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PubMed2006

Effects of short-term CPAP withdrawal on neurobehavioral performance in patients with obstructive sleep apnea.

STUDY OBJECTIVE: Changes in sleep parameters and neurobehavioral functioning were systematically investigated after an acute (1 night) and short-term (7 nights) period of withdrawal from continuous positive airway pressure (CPAP) treatment and 1 subsequent night of CPAP reintroduction in patients with obstructive sleep apnea. DESIGN: Repeated-measurement within-subject design. SETTING: Sleep laboratory, university teaching hospital. PARTICIPANTS: Twenty participants receiving optimal CPAP therapy for > or = 12 months. INTERVENTIONS: CPAP withdrawal. MEASUREMENTS AND RESULTS: Polysomnograms were performed on Night 0 (with CPAP), Night 1 and Night 7 (without CPAP) and Night 8_R (with CPAP). Acute CPAP withdrawal resulted in the recurrence of sleep-disordered breathing with sleep disruption, hypoxemia, and increased subjective sleepiness. Short-term CPAP withdrawal exacerbated hypoxemia, increased subjective and objective sleepiness and poor mood ratings. Neurobehavioral functioning assessed using the Psychomotor Vigilance Task was impaired following Night 7 and associated with hypoxemia and changes in morning levels of tumor necrosis factor-alpha. However, other neurobehavioral measures were not affected. Autonomic arousals measured via respiratory-related reductions in finger blood volume by peripheral arterial tonometry decreased from Night 1 to Night 7. On Night 8_R, reintroduction of CPAP treatment eliminated most airway obstruction, maintained oxygenation, and reversed daytime sleepiness and some vigilance decrements. CONCLUSION: Despite recurrence of sleep-disordered breathing with increased sleepiness and impaired vigilance, most neurobehavioral variables were unaffected by CPAP withdrawal. The reduction in vigilance appeared to be associated with worsened hypoxemia and changed levels of tumor necrosis factor-alpha. Resumption of CPAP treatment had immediate benefits on sleep consolidation and subjective sleepiness.

Body Mass Index↗

PubMed2001

[Rhythm of melatonin excretion in obstructive sleep apnea syndrome].

UNLABELLED: Melatonin is a pineal hormone that regulates sleep and wake status. Melatonin concentrations in blood serum were measured using radioisotope method in 33 males (age 48 +/- 10) with obstructive sleep apnea syndrome. The following melatonin concentrations were measured: 54 +/- 72 pg/ml (9 p.m.) 424 +/- 838 pg/ml (2 a.m.) and 307 +/- 534 pg/ml (6 a.m.). In patients with high peak melatonin concentration (> 200 pg/ml) as compared with the patients with low peak melatonin concentration (< 200 pg/ml) there were higher index of respiratory disorders during sleep (53 +/- 18 vs 38 +/- 20, p < 0.05) and lower minimal SaO2 during sleep apnea (52 +/- 17% vs 70 +/- 10%, p < 0.05); they were also more tired in the morning and were more sleepy during the day (Epworth sleepiness scale 17 +/- 6 vs 11 +/- 6, p < 0.01). In 66% of patients peak melatonin concentration was observed at 2 a.m. In 24% of patients peak melatonin secretion was prolonged to early morning hours. CONCLUSIONS: In most of patients there is peak melatonin excretion at 2 a.m. Patients with high apnea and hypopnea index and daytime sleepiness have high peak melatonin concentrations.

Adult↗

PubMed2004

Obstructive sleep apnea syndrome, sleepiness, and quality of life.

OBJECTIVE: To evaluate the addition of short arousals of > 3 s on indexes of sleep-disordered breathing (SDB) and subjective sleepiness in patients with obstructive sleep apnea (OSA), and to evaluate the quality of life and reported difficulty driving with arousal index and indexes of SDB. METHOD: Data was collected from a general clinical evaluation, and evaluations using the Epworth sleepiness scale (ESS), the sleep disorders questionnaire, the Beck depression inventory (BDI), the Medical Outcomes Study 36-item short form health survey (SF-36), a questionnaire on driving difficulties and accidents, and polysomnography. RESULTS: A total of 135 male subjects (mean [+/- SD] age, 52 +/- 12.1 years; mean body mass index [BMI], 27.8 +/- 5.6 kg/m(2); mean apnea-hypopnea index [AHI], 48.7 +/- 26.8 events per hour) were studied. Of these subjects, 70.4% acknowledged having driven while sleepy. ESS scores correlated significantly with the arousal index and AHI, and negatively with the lowest arterial oxygen saturation. The "physical functioning," "general health," and "role physical" subscales of the SF-36 correlated with the arousal index. No significant correlation was seen in multiple regression analyses after adjusting for age and BMI, using "reports of sleepiness while driving" as the dependent variable. CONCLUSION: Several subjective complaints and subscales of the SF-36 correlated significantly with a frequency of SDB-related arousal of > 3 s. Patients perceived that an organic health problem had been impairing their quality of life more than an emotional problem, despite elevated scores on the BDI. However, if sleepiness while driving was common in OSA patients, it was not significant. Many clinical and polysomnographic variables may be considered as possible independent variables in the regression analysis. Other unrelated factors have a greater impact. To relate sleepiness while driving only to the usually studied variables in OSA patients is an oversimplification.

Adult↗

PubMed2006

[Obstructive sleep apnea in shift workers].

UNLABELLED: The aim of the study was to compare intensity of sleep disordered breathing in standard nocturnal polisomnography (PSG) and diurnal PSG after night shift in shift workers with obstructive sleep apnea syndrome. METHODS: 25 shift workers (24 M, 1 F), aged 45,4 +/- 9,1 yrs, of mean BMI 31,9 +/- 4,02 kg/m2 were studied. Nocturnal PSG and diurnal PSG after night shift were performed in all participants. RESULTS: The mean apnea/hypopnea index (AHI) in diurnal PSG was higher than AHI in nocturnal PSG, 47,8+/- 27,4/h vs 38,0 +/-24,1/h respectively, (p<0,05). Not significant tendency towards higher oxygen desaturation index (ODI) in diurnal PSG was observed, 40,4 +/-25,5/h vs 31,9 +/-25,8/h respectively. CONCLUSION: The study demonstrated that there is a significant increase in AHI in diurnal PSG after night shift compared to standard night PSG in shift workers with OSAS. This may negatively influence diagnosis and treatment.

Adult↗

PubMed1995

Obstructive sleep apnea: a multisystemic disorder.

Obstructive sleep apnea is a multisystemic disorder with pathologic sequelae that become apparent after a number of years. Patients with obstructive sleep apnea generally present with hypersomnolence, and diagnosis is eventually established through observation of the patient during sleep. Patients with obstructive sleep apnea snore loudly and experience nocturnal oxygen desaturation and repetitive disruptions from sleep that eventually lead to daytime hypersomnolence. Numerous complex interactive pathophysiologic events occur during each obstructive episode, and it is important for the clinician to be aware of the cardiopulmonary, neurologic, and anatomic abnormalities associated with this condition. The anatomic configuration of the pharynx and the physiologic response to occlusion of the upper airway have a major role in the pathogenesis of this disorder. Alveolar ventilation during an apneic episode is immediately reduced to zero, and the metabolic demands for oxygen must be met by oxygen stores within the body. With repetitive episodes of obstruction, the oxygen stores within the lungs are diminished and the rate of arterial oxyhemoglobin desaturation increases. During apneic episodes, the systemic blood pressure increases while heart rate and cardiac output decrease. Bradydysrhythmias have been noted with the obstructive apneic episodes, and ventricular dysrhythmias are associated with episodes of severe oxyhemoglobin desaturation. Coexisting cardiopulmonary or neuromuscular disease in patients with obstructive sleep apnea contributes to the development of hypoventilation, serious gas exchange derangement, and general cardiovascular instability.

Female↗

PubMed2000

[The relationship of vasoactive intestinal peptide, other substances and the changes of nocturnal blood pressure in patients with obstructive sleep apnea syndrome].

OBJECTIVE: To determine the difference of plasma VIP, NO and ET concentrations in awake and in different sleep periods and the relationship between VIP, NO and ET values and the changes in nocturnal blood pressure in patients with obstructive sleep apnea syndrome(OSAS). METHODS: Retaining manometric tube in radial artery and polysomnography(PSG) were done synchronously in 12 patients with OSAS whom was diagnosed by whole-night PSG. Blood specimens were collected before sleep, during NREM sleep and REM sleep and the next morning to detect the concentrations of VIP and ET by radioimmunoassay(RIA) and NO by nitrate reductase method. RESULTS: (1) Plasma NO values were significantly decreased in the morning than those before sleep (P = 0.014). There was no remarkable changes of VIP and ET values in different testing periods. (2) Plasma NO and ET values in the morning were correlated with hypoxia at night, but not with AHI (P > 0.05). (3) Plasma VIP values were significantly correlated with the baseline of SBP (r = 0.654, P < 0.05) and DBP (r = 0.706, P < 0.01) in NREM sleep and that of DBP (r = 0.613, P < 0.05) in REM sleep. There was no significant correlation between BP and plasma NO and ET values in different times. CONCLUSIONS: Endothelial dysfunction associated with NO reduction might be present and VIP might be involved in regulating BP changes in patients with OSAS.

Adult↗

PubMed2000

Does obstructive sleep apnea confound sleep architecture findings in subjects with depressive symptoms?

BACKGROUND: Compared with normal subjects, depressed patients have shorter rapid eye movement sleep latency (REML), increased REM and decreased slow wave sleep as a percentage of total sleep time (REM%, SWS%), and longer sleep latency (SL). Obstructive sleep apnea (OSA) patients experience longer REML, decreased REM% and SWS%, and shorter SL. We examined the interplay of depressive symptoms, OSA, and sleep architecture. METHODS: Subjects (n = 106) were studied with polysomnography. OSA was defined as a Respiratory Disturbance Index > or = 15. Subjects were divided into Hi/Lo groups using a Center for Epidemiological Studies-Depression (CES-D) score of 16. RESULTS: OSA patients had shorter SL than non-OSA patients (14.5 vs. 26.8 min, p <.001); Hi CES-D subjects showed a trend toward longer SL than Lo CES-D subjects (23.7 vs. 17.5 min, p =.079). Significant OSA x CES-D interactions emerged, however, for REM% (p =.040) and SL (p =.002): OSA/Hi CES-D subjects had higher REM% than OSA/Lo CES-D subjects (19.3% vs. 14.3%, p =.021); non-OSA/Hi CES-D subjects had SL (35.3 min) 2-3 times as long as other subjects (p =.002-.012). CONCLUSIONS: Because of the high prevalence of OSA and depression, findings suggest that OSA must be considered in studies of mood and sleep architecture. Conversely, depressive symptoms must be considered in studies of OSA and sleep architecture.

Adult↗

PubMed1988

Paradoxical glottic narrowing in patients with severe obstructive sleep apnea.

Most patients with obstructive sleep apnea have increased pharyngeal collapsibility (defined in the present study as an increased lung volume dependence of pharyngeal area), which predisposes them to upper airway occlusion during sleep. However, there are patients with severe obstructive sleep apnea who have low-normal pharyngeal collapsibility. The factors leading to nocturnal upper airway obstruction in such patients have not been ascertained. We studied 10 overweight male patients with severe obstructive sleep apnea and low-normal pharyngeal collapsibility to determine the site of upper airway pathology in these patients. We found that all 10 patients exhibited paradoxical inspiratory narrowing of the glottis during quiet tidal breathing. This phenomenon was not observed in a matched group of 10 snoring, nonapneic male controls. We conclude that paradoxical glottic narrowing may be a contributing factor in the pathogenesis of upper airway obstruction in patients with severe obstructive sleep apnea who have low-normal pharyngeal collapsibility.

Adult↗

PubMed1998

Nasal patency and the effectiveness of nasal continuous positive air pressure in obstructive sleep apnea.

Nasal airway obstruction may exacerbate sleep apnea and is difficult to quantify on clinical examination. In this study, we examined the relationship among nasal patency, the frequency of sleep apnea events, and effective nasal continuous positive air pressures. Acoustic rhinometry was used as an objective measurement of nasal cross-sectional areas in 76 patients without nasal symptoms who underwent study with diagnostic polysomnography because of obstructive sleep apnea. Patients with persistent obstructive sleep apnea were titrated to nasal continuous positive air pressure in a split night study. All subjects had a mean apnea/hypopnea index of 28, and those with obstructive sleep apnea had a mean apnea/hypopnea index of 43. Mean cross-sectional areas 1 to 4 cm into the nose were 1.7, 1.1, 2.1, and 2.8 cm2, respectively (F = 39, p < 0.001). However, there was no correlation between the apnea/hypopnea index and the cross-sectional area at the four distances (r = 0.03, 0.06, 0.02, and 0.02, respectively, p = not significant). Correlations between nasal continuous positive air pressures and cross-sectional areas did not reveal a significant relationship at any of the four sites (r = 0.09, 0.07, -0.03, 0.00, respectively). Findings in patients with apnea were also compared with those in patients without apnea and significant differences were not found (F = 0.019, p = not significant). Although it would seem intuitive that increased nasal obstruction is associated with the severity of obstructive sleep apnea and difficulty with the use of nasal continuous positive air pressure, this study shows that nasal patency, as measured by acoustic rhinometry, does not correlate with the severity of obstructive sleep apnea, as determined by the apnea/hypopnea index or the effective nasal continuous positive air pressure.

Adult↗

PubMed2006

Obstructive sleep apnea and hypertension: epidemiology, mechanisms and treatment effects.

Obstructive sleep apnea (OSA) is a highly prevalent disorder of breathing during sleep. A growing body of evidence suggests that OSA is independently associated with an increased risk of cardiovascular disease, although the extent of this risk and underlying mechanisms remain to be elucidated. However, there is clearer evidence from epidemiological and pathophysiological research of a causal link between OSA and hypertension. The acute hemodynamic and autonomic perturbations that accompany obstructive apneas during sleep, with associated repeated arousals and intermittent hypoxemia, appear to result in sustained hypertension. In addition to the metabolic and humoral effects from obesity, OSA appears to predispose individuals to autonomic imbalance characterized by sympathetic overactivity and altered baroreflex mechanisms as well as alterations to vascular function. Treatment of OSA restores normal sleep architecture and generally mitigates the acute hemodynamic effects of OSA. Treatment of symptomatic OSA, particular at the severe end of the spectrum, appears to be associated with improvements in blood pressure, both during sleep and wakefulness, and there may also be additional gains in subjects who are hypertensive and/or resistant to antihypertensive medications. The severe group appears to be particularly at risk for developing fatal and non-fatal cardiovascular events and treatment with continuous positive airway pressure appears to markedly reduce that risk. Future treatment studies will need to be extended for greater than the current average of 1-2 months in order to more fully evaluate any time dependent improvements in blood pressure, and consequent cardiovascular risk.

Adult↗

PubMed1997

Absence of bradycardic response to apnea and hypoxia in heart transplant recipients with obstructive sleep apnea.

In patients with obstructive sleep apnea, the vagal stimulation caused by inspiration against the upper airway obstruction results in sinus bradycardia during the apnea followed by a reflex tachycardia at apnea termination. We report on five heart transplant recipients with obstructive sleep apnea who demonstrated no change in baseline heart rate in spite of marked hemoglobin oxygen desaturation, presumably on account of parasympathetic denervation of the allograft. Heart transplant recipients with obstructive sleep apnea may be at an increased risk of development of potentially fatal ventricular arrhythmias if the allograft is unable to respond appropriately to hypoxia. Should cardiac parasympathetic reinnervation occur, prospective polysomnography may be a marker for this process in these patients.

Bradycardia↗

PubMed2003

Can patients with obstructive sleep apnea titrate their own continuous positive airway pressure?

Manual continuous positive airway pressure (CPAP) titration in a sleep laboratory is costly and limits access for diagnostic studies. Many factors affect CPAP compliance, but education and support, rather than in-laboratory CPAP titration, appear to be pivotal. Self-adjustment of CPAP at home will provide equal or superior efficacy in the treatment of obstructive sleep apnea (OSA) as compared with in-laboratory titration. A randomized, single-blind, two-period crossover trial of CPAP treatment at the in-laboratory-determined optimal pressure versus at-home self-adjustment of CPAP (starting pressure based on prediction equation). Eighteen CPAP-naive patients (16 males, 50 +/- 15 years old, apnea hypopnea index 40 +/- 20) with a new diagnosis of OSA were tested. Testing was performed before and after CPAP treatment in each of two 5-week study limbs. CPAP, compliance with CPAP treatment, the Sleep Apnea Quality of Life Index, the Functional Outcomes of Sleep Questionnaire score, the Epworth sleepiness scale score, sleep architecture, sleep apnea severity, and maintenance of wakefulness tests were performed. Both modes of CPAP treatment significantly improved objective and subjective measures of OSA, but they did not differ in efficacy. Home self-titration of CPAP is as effective as in-laboratory manual titration in the management of patients with OSA.

Adult↗

PubMed1999

Autonomic cardiovascular control in children with obstructive sleep apnea.

Autonomic cardiorespiratory control changes with sleep-wake states and is influenced by sleep-related breathing disorders. Power spectrum (PS) analysis of instantaneous fluctuations in heart rate (HR) is used to investigate the role of the autonomic nervous system (ANS) in cardiorespiratory control. The two spectral regions of interest are the low frequency component (LF) and high frequency component (HF). The aim of the present study was to investigate the autonomic cardiorespiratory control in children with obstructive sleep apnea (OSA) syndrome. We studied 10 children with OSA versus 10 normal children. All subjects underwent whole night polysomnography. Spectral analysis of the HR and breathing signals was performed for 256 second long, artifact-free epochs in each sleep-wake state. The LF power was higher in the OSA group compared with control subjects for all states, reflecting enhanced sympathetic activity in OSA subjects. The results indicated sympathetic predominance during REM sleep in all subjects and parasympathetic predominance in slow wave sleep only in controls. The autonomic balance (LF/HF) was significantly higher in OSA patients than in control subjects, at all stages during night sleep, and while awake before sleep onset. An index of overall autonomic balance (ABI) was computed for each subject and correlated well with the measured respiratory disturbance index (RDI).

Autonomic Nervous System↗

PubMed2004

Treatment of obstructive sleep apnea in primary care.

Obstructive sleep apnea should be suspected in patients who are overweight snore loudly, and have chronic daytime sleepiness. The diagnosis of sleep apnea may be confirmed by sleep laboratory studies. Patients' symptoms and the frequency of respiratory events on laboratory testing are important factors in determining the severity of disease. In patients with mild sleep apnea, conservative treatment measures include getting sufficient sleep, abstaining from the use of alcohol and sedatives, losing weight, and avoiding the supine position during sleep. Continuous positive airway pressure (CPAP) is the most consistently effective treatment for clinically significant obstructive sleep apnea. In general, heavier patients with thicker necks require higher pressure settings. As patients age or gain weight, additional pressure may be necessary. Bilevel pressure machines or machines that slowly ramp up the pressure may increase patient acceptance of CPAP therapy. Complications of CPAP use include nasal dryness and congestion, claustrophobia, facial skin abrasions, air leaks, and conjunctivitis. Strategies to improve patient compliance include allowing patients to try a number of masks to find the most comfortable fit, adding humidification, treating nasal disease and, most importantly, providing close follow-up and encouragement. Oral appliances are inconsistently effective in the management of obstructive sleep apnea but may be an option in patients with mild disease who cannot tolerate CPAP. Palatal surgery often decreases snoring but may not reduce the occurrence of sleep apnea. Patients with severe disease and intolerance of CPAP may be candidates for more invasive surgical procedures. Supplemental oxygen and drug therapy may have limited, adjunctive roles in the treatment of obstructive sleep apnea.

Diagnosis, Differential↗

PubMed2002

Sleep disorders. Obstructive sleep apnea syndrome, restless legs syndrome, and insomnia in geriatric patients.

Sleep disorders may affect one out of two older Americans and may present as insomnia, excessive daytime sleepiness, or both. Age-related changes seem to cause a decreased need for sleep. The average 70-year-old sleeps only 6 hours a night, but may obtain an additional hour or even 2 during daytime naps. Older adults also experience an increase in the number of sleep disruptions and an increased incidence of chronic diseases, which can contribute to poorer sleep in this group. The two most common geriatric sleep disorders are obstructive sleep apnea syndrome and restless legs syndrome. Detailed diagnostic workup and treatment are usually referred to a center for sleep medicine where polysomnographic studies are performed. Left untreated, sleep disorders may present a serious threat to the patient's health and lead to increased morbidity and mortality.

Age Factors↗

PubMed2006

Upper airway imaging in obstructive sleep apnea.

PURPOSE OF REVIEW: Obstructive sleep apnea continues to be a significant public health problem. A variety of imaging modalities have been used recently to gain insight into the pathogenesis of this disease, as well as to identify therapeutic options. RECENT FINDINGS: Data from more recent imaging studies have highlighted key findings regarding the anatomic sites of collapse and local tissue factors promoting upper airway compromise. The role of genetics, aging, gender and ethnicity in the development of sleep apnea and the identification of predictors for successful treatment outcomes for sleep-disordered breathing are also reviewed. SUMMARY: As our understanding of obstructive sleep apnea evolves, newer imaging techniques and computerized models may be able to further enhance our understanding of the pathogenesis and treatment of this disease.

Aging↗

PubMed2004

Reliability of scoring arousals in normal children and children with obstructive sleep apnea syndrome.

STUDY OBJECTIVES: Scoring of arousals in children is based on an extension of adult criteria, as defined by the American Sleep Disorders Association (ASDA). By this, a minimum duration of 3 seconds is required. A few recent studies utilized modified criteria for the study of children, with durations as short as 1 second. However, the validity and reliability of scoring these shorter arousals have never been verified. Based on studies in adults, we hypothesized that interscorer agreement for scoring arousals shorter than 3 seconds was poor. DESIGN: Retrospective review of polysomnograms by 2 experienced sleep practitioners who independently scored arousals according to the ASDA 3-second criteria and modified duration criteria of 1 and 2 seconds. SETTING: Academic hospital. PATIENTS OR PARTICIPANTS: 20 polysomnographic studies from children aged 3 to 8 years with mild to severe obstructive sleep apnea syndrome, and 16 polysomnographic studies from normal children. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The intraclass correlation coefficient for scoring ASDA arousals was 0.90 (95% confidence interval: 0.81-0.95), indicating excellent interscorer agreement. The intraclass correlation coefficient for scoring modified 1-second and 2-second arousals were 0.35 (95% confidence interval: 0.02-0.61) and 0.42 (95% confidence interval: 0.12-0.65) respectively, indicating poor to fair interscorer agreement. Furthermore, modified 1-second and 2-second arousals accounted for less than 15% of all arousals scored. CONCLUSIONS: We conclude that there is much poorer interscorer agreement for scoring arousals shorter than 3 seconds, when compared to the standard ASDA criteria. We propose that scoring of arousals in children should follow the standard ASDA criteria.

Arousal↗

PubMed1997

Heart rate variability in children with obstructive sleep apnea.

Adults with obstructive sleep apnea syndrome (OSAS) display substantial heart rate changes associated with obstructive events, and recent reports suggest similar heart rate changes in children with OSAS. These rate changes could assist screening of young patients for OSAS. Six-hour polysomnographic recordings were obtained from seven children with OSAS (mean age: 4.5 years; apnea index: 19.5 +/- 5.1) and from seven primary snorers without OSAS who served as controls (mean age: 4.7; apnea index: 0). Scatterplots of each cardiac R-R interval against the preceding interval (Poincaré plots) were used to assess beat-to-beat cardiac variability at different heart rates. Beat-to-beat variation at slow rates was significantly increased in children with OSAS relative to controls, while variation at fast and intermediate heart rates was significantly reduced in these children. We conclude that OSAS alters beat-to-beat variation in characteristic fashions in children, that the variability changes occur at all heart rates but are most significant at slow heart rates, and that these heart rate patterns could assist in screening of suspected cases of OSAS.

Body Weight↗