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Chest Feb 2007Central sleep apnea (CSA) is characterized by a lack of drive to breathe during sleep, resulting in repetitive periods of insufficient ventilation and compromised gas... (Review)
Review
Central sleep apnea (CSA) is characterized by a lack of drive to breathe during sleep, resulting in repetitive periods of insufficient ventilation and compromised gas exchange. These nighttime breathing disturbances can lead to important comorbidity and increased risk of adverse cardiovascular outcomes. There are several manifestations of CSA, including high altitude-induced periodic breathing, idiopathic CSA, narcotic-induced central apnea, obesity hypoventilation syndrome, and Cheyne-Stokes breathing. While unstable ventilatory control during sleep is the hallmark of CSA, the pathophysiology and the prevalence of the various forms of CSA vary greatly. This brief review summarizes the underlying physiology and modulating components influencing ventilatory control in CSA, describes the etiology of each of the various forms of CSA, and examines the key factors that may exacerbate apnea severity. The clinical implications of improved CSA pathophysiology knowledge and the potential for novel therapeutic treatment approaches are also discussed.
Topics: Humans; Respiration; Sleep; Sleep Apnea, Central
PubMed: 17296668
DOI: 10.1378/chest.06.2287 -
The New England Journal of Medicine Feb 2021Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death.
METHODS
In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the final results of this assessment.
RESULTS
A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.92 to 1.55).
CONCLUSIONS
In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.).
Topics: Administration, Oral; Aged; Aged, 80 and over; Anti-Infective Agents; COVID-19; Dexamethasone; Drug Therapy, Combination; Female; Glucocorticoids; Hospitalization; Humans; Injections, Intravenous; Kaplan-Meier Estimate; Length of Stay; Male; Odds Ratio; Oxygen Inhalation Therapy; Respiration, Artificial; United Kingdom; COVID-19 Drug Treatment
PubMed: 32678530
DOI: 10.1056/NEJMoa2021436 -
The European Respiratory Journal Jan 2021Sleep-related breathing disorders (SBDs) include obstructive apnoea, central apnoea and sleep-related hypoventilation. These nocturnal events have the potential to... (Review)
Review
Sleep-related breathing disorders (SBDs) include obstructive apnoea, central apnoea and sleep-related hypoventilation. These nocturnal events have the potential to increase pulmonary arterial pressure (PAP) during sleep but also in the waking state. "Pure" obstructive sleep apnoea syndrome (OSAS) is responsible for a small increase in PAP whose clinical impact has not been demonstrated. By contrast, in obesity hypoventilation syndrome (OHS) or overlap syndrome (the association of chronic obstructive pulmonary disease (COPD) with obstructive sleep apnoea (OSA)), nocturnal respiratory events contribute to the development of pulmonary hypertension (PH), which is often severe. In the latter circumstances, treatment of SBDs is essential in order to improve pulmonary haemodynamics.Patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) are at risk of developing SBDs. Obstructive and central apnoea, as well as a worsening of ventilation-perfusion mismatch, can be observed during sleep. There should be a strong suspicion of SBDs in such a patient population; however, the precise indications for sleep studies and the type of recording remain to be specified. The diagnosis of OSAS in patients with PAH or CTEPH should encourage treatment with continuous positive airway pressure (CPAP). The presence of isolated nocturnal hypoxaemia should also prompt the initiation of long-term oxygen therapy. These treatments are likely to avoid worsening of PH; however, it is prudent not to treat central apnoea and Cheyne-Stokes respiration (CSR) with adaptive servo-ventilation in patients with chronic right-heart failure because of a potential risk of serious adverse effects from such treatment.In this review we will consider the current knowledge of the consequences of SBDs on pulmonary haemodynamics in patients with and without chronic respiratory disease (group 3 of the clinical classification of PH) and the effect of treatments of respiratory events during sleep on PH. The prevalence and consequences of SBDs in PAH and CTEPH (groups 1 and 4 of the clinical classification of PH, respectively), as well as therapeutic options, will also be discussed.
Topics: Cheyne-Stokes Respiration; Continuous Positive Airway Pressure; Humans; Hypertension, Pulmonary; Sleep; Sleep Apnea, Central
PubMed: 32747397
DOI: 10.1183/13993003.02258-2020 -
The Oncologist Jun 2014The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to...
BACKGROUND
The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to diagnose impending death. We examined the frequency and onset of 10 bedside physical signs and their diagnostic performance for impending death.
METHODS
We systematically documented 10 physical signs every 12 hours from admission to death or discharge in 357 consecutive patients with advanced cancer admitted to two acute palliative care units. We examined the frequency and median onset of each sign from death backward and calculated their likelihood ratios (LRs) associated with death within 3 days.
RESULTS
In total, 203 of 357 patients (52 of 151 in the U.S., 151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale ≤20%, and dysphagia of liquids appeared at high frequency and >3 days before death and had low specificity (<90%) and positive LR (<5) for impending death. In contrast, apnea periods, Cheyne-Stokes breathing, death rattle, peripheral cyanosis, pulselessness of radial artery, respiration with mandibular movement, and decreased urine output occurred mostly in the last 3 days of life and at lower frequency. Five of these signs had high specificity (>95%) and positive LRs for death within 3 days, including pulselessness of radial artery (positive LR: 15.6; 95% confidence interval [CI]: 13.7-17.4), respiration with mandibular movement (positive LR: 10; 95% CI: 9.1-10.9), decreased urine output (positive LR: 15.2; 95% CI: 13.4-17.1), Cheyne-Stokes breathing (positive LR: 12.4; 95% CI: 10.8-13.9), and death rattle (positive LR: 9; 95% CI: 8.1-9.8).
CONCLUSION
We identified highly specific physical signs associated with death within 3 days among cancer patients.
Topics: Death; Humans; Neoplasms; Palliative Care; Patients; Physical Examination
PubMed: 24760709
DOI: 10.1634/theoncologist.2013-0457 -
Swiss Medical Weekly Aug 2009
Topics: Cheyne-Stokes Respiration; Humans
PubMed: 19685353
DOI: 10.57187/smw.2009.12749 -
Lancet (London, England) May 2021In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
In this study, we aimed to evaluate the effects of tocilizumab in adult patients admitted to hospital with COVID-19 with both hypoxia and systemic inflammation.
METHODS
This randomised, controlled, open-label, platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing several possible treatments in patients hospitalised with COVID-19 in the UK. Those trial participants with hypoxia (oxygen saturation <92% on air or requiring oxygen therapy) and evidence of systemic inflammation (C-reactive protein ≥75 mg/L) were eligible for random assignment in a 1:1 ratio to usual standard of care alone versus usual standard of care plus tocilizumab at a dose of 400 mg-800 mg (depending on weight) given intravenously. A second dose could be given 12-24 h later if the patient's condition had not improved. The primary outcome was 28-day mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN (50189673) and ClinicalTrials.gov (NCT04381936).
FINDINGS
Between April 23, 2020, and Jan 24, 2021, 4116 adults of 21 550 patients enrolled into the RECOVERY trial were included in the assessment of tocilizumab, including 3385 (82%) patients receiving systemic corticosteroids. Overall, 621 (31%) of the 2022 patients allocated tocilizumab and 729 (35%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0·85; 95% CI 0·76-0·94; p=0·0028). Consistent results were seen in all prespecified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital within 28 days (57% vs 50%; rate ratio 1·22; 1·12-1·33; p<0·0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (35% vs 42%; risk ratio 0·84; 95% CI 0·77-0·92; p<0·0001).
INTERPRETATION
In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes. These benefits were seen regardless of the amount of respiratory support and were additional to the benefits of systemic corticosteroids.
FUNDING
UK Research and Innovation (Medical Research Council) and National Institute of Health Research.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Antibodies, Monoclonal, Humanized; COVID-19; Female; Hospital Mortality; Hospitalization; Humans; Hypoxia; Male; Middle Aged; Oxygen Saturation; Respiration, Artificial; SARS-CoV-2; Severity of Illness Index; Treatment Outcome; Young Adult; COVID-19 Drug Treatment
PubMed: 33933206
DOI: 10.1016/S0140-6736(21)00676-0 -
Annals of Noninvasive Electrocardiology... Nov 2017Cheyne-Stokes respiration (CSR) has been investigated primarily in outpatients with heart failure. In this study we compare CSR and periodic breathing (PB) between...
BACKGROUND
Cheyne-Stokes respiration (CSR) has been investigated primarily in outpatients with heart failure. In this study we compare CSR and periodic breathing (PB) between healthy and cardiac groups.
METHODS
We compared CSR and PB, measured during 24 hr of continuous 12-lead electrocardiographic (ECG) Holter recording, in a group of 90 hospitalized patients presenting to the emergency department with symptoms suggestive of acute coronary syndrome (ACS) to a group of 100 healthy ambulatory participants. We also examined CSR and PB in the 90 patients presenting with ACS symptoms, divided into a group of 39 (43%) with confirmed ACS, and 51 (57%) with a cardiac diagnosis but non-ACS. SuperECG software was used to derive respiration and then calculate CSR and PB episodes from the ECG Holter data. Regression analyses were used to analyze the data. We hypothesized SuperECG software would differentiate between the groups by detecting less CSR and PB in the healthy group than the group of patients presenting to the emergency department with ACS symptoms.
RESULTS
Hospitalized patients with suspected ACS had 7.3 times more CSR episodes and 1.6 times more PB episodes than healthy ambulatory participants. Patients with confirmed ACS had 6.0 times more CSR episodes and 1.3 times more PB episodes than cardiac non-ACS patients.
CONCLUSION
Continuous 12-lead ECG derived CSR and PB appear to differentiate between healthy participants and hospitalized patients.
Topics: Acute Coronary Syndrome; Adult; Aged; Cheyne-Stokes Respiration; Electrocardiography, Ambulatory; Female; Humans; Male; Respiration
PubMed: 28618169
DOI: 10.1111/anec.12462 -
Journal of the American College of... Jun 2020
Topics: Cheyne-Stokes Respiration; Heart Failure; Humans; Sleep Apnea, Central
PubMed: 32527404
DOI: 10.1016/j.jacc.2020.04.055 -
Respirology (Carlton, Vic.) Feb 2022
Topics: Cheyne-Stokes Respiration; Humans; Sleep Apnea, Central
PubMed: 34989085
DOI: 10.1111/resp.14200