Apneas of Heart Failure and Phenotype-Guided Treatments: Part One: OSA. Javaheri Shahrokh,Brown Lee K,Abraham William T,Khayat Rami Chest Sleep-disordered breathing (SDB), including OSA and central sleep apnea, is highly prevalent in patients with heart failure (HF). Multiple studies have reported this high prevalence in asymptomatic as well as symptomatic patients with reduced left ventricular ejection fraction (HFrEF), as well as in those with HF with preserved ejection fraction. The acute pathobiologic consequences of OSA, including exaggerated sympathetic activity, oxidative stress, and inflammation, eventually could lead to progressive left ventricular dysfunction, repeated hospitalization, and excessive mortality. Large numbers of observational studies and a few small randomized controlled trials have shown improvement in various cardiovascular consequences of SDB with treatment. There are no long-term randomized controlled trials to show improved survival of patients with HF and treatment of OSA. One trial of positive airway pressure treatment of OSA included patients with HF and showed no improvement in clinical outcomes. However, any conclusions derived from this trial must take into account several important pitfalls that have been extensively discussed in the literature. With the role of positive airway pressure as the sole therapy for SDB in HF increasingly questioned, a critical examination of long-accepted concepts in this field is needed. The objective of this review was to incorporate recent advances in the field into a phenotype-based approach to the management of OSA in HF. 10.1016/j.chest.2019.02.407
    Predominant obstructive or central sleep apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas. Strotmann Johanna,Fox Henrik,Bitter Thomas,Schindhelm Florian,Gutleben Klaus-Jürgen,Horstkotte Dieter,Oldenburg Olaf Sleep medicine OBJECTIVE/BACKGROUND:Sleep-disordered breathing (SDB) is common in patients with atrial fibrillation (Afib). Although a high proportion of respiratory events are hypopneas, previous studies have only used apneas to differentiate obstructive (OSA) from central (CSA) sleep apnea. This study investigated the impact of using apneas and hypopneas versus apneas only to define the predominant type of SDB in Afib patients with preserved ejection fraction. PATIENTS/METHODS:This retrospective analysis was based on high-quality cardiorespiratory polygraphy (PG) recordings (07/2007-03/2016) that were re-analyzed using 2012 American Academy of Sleep Medicine criteria, with differentiation of apneas and hypopneas as obstructive or central. Classification of predominant (>50% of events) OSA and CSA was defined based on apneas only (OSA and CSA) or apneas and hypopneas (OSA and CSA). SDB was defined as an apnea-hypopnea index ≥5/h. RESULTS:A total of 211 patients were included (146 male, age 68.7 ± 8.5 y). Hypopneas accounted for >50% of all respiratory events. Based on apneas only, 46% of patients had predominant OSA and 44% had predominant CSA. Based on apneas and hypopneas, the proportion of patients with OSA was higher (56%) and that with CSA was lower (36%). In the subgroup of patients with moderate to severe SDB (AHI ≥ 15/h), the proportion with predominant CSA was 55.2% based on apneas only versus 42.1% with apneas and hypopneas. CONCLUSIONS:In hospitalized patients with Afib and SDB, use of apneas and hypopneas versus apneas alone had an important influence on the proportion of patients classified as having predominant OSA or CSA. 10.1016/j.sleep.2017.06.003
    Prognostic Significance of Central Apneas Throughout a 24-Hour Period in Patients With Heart Failure. Emdin Michele,Mirizzi Gianluca,Giannoni Alberto,Poletti Roberta,Iudice Giovanni,Bramanti Francesca,Passino Claudio Journal of the American College of Cardiology BACKGROUND:Large trials using noninvasive mechanical ventilation to treat central apnea (CA) occurring at night ("sleep apnea") in patients with systolic heart failure (HF) have failed to improve prognosis. The prevalence and prognostic value of CA during daytime and over an entire 24-h period are not well described. OBJECTIVES:This study evaluated the occurrence and prognostic significance of nighttime, daytime, and 24-h CA episodes in a large cohort of patients with systolic HF. METHODS:Consecutive patients receiving guideline-recommended treatment for HF (n = 525; left ventricular ejection fraction [LVEF] of 33 ± 9%; 66 ± 12 years of age; 77% males) underwent prospective evaluation, including 24-h respiratory recording, and were followed-up using cardiac mortality as an endpoint. RESULTS:The 24-h prevalence of predominant CAs (apnea/hypopnea index [AHI] ≥5 events/h, with CA of >50%) was 64.8% (nighttime: 69.1%; daytime: 57.0%), whereas the prevalence of predominant obstructive apneas (OA) was 12.8% (AHI ≥5 events/h with OAs >50%; nighttime: 14.7%; daytime: 5.9%). Episodes of CA were associated with neurohormonal activation, ventricular arrhythmic burden, and systolic/diastolic dysfunction (all p < 0.05). During a median 34-month follow-up (interquartile range [IQR]: 17 to 36 months), 50 cardiac deaths occurred. Nighttime, daytime, and 24-h moderate-to-severe CAs were associated with increased cardiac mortality (AHI of </≥15 events/h; log-rank: 6.6, 8.7, and 5.3, respectively; all p < 0.05; central apnea index [CAI] of </≥10 events/h; log-rank 8.9, 11.2, and 10.9, respectively; all p < 0.001). Age, B-type natriuretic peptide level, renal dysfunction, 24-h AHI, CAI, and time with oxygen saturation of <90% were independent predictors of outcome. CONCLUSIONS:In systolic HF patients, CAs occurred throughout a 24-h period and were associated with a neurohormonal activation, ventricular arrhythmic burden, and worse prognosis. 10.1016/j.jacc.2017.07.740
    Central Sleep Apnea - a Rare Cause for Acute Respiratory Insufficiency in Children. Case Report. Popescu Nicoleta Aurelia,Ionescu Marcela Daniela,Balan Georgiana,Visan Simina,Cinteza Eliza,Stanescu Diana,Gobej Ionut,Balgradean Mihaela Maedica Central sleep apnea is characterized by frequent cessation of breathing during sleep, resulting in repetitive episodes of insufficient ventilation and abnormalities of acid-base balance. It may be primary or secondary, and it is uncommon in children, with limited data for this population. We present here the case of a five-year-old girl, known to have thoracolumbar myelomeningocele (for which she underwent a surgical procedure in infancy), secondary hydrocephalus (with a ventriculoperitoneal shunt) and flaccid paralysis, who was admitted in our hospital with prolonged fever syndrome, productive cough, severe dyspnea and perioral cyanosis. Following physical examination, laboratory investigations and thoracic radiography, we established the diagnosis of aspiration pneumonia with acute respiratory failure. Medical treatment with multiple systemic antibiotics, antifungal agents, systemic and inhaled bronchodilator, oxygen therapy and respiratory nursing were initiated, with favorable evolution. During the entire hospitalization, the patient showed nocturnal respiratory rhythm disorders, with sleep apnea crisis of approximately 20 seconds and desaturation, followed by severe hypercapnic respiratory acidosis, manifestations that persisted even after the remission of pulmonary infection, raising the suspicion of an apnea syndrome. After excluding the causes of obstructive apnea, a cerebral CT scan was performed, revealing isolated fourth ventricle compressing the brainstem. The patient underwent neurosurgical intervention and postoperatively, the evolution was favorable, with remission of apnea crisis.
    Aging is associated with increased propensity for central apnea during NREM sleep. Chowdhuri Susmita,Pranathiageswaran Sukanya,Loomis-King Hillary,Salloum Anan,Badr M Safwan Journal of applied physiology (Bethesda, Md. : 1985) The reason for increased sleep-disordered breathing with predominance of central apneas in the elderly is unknown. We hypothesized that the propensity to central apneas is increased in older adults, manifested by a reduced carbon-dioxide (CO) reserve in older compared with young adults during non-rapid eye movement sleep. Ten elderly and 15 young healthy adults underwent multiple brief trials of nasal noninvasive positive pressure ventilation during stable NREM sleep. Cessation of mechanical ventilation (MV) resulted in hypocapnic central apnea or hypopnea. The CO reserve was defined as the difference in end-tidal CO ([Formula: see text]) between eupnea and the apneic threshold, where the apneic threshold was [Formula: see text] that demarcated the central apnea closest to the eupneic [Formula: see text]. For each MV trial, the hypocapnic ventilatory response (controller gain) was measured as the change in minute ventilation (V̇e) during the MV trial for a corresponding change in [Formula: see text]. The eupneic [Formula: see text] was significantly lower in elderly vs. young adults. Compared with young adults, the elderly had a significantly reduced CO reserve (-2.6 ± 0.4 vs. -4.1 ± 0.4 mmHg, P = 0.01) and a higher controller gain (2.3 ± 0.2 vs. 1.4 ± 0.2 l·min·mmHg, P = 0.007), indicating increased chemoresponsiveness in the elderly. Thus elderly adults are more prone to hypocapnic central apneas owing to increased hypocapnic chemoresponsiveness during NREM sleep. NEW & NOTEWORTHY The study describes an original finding where healthy older adults compared with healthy young adults demonstrated increased breathing instability during non-rapid eye movement sleep, as suggested by a smaller carbon dioxide reserve and a higher controller gain. The findings may explain the increased propensity for central apneas in elderly adults during sleep and potentially guide the development of pathophysiology-defined personalized therapies for sleep apnea in the elderly. 10.1152/japplphysiol.00125.2017
    Effects of Adaptive Servoventilation Therapy for Central Sleep Apnea on Health Care Utilization and Mortality: A Population-Based Study. Mansukhani Meghna P,Kolla Bhanu Prakas,Naessens James M,Gay Peter C,Morgenthaler Timothy I Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine STUDY OBJECTIVES:Adaptive servoventilation (ASV) is the suggested treatment for many forms of central sleep apnea (CSA). We aimed to evaluate the impact of treating CSA with ASV on health care utilization. METHODS:In this population-based study using the Rochester Epidemiology Project database, we identified patients over a 9-year period who were diagnosed with CSA (n = 1,237), commenced ASV therapy, and had ≥ 1 month of clinical data before and after ASV initiation. The rates of hospitalizations, emergency department visits (EDV), outpatient visits (OPV) and medications prescribed per year (mean ± standard deviation) in the 2 years pre-ASV and post-ASV initiation were compared. RESULTS:We found 309 patients (68.0 ± 14.6 years, 80.3% male, apnea-hypopnea index 41.6 ± 26.5 events/h, 78% with cardiovascular comorbidities, 34% with heart failure) who met inclusion criteria; 65% used ASV ≥ 4 h/night on ≥ 70% nights in their first month. The overall 2-year mortality rate was 9.4% and CSA secondary to cardiac cause was a significant risk factor for mortality (hazard ratio 1.81, 95% CI 1.09-3.01, = .02). Comparing pre-ASV and post-ASV initiation, there was no change in the rate of hospitalization (0.72 ± 1.63 versus 0.79 ± 1.44, = .46), EDV (1.19 ± 2.18 versus 1.26 ± 2.08, = .54), OPV (31.59 ± 112.42 versus 13.60 ± 17.36, = .22), or number of prescribed medications (6.68 ± 2.0 versus 5.31 ± 5.86, = .06). No differences in these outcomes emerged after accounting for adherence to ASV, CSA subtype and comorbidities via multiple regression analysis (all > .05). CONCLUSIONS:Our cohort of patients with CSA was quite ill and the use of ASV was not associated with a change in health care utilization. 10.5664/jcsm.7584
    Adaptive servo-ventilation and sleep quality in treatment emergent central sleep apnea and central sleep apnea in patients with heart disease and preserved ejection fraction. Heider Katharina,Arzt Michael,Lerzer Christoph,Kolb Leonie,Pfeifer Michael,Maier Lars S,Gfüllner Florian,Malfertheiner Maximilian Valentin Clinical research in cardiology : official journal of the German Cardiac Society BACKGROUND:Reduced sleep quality is associated with impaired quality of life and increased mortality in patients with heart failure. The aim of this study was to observe changes in sleep fragmentation and sleep quality in patients with heart disease and preserved left ventricular ejection fraction (pEF) treated with adaptive servo-ventilation (ASV) therapy for treatment of emergent central sleep apnea (TECSA) or central sleep apnea (CSA). METHODS:114 patients with structural heart disease and pEF introduced to ASV therapy between 2010 and 2015 were retrospectively analyzed. Patients were stratified into two groups; TECSA (n = 60) or CSA (n = 54). Changes of sleep fragmentation and sleep quality from baseline to ASV initiation were compared. RESULTS:ASV therapy leads to a significant reduction of apnea-hypopnea index (AHI) and arousal index in patients with TECSA and CSA (∆AHI: - 43 ± 21 vs. - 47 ± 22/h; ∆arousal index - 11 ± 15, vs. - 11 ± 21/h). ASV treatment leads to a significant increase in sleep efficiency in TECSA compared to CSA (∆SE: 10 ± 19 vs. 1 ± 18%, p = 0.019). Both groups had significantly longer stage N3 (N3) and rapid eye movement sleep (REM) on ASV (∆N3: 8 ± 11 vs. 9 ± 13%; ∆REM 7 ± 9 vs. 3 ± 8%; p < 0.05 for all comparisons baseline vs. ASV). CONCLUSIONS:In patients with heart disease and pEF, whose TECSA and CSA were treated with ASV, a significant reduction of AHI and arousal index as well as an increase of N3 and REM sleep was observed. Increase of sleep efficiency was significantly greater in TECSA compared to CSA. Hence, improvements of sleep quality were modestly greater in patients with TECSA compared to those with CSA. 10.1007/s00392-018-1203-9
    Epilepsy and Sleep-Related Breathing Disturbances. Somboon Thapanee,Grigg-Damberger Madeleine M,Foldvary-Schaefer Nancy Chest Epilepsy is the fourth most common neurologic disorde in the United States, affecting over 2.2 million people. Epilepsy is associated with a number of medical and psychiatric comorbidities, higher health-care use and cost, and substantial economic burden. OSA is twofold more common in adults with epilepsy than in age-matched control subjects, and the incidence increases with age. Self-reported daytime sleepiness is not helpful in predicting OSA, possibly related to the ceiling effect of general sleepiness among people with epilepsy from diverse causes. Mostly small retrospective series found a significant reduction in seizures in people with epilepsy and OSA adherent with positive airway pressure therapy compared with untreated individuals. This finding illustrates the potential beneficial effects of sleep therapies on epilepsy. Central apnea, oxygen desaturations, and hypercapnia can occur during the ictal and immediate postictal period, especially with generalized tonic-clonic seizures. Central apneas have been produced by electrical stimulation of mesial temporal structures. These respiratory disturbances suggest activation of the central autonomic network and may contribute to sudden unexpected death in epilepsy (SUDEP), the leading cause of epilepsy-related death in people with drug-resistant epilepsy. SUDEP typically occurs during sleep, and patients are more often found in a prone position and have a history of nocturnal seizures. Whether OSA contributes to SUDEP is unknown. Vagus nerve stimulation is a form of neuromodulation for drug-resistant focal epilepsy. When the device activates during sleep it causes reduction in airflow and respiratory effort, airflow obstruction, and oxygen desaturations, sometimes producing a clinical sleep apnea syndrome. The goal of this review is to discuss firmly established and recently recognized clinical, neurobiologic, electrophysiologic, and polysomnographic relationships between sleep-disordered breathing and epilepsy. 10.1016/j.chest.2019.01.016
    Autonomic regulation during sleep and wakefulness: a review with implications for defining the pathophysiology of neurological disorders. Fink Anne M,Bronas Ulf G,Calik Michael W Clinical autonomic research : official journal of the Clinical Autonomic Research Society Cardiovascular and respiratory parameters change during sleep and wakefulness. This observation underscores an important, albeit incompletely understood, role for the central nervous system in the differential regulation of autonomic functions. Understanding sleep/wake-dependent sympathetic modulations provides insights into diseases involving autonomic dysfunction. The purpose of this review was to define the central nervous system nuclei regulating sleep and cardiovascular function and to identify reciprocal networks that may underlie autonomic symptoms of disorders such as insomnia, sleep apnea, restless leg syndrome, rapid eye movement sleep behavior disorder, and narcolepsy/cataplexy. In this review, we examine the functional and anatomical significance of hypothalamic, pontine, and medullary networks on sleep, cardiovascular function, and breathing. 10.1007/s10286-018-0560-9
    Effect of Treatment of Central Sleep Apnea/Cheyne-Stokes Respiration on Left Ventricular Ejection Fraction in Heart Failure: A Network Meta-Analysis. Schwarz Esther I,Scherff Frank,Haile Sarah R,Steier Joerg,Kohler Malcolm Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine STUDY OBJECTIVES:Patients who have experienced heart failure with central sleep apnea/Cheyne-Stokes respiration (CSA/CSR) have an impaired prognosis. Continuous positive airway pressure (CPAP) and adaptive servoventilation (ASV) as well as nocturnal oxygen (O₂) are proposed treatment modalities of CSA/CSR. The goal of the study is to assess whether and how different treatments of CSA/CSR affect cardiac function. METHODS:Databases were searched up to December 2017 for randomized controlled trials (RCTs) comparing the effect of any combination of CPAP, ASV, O₂ or an inactive control on left ventricular ejection fraction (LVEF) in patients with heart failure and CSA/CSR. A systematic review and network meta-analysis using multivariate random-effects meta-regression were performed. RESULTS:Twenty-four RCTs (1,289 patients) were included in the systematic review and data of 16 RCTs (951 patients; apnea-hypopnea-index 38 ± 3/h, LVEF 29 ± 3%) could be pooled in a network meta-analysis. Compared to an inactive control, both CPAP and ASV significantly improved LVEF by 4.4% (95% confidence interval 0.3-8.5%, P = 0.036) and 3.8% (95% confidence interval 0.6-7.0%, P = 0.025), respectively, whereas O₂ had no effect on LVEF (P = 0.35). There was no difference in treatment effects on LVEF between CPAP and ASV (P = 0.76). The treatment effect of positive pressure ventilation was larger when baseline LVEF was lower in systolic heart failure. CONCLUSIONS:CPAP and ASV are effective in improving LVEF in patients with heart failure and CSA/CSR to a clinically relevant amount, whereas nocturnal O₂ is not. There is no difference between CPAP and ASV in the comparative beneficial effect on cardiac function. 10.5664/jcsm.8092
    Natural history of treatment-emergent central sleep apnea on positive airway pressure: A systematic review. Nigam Gaurav,Riaz Muhammad,Chang Edward T,Camacho Macario Annals of thoracic medicine 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. 10.4103/atm.ATM_321_17
    Emergence of Central Sleep Apnea Events After Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea. Goodday Reginald H,Fay Matthew B Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons PURPOSE:Central sleep apnea (CSA) can develop after the treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP). No studies have identified whether treatment of OSA with maxillomandibular advancement surgery (MMA) can result in CSA. The purpose of our study was to determine the incidence and clinical significance of CSA emerging after MMA surgery to treat OSA. PATIENTS AND METHODS:A retrospective review was conducted of all patients who had undergone MMA surgery for OSA at the Department of Oral and Maxillofacial Surgery at the QEII Health Sciences Centre (Halifax, NS, Canada) from 1996 through 2016. All patients with preoperative level 1 polysomnography and follow-up level 1 study results available at least 6 months postoperatively were included the present study. The pre- and postoperative central apnea index (CAI) results were compared. RESULTS:A total of 113 patients (84 men and 29 women) with an average age of 44.0 years were included in the present study. In 35 patients (31.0%), the emergence of CSA events were recorded on postoperative polysomnograms. Only 2 of the 113 patients experienced the emergence of clinically significant postoperative CSA (CAI >5). In our patient cohort, gender (P = .085), patient age (P = .238), and preoperative (P = .716) and postoperative (P = .209) Apnea-Hypopnea Index (AHI) results correlated with the postoperative development of CSA events after MMA surgery. The mean AHI values had decreased from 41.4 to 8.7 in all patients treated with MMA in our study. CONCLUSIONS:The emergence of CSA events occurred in 31% of patients after OSA treatment with MMA surgery. The rate of clinically significant CSA events emerging after MMA surgery in our study was 1.8%. These findings help to support the use of MMA surgery for OSA as a reasonable treatment alternative for patients unable to tolerate CPAP. 10.1016/j.joms.2019.06.002
    Cerebral Oxygenation During Respiratory Events in Children with Sleep-Disordered Breathing and Associated Disorders. Tabone Laurence,Khirani Sonia,Olmo Arroyo Jorge,Amaddeo Alessandro,Sabil Abdelkebir,Fauroux Brigitte The Journal of pediatrics OBJECTIVES:To evaluate changes in cerebral oxygenation by means of near-infrared spectroscopy during respiratory events in children with sleep-disordered breathing (SDB) and associated disorders. STUDY DESIGN:Sixty-five children suspected of having SDB underwent a respiratory polygraphy with simultaneous recording of cerebral oxygenation indices. Respiratory events were analyzed by type of event, duration, variations of pulse oximetry (oxygen saturation [SpO]), cerebral tissue oxygenation index (TOI), and heart rate. Data were categorized according to the severity of SDB and age. RESULTS:There were 540 obstructive and mixed apneas, 172 central apneas, and 393 obstructive hypopneas analyzed. The mean decreases in SpO and TOI were 4.1 ± 3.1% and 3.4 ± 2.8%, respectively. The mean TOI decrease was significantly smaller for obstructive hypopnea compared with apneas. The TOI decrease was significantly less in children with mild SDB as compared with those with moderate-to-severe SDB and in children >7 years as compared with those <7 years old. TOI decreases correlated significantly with SpO decreases, duration of event, and age, regardless of the type of event. In a multivariable regression model, predictive factors of TOI decreases were the type of respiratory event, SpO decrease, apnea-hypopnea index, and age. CONCLUSIONS:In children with SDB and associated disorders, cerebral oxygenation variations depend on the type of respiratory event, severity of SDB, and age. 10.1016/j.jpeds.2019.07.040
    Hypoglossal Nerve Stimulator Outcomes for Patients Outside the U.S. FDA Recommendations. Sarber Kathleen M,Chang Katherine W,Ishman Stacey L,Epperson Madison V,Dhanda Patil Reena The Laryngoscope OBJECTIVES:The hypoglossal nerve stimulator (HGNS) is currently approved for the treatment of obstructive sleep apnea (OSA) in patients with an apnea-hypopnea index (AHI) of >15 to ≤65 events/hour, and a central apnea index (CAI) <25% of the AHI, no complete concentric collapse on drug-induced sleep endoscopy, and a recommended body mass index (BMI) <32 kg/m . We present 18 patients implanted as a salvage procedure despite being outside these guidelines. METHODS:We included all patients who underwent HGNS but who did not meet all FDA guidelines. Demographic data, previous OSA treatments, polysomnographic (PSG) parameters from baseline and HGNS titration PSG, Epworth sleepiness score (ESS), and BMI were compared before and after surgery. RESULTS:Eighteen patients were identified: 94.4% male, median age 63 years. Seven underwent previous sleep surgery. Four had an AHI <15 (mean 10.5 events/hour), four had an AHI >65 (mean 86.9 events/hour), two had an elevated CAI (mean 31.3% of AHI), and 12 had a BMI >32 kg/m (range 32.1-39.1). Median AHI decreased from 25.3 to 3.75 events/hour on titration polysomnography (P = .0006), oxyhemoglobin saturation nadir increased from 82% to 88.5% (P = .0001) and median ESS dropped from 11 to 7.5 (P = .0016). Fifteen (83.3%) patients achieved surgical success (decrease in AHI >50% and AHI <20 events/hour) and 12 (66.7%) had an AHI <5 events/hour. Neither patient with CAI >25% was successfully treated. Median adherence = 33.5 hours/week. CONCLUSION:Our success rate for patients outside the Food and Drug Administration guidelines for HGNS (67%) was similar to the 1-year STAR trial results (66%). Future studies are necessary to consider expansion of these guidelines. LEVEL OF EVIDENCE:4 Laryngoscope, 130:866-872, 2020. 10.1002/lary.28175
    Phrenic nerve stimulation in patients with central sleep apnea: a single‑center experience from pilot and pivotal trials evaluating the remedē System. Jagielski Dariusz,Kołodziej Adam,Westlund Randy,Biel Bartosz,Nowak Krzysztof,Szemplińska Iwona,Flinta Irena,Krawczyk Magdalena,Kulej Katarzyna,Krakowiak Bartosz,Germany Robin,Panteleon Antonis,McKane Scott,Banasiak Waldemar,Abraham William T,Ponikowski Piotr Kardiologia polska BACKGROUND:Patients with central sleep apnea (CSA) have recently been shown to have improved sleep metrics and quality of life (QoL) with phrenic nerve stimulation (PNS). AIMS:The aim of this study was to report the results of a partnership between cardiology, sleep medicine, and electrophysiology in a single clinical center as well as the enrollment, implantation, and follow‑up experience demonstrating both the safety and efficacy of PNS. METHODS:This analysis included data from the pilot and pivotal trials investigating the effect of PNS using an implantable transvenous system in patients with CSA. We present our experience and data on the enrollment processes, implantation feasibility and safety, sleep indices, and QoL at 6 and 12 months of follow‑up. RESULTS:Between June 2010 and May 2015, cardiology patients were prescreened and 588 of them were sent for in‑home sleep test. Ninety‑six patients were referred for polysomnographic studies, and 33 were enrolled and had an implant attempt, with 31 successfully receiving an implant. The apnea-hypopnea index was reduced in the pilot trial (mean [SD] of 48.7 [15.5] events/h to 22.5 [13.2] events/h; P <0.001) and in the pivotal trial (mean [SD] of 48.3 [18.8] events/h to 26.0 [21.9] events/h; P <0.001). Improvement in QoL was also observed. CONCLUSIONS:We showed that PNS improved sleep metrics and QoL in patients with CSA, which is a result of multiple factors, including a comprehensive coordination between cardiology, sleep medicine, and electrophysiology. This ensures appropriate patient identification leading to safe implantation and full patient compliance during follow‑up visits. 10.5603/KP.a2019.0061
    Positional impairment of gas exchange during diaphragm pacing alleviated by increasing amplitude settings in congenital central hypoventilation syndrome. Chada Aditya,Leu Roberta M,Perez Iris A,Esther Charles R,Kasi Ajay S Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine None:Diaphragm pacing (DP) by phrenic nerve stimulation is a modality of chronic ventilatory support in individuals with congenital central hypoventilation syndrome (CCHS). We report a 9-year-old girl with CCHS who uses DP without tracheostomy during sleep. Her parents report hypoxemia and hypercapnia related to positional changes of the body during sleep requiring frequent adjustment of pacer settings. Overnight polysomnography was performed to titrate DP settings that showed adequate gas exchange in the supine position, but intermittent hypoxemia and hypercapnia were noted in the left decubitus position without obstructive sleep apnea occurring. Subsequently, the DP amplitude settings were increased during polysomnography, thereby identifying and treating positional hypoxemia and hypercapnia in various body positions. Our case emphasizes the importance of polysomnography in children with CCHS using DP to monitor for sleep-disordered breathing and titration of DP settings to achieve optimal oxygenation and ventilation with different body positions during sleep. 10.5664/jcsm.8232
    Portable Sleep Monitoring for Diagnosing Sleep Apnea in Hospitalized Patients With Heart Failure. Aurora R Nisha,Patil Susheel P,Punjabi Naresh M Chest BACKGROUND:Sleep apnea is an underdiagnosed condition in patients with heart failure. Efficient identification of sleep apnea is needed, as treatment may improve heart failure-related outcomes. Currently, use of portable sleep monitoring in hospitalized patients and those at risk for central sleep apnea is discouraged. This study examined whether portable sleep monitoring with respiratory polygraphy can accurately diagnose sleep apnea in patients hospitalized with decompensated heart failure. METHODS:Hospitalized patients with decompensated heart failure underwent concurrent respiratory polygraphy and polysomnography. Both recordings were scored for obstructive and central disordered breathing events in a blinded fashion, using standard criteria, and the apnea-hypopnea index (AHI) was determined. Pearson's correlation coefficients and Bland-Altman plots were used to examine the concordance among the overall, obstructive, and central AHI values derived by respiratory polygraphy and polysomnography. RESULTS:The sample consisted of 53 patients (47% women) with a mean age of 59.0 years. The correlation coefficient for the overall AHI from the two diagnostic methods was 0.94 (95% CI, 0.89-0.96). The average difference in AHI between the two methods was 3.6 events/h. Analyses of the central and obstructive AHI values showed strong concordance between the two methods, with correlation coefficients of 0.98 (95% CI, 0.96-0.99) and 0.91 (95% CI, 0.84-0.95), respectively. Complete agreement in the classification of sleep apnea severity between the two methods was seen in 89% of the sample. CONCLUSIONS:Portable sleep monitoring can accurately diagnose sleep apnea in hospitalized patients with heart failure and may promote early initiation of treatment. 10.1016/j.chest.2018.04.008
    Nocturnal supports for patients with central sleep apnea and heart failure: a systemic review and network meta-analysis of randomized controlled trials. Chen Chongxiang,Wen Tianmeng,Liao Wei Annals of translational medicine Background:Sleep apnea probably brings poor outcomes of chronic heart failure (CHF), and some methods show benefit to patients with heart failure (HF) and central sleep apnea (CSA). Our study based on the randomized controlled trials (RCTs) to find out the most beneficial therapy of nocturnal support to decrease the apnea hypopnea index (AHI). Methods:The PubMed, and the Web of Science were used to find out the included studies. RevMan 5.3 and Stata 15.1 were performed to this systemic review and network meta-analysis. Results:After searching and screening the articles, finally we included 14 articles with total 919 patients, and 4 arms [adaptive servo ventilation (ASV), continuous positive airway pressure (CPAP), oxygen treatment, control]. Compared with the control group, the therapeutic regimens did not show significant difference in AHI. Ranking the different nocturnal supports in the order of estimated probabilities of each treatment by using the network meta-analysis, the result showed that ASV was the best one (87.8%), followed by oxygen (12.2%), CPAP (0%), and control (0%). Conclusions:Based on our study, the adoptive servo ventilation is probably the best choice to down the AHI in patients with HF and CSA. 10.21037/atm.2019.06.72
    Sustained 12 Month Benefit of Phrenic Nerve Stimulation for Central Sleep Apnea. Costanzo Maria Rosa,Ponikowski Piotr,Javaheri Shahrokh,Augostini Ralph,Goldberg Lee R,Holcomb Richard,Kao Andrew,Khayat Rami N,Oldenburg Olaf,Stellbrink Christoph,Abraham William T, The American journal of cardiology Transvenous phrenic nerve stimulation improved sleep metrics and quality of life after 6 months versus control in the remedē System Pivotal Trial. This analysis explored the effectiveness of phrenic nerve stimulation in patients with central sleep apnea after 12 months of therapy. Reproducibility of treatment effect was assessed in the former control group in whom the implanted device was initially inactive for the sixth month and subsequently activated when the randomized control assessments were complete. Patients with moderate-to-severe central sleep apnea implanted with the remedē System were randomized to therapy activation at 1 month (treatment) or after 6 months (control). Sleep indices were assessed from baseline to 12 months in the treatment group and from 6 to 12 months in former controls. In the treatment group, a ≥50% reduction in apnea-hypopnea index occurred in 60% of patients at 6 months (95% confidence interval [CI] 47% to 64%) and 67% (95% CI 53% to 78%) at 12 months. After 6 months of therapy, 55% of former controls (95% CI 43% to 67%) achieved ≥50%reduction in apnea-hypopnea index. Patient Global Assessment was markedly ormoderately improved at 6 and 12 months in 60% of treatment patients.Improvements persisted at 12 months. A serious adverse event within 12 months occurred in 13 patients (9%). Phrenic nerve stimulation produced sustained improvements in sleep indices and quality of life to at least 12 months in patients with central sleep apnea. The similar improvement of former controls after 6 months of active therapy confirms benefits are reproducible and reliable. 10.1016/j.amjcard.2018.02.022
    Phrenic Nerve Stimulation for the Treatment of Central Sleep Apnea: A Pooled Cohort Analysis. Fudim Marat,Spector Andrew R,Costanzo Maria-Rosa,Pokorney Sean D,Mentz Robert J,Jagielski Dariusz,Augostini Ralph,Abraham William T,Ponikowski Piotr P,McKane Scott W,Piccini Jonathan P Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine STUDY OBJECTIVES:Early evidence with transvenous phrenic nerve stimulation (PNS) demonstrates improved disease severity and quality of life (QOL) in patients with central sleep apnea (CSA). The goal of this analysis is to evaluate the complete prospective experience with PNS in order to better characterize its efficacy and safety, including in patients with concomitant heart failure (HF). METHODS:Using pooled individual data from the pilot (n = 57) and pivotal (n = 151) studies of the remedē System in patients with predominant moderate to severe CSA, we evaluated 12-month safety and 6- and 12-month effectiveness based on polysomnography data, QOL, and cardiac function. RESULTS:Among 208 combined patients (June 2010 to May 2015), a remedē device implant was successful in 197 patients (95%), 50/57 pilot study patients (88%) and 147/151 pivotal trial patients (97%). The pooled cohort included patients with CSA of various etiologies, and 141 (68%) had concomitant HF. PNS reduced apnea-hypopnea index (AHI) at 6 months by a median of -22.6 episodes/h (25th and 75th percentile; -38.6 and -8.4, respectively) (median 58% reduction from baseline, P < .001). Improvement in sleep variables was maintained through 12 months of follow-up. In patients with HF and ejection fraction ≤ 45%, PNS was associated with improvement in systolic function from 27.0% (23.3, 36.0) to 31.1% (24.0, 41.5) at 12 months (P = .003). In the entire cohort, improvement in QOL was concordant with amelioration of sleep measures. CONCLUSIONS:Transvenous PNS significantly improves CSA severity, sleep quality, ventricular function, and QOL regardless of HF status. Improvements, which are independent of patient compliance, are sustained at 1 year and are associated with acceptable safety. 10.5664/jcsm.8076
    Ticagrelor-Associated Shift From Obstructive to Central Sleep Apnea: A Case Report. Paboeuf Caroline,Priou Pascaline,Meslier Nicole,Roulaud Frédéric,Trzepizur Wojciech,Gagnadoux Frédéric Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine None:Ticagrelor, a P2Y12 receptor antagonist, is used in combination with aspirin in patients with coronary artery disease. Recent reports suggest that ticagrelor might induce central sleep apnea (CSA) by increasing chemosensitivity to hypercapnia. We herein describe the case of a patient with positive airway pressure (PAP)-treated obstructive sleep apnea (OSA), in whom PAP-telemonitoring revealed the emergence of CSA and Cheyne-Stokes respiration (CSR) after initiation of ticagrelor for an acute coronary syndrome with preserved left ventricular ejection fraction. Ticagrelor-associated shift from OSA to CSA was confirmed by respiratory polygraphy after PAP withdrawal, and was associated with an increased chemosensitivity to hypercapnia. Ticagrelor discontinuation was associated with the recurrence of pure OSA and the normalization of hypercapnic ventilatory response. A transient recurrence of CSA and CSR was identified by PAP-telemonitoring after accidental reintroduction of the drug. Further studies are required to determine the mechanisms, incidence, and consequences of ticagrelor-associated CSA. CITATION:Paboeuf C, Priou P, Meslier N, Roulaud F, Trzepizur W, Gagnadoux F. Ticagrelor-associated shift from obstructive to central sleep apnea: a case report. J Clin Sleep Med. 2019;15(8):1179-1182. 10.5664/jcsm.7818
    Real-time apnea-hypopnea event detection during sleep by convolutional neural networks. Choi Sang Ho,Yoon Heenam,Kim Hyun Seok,Kim Han Byul,Kwon Hyun Bin,Oh Sung Min,Lee Yu Jin,Park Kwang Suk Computers in biology and medicine Sleep apnea-hypopnea event detection has been widely studied using various biosignals and algorithms. However, most minute-by-minute analysis techniques have difficulty detecting accurate event start/end positions. Furthermore, they require hand-engineered feature extraction and selection processes. In this paper, we propose a new approach for real-time apnea-hypopnea event detection using convolutional neural networks and a single-channel nasal pressure signal. From 179 polysomnographic recordings, 50 were used for training, 25 for validation, and 104 for testing. Nasal pressure signals were adaptively normalized, and then segmented by sliding a 10-s window at 1-s intervals. The convolutional neural networks were trained with the data, which consisted of class-balanced segments, and were then tested to evaluate their event detection performance. According to a segment-by-segment analysis, the proposed method exhibited performance results with a Cohen's kappa coefficient of 0.82, a sensitivity of 81.1%, a specificity of 98.5%, and an accuracy of 96.6%. In addition, the Pearson's correlation coefficient between estimated apnea-hypopnea index (AHI) and reference AHI was 0.99, and the average accuracy of sleep apnea and hypopnea syndrome (SAHS) diagnosis was 94.9% for AHI cutoff values of ≥5, 15, and 30 events/h. Our approach could potentially be used as a supportive method to reduce event detection time in sleep laboratories. In addition, it can be applied to screen SAHS severity before polysomnography. 10.1016/j.compbiomed.2018.06.028
    [Association between mixed sleep apnea and treatment-emergent central sleep apnea]. Lei F,Tan L,Li T M,Ren R,Zhou J Y,Zhou X Y,Tang X D,Yang L H Zhonghua yi xue za zhi To examine the association between mixed sleep apnea (MA) and treatment-emergent central sleep apnea (TE-CSA). A total of 256 patients meeting the diagnostic criteria of moderate to severe obstructive sleep apnea (OSA) based on overnight polysomnography (PSG) and receiving continuous positive airway pressure (CPAP) therapy in West China Hospital, Sichuan University during the period from August 2013 to November 2018 were enrolled in the study. Based on the mixed apnea index (MAI) and apnea-hypopnea index (AHI) in the baseline PSG study during non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, the subjects were categorized into three groups of A (MAI=0/h, 110), B (NREM-MAI≥5/h and REM-MAI<5/h, 72) and C (REM-MAI≥5/h and NREM-MAI< 5/h, 74). Sleep and breathing related parameters before and after CPAP therapy among three groups and the difference of TE-CSA incidence were analyzed. The AHI [(44.2(26.8,64.5)/h,66.6(56.0,81.7)/h, 79.8(63.6, 88.3)/h], REM-AHI [50.0(34.7, 64.7)/h, 60.1(49.1, 70.0)/h, 66.3(56.1, 74.6)/h] and NREM-AHI[43.5(25.9, 65.1)/h,67.6(53.7, 82.4)/h,81.3(64.2, 91.5)/h]) were higher in group B and C compared to group A (all 0.05),while the mean and lowest oxygen saturation [(92.6%±3.5%),(90.8%±3.6%),(87.3%±5.1%) and (70.6%±14.1%), (61.0%±16.0%), (47.9%±17.0%)] were lower in group B and group C compared to group A (all 0.05). The incidence of TE-CSA after initial CPAP was 7.8% in all patients, and the incidence was significantly higher in group B of 14.1% compared to group C of 4.1% and group A of 2.7% (all 0.05). TE-CSA is correlated with baseline MA, and baseline MA in NREM sleep can predict the incidence of TE-CSA after initial CPAP. 10.3760/cma.j.issn.0376-2491.2019.24.006
    Proteomic biomarkers of sleep apnea. Ambati Aditya,Ju Yo-El,Lin Ling,Olesen Alexander N,Koch Henriette,Hedou Julien Jacques,Leary Eileen B,Sempere Vicente Peris,Mignot Emmanuel,Taheri Shahrad Sleep Obstructive sleep apnea (OSA) is characterized by recurrent partial to complete upper airway obstructions during sleep, leading to repetitive arousals and oxygen desaturations. Although many OSA biomarkers have been reported individually, only a small subset have been validated through both cross-sectional and intervention studies. Here, we used a highly multiplexed aptamer array (SomaScan) for proteomic analysis of serum samples from 713 individuals in the Stanford Sleep Cohort, a patient-based registry. Outcome measures derived from overnight polysomnography included Obstructive Apnea Hypopnea Index (OAHI), Central Apnea Index (CAI), 2% Oxygen Desaturation index, mean and minimum oxygen saturation indices during sleep. Additionally, a separate intervention-based cohort of 16 individuals was used to assess proteomic profiles pre- and post-intervention with positive airway pressure. After statistical adjustment for age, age of sample, gender and body mass index, OAHI was associated with 65 proteins, predominantly pathways of complement, coagulation, cytokine signaling, and hemostasis which were upregulated. CAI was associated with two proteins including Roundabout homolog 3 (ROBO3), a protein involved in bilateral synchronization of the pre-Bötzinger complex and cystatin F. Analysis of pre- and post- intervention samples were less revealing as only 2 proteins that were differentially associated with active treatment: Insulin-like growth factor-binding protein3 (IGFBP-3) increased while LEAP1 (Hepicidin) decreased with intervention. An OAHI machine learning classifier (OAHI >=15 vs OAHI<15) trained on SomaScan protein measures alone performed robustly, achieving 76% accuracy in a validation dataset. Multiplex protein assays offer diagnostic potential and provide new insights into the biological basis of sleep disordered breathing. 10.1093/sleep/zsaa086
    Central Sleep Apnea With Sodium Oxybate in a Pediatric Patient. Heshmati Arezou Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine ABSTRACT:A 12-year-old girl with normal neurodevelopment and narcolepsy type 1 presented with unexpected central apneas in response to sodium oxybate (SO). The patient underwent overnight polysomnography on SO (2.75 + 2.5 grams) which showed an apnea-hypopnea index of 4.3 events/h, and all the events were central apneas. A majority of central apneas clustered at about 1.5 hours after the first dose of SO. Remarkably, after a second dose of SO that was 0.25 grams smaller, she did not exhibit clusters of central sleep apneas. However, she did experience similar but milder breathing abnormalities that did not meet criteria to be scored as central apneas or hypopneas. Based on this observation, there may be an association between SO treatment and the development of central apnea. Further polysomnographic research on pediatric patients taking SO would help determine if there is a significant association between SO treatment and the development of central apnea in the pediatric population. 10.5664/jcsm.7690
    Meta-analysis of Usefulness of Phrenic Nerve Stimulation in Central Sleep Apnea. Luni Faraz Khan,Daniels James,Link Mark S,Joglar Jose A,Zungsontiporn Nath,Wu Richard,Kaplish Neeraj,Malik Sonia Ali The American journal of cardiology Transvenous neurostimulation of the phrenic nerve (PNS) is a potentially improved and unique approach to the treatment of central sleep apnea (CSA). There have been multiple studies with limited individuals evaluating the efficacy of PNS. Our aim was to review and pool those studies to better understand whether phrenic nerve stimulation is efficacious in the treatment of CSA. The initial search on Pubmed retrieved a total of 97 articles and after screening all articles, only 5 could be included in our quantitative analysis. Pooling of data from 5 studies with a total of 204 patients demonstrated a reduction of mean apnea hypopnea index with PNS compared to controls by -26.7 events/hour with 95% confidence interval and P value of [CI (-31.99, -21.46), I 85, p 0.00]. The mean difference in central apnea index was -22.47 [CI (-25.19, -19.76), I 0, p 0.00]. The mean reduction in the oxygen desaturation index of 4% or more demonstrated a decrease in PNS group by -24.16 events/hour [(CI -26.20, -22.12), I 0, p 0.00] compared with controls. PNS resulted in mean reduction in arousal index of -13.77 [CI (-16.15, -11.40), I 0, p 0.00]. The mean change in percent of time spent in rapid eye movement sleep demonstrated a nonsignificant increase in PNS group by 1.01 % [CI (-5.67, 7.86), I93, p 0.75]. In conclusion, PNS therapy for treating CSA demonstrated positive outcomes but larger randomized studies are needed to evaluate the safety and clinical outcomes. 10.1016/j.amjcard.2020.02.012
    The influence of cardiac resynchronization therapy on subjective and objective parameters of sleep, and their association with the function of the autonomous nervous system. Przybyła Anna,Czarnecka Danuta Postepy w kardiologii interwencyjnej = Advances in interventional cardiology Introduction:Cardiac resynchronization therapy (CRT) was a breakthrough in the treatment of heart failure, but data regarding the effect of this therapy on numerous disorders associated with heart failure are limited. Aim:To assess the impact of CRT on sleep breathing disorders, and to determine the relationship between the changes in the autonomous nervous system and sleep disorders after CRT. Material and methods:The study included 55 patients with chronic heart failure stable for at least last 3 months, in New York Heart Association (NYHA) class III or IV despite optimal medical therapy, with a reduced left ventricular ejection fraction (LVEF) ≤ 35%, QRS complex duration ≥ 120 ms, and sinus rhythm. Before and 3 months after implementation of CRT echocardiography, 6-minute walk test (6MWT), polysomnography with the Pittsburgh Sleep Quality Index (PSQI) questionnaire and the Epworth Sleepiness Scale (ESS) were performed. Also baroreflex sensitivity (BRS) was evaluated. Results:After implementation of CRT, the values of the apnea-hypopnea index (AHI), apnea index (AI), and central and mixed apnea indexes (CAI, MAI) were statistically significantly reduced. The strongest negative correlations were demonstrated for changes in CAI and changes in BRS. An improvement in sleep quality, daytime sleepiness, LVEF, NYHA class, and 6MWT was observed and was the most strongly associated with the improvement in CAI, too. Conclusions:CRT has a beneficial effect on subjective and objective features of sleep, as well as on the function of the autonomous nervous system. In addition, patients with heart failure and coexisting central sleep apnea may benefit most from this therapy. 10.5114/aic.2019.87892
    Detecting central sleep apnea in adult patients using WatchPAT-a multicenter validation study. Pillar Giora,Berall Murray,Berry Richard,Etzioni Tamar,Shrater Noam,Hwang Dennis,Ibrahim Marai,Litman Efrat,Manthena Prasanth,Koren-Morag Nira,Rama Anil,Schnall Robert P,Sheffy Koby,Spiegel Rebecca,Tauman Riva,Penzel Thomas Sleep & breathing = Schlaf & Atmung STUDY OBJECTIVES:To assess the accuracy of WatchPAT (WP-Itamar-Medical, Caesarea, Israel) enhanced with a novel systolic upstroke analysis coupled with respiratory movement analysis derived from a dedicated snoring and body position (SBP) sensor, to enable automated algorithmic differentiation between central sleep apnea (CSA) and obstructive sleep apnea (OSA) compared with simultaneous in-lab sleep studies with polysomnography (PSG). METHODS:Eighty-four patients with suspected sleep-disordered breathing (SDB) underwent simultaneous WP and PSG studies in 11 sleep centers. PSG scoring was blinded to the automatically analyzed WP data. RESULTS:Overall WP apnea-hypopnea index (AHI; mean ± SD) was 25.2 ± 21.3 (range 0.2-101) versus PSG AHI 24.4 ± 21.2 (range 0-110) (p = 0.514), and correlation was 0.87 (p < 0.001). Using a threshold of AHI ≥ 15, the sensitivity and specificity of WP versus PSG for diagnosing sleep apnea were 85% and 70% respectively and agreement was 79% (kappa = 0.867). WP central AHI (AHIc) was 4.2 ± 7.7 (range 0-38) versus PSG AHIc 5.9 ± 11.8 (range 0-63) (p = 0.034), while correlation was 0.90 (p < 0.001). Using a threshold of AHI ≥ 15, the sensitivity and specificity of WP versus PSG for diagnosing CSA were 67% and 100% respectively with agreement of 95% (kappa = 0.774), and receiver operator characteristic (ROC) area under the curve of 0.866, (p < 0.01). Using a threshold of AHI ≥ 10 showed comparable overall sleep apnea and CSA diagnostic accuracies. CONCLUSIONS:These findings show that WP can accurately detect overall AHI and effectively differentiate between CSA and OSA. 10.1007/s11325-019-01904-5
    Distinguishing Obstructive Versus Central Apneas in Infrared Video of Sleep Using Deep Learning: Validation Study. Akbarian Sina,Montazeri Ghahjaverestan Nasim,Yadollahi Azadeh,Taati Babak Journal of medical Internet research BACKGROUND:Sleep apnea is a respiratory disorder characterized by an intermittent reduction (hypopnea) or cessation (apnea) of breathing during sleep. Depending on the presence of a breathing effort, sleep apnea is divided into obstructive sleep apnea (OSA) and central sleep apnea (CSA) based on the different pathologies involved. If the majority of apneas in a person are obstructive, they will be diagnosed as OSA or otherwise as CSA. In addition, as it is challenging and highly controversial to divide hypopneas into central or obstructive, the decision about sleep apnea type (OSA vs CSA) is made based on apneas only. Choosing the appropriate treatment relies on distinguishing between obstructive apnea (OA) and central apnea (CA). OBJECTIVE:The objective of this study was to develop a noncontact method to distinguish between OAs and CAs. METHODS:Five different computer vision-based algorithms were used to process infrared (IR) video data to track and analyze body movements to differentiate different types of apnea (OA vs CA). In the first two methods, supervised classifiers were trained to process optical flow information. In the remaining three methods, a convolutional neural network (CNN) was designed to extract distinctive features from optical flow and to distinguish OA from CA. RESULTS:Overnight sleeping data of 42 participants (mean age 53, SD 15 years; mean BMI 30, SD 7 kg/m; 27 men and 15 women; mean number of OA 16, SD 30; mean number of CA 3, SD 7; mean apnea-hypopnea index 27, SD 31 events/hour; mean sleep duration 5 hours, SD 1 hour) were collected for this study. The test and train data were recorded in two separate laboratory rooms. The best-performing model (3D-CNN) obtained 95% accuracy and an F score of 89% in differentiating OA vs CA. CONCLUSIONS:In this study, the first vision-based method was developed that differentiates apnea types (OA vs CA). The developed algorithm tracks and analyses chest and abdominal movements captured via an IR video camera. Unlike previously developed approaches, this method does not require any attachment to a user that could potentially alter the sleeping condition. 10.2196/17252
    Association of Valproic Acid With Central Sleep Apnea Syndrome: Two Case Reports. Guichard Kelly,Micoulaud-Franchi Jean-Arthur,McGonigal Aileen,Coulon Paul,Sureau Christophe,Ghorayeb Imad,Salvo Francesco,Philip Pierre Journal of clinical psychopharmacology 10.1097/JCP.0000000000001106
    Association between Sleep Apnea Hypopnea Syndrome and the Risk of Atrial Fibrillation: A Meta-Analysis of Cohort Study. Zhao Enfa,Chen Shimin,Du Yajuan,Zhang Yushun BioMed research international Numerous reports have been done to seek the relationship between sleep apnea hypopnea syndrome (SAHS) and the risk of atrial fibrillation (AF). However, definite conclusion has not yet been fully established. We examined whether SAHS increases AF incidence in common population and summarized all existing studies in a meta-analysis. We summarized the current studies by searching related database for potential papers of the association between SAHS and the risk of AF. Studies that reported original data or relative risks (RRs) with 95% confidence intervals (CIs) for the associations were included. Sensitivity analyses were performed by omitting each study iteratively and publication bias was detected by Begg's tests. Eight eligible studies met the inclusion criteria. Fixed effects meta-analysis showed that SAHS increased AF risk in the common population (RR = 1.70, 95% CI: 1.53-1.89, = 0.002, = 69.2%). There was a significant association between mild SAHS and the risk of AF (RR = 1.52, 95% CI: 1.28-1.79, = 0.01, = 78.4%), moderate SAHS (RR = 1.88, 95% CI: 1.55-2.27, = 0.017, = 75.6%), and severe SAHS (RR = 2.16, 95% CI: 1.78-2.62, < 0.001, = 91.0%). The results suggest that sleep apnea hypopnea syndrome could increase the risk of AF, and the higher the severity of SAHS, the higher risk of atrial fibrillation. 10.1155/2018/5215868
    Association of Acromegaly and Central Sleep Apnea Syndrome. Pazarlı Ahmet Cemal,Köseoğlu Handan İnönü,Kutlutürk Faruk,Gökçe Erkan Turkish thoracic journal Acromegaly is usually characterized by the excessive secretion of growth hormone (GH) after the closure of epiphyseal plaques, resulting from functional pituitary adenomas. The most common manifestations of acromegaly are acral and soft tissue overgrowth, diabetes mellitus, hypertension, and heart and respiratory failure. In patients, obstruction of the upper airway may develop due to enlargement of the tongue and thickening of the tissues of the larynx; consequently, obstructive sleep apnea syndrome (OSAS) occurs commonly in acromegaly. Previous studies have shown an association between acromegaly and central sleep apnea syndrome (CSAS). Some of these described patients described showed that an elevation in the GH level may cause a defect in the respiratory drive. Most systemic diseases seen in acromegaly require effective treatment. We believe that it is necessary to perform effective treatments by examining respiratory disorders in sleep. 10.5152/TurkThoracJ.2017.17003
    Diagnosis and management of central sleep apnea syndrome. Baillieul Sébastien,Revol Bruno,Jullian-Desayes Ingrid,Joyeux-Faure Marie,Tamisier Renaud,Pépin Jean-Louis Expert review of respiratory medicine : Central sleep apnea (CSA) syndrome has gained a considerable interest in the sleep field within the last 10 years. It is overrepresented in particular subpopulations such as patients with stroke or heart failure. Early detection and diagnosis, as well as appropriate treatment of central breathing disturbances during sleep remain challenging. : Based on a systematic review of CSA in adults the clinical evidence and polysomnographic patterns useful for discerning central from obstructive events are discussed. Current therapeutic indications of CSA and perspectives are presented, according to the type of respiratory disturbances during sleep, alterations in blood gases and ventilatory control. : The precise identification of central events during polysomnographic recording is mandatory. Therapeutic choices for CSA depend on the typology of respiratory disturbances observed by polysomnography, changes in blood gases and ventilatory control. In CSA with normocapnia and ventilatory instability, adaptive servo-ventilation is recommended. In CSA with hypercapnia and/or rapid-eye movement sleep hypoventilation, non-invasive ventilation is required. Further studies are required as strong evidence is lacking regarding the long-term consequences of CSA and the long-term impact of current treatment strategies. 10.1080/17476348.2019.1604226
    Central sleep apnea in children with obstructive sleep apnea syndrome and improvement following adenotonsillectomy. Del-Río Camacho Genoveva,Medina Castillo Lucía,Rodríguez-Catalán Jesús,Soto Insuga Victor,Gómez García Teresa Pediatric pulmonology BACKGROUND:Although the pathogenesis of central and obstructive events seems to be different, these two entities may somehow be related. We aimed to determine whether, as reported in previous research, the number of central sleep apnea (CSA) cases in a population of children with obstructive sleep apnea syndrome (OSAS) was greater than in patients without obstructive events, and if CSA worsens with increasing OSAS severity. As a second objective, we analyzed changes in central apnea index (CAI) after adenotonsillar surgery compared to changes when no surgery has been performed. METHODS:We retrospectively reviewed nocturnal polysomnography (PSG) data from children between 1 and 14 years of age with no neurological conditions or syndromes. Patients with CAI values greater than 5 per hour were diagnosed as having CSA. Improvements of greater than 50% in CAI on repeat PSG were considered to represent a real change. RESULTS:Data were available from 1279 PSG studies, resulting in 72 children with a CAI greater than 5 per hour (5.6%). Patients with OSAS showed a higher CAI (2.16) compared with those without OSAS (1.17), and this correlation increased with higher degrees of obstructive apnea severity. When adenotonsillectomy was performed due to OSAS, the CAI decreased by 1.37. The average decrease in PSG values was only 0.38 in cases where no surgery was performed. CONCLUSION:The results of this study suggest that although CSA is perceived to be mostly associated with central nervous system ventilatory control, there may be a connection with airway obstruction and in children with CSA and OSA diagnosis adenotonsillectomy may improve both conditions. 10.1002/ppul.24469
    Evaluation of the Impact of Body Position on Primary Central Sleep Apnea Syndrome. Oktay Arslan Burcu,Ucar Hosgor Zeynep Zeren,Ekinci Selim,Cetinkol Isil Archivos de bronconeumologia OBJECTIVE:To evaluate the impact of the body position on primary central sleep apnea syndrome. METHODS:Fifty-five subjects diagnosed with central sleep apnea (CSA) through polysomnographic examinations were prospectively enrolled in the study. All patients underwent cardiologic and neurologic examinations. Primary positional central sleep apnea (PCSA) was determined when the supine Apnea-Hypopnea Index (AHI) was greater than two times the non-supine AHI. The primary PCSA and non-PCSA groups were compared in terms of demographic characteristics, sleep parameters, and treatment approaches. RESULTS:Overall, 39 subjects diagnosed with primary CSA were included in the study; 61.5% of the subjects had primary PCSA. There were no differences between the primary PCSA and non-PCSA groups regarding age, sex, body mass index (BMI), co-morbidities, and history of septoplasty. In terms of polysomnography parameters, AHI (P=.001), oxygen desaturation index (P=.002), the time spent under 88% saturation during sleep (P=.003), number of obstructive apnea (P=.011), mixed apnea (P=.009), and central apnea (P=.007) was lower in the primary PCSA group than in the non-PCSA group. Twenty-nine percent of the patients in the primary PCSA group were recommended position treatment and 71% were recommended positive airway pressure (PAP) therapy; all patients in the non-PCSA group were recommended PAP therapy. CONCLUSIONS:Our results demonstrated that the rate of primary PCSA was high (61.5%) and primary PCSA was associated with milder disease severity compared with non-PCSA. The classification of patients with primary CSA regarding positional dependency may be helpful in terms of developing clinical approaches and treatment recommendations. 10.1016/j.arbres.2020.03.004