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European Journal of Heart Failure Apr 2016Sleep-disordered breathing-comprising obstructive sleep apnoea (OSA), central sleep apnoea (CSA), or a combination of the two-is found in over half of heart failure (HF)... (Review)
Review
Sleep-disordered breathing-comprising obstructive sleep apnoea (OSA), central sleep apnoea (CSA), or a combination of the two-is found in over half of heart failure (HF) patients and may have harmful effects on cardiac function, with swings in intrathoracic pressure (and therefore preload and afterload), blood pressure, sympathetic activity, and repetitive hypoxaemia. It is associated with reduced health-related quality of life, higher healthcare utilization, and a poor prognosis. Whilst continuous positive airway pressure (CPAP) is the treatment of choice for patients with daytime sleepiness due to OSA, the optimal management of CSA remains uncertain. There is much circumstantial evidence that the treatment of OSA in HF patients with CPAP can improve symptoms, cardiac function, biomarkers of cardiovascular disease, and quality of life, but the quality of evidence for an improvement in mortality is weak. For systolic HF patients with CSA, the CANPAP trial did not demonstrate an overall survival or hospitalization advantage for CPAP. A minute ventilation-targeted positive airway therapy, adaptive servoventilation (ASV), can control CSA and improves several surrogate markers of cardiovascular outcome, but in the recently published SERVE-HF randomized trial, ASV was associated with significantly increased mortality and no improvement in HF hospitalization or quality of life. Further research is needed to clarify the therapeutic rationale for the treatment of CSA in HF. Cardiologists should have a high index of suspicion for sleep-disordered breathing in those with HF, and work closely with sleep physicians to optimize patient management.
Topics: Atrial Fibrillation; Continuous Positive Airway Pressure; Health Services; Heart; Heart Failure; Heart Failure, Systolic; Hospitalization; Humans; Inflammation; Myocardial Ischemia; Positive-Pressure Respiration; Pressure; Prognosis; Quality of Life; Reactive Oxygen Species; Sleep Apnea Syndromes; Sleep Apnea, Central; Sleep Apnea, Obstructive; Survival Rate; Sympathetic Nervous System; Thoracic Cavity
PubMed: 26869027
DOI: 10.1002/ejhf.492 -
Pulmonary Pharmacology & Therapeutics Dec 2015Obstructive Sleep Apnoea (OSA) has recently been reported to be a cause of chronic cough. It should be considered when cough remains unexplained following investigations... (Review)
Review
Obstructive Sleep Apnoea (OSA) has recently been reported to be a cause of chronic cough. It should be considered when cough remains unexplained following investigations and treatments for common causes. The presence of nocturnal cough, snoring and gastro-oesophageal reflux may be helpful in identifying patients who require further investigation. Daytime somnolence is often absent. Continuous positive airway pressure (CPAP) therapy has been reported to be effective in alleviating cough. Therapy for gastro-oesophageal reflux disease, if present, should be optimised. The mechanism of the association between OSA and cough is not clear, but airway inflammation, gastro-oesophageal reflux disease, increased cough reflex sensitivity and tracheobronchomalacia are possible explanations. Further studies should identify clinical predictors of OSA-cough, establish mechanisms and the optimal therapy.
Topics: Animals; Continuous Positive Airway Pressure; Cough; Humans; Prevalence; Sleep Apnea, Obstructive
PubMed: 26068465
DOI: 10.1016/j.pupt.2015.05.008 -
Emerging Topics in Life Sciences Dec 2023Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a common disorder characterised by repetitive episodes of the complete or partial collapse of the pharyngeal...
Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a common disorder characterised by repetitive episodes of the complete or partial collapse of the pharyngeal airway during sleep. This results in cessation (apnoea) or reduction (hypopnoea) of airflow, leading to oxygen desaturation and sleep fragmentation. An individual's disposition to develop OSAHS depends on the collapsibility of a segment of the upper airway. The degree of collapsibility can be quantified by the balance between occluding or extraluminal pressures of the surrounding tissues. Patients can experience snoring, unrefreshing sleep, witnessed apnoeas, waking with a choking sensation and excessive daytime sleepiness. OSAHS has a broad range of consequences, including cardiovascular, metabolic, and neurocognitive sequelae. Treatment options include lifestyle measures, in particular weight loss, and strategies to maintain upper airway patency overnight, including continuous positive airway pressure, mandibular advancement devices and positional modifiers.
Topics: Humans; Sleep Apnea, Obstructive; Syndrome; Lung; Snoring; Continuous Positive Airway Pressure
PubMed: 38130167
DOI: 10.1042/ETLS20180939 -
Respirology (Carlton, Vic.) Jul 2017P4 medicine is an evolving approach to personalized medicine. The four Ps offer a means to: Predict who will develop disease and co-morbidities; Prevent rather than... (Review)
Review
P4 medicine is an evolving approach to personalized medicine. The four Ps offer a means to: Predict who will develop disease and co-morbidities; Prevent rather than react to disease; Personalize diagnosis and treatment; have patients Participate in their own care. P4 medicine is very applicable to obstructive sleep apnoea (OSA) because each OSA patient has a different pathway to disease and its consequences. OSA has both structural and physiological mechanisms with different clinical subgroups, different molecular profiles and different consequences. This may explain why there are different responses to alternative therapies, such as intraoral devices and hypoglossal nerve stimulation therapy. Currently, technology facilitates patients to participate in their own care from screening for OSA (snoring and apnoea apps) to monitoring response to therapy (sleep monitoring, blood pressure, oxygen saturation and heart rate) as well as monitoring their own continuous positive airway pressure (CPAP) compliance. We present a conceptual framework that provides the basis for a new, P4 medicine approach to OSA and should be considered more in depth: predict and prevent those at high risk for OSA and consequences, personalize the diagnosis and treatment of OSA and build in patient participation to manage OSA.
Topics: Continuous Positive Airway Pressure; Humans; Patient Compliance; Patient Participation; Precision Medicine; Primary Prevention; Risk Assessment; Sleep Apnea, Obstructive
PubMed: 28477347
DOI: 10.1111/resp.13063 -
Expert Opinion on Pharmacotherapy 2023Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice... (Review)
Review
INTRODUCTION
Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA.
AREAS COVERED
This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities.
EXPERT OPINION
There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.
Topics: Humans; Sleep Initiation and Maintenance Disorders; Sleep Apnea, Obstructive; Sleep Apnea Syndromes; Comorbidity; Continuous Positive Airway Pressure
PubMed: 38099435
DOI: 10.1080/14656566.2023.2292186 -
Heart (British Cardiac Society) Nov 2023Sleep-disordered breathing (SDB) is common in individuals with established cardiovascular disease (CVD), particularly those with heart failure (HF). There are two main... (Randomized Controlled Trial)
Randomized Controlled Trial
Sleep-disordered breathing (SDB) is common in individuals with established cardiovascular disease (CVD), particularly those with heart failure (HF). There are two main types of SDB, central sleep apnoea (CSA) and obstructive sleep apnoea (OSA) which frequently overlap as mixed SDB. Investigating for SDB could be considered in patients with excessive daytime sleepiness, male sex, high body mass index, low ejection fraction, atrial fibrillation (AF), in patients with no dipping blood pressure pattern, recurrent paroxysms of nocturnal dyspnoea or when an apnoea is witnessed. Excessive daytime sleepiness is less likely to be reported by patients with HF than by the general population. In patients with CVD and OSA, continuous positive airway pressure (CPAP) ventilation for over 4 hours daily reduced the risk of major adverse cardiovascular events, but there was no reduction in mortality. In patients with AF and OSA treated with AF ablation, CPAP use was associated with a reduced risk of recurrence of AF. In patients with HF and OSA, small studies have demonstrated that CPAP improves symptoms, brain natriuretic peptide levels and ejection fraction, but data on survival are lacking. Treatment remains unclear in patients with HF and CSA. The presence of CSA may be a defensive adaptive response to HF, and effectively treating CSA as demonstrated in a randomised clinical trial of adaptive servo-ventilation caused more harm than benefit when compared to optimal medical therapy. Thus, the focus of treating CSA should remain on improving the underlying HF by optimising medical therapy and, if indicated, cardiac resynchronisation therapy.
Topics: Humans; Male; Cardiovascular Diseases; Sleep Apnea Syndromes; Sleep Apnea, Central; Sleep Apnea, Obstructive; Heart Failure; Atrial Fibrillation; Disorders of Excessive Somnolence
PubMed: 37607811
DOI: 10.1136/heartjnl-2019-316375 -
IEEE Transactions on Bio-medical... Apr 2022The physiological mechanisms involved in cardio-respiratory responses to sleep apnea events are not yet fully elucidated. A model-based approach is proposed to analyse...
OBJECTIVE
The physiological mechanisms involved in cardio-respiratory responses to sleep apnea events are not yet fully elucidated. A model-based approach is proposed to analyse the acute desaturation response to obstructive apneas.
METHODS
An integrated model of cardio-respiratory interactions was proposed and parameters were identified, using an evolutionary algorithm, on a database composed of 107 obstructive apneas acquired from 10 patients (HYPNOS clinical study). Unsupervised clustering was applied to the identified parameters in order to characterize the phenotype of each response to obstructive apneas.
RESULTS
A close match was observed between simulated oxygen saturation ( SaO) and experimental SaO in all identifications (median RMSE = 1.3892 %). Two clusters of parameters, associated with different dynamics related to sleep apnea and periodic breathing were obtained.
CONCLUSION AND SIGNIFICANCE
The proposed patient and event-specific model-based analysis provides understanding on specific desaturation patterns, consequent to apnea events, with potential applications for personalized diagnosis and treatment.
Topics: Airway Obstruction; Humans; Oxygen; Sleep Apnea Syndromes; Sleep Apnea, Obstructive
PubMed: 34665719
DOI: 10.1109/TBME.2021.3121170 -
Current Neurology and Neuroscience... May 2017This review aims to explain the inevitable imbalance between respiratory load, drive, and muscular force that occurs in the natural aging of Duchenne muscular dystrophy... (Review)
Review
This review aims to explain the inevitable imbalance between respiratory load, drive, and muscular force that occurs in the natural aging of Duchenne muscular dystrophy and that predisposes these patients to sleep disordered breathing (SDB). In DMD, SDB is characterized by oxygen desaturation, apneas, hypercapnia, and hypoventilation during sleep and ultimately develops into respiratory failure during wakefulness. It can be present in all age groups. Young patients risk obstructive apneas because of weight gain, secondary to progressive physical inactivity and prolonged corticosteroid therapy; older patients hypoventilate and desaturate because of respiratory muscle weakness, in particular the diaphragm. These conditions are further exacerbated during REM sleep, the phase of maximal muscle hypotonia during which the diaphragm has to provide most of the ventilation. Evidence is given to the daytime predictors of early symptoms of SDB, important indicators for the proper time to initiate mechanical ventilation.
Topics: Humans; Muscular Dystrophy, Duchenne; Sleep Apnea Syndromes
PubMed: 28397169
DOI: 10.1007/s11910-017-0750-1 -
Journal of Sleep Research Dec 2021Central sleep apneas and periodic breathing are poorly described in childhood. The aim of the study was to describe the prevalence and characteristics of central sleep...
Central sleep apneas and periodic breathing are poorly described in childhood. The aim of the study was to describe the prevalence and characteristics of central sleep apnea and periodic breathing in children with associated medical conditions, and the therapeutic management. We retrospectively reviewed all poly(somno)graphies with a central apnea index ≥ 5 events per hr in children aged > 1 month performed in a paediatric sleep laboratory over a 6-year period. Clinical data and follow-up poly(somno)graphies were gathered. Ninety-five out of 2,981 patients (3%) presented central sleep apnea: 40% were < 1 year, 41% aged 1-6 years, and 19% aged ≥ 6 years. Chiari malformation was the most common diagnosis (13%). Mean central apnea index was 20 ± 30 events per hr (range 5-177). Fifty-eight (61%) children had an exclusive central pattern with < 5 obstructive events per hr. Periodic breathing was present in 79 (83%) patients, with a mean percentage of time with periodic breathing of 9 ± 16%. Among periodic breathing episodes, 40% appeared after a sigh, 8% after an obstructive event, 6% after breathing instability and 2% after bradypnea. The highest clinical apnea index and percentage of time with periodic breathing were observed in children with encephalopathy and/or epilepsy (68 ± 63 events per hr and 30 ± 34%). Clinical apnea index did not differ according to age, while periodic breathing duration was longer in children > 1 year old. Watchful waiting was performed in 22 (23%) patients with spontaneous improvement in 20. Other treatments (upper airway or neurosurgery, nocturnal oxygen therapy, continuous positive airway pressure, non-invasive ventilation) were effective in selected patients. Central sleep apnea is rare in children and comprises heterogeneous conditions. Sleep studies are essential for the diagnosis, characterization and management of central sleep apnea.
Topics: Child; Continuous Positive Airway Pressure; Humans; Infant; Polysomnography; Retrospective Studies; Sleep Apnea, Central; Sleep Apnea, Obstructive
PubMed: 34075643
DOI: 10.1111/jsr.13388 -
British Journal of Hospital Medicine... Sep 2022Obstructive sleep apnoea represents a sizable public health and economic burden. Owing to rising obesity rates, the prevalence of obstructive sleep apnoea is increasing,... (Review)
Review
Obstructive sleep apnoea represents a sizable public health and economic burden. Owing to rising obesity rates, the prevalence of obstructive sleep apnoea is increasing, and it is a condition that is significantly underdiagnosed. Exacerbated by the COVID-19 pandemic, the backlog of elective surgeries is also sizable and growing. A combination of these factors means that many patients due to have surgery will have obstructive sleep apnoea, either diagnosed or otherwise. Patients with obstructive sleep apnoea have a significantly increased risk of operative complications, but the evidence base for optimum perioperative management of these patients is limited. This article reviews sleep apnoea, its prevalence and its impact on operative management and perioperative outcomes for patients. The evidence base for screening and treating undiagnosed obstructive sleep apnoea is also comprehensively assessed. Finally, a pathway to manage patients with possible undiagnosed obstructive sleep apnoea is proposed, and areas for further research identified.
Topics: COVID-19; Continuous Positive Airway Pressure; Humans; Pandemics; Perioperative Medicine; Sleep Apnea, Obstructive
PubMed: 36193921
DOI: 10.12968/hmed.2022.0297