. Prevalence and Predicting Factors of Complex Sleep Apnea in Patients with Obstructive Sleep Apnea Syndrome. ACTA ACUST UNITED AC 2013. [DOI: 10.13078/jksrs.13010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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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.
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Affiliation(s)
- S Javaheri
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Abstract
OPINION STATEMENT Complex sleep apnea currently refers to the emergence and persistence of central apneas and hypopneas following the application of positive airway pressure therapy in patients with obstructive sleep apnea. However, this narrow definition is an "outcome" and does not capture the spectrum of pathological activation of the respiratory chemoreflex in sleep apnea. The International Classification of Sleep Disorders - 3rd edition recognizes the phenomenon of Treatment-Related Central Sleep Apnea, but the phenotype is usually evident prior to onset of therapy. The key polysomnographic characteristics of chemoreflex modulated and mediated sleep apnea are nonrapid eye movement (NREM) dominance of respiratory events, short (<30 seconds) or long (>60 seconds) cycle time with a self-similar metronomic timing, and spontaneous improvement during rapid eye movement (REM) sleep. Thus, the majority of chemoreflex effects go unrecognized due to the bias toward obstructive sleep apnea's current scoring criteria. Any treatment of apparently obstructive sleep apnea, including surgery and oral appliances, can expose chemoreflex-driven instabilities. As both sleep fragmentation and a narrow CO2 reserve or increased loop gain drive the disease, sedatives (to induce longer periods of stable NREM sleep and reduce the destabilizing effects of arousals in NREM sleep) and CO2-based stabilization approaches are logical. Adaptive ventilation reduces mean hyperventilation yet can induce ventilator-patient desynchrony, while enhanced expiratory rebreathing space (EERS, dead space during positive pressure therapy) and CO2 manipulation directly stabilize respiratory control by moving CO2 above the apnea threshold. Carbonic anhydrase inhibition can provide further adjunctive benefits. Novel pharmacological approaches may target mediators of carotid body hypoxic sensitization, such as the balance between gas neurotransmitters. In complex apnea patients, single mode therapy is unlikely to be successful, and the power of multi-modality therapy should be harnessed for optimal outcomes.
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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; 9:1187-91. [PMID: 24235901 DOI: 10.5664/jcsm.3166] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Sydney B Montesi
- Sleep Disorders Research Program, Brigham and Women's Hospital and Harvard Medical School, Boston, MA ; Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA
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Edwards BA, Malhotra A, Sands SA. Adapting our approach to treatment-emergent central sleep apnea. Sleep 2013; 36:1121-2. [PMID: 23904668 DOI: 10.5665/sleep.2862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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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; 36:1163-71. [PMID: 23904676 DOI: 10.5665/sleep.2878] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Dominic Dellweg
- Kloster Grafschaft, Pulmonary Medicine I, Home Mechanical Ventilation Unit and Sleep Laboratory, Schmallenberg, Germany.
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Sleep-disordered breathing in patients with heart failure: new trends in therapy. BIOMED RESEARCH INTERNATIONAL 2013; 2013:459613. [PMID: 23984365 PMCID: PMC3745910 DOI: 10.1155/2013/459613] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 07/02/2013] [Indexed: 01/25/2023]
Abstract
Heart failure (HF) is a growing health problem which paradoxically results from the advances in the treatment of etiologically related diseases (especially coronary artery disease). HF is commonly accompanied by sleep-disordered breathing (SDB), which may directly exacerbate the clinical manifestations of cardiovascular disease and confers a poorer prognosis. Obstructive sleep apnoea predominates in mild forms while central sleep apnoea in more severe forms of heart failure. Identification of SDB in patients with HF is important, as its effective treatment may result in notable clinical benefits to the patients. Continuous positive airway pressure (CPAP) is the gold standard in the management of SDB. The treatments for central breathing disorders include CPAP, bilevel positive airway pressure (BPAP), and adaptive servoventilation (ASV), with the latter being the most modern method of treatment for the Cheyne-Stokes respiration and involving ventilation support with a variable synchronisation dependent on changes in airflow through the respiratory tract and on the patient's respiratory rate. ASV exerts the most favourable effect on long-term prognosis. In this paper, we review the current state of knowledge on the diagnosis and treatment of SDB with a particular emphasis on the latest methods of treatment.
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Abstract
Complex sleep apnea syndrome (CompSAS) describes the coexistence or appearance and persistence of central apneas or hypopneas in patients with obstructive sleep apnea upon successful restoration of airway patency. We review data on treatment of CompSAS with CPAP, bilevel positive airway pressure, and adaptive servoventilation and discuss evidence for the addition of medications (analgesics, hypnotics, acetazolamide) and gases (oxygen, CO2) to positive airway pressure therapy. Future research should focus on defining outcomes in patients with CompSAS and allow for more accurate tailoring of therapy to the pathophysiology present in the individual patient.
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Affiliation(s)
- Tomasz J Kuźniar
- Department of Internal Medicine, 4th Clinical Military Hospital, Wrocław, Poland
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Strey KA, Baertsch NA, Baker-Herman TL. Inactivity-induced respiratory plasticity: protecting the drive to breathe in disorders that reduce respiratory neural activity. Respir Physiol Neurobiol 2013; 189:384-94. [PMID: 23816599 DOI: 10.1016/j.resp.2013.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/04/2013] [Accepted: 06/24/2013] [Indexed: 12/25/2022]
Abstract
Multiple forms of plasticity are activated following reduced respiratory neural activity. For example, in ventilated rats, a central neural apnea elicits a rebound increase in phrenic and hypoglossal burst amplitude upon resumption of respiratory neural activity, forms of plasticity called inactivity-induced phrenic and hypoglossal motor facilitation (iPMF and iHMF), respectively. Here, we provide a conceptual framework for plasticity following reduced respiratory neural activity to guide future investigations. We review mechanisms giving rise to iPMF and iHMF, present new data suggesting that inactivity-induced plasticity is observed in inspiratory intercostals (iIMF) and point out gaps in our knowledge. We then survey conditions relevant to human health characterized by reduced respiratory neural activity and discuss evidence that inactivity-induced plasticity is elicited during these conditions. Understanding the physiological impact and circumstances in which inactivity-induced respiratory plasticity is elicited may yield novel insights into the treatment of disorders characterized by reductions in respiratory neural activity.
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Affiliation(s)
- K A Strey
- Department of Comparative Biosciences, University of Wisconsin, Madison, WI 53706, USA.
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Central sleep apnea and complex sleep apnea in patients with epilepsy. Sleep Breath 2013; 18:119-24. [DOI: 10.1007/s11325-013-0858-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 04/17/2013] [Accepted: 04/22/2013] [Indexed: 01/20/2023]
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Kuźniar TJ, Kasibowska-Kuźniar K, Ray DW, Freedom T. Clinical heterogeneity of patients with complex sleep apnea syndrome. Sleep Breath 2013; 17:1209-14. [PMID: 23436008 PMCID: PMC3898341 DOI: 10.1007/s11325-013-0825-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/31/2013] [Accepted: 02/11/2013] [Indexed: 12/31/2022]
Abstract
Background The definition of complex sleep apnea (CompSAS) encompasses patients with obstructive sleep apnea (OSA) who develop central apnea activity upon restitution of airway patency. Presence of arterial hypertension (HTN), coronary artery disease (CAD) and heart failure (HF) have been proposed as risk factors for CompSAS among OSA patients. Using our database of patients with CompSAS, we examined the prevalence of these risk factors and defined other clinical characteristics of patients with CompSAS. Methods Through retrospective search of the database, we examined the medical and clinical characteristics of consecutive patients diagnosed with CompSAS between 11/1/2006 and 6/30/2011 at NorthShore University HealthSystem. Results One hundred and fifty patients with CompSAS were identified. Among patients included in the study, 97 (64.7 %) had at least one risk factor for CompSAS, while 53 (35.3 %) did not have any of them. Prevalence of low left ventricular ejection fraction and hypocapnia were low. Therapeutic interventions consisted of several positive airway pressure therapies, mainly adaptive servo ventilation. A hundred and ten patients (73.3 %) complied with recommended therapy and improved clinically. Conclusions Although most patients with CompSAS have cardiac comorbidities, about one third of patients do not have any risk factors of CompSAS prior to sleep testing. Further research on factors involved in development of CompSAS will allow for better tailoring of therapy to pathophysiology involved in an individual case.
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Affiliation(s)
- Tomasz J Kuźniar
- Division of Pulmonary and Critical Care Medicine, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL, USA,
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Abstract
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.
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Affiliation(s)
- Juan Wang
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Yan Wang
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jing Feng
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
- Correspondence: Jing Feng, Respiratory Department of Tianjin Medical University General Hospital, Tianjin 300052, People’s Republic of China Email ;
| | - Bao-yuan Chen
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jie Cao
- Respiratory Department of Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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