Central sleep apnoea syndrome with upper airway collapse.
Pépin J L,Pajon A,Veale D,Ferretti G,Lévy P
The European respiratory journal
We report on an 83 yr old man with hypersomnia and central sleep apnoea (CSA). He had several possible causes for CSA, including a central nervous system lesion, hypocapnia and anatomical narrowing of the airway at the hypopharyngeal level. We postulate that reduced central respiratory drive occurring in conjunction with upper airway narrowing may have led to central apnoeas. These in turn could have facilitated a complete passive hypopharyngeal collapse at the end of each apnoea, as visualized by somnofluoroscopy. The CSA could also have been favoured by respiratory instability due to chronic hypocapnia.
Endoscopy evaluation to predict oral appliance outcomes in obstructive sleep apnoea.
Okuno Kentaro,Sasao Yasuhiro,Nohara Kanji,Sakai Takayoshi,Pliska Benjamin T,Lowe Alan A,Ryan C Frank,Almeida Fernanda R
The European respiratory journal
The objective of this study was to determine the utility of nasoendoscopy of the upper airway as a predictor of the efficacy of oral appliance treatment in obstructive sleep apnoea (OSA).A total of 61 consecutive patients with moderate-to-severe polysomnographically diagnosed OSA were recruited for this study. Using nasoendoscopy, we prospectively assessed the velopharynx and oro/hypopharynx in each patient while awake and in the supine position. We measured cross-sectional area (CSA), and anteroposterior and lateral diameters of the airway before and after mandibular advancement, and expressed the changes in dimensions as expansion ratios (after/before). We then compared the measurements of responders and nonresponders with oral appliance treatment.The expansion ratio (median (interquartile range)) for the CSA was greater in responders compared with nonresponders in the velopharynx (2.9 (2.3-5.0) versus 1.7 (1.5-1.9), p<0.001) and in the oro/hypopharynx (3.4 (2.5-5.6) versus 2.4 (1.8-3.7), p<0.05). Baseline apnoea-hypopnoea index and the CSA expansion ratio of the velopharynx were independent predictors of oral appliance treatment outcome based on a multivariate logistic regression analysis. The estimated area under the receiver operator characteristic curve was 0.87 and the cut-off value of the expansion ratio was 2.00.These results indicate that nasoendoscopy may have significant clinical utility in predicting the success of oral appliance treatment.
10.1183/13993003.01088-2015
Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.
Turino Cecilia,de Batlle Jordi,Woehrle Holger,Mayoral Ana,Castro-Grattoni Anabel Lourdes,Gómez Sílvia,Dalmases Mireia,Sánchez-de-la-Torre Manuel,Barbé Ferran
The European respiratory journal
Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnoea (OSA), but treatment compliance is often unsatisfactory. This study investigated the efficacy and cost-effectiveness of telemonitoring for improving CPAP compliance.100 newly diagnosed OSA patients requiring CPAP (apnoea-hypopnoea index >15 events·h) were randomised to standard management or a telemonitoring programme that collected daily information about compliance, air leaks and residual respiratory events, and initiated patient contact to resolve issues. Clinical/anthropometric variables, daytime sleepiness and quality of life were recorded at baseline and after 3 months. Patient satisfaction, additional visits/calls, side-effects and total costs were assessed.There were no significant differences between the standard and telemedicine groups in terms of CPAP compliance (4.9±2.2 5.1±2.1 h·night), symptoms, clinical variables, quality of life and unwanted effects. Telemedicine was less expensive than standard management (EUR123.65 EUR170.97; p=0.022) and was cost-effective (incremental cost-effectiveness ratio EUR17 358.65 per quality-adjusted life-year gained). Overall patient satisfaction was high, but significantly more patients rated satisfaction as high/very high in the standard management telemedicine group (96% 74%; p=0.034).Telemonitoring did not improve CPAP treatment compliance and was associated with lower patient satisfaction. However, it was more cost-effective than traditional follow-up.
10.1183/13993003.01128-2016
The hypoxic burden of sleep apnoea predicts cardiovascular disease-related mortality: the Osteoporotic Fractures in Men Study and the Sleep Heart Health Study.
European heart journal
AIMS:Apnoea-hypopnoea index (AHI), the universal clinical metric of sleep apnoea severity, poorly predicts the adverse outcomes of sleep apnoea, potentially because the AHI, a frequency measure, does not adequately capture disease burden. Therefore, we sought to evaluate whether quantifying the severity of sleep apnoea by the 'hypoxic burden' would predict mortality among adults aged 40 and older. METHODS AND RESULTS:The samples were derived from two cohort studies: The Outcomes of Sleep Disorders in Older Men (MrOS), which included 2743 men, age 76.3 ± 5.5 years; and the Sleep Heart Health Study (SHHS), which included 5111 middle-aged and older adults (52.8% women), age: 63.7 ± 10.9 years. The outcomes were all-cause and Cardiovascular disease (CVD)-related mortality. The hypoxic burden was determined by measuring the respiratory event-associated area under the desaturation curve from pre-event baseline. Cox models were used to calculate the adjusted hazard ratios for hypoxic burden. Unlike the AHI, the hypoxic burden strongly predicted CVD mortality and all-cause mortality (only in MrOS). Individuals in the MrOS study with hypoxic burden in the highest two quintiles had hazard ratios of 1.81 [95% confidence interval (CI) 1.25-2.62] and 2.73 (95% CI 1.71-4.36), respectively. Similarly, the group in the SHHS with hypoxic burden in the highest quintile had a hazard ratio of 1.96 (95% CI 1.11-3.43). CONCLUSION:The 'hypoxic burden', an easily derived signal from overnight sleep study, predicts CVD mortality across populations. The findings suggest that not only the frequency but the depth and duration of sleep related upper airway obstructions, are important disease characterizing features.
10.1093/eurheartj/ehy624
Principles of practice parameters for the treatment of sleep disordered breathing in the elderly and frail elderly: the consensus of the International Geriatric Sleep Medicine Task Force.
Netzer Nikolaus C,Ancoli-Israel Sonia,Bliwise Donald L,Fulda Stephany,Roffe Christine,Almeida Fernanda,Onen Hakki,Onen Fannie,Raschke Friedhart,Martinez Garcia Miguel Angel,Frohnhofen Helmut
The European respiratory journal
Sleep disordered breathing (SDB) is a leading cause of morbidity worldwide. Its prevalence increases with age. Due to the demographic changes in industrial societies, pulmonologists and sleep physicians are confronted with a rapidly growing number of elderly SDB patients. For many physicians, it remains unclear how current guidelines for SDB management apply to elderly and frail elderly patients. The goal of this consensus statement is to provide guidance based on published evidence for SDB treatment in this specific patient group.Clinicians and researchers with expertise in geriatric sleep medicine representing several countries were invited to participate in a task force. A literature search of PubMed from the past 12 years and a systematic review of evidence of studies deemed relevant was performed.Recommendations for treatment management of elderly and frail elderly SDB patients based on published evidence were formulated via discussion and consensus.In the last 12 years, there have been surprisingly few studies examining treatment of SDB in older adults and even fewer in frail older adults. Studies that have been conducted on the management of SDB in the older patient population were rarely stratified for age. Studies in SDB treatment that did include age stratification mainly focused on middle-aged and younger patient groups. Based on the evidence that is available, this consensus statement highlights the treatment forms that can be recommended for elderly SDB patients and encourages treatment of SDB in this large patient group.
10.1183/13993003.01975-2015
Sleep Apnea: Types, Mechanisms, and Clinical Cardiovascular Consequences.
Javaheri Shahrokh,Barbe Ferran,Campos-Rodriguez Francisco,Dempsey Jerome A,Khayat Rami,Javaheri Sogol,Malhotra Atul,Martinez-Garcia Miguel A,Mehra Reena,Pack Allan I,Polotsky Vsevolod Y,Redline Susan,Somers Virend K
Journal of the American College of Cardiology
Sleep apnea is highly prevalent in patients with cardiovascular disease. These disordered breathing events are associated with a profile of perturbations that include intermittent hypoxia, oxidative stress, sympathetic activation, and endothelial dysfunction, all of which are critical mediators of cardiovascular disease. Evidence supports a causal association of sleep apnea with the incidence and morbidity of hypertension, coronary heart disease, arrhythmia, heart failure, and stroke. Several discoveries in the pathogenesis, along with developments in the treatment of sleep apnea, have accumulated in recent years. In this review, we discuss the mechanisms of sleep apnea, the evidence that addresses the links between sleep apnea and cardiovascular disease, and research that has addressed the effect of sleep apnea treatment on cardiovascular disease and clinical endpoints. Finally, we review the recent development in sleep apnea treatment options, with special consideration of treating patients with heart disease. Future directions for selective areas are suggested.
10.1016/j.jacc.2016.11.069
Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep.
Randerath Winfried,Verbraecken Johan,Andreas Stefan,Arzt Michael,Bloch Konrad E,Brack Thomas,Buyse Bertien,De Backer Wilfried,Eckert Danny Joel,Grote Ludger,Hagmeyer Lars,Hedner Jan,Jennum Poul,La Rovere Maria Teresa,Miltz Carla,McNicholas Walter T,Montserrat Josep,Naughton Matthew,Pepin Jean-Louis,Pevernagie Dirk,Sanner Bernd,Testelmans Dries,Tonia Thomy,Vrijsen Bart,Wijkstra Peter,Levy Patrick
The European respiratory journal
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.
10.1183/13993003.00959-2016