Abstract
Sleep disordered breathing (SDB) is highly prevalent among patients with cardiovascular
disease (CVD), and the relationship between SDB and CVD may be bidirectional. However,
SDB remains underdiagnosed and undertreated. One of the major barriers identified
by cardiologists is lack of satisfaction with SDB therapy. This situation could be
the result of the discordance between treatment and the pathophysiological characteristics
of SDB. This condition is caused by multiple pathophysiological mechanisms, which
could be classified into upper airway anatomic compromise, pharyngeal dilator muscle
dysfunction, and ventilatory control instability. However, the effective treatment
of SDB remains limited, and positive airway pressure therapy is still the mainstay
of the treatment. Therefore, we review the pathophysiological characteristics of SDB
in this article, and we propose to provide individualized treatment of SDB based on
the underlying mechanism. This approach requires further study but could potentially
improve adherence and success of therapy.
Résumé
Les troubles respiratoires du sommeil (TRS) sont très répandus chez les patients souffrant
de maladies cardiovasculaires (MCV). Par conséquent, les TRS et les MCV montreraient
un lien bidirectionnel. Cependant, les TRS demeurent sous-diagnostiqués et sous-traités.
L’un des obstacles majeurs déterminés par les cardiologues est l’insatisfaction concernant
le traitement des TRS. Cette situation pourrait résulter de la discordance entre le
traitement et les caractéristiques physiopathologiques des TRS. Cette affection est
causée par de multiples mécanismes physiopathologiques, qui pourraient être classifiés
comme suit : le compromis anatomique des voies aériennes supérieures, la dysfonction
des muscles dilatateurs du pharynx et l’instabilité de la maîtrise ventilatoire. Cependant,
le traitement efficace des TRS étant limité, leur traitement repose encore sur la
thérapie par pression positive expiratoire continue. Par conséquent, dans cet article,
nous passons en revue les caractéristiques physiopathologiques des TRS et nous proposons
d’offrir un traitement individualisé des TRS reposant sur le mécanisme sous-jacent.
Cette approche nécessite des études plus approfondies, mais pourrait favoriser l’observance
et le succès du traitement.
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References
- The occurrence of sleep-disordered breathing among middle-aged adults.N Engl J Med. 1993; 328: 1230-1235
- Detection of flow limitation with a nasal cannula/pressure transducer system.Am J Respir Crit Care Med. 1998; 157: 1461-1467
- Cardiovascular risk factors, mortality, and overweight.JAMA. 2008; 299 (author reply 1261): 1260-1261
- Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study.Sleep Med. 2010; 11: 441-446
- Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.J Am Coll Cardiol. 2007; 49: 565-571
- Association of sleep apnoea with myocardial infarction in men.Lancet. 1990; 336: 261-264
- Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study.JAMA. 2000; 283: 1829-1836
- Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.Sleep. 2008; 31: 1071-1078
- Obstructive sleep apnoea syndrome—an oxidative stress disorder.Sleep Med Rev. 2003; 7: 35-51
- Selective activation of inflammatory pathways by intermittent hypoxia in obstructive sleep apnea syndrome.Circulation. 2005; 112: 2660-2667
- Hypoxia potentiates nitric oxide-mediated apoptosis in endothelial cells via peroxynitrite-induced activation of mitochondria-dependent and -independent pathways.J Biol Chem. 2004; 279: 4425-4432
- Pathophysiology of sleep apnea.Physiol Rev. 2010; 90: 47-112
- Obstructive sleep apnoea and its cardiovascular consequences.Lancet. 2009; 373: 82-93
- Hemodynamic effects of simulated obstructive apneas in humans with and without heart failure.Chest. 2001; 119: 1827-1835
- Left ventricular structural adaptations to obstructive sleep apnea in dilated cardiomyopathy.Am J Respir Crit Care Med. 2006; 173: 1170-1175
- Immediate effects of arousal from sleep on cardiac autonomic outflow in the absence of breathing in dogs.J Appl Physiol. 1995; 79: 151-162
- Nocturnal rostral fluid shift: a unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure.Circulation. 2010; 121: 1598-1605
- Diuretics in obstructive sleep apnea with diastolic heart failure.Chest. 2007; 132: 440-446
- Overnight shift from obstructive to central apneas in patients with heart failure: role of PCO2 and circulatory delay.Circulation. 2001; 103: 238-243
- Chemical control stability in patients with obstructive sleep apnea.Am J Respir Crit Care Med. 2001; 163: 1181-1190
- A mechanism of central sleep apnea in patients with heart failure.N Engl J Med. 1999; 341: 949-954
- Relationship of carbon dioxide tension in arterial blood to pulmonary wedge pressure in heart failure.Eur Respir J. 2002; 19: 37-40
- Enhanced peripheral chemoreflex function in conscious rabbits with pacing-induced heart failure.J Appl Physiol. 1999; 86: 1264-1272
- Sleep apnea and cardiovascular disease: a bidirectional relationship.Circulation. 2012; 126: 1495-1510
- Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP).Circulation. 2007; 115: 3173-3180
- Sleep apnea testing and outcomes in a large cohort of Medicare beneficiaries with newly diagnosed heart failure.Am J Respir Crit Care Med. 2011; 183: 539-546
- Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study.Lancet. 2005; 365: 1046-1053
- Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation.J Am Coll Cardiol. 2013; 62: 300-305
- Obstructive sleep apnea and the recurrence of atrial fibrillation.Circulation. 2003; 107: 2589-2594
- 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 62: e147-239
Fang E, Loo G, Lee CH. Sleep Apnea and the Heart—the Singapore Experience. Available at: http://www.acc.org/latest-in-cardiology/articles/2014/07/18/15/46/sleep-apnea-and-the-heart-the-singapore-experience?w_nav=S. Accessed October 15, 2014.
- Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.J Clin Sleep Med. 2009; 5: 263-276
- Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults.Sleep. 2006; 29: 381-401
- Night-to-night variability in CPAP use over the first three months of treatment.Sleep. 1997; 20: 278-283
- Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.Cochrane Database Syst Rev. 2014; 1: CD007736
- Adherence to continuous positive airway pressure therapy: the challenge to effective treatment.Proc Am Thorac Soc. 2008; 5: 173-178
- A new educational program for patients suffering from sleep apnea syndrome.Patient education and counseling. 2006; 60: 220-227
- CPAP compliance: video education may help!.Sleep Med. 2005; 6: 171-174
- Effects of augmented continuous positive airway pressure education and support on compliance and outcome in a Chinese population.Chest. 2000; 117: 1410-1416
- Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.J Med Internet Res. 2007; 9: e14
- Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome?.Am J Respir Crit Care Med. 1999; 159: 1096-1100
- Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: preliminary findings.Behav Sleep Med. 2007; 5: 89-104
- Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial.Sleep. 2007; 30: 635-640
- 5-years APAP adherence in OSA patients—do first impressions matter?.Respir Med. 2013; 107: 2046-2052
- Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning.Sleep. 2007; 30: 711-719
- Oral appliances for snoring and obstructive sleep apnea: a review.Sleep. 2006; 29: 244-262
- Anatomic and physiologic predictors of apnea severity in morbidly obese subjects.Sleep. 2003; 26: 150-155
- Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls.Am J Respir Crit Care Med. 1995; 152: 1673-1689
- Family aggregation of upper airway soft tissue structures in normal subjects and patients with sleep apnea.Am J Respir Crit Care Med. 2006; 173: 453-463
- Pathophysiology of adult obstructive sleep apnea.Proc Am Thorac Soc. 2008; 5: 144-153
- Pathogenesis of obstructive and central sleep apnea.Am J Respir Crit Care Med. 2005; 172: 1363-1370
- Computerized tomography in obstructive sleep apnea. Correlation of airway size with physiology during sleep and wakefulness.Am Rev Respir Dis. 1983; 127: 221-226
- Computational simulation of human upper airway collapse using a pressure-/state-dependent model of genioglossal muscle contraction under laminar flow conditions.J Appl Physiol. 2005; 99: 1138-1148
- The impact of anatomic manipulations on pharyngeal collapse: results from a computational model of the normal human upper airway.Chest. 2005; 128: 1324-1330
- Use of computational modeling to predict responses to upper airway surgery in obstructive sleep apnea.Laryngoscope. 2007; 117: 648-653
- Coupling of fluid and elastic models for biomechanical simulations of brain deformations using FEM.Med Image Anal. 2002; 6: 375-388
- Application of finite element analysis in neurosurgery.Child Nerv Dys. 2001; 17: 87-96
Colrain I, Bogan R, Becker P, et al. A multi-center evaluation of oral pressure therapy for the treatment of obstructive sleep apnoea. Paper presented at: 21st Congress of the European Sleep Research Society. September 4-8, 2012; Paris, France.
Schwab RJ, Kim C, Siegel L, et al. Mechanism of action of a novel device using oral pressure therapy (OPT) for the treatment of OSA. Paper presented at: American Thoracic Society 2012 International Conference. May 18-23, 2012; San Francisco, CA.
- Examining the mechanism of action of a new device using oral pressure therapy for the treatment of obstructive sleep apnea.Sleep. 2014; 37: 1237-1247
- Novel and emerging nonpositive airway pressure therapies for sleep apnea.Chest. 2013; 144: 1946-1952
- Waking genioglossal electromyogram in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanism).J Clin Invest. 1992; 89: 1571-1579
- Mechanics of the respiratory system and breathing pattern during sleep in normal humans.J Appl Physiol. 1984; 56: 133-137
- Genioglossus muscle responsiveness to chemical and mechanical stimuli during non-rapid eye movement sleep.Am J Respir Crit Care Med. 2002; 165: 945-949
- Motor control of the pharyngeal musculature and implications for the pathogenesis of obstructive sleep apnea.Sleep. 1996; 19: 827-853
- The neuropharmacology of upper airway motor control in the awake and asleep states: implications for obstructive sleep apnoea.Respir Res. 2001; 2: 286-294
- Airway dilator muscle activity and lung volume during stable breathing in obstructive sleep apnea.Sleep. 2009; 32: 361-368
- Arousal: the forgotten response to respiratory stimuli.Am Rev Respir Dis. 1978; 118: 807-809
- Respiratory arousal from sleep: mechanisms and significance.Sleep. 1997; 20: 654-675
- Genioglossus premotoneurons and the negative pressure reflex in rats.J Physiol. 2007; 579: 515-526
- Hypoglossal premotor neurons of the intermediate medullary reticular region express cholinergic markers.J Appl Physiol. 2008; 105: 1576-1584
- Donepezil improves obstructive sleep apnea in Alzheimer disease: a double-blind, placebo-controlled study.Chest. 2008; 133: 677-683
- Changes in upper airway muscle activation and ventilation during phasic REM sleep in normal men.J Appl Physiol. 1991; 71: 488-497
- Neurophysiology of sleep and wakefulness: basic science and clinical implications.Curr Neuropharmacol. 2008; 6: 367-378
- Targeted hypoglossal neurostimulation for obstructive sleep apnoea: a 1-year pilot study.Eur Respir J. 2013; 41: 360-367
- Upper-airway stimulation for obstructive sleep apnea.N Engl J Med. 2014; 370: 139-149
- Effect of lung inflation on pulmonary resistance during NREM sleep.Am Rev Respir Dis. 1990; 141: 854-860
- Lung volume and continuous positive airway pressure requirements in obstructive sleep apnea.Am J Respir Crit Care Med. 2005; 172: 114-117
- Effect of increased lung volume on sleep disordered breathing in patients with sleep apnoea.Thorax. 2006; 61: 435-439
- Effects of obesity on respiratory function.Am Rev Respir Dis. 1983; 128: 501-506
- Changes in lung volume and upper airway using MRI during application of nasal expiratory positive airway pressure in patients with sleep-disordered breathing.J Appl Physiol. 2011; 111: 1400-1409
- Interaction of chemical and state effects on ventilation during sleep onset.J Appl Physiol. 1996; 81: 2235-2243
- Sleep-induced periodic breathing and apnea: a theoretical study.J Appl Physiol. 1991; 70: 2014-2024
- Role of arousals in the pathogenesis of obstructive sleep apnea.Am J Respir Crit Care Med. 2004; 169: 623-633
- Eszopiclone increases the respiratory arousal threshold and lowers the apnoea/hypopnoea index in obstructive sleep apnoea patients with a low arousal threshold.Clin Sci. 2011; 120: 505-514
- Trazodone increases arousal threshold in obstructive sleep apnoea.Eur Respir J. 2008; 31: 1308-1312
- Respiratory dysrhythmias during sleep.N Engl J Med. 1981; 305: 325-330
- Influence of pulmonary capillary wedge pressure on central apnea in heart failure.Circulation. 1999; 99: 1574-1579
- Cardiac failure presenting as sleep apnea. Elimination of apnea following medical management of cardiac failure.Chest. 1988; 94: 1298-1300
- Breathing pattern abnormalities and arterial oxygen desaturation during sleep in the congestive heart failure syndrome. Improvement following medical therapy.Chest. 1987; 91: 833-836
- Cardiac resynchronization therapy improves central sleep apnea and Cheyne-Stokes respiration in patients with chronic heart failure.J Am Coll Cardiol. 2004; 44: 68-71
- The effect of successful heart transplant treatment of heart failure on central sleep apnea.Chest. 2003; 124: 1675-1681
- Continuous positive airway pressure for central sleep apnea and heart failure.N Engl J Med. 2005; 353: 2025-2033
- A randomized controlled trial of adaptive ventilation for Cheyne-Stokes breathing in heart failure.Am J Respir Crit Care Med. 2003; 168: 1109-1114
- Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure.Am J Respir Crit Care Med. 2001; 164: 614-619
- Effects of inhaled carbon dioxide and oxygen on cheyne-stokes respiration in patients with heart failure.Am J Respir Crit Care Med. 1999; 159: 1490-1498
- Effect of oxygen in obstructive sleep apnea: role of loop gain.Respir Physiol Neurobiol. 2008; 162: 144-151
- Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study.Am J Respir Crit Care Med. 2006; 173: 234-237
- Effect of theophylline on sleep-disordered breathing in heart failure.N Engl J Med. 1996; 335: 562-567
- Transvenous phrenic nerve stimulation for the treatment of central sleep apnoea in heart failure.Eur Heart J. 2012; 33: 889-894
- Transvenous phrenic nerve stimulation in patients with Cheyne-Stokes respiration and congestive heart failure: a safety and proof-of-concept study.Chest. 2012; 142: 927-934
- A method for measuring and modeling the physiological traits causing obstructive sleep apnea.J Appl Physiol. 2011; 110: 1627-1637
- A simplified method for determining phenotypic traits in patients with obstructive sleep apnea.J Appl Physiol. 2013; 114: 911-922
- Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets.Am J Respir Crit Care Med. 2013; 188: 996-1004
- An integrative model of physiological traits can be used to predict obstructive sleep apnea and response to non positive airway pressure therapy.Sleep. 2015; 38: 961-970
- Quantifying the ventilatory control contribution to sleep apnoea using polysomnography.Eur Respir J. 2015; 45: 408-418
- Clinical predictors of the respiratory arousal threshold in patients with obstructive sleep apnea.Am J Respir Crit Care Med. 2014; 190: 1293-1300
Article info
Publication history
Published online: February 13, 2015
Accepted:
February 8,
2015
Received:
November 14,
2014
Footnotes
See page 885 for disclosure information.
Identification
Copyright
© 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
