Looking both ways before crossing the street: Assessing the benefits and risk of opioids in treating patients at risk of sleep disordered breathing for pain and dyspnea

2017 ◽  
Vol 13 (3) ◽  
pp. 183 ◽  
Author(s):  
Mellar P. Davis, MD, FCCP, FAAHPM ◽  
Bertrand Behm, MD ◽  
Diwakar Balachandran, MD
Keyword(s):  
At Risk ◽  
Sleep Apnea ◽  
Cardiovascular Events ◽  
Sleep Disordered Breathing ◽  
Central Sleep Apnea ◽  
Chronic Obstructive ◽  
Chronic Noncancer Pain ◽  
Obstructive Sleep ◽  
Increased Risk ◽  
Disordered Breathing

Opioids adversely influence respiration in five distinct ways. Opioids reduce the respiratory rate, tidal volume, amplitude, reflex responses to hypercapnia and hypoxia, and arousability related necessary for respiratory adaptive responses. Opioids cause impairment of upper pharyngeal dilator muscles leading to obstructive apnea. Opioids cause complex sleep disordered breathing (SDB) consisting of central sleep apnea and obstructive sleep apnea. Clinically opioids worsen preexisting SDB. Recent studies have shown increased morbidity and mortality in patients receiving opioids for chronic noncancer pain and chronic obstructive pulmonary disease, which appear to be related to cardiovascular events, not overdose. Both patient populations are at risk for sleep disordered breathing and increased risk for adverse cardiovascular events on opioids for dyspnea or pain. This review discusses the influence of opioids on respiration and SDB and will review the adverse respiratory and cardiovascular effects of opioid use in at risk populations. Recommendations regarding management will follow as a summary.

827 Central Sleep Apnea in a patient with Multiple Sclerosis

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A322-A323
Author(s):  
Rahul Dasgupta ◽  
Sonja Schütz ◽  
Tiffany Braley
Keyword(s):  
Multiple Sclerosis ◽  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Sleep Disordered Breathing ◽  
Central Sleep Apnea ◽  
Progressive Multiple Sclerosis ◽  
Obstructive Sleep ◽  
Increased Risk ◽  
Demyelinating Lesions ◽  
The Brain

Abstract Introduction Sleep-disordered breathing is common in persons with multiple sclerosis (PwMS), and may contribute to debilitating fatigue and other chronic MS symptoms. The majority of research to date on SDB in MS has focused on the prevalence and consequences of obstructive sleep apnea; however, PwMS may also be at increased risk for central sleep apnea (CSA), and the utility of methods to assess CSA in PwMS warrant further exploration. We present a patient with secondary progressive multiple sclerosis who was found to have severe central sleep apnea on WatchPAT testing. Report of case(s) A 61 year-old female with a past medical history of secondary progressive multiple sclerosis presented with complaints of fragmented sleep. MRI of the brain, cervical spine, and thoracic spine showed numerous demyelinating lesions in the brain, brainstem, cervical, and thoracic spinal cord. Upon presentation, the patient noted snoring, witnessed apneas, and daytime sleepiness. WatchPAT demonstrated severe sleep apnea, with a pAHI of 63.3, and a minimum oxygen saturation of 90%. The majority of the scored events were non-obstructive in nature (73.1% of all scored events), and occurred intermittently in a periodic fashion. Conclusion The differential diagnosis of fatigue in PwMS should include sleep-disordered breathing, including both obstructive and central forms of sleep apnea. Demyelinating lesions in the brainstem (which may contribute to impairment of motor and sensory networks that control airway patency and respiratory drive), and progressive forms of MS, have been linked to both OSA and CSA. The present data illustrate this relationship in a person with progressive MS, and offer support for the WatchPAT as a cost-effective means to evaluate for both OSA and CSA in PwMS, while reducing patient burden. PwMS may be at increased risk for CSA. Careful clinical consideration should be given to ordering appropriate sleep testing to differentiate central from obstructive sleep apnea in PwMS, particularly for patients with demyelinating lesions in the brainstem. Support (if any) 1. Braley TJ, Segal BM, Chervin RD. Obstructive sleep apnea and fatigue in patients with multiple sclerosis. J Clin Sleep Med. 2014 Feb 15;10(2):155–62. doi: 10.5664/jcsm.3442. PMID: 24532998; PMCID: PMC3899317.

scholarly journals Sleep-disordered Breathing in Uncontrolled Blood Pressure: Our Experience

2018 ◽  
Vol 1 (1) ◽  
pp. 36-38
Author(s):  
Milesh Jung Sijapati ◽  
Minalma Pandey ◽  
Nirupama Khadka ◽  
Poojyashree Karki
Keyword(s):  
Blood Pressure ◽  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Sleep Disordered Breathing ◽  
Central Sleep Apnea ◽  
Upper Airway Resistance Syndrome ◽  
Uncontrolled Blood Pressure ◽  
Antihypertensive Regimen ◽  
Obstructive Sleep ◽  
Disordered Breathing

Introduction: Sleep-disordered breathing is one of the greatest health problems. It comprises of obstructive sleep apnea, central sleep apnea, periodic breathing, and upper airway resistance syndrome. There are several studies reporting association of uncontrolled blood pressurewith individuals having sleep disordered breathing. Data regarding this were sparse in developing countries. Therefore this study was performed to find out the sleep-disordered breathing among uncontrolled hypertensive patients.Materials and Methods: Study was performed from January, 2014 to January, 2017 in sleep center in Kathmandu, Nepal. Patient with uncontrolled BP were included. Uncontrolled BP was defined as blood pressure>130/80mmHg not on intensive antihypertensive regimen and resistant elevated BP was defined as blood pressure >130/80 mmHg despite intensive antihypertensive regimen. These patients were subjected for polysomnography.Results: Three hundred patients were selected out of which 250 patients with uncontrolled blood pressure were included. They were subjected for overnight polysomnography. Among them, 70patients (28%)were found to have mild obstructive sleep apnea, 20 patients had moderate obstructive sleep apnea (8%)&15 had severe obstructive sleep apnea (6%).Conclusions: This study concludes that those individuals having uncontrolled blood pressure has obstructive sleep apnea and these individuals have to undergo polysomnography.Nepalese Medical Journal, vol.1, No. 1, 2018, page: 36-38

scholarly journals Canadian Thoracic Society 2011 Guideline Update: Diagnosis and Treatment of Sleep Disordered Breathing

2011 ◽  
Vol 18 (1) ◽  
pp. 25-47 ◽  
Author(s):  
John Fleetham ◽  
Najib Ayas ◽  
Douglas Bradley ◽  
Michael Fitzpatrick ◽  
Thomas K Oliver ◽  
...  
Keyword(s):  
Sleep Apnea ◽  
Continuous Positive Airway Pressure ◽  
Airway Pressure ◽  
Sleep Disordered Breathing ◽  
Positive Airway Pressure ◽  
Sleep Apnea Syndrome ◽  
Central Sleep Apnea ◽  
Diagnosis And Treatment ◽  
Obstructive Sleep ◽  
Disordered Breathing

The Canadian Thoracic Society (CTS) published an executive summary of guidelines for the diagnosis and treatment of sleep disordered breathing in 2006/2007. These guidelines were developed during several meetings by a group of experts with evidence grading based on committee consensus. These guidelines were well received and the majority of the recommendations remain unchanged. The CTS embarked on a more rigorous process for the 2011 guideline update, and addressed eight areas that were believed to be controversial or in which new data emerged. The CTS Sleep Disordered Breathing Committee posed specific questions for each area. The recommendations regarding maximum assessment wait times, portable monitoring, treatment of asymptomatic adult obstructive sleep apnea patients, treatment with conventional continuous positive airway pressure compared with automatic continuous positive airway pressure, and treatment of central sleep apnea syndrome in heart failure patients replace the recommendations in the 2006/2007 guidelines. The recommendations on bariatric surgery, complex sleep apnea and optimum positive airway pressure technologies are new topics, which were not covered in the 2006/2007 guidelines.

scholarly journals Sleep-Disordered Breathing Is Associated with Reduced Mandibular Cortical Width in Children

2018 ◽  
Vol 4 (1) ◽  
pp. 58-67
Author(s):  
H. Eimar ◽  
M.A.Q. Al-Saleh ◽  
A.R.G. Cortes ◽  
D. Gozal ◽  
D. Graf ◽  
...  
Keyword(s):  
At Risk ◽  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Sleep Disordered Breathing ◽  
Severe Form ◽  
Children At Risk ◽  
Cortical Width ◽  
Obstructive Sleep ◽  
Mandibular Cortical Width ◽  
Disordered Breathing

Introduction: Evidence from the adult population suggests that sleep-disordered breathing (SDB) (i.e., obstructive sleep apnea [OSA]) is negatively associated with bone mineral density. Whether a similar association exists in children with SDB has not been investigated. Using the mandibular cortical width (MCW) as a proxy for skeletal bone density, we investigated if children at risk of SDB or diagnosed with OSA have a reduced mandibular cortical width compared to children without SDB. Methods: Two retrospective cross-sectional studies were performed. The first study included comparison of MCW between 24 children with polysomnographically (PSG) diagnosed OSA and 72 age- and sex-matched control children. The second study included a cohort of children in which SDB was suggested by the Pediatric Sleep Questionnaire (PSQ) ( n = 101). MCW was measured from panoramic radiographs. Results: Multiple-predictors regression analysis from the first study indicated that in children with a severe form of SDB, as induced by OSA severity, there was a negative association with MCW (β = –0.290, P = 0.049). Moreover, PSG-diagnosed OSA children had thinner MCW (2.9. ± 0.6mm) compared to healthy children (3.5 ± 0.6 mm; P = 0.002). These findings were further supported by the second study illustrating that PSQ total scores were negatively associated with MCW (β = –0.391, P < 0.001). Conclusions: Findings suggest that children at risk for or diagnosed with SDB exhibit reduced mandibular cortical width that purportedly may reflect alterations in bone homeostasis. Knowledge Transfer Statement: We report that sleep-disordered breathing (including its severe form, obstructive sleep apnea) in children is associated with reduced mandibular cortical width. This association might be a direct consequence of reduced bone health to sleep-disordered breathing or a reflection that reduced bone formation underlies the development of sleep-disordered breathing. Our findings suggest that mandibular cortical width can be used as an adjunct diagnostic parameter for the diagnosis of sleep-disordered breathing.

Sleep-Disordered Breathing and Nocturnal Hypoxemia in Precapillary Pulmonary Hypertension: Prevalence, Pathophysiological Determinants, and Clinical Consequences

Respiration ◽  
2021 ◽  
pp. 1-12
Author(s):  
Jens Spiesshoefer ◽  
Simon Herkenrath ◽  
Katharina Harre ◽  
Florian Kahles ◽  
Anca Florian ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Sleep Apnea ◽  
Sleep Quality ◽  
Sleep Disordered Breathing ◽  
Central Sleep Apnea ◽  
Apnea Hypopnea Index ◽  
Amino Terminal ◽  
Nocturnal Hypoxemia ◽  
Obstructive Sleep ◽  
Disordered Breathing

<b><i>Background and objective:</i></b> The clinical relevance and interrelation of sleep-disordered breathing and nocturnal hypoxemia in patients with precapillary pulmonary hypertension (PH) is not fully understood. <b><i>Methods:</i></b> Seventy-one patients with PH (age 63 ± 15 years, 41% male) and 35 matched controls were enrolled. Patients with PH underwent clinical examination with assessment of sleep quality, daytime sleepiness, 6-minute walk distance (6MWD), overnight cardiorespiratory polygraphy, lung function, hypercapnic ventilatory response (HCVR; by rebreathing technique), amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and cardiac MRI (<i>n</i> = 34). <b><i>Results:</i></b> Prevalence of obstructive sleep apnea (OSA) was 68% in patients with PH (34% mild, apnea-hypopnea index [AHI] ≥5 to &#x3c;15/h; 34% moderate to severe, AHI ≥15/h) versus 5% in controls (<i>p</i> &#x3c; 0.01). Only 1 patient with PH showed predominant central sleep apnea (CSA). Nocturnal hypoxemia (mean oxygen saturation [SpO<sub>2</sub>] &#x3c;90%) was present in 48% of patients with PH, independent of the presence of OSA. There were no significant differences in mean nocturnal SpO<sub>2</sub>, self-reported sleep quality, 6MWD, HCVR, and lung and cardiac function between patients with moderate to severe OSA and those with mild or no OSA (all <i>p</i> &#x3e; 0.05). Right ventricular (RV) end-diastolic (<i>r</i> = −0.39; <i>p</i> = 0.03) and end-systolic (<i>r</i> = −0.36; <i>p</i> = 0.04) volumes were inversely correlated with mean nocturnal SpO<sub>2</sub> but not with measures of OSA severity or daytime clinical variables. <b><i>Conclusion:</i></b> OSA, but not CSA, is highly prevalent in patients with PH, and OSA severity is not associated with nighttime SpO<sub>2</sub>, clinical and functional status. Nocturnal hypoxemia is a frequent finding and (in contrast to OSA) relates to structural RV remodeling in PH.

Sleep-disordered breathing in adult patients with mitochondrial diseases

Neurology ◽  
2020 ◽  
pp. 10.1212/WNL.0000000000011005
Author(s):  
Guido Primiano ◽  
Valerio Brunetti ◽  
Catello Vollono ◽  
Anna Losurdo ◽  
Rossana Moroni ◽  
...  
Keyword(s):  
Sleep Apnea ◽  
Sleep Disordered Breathing ◽  
Prospective Observational Study ◽  
Central Sleep Apnea ◽  
Mitochondrial Diseases ◽  
Population Based ◽  
Genotype Combination ◽  
Obstructive Sleep ◽  
Specific Subgroup ◽  
Disordered Breathing

ObjectiveTo describe the prevalence and characteristics of sleep-disordered breathing (SDB) in a large cohort of patients with genetically confirmed mitochondrial diseases.MethodsThis is a prospective observational study performed at the Neurophysiopatology Unit of Fondazione Policlinico Universitario A. Gemelli IRCCS. All subjects had a defined mitochondrial disease and were investigated by full night polysomnography.Results103 consecutive patients were enrolled. SDB was demonstrated in 49 patients (47.6%). Regarding phenotypes, we found differences in distribution between the groups: patients affected by PEO with single or multiple mtDNA deletions frequently had obstructive apneas (50% and 43.8%) or REM-related hypoventilation when associated with m.3243A>G mutations (75%). Furthermore, a high percentage of subjects with MIDD and MERRF syndromes were characterized respectively by obstructive sleep apnea and REM-related hypoventilation. Differently from what is previously reported, central sleep apnea was rarely reported in our cohort.ConclusionsSDB has a higher prevalence in MDs compared to general population-based data. Overall, these results suggest that patients characterized by a specific phenotype-genotype combination are most at risk of developing a specific subgroup of SDB. The early identification of this disorder is crucial in the management of these fragile patients.

scholarly journals The prevalence of sleep-disordered breathing in Northwest Russia: The ARKHsleep study

2020 ◽  
Vol 17 ◽  
pp. 147997312092810
Author(s):  
Anna Khokhrina ◽  
Elena Andreeva ◽  
Jean-Marie Degryse
Keyword(s):  
Sleep Apnea ◽  
Sleep Disordered Breathing ◽  
Large Scale ◽  
Early Recognition ◽  
Background Characteristics ◽  
Cardiovascular Prognosis ◽  
Obstructive Sleep ◽  
Increased Risk ◽  
Home Sleep Apnea Testing ◽  
Disordered Breathing

Sleep-disordered breathing (SDB) is a chronic condition characterized by repeated breathing pauses during sleep. The reported prevalence of SDB in the general population has increased over time. Furthermore, in the literature, a distinction is made between SDB, obstructive sleep apnea (OSA), and “OSA syndrome” (OSAS). Patients with SDB are at increased risk of comorbid cardiovascular diseases (CVDs). The aim of the ARKHsleep study was to assess the prevalence of SDB in general and of OSA and OSAS in particular. A total of 1050 participants aged 30–70 years, who were randomly selected from a population register, were evaluated for the probability of SDB using the Epworth Sleepiness Scale score and body mass index. Sleep was recorded for one night via home sleep apnea testing (Somnolter®). Medical conditions were determined from medical records. Additional data included background characteristics, anthropometric variables, blood pressure, and scores from four questionnaires. The survey sample consisted of 41.2% males and had a mean age of 53.1 ± 11.3 years. The prevalence of mild-to-severe, moderate-to-severe, and severe SDB was 48.9% [45.8–51.9], 18.1% [15.9–20.6], and 4.5% [3.2–5.8], respectively. Individuals reporting snoring or breathing pauses had a higher severity of SDB than individuals free of symptoms. The ARKHsleep study revealed a high burden of both SDB and CVD; however, more large-scale cohort studies and intervention studies are needed to better understand whether the early recognition and treatment of mild SDB with or without symptoms will improve cardiovascular prognosis and/or quality of life.

Sleep-disordered breathing in patients on opioids for chronic pain

2020 ◽  
Vol 45 (10) ◽  
pp. 826-830
Author(s):  
Janannii Selvanathan ◽  
Philip W H Peng ◽  
Jean Wong ◽  
Clodagh M Ryan ◽  
Frances Chung
Keyword(s):  
Chronic Pain ◽  
Sleep Apnea ◽  
Sleep Disordered Breathing ◽  
Clinical Care ◽  
Central Sleep Apnea ◽  
Well Being ◽  
Pressure Therapy ◽  
Obstructive Sleep ◽  
Pain Clinics ◽  
Disordered Breathing

The past two decades has seen a substantial rise in the use of opioids for chronic pain, along with opioid-related mortality and adverse effects. A contributor to opioid-associated mortality is the high prevalence of moderate/severe sleep-disordered breathing, including central sleep apnea and obstructive sleep apnea, in patients with chronic pain. Although evidence-based treatments are available for sleep-disordered breathing, patients are not frequently assessed for sleep-disordered breathing in pain clinics. To aid healthcare providers in this area of clinical uncertainty, we present evidence on the interaction between opioids and sleep-disordered breathing, and the prevalence and predictive factors for sleep-disordered breathing in patients on opioids for chronic pain. We provide recommendations on how to evaluate patients on opioids for risk of moderate/severe sleep-disordered breathing in clinical care, which could lead to earlier use of therapeutic interventions for opioid-associated sleep-disordered breathing, such as opioid cessation or positive airway pressure therapy. This would improve quality of life and well-being of patients with chronic pain.

scholarly journals Sleep-Disordered Breathing During Congestive Heart Failure: To Intervene or Not to Intervene?

2017 ◽  
Vol 3 (2) ◽  
pp. 134 ◽  
Author(s):  
Ali Valika ◽  
Maria Rosa Costanzo ◽  
◽  
Keyword(s):  
Heart Failure ◽  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Ejection Fraction ◽  
Sleep Disordered Breathing ◽  
Treatment Strategies ◽  
Central Sleep Apnea ◽  
Reduced Ejection Fraction ◽  
Obstructive Sleep ◽  
Disordered Breathing

Sleep-disordered breathing is common in heart failure patients and is associated with increased morbidity and mortality. Central sleep apnea occurs more commonly in heart failure-reduced ejection fraction, and obstructive sleep apnea occurs more frequently in heart failure with preserved ejection fraction. Although the two types of sleep-disordered breathing have distinct pathophysiologic mechanisms, both contribute to abnormal cardiovascular consequences. Treatment with continuous positive airway pressure for obstructive sleep apnea in heart failure has been well defined, whereas treatment strategies for central sleep apnea in heart failure continue to evolve. Unilateral transvenous neurostimulation has shown promise for the treatment of central sleep apnea. In this paper, we examine the current state of knowledge of treatment options for sleep-disordered breathing in heart failure.

Abstract 15777: Association Between Sleep Disordered Breathing, Obstructive Sleep Apnea and Incident Cancer: A Systematic Review and Meta-Analysis

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Ghanshyam Palamaner Subash Shantha ◽  
Anita A Kumar ◽  
Lawrence J Cheskin ◽  
Samir B Pancholy
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Head And Neck ◽  
Sleep Disordered Breathing ◽  
Meta Analysis ◽  
Incident Cancer ◽  
Obstructive Sleep ◽  
Increased Risk ◽  
Disordered Breathing

Introduction: Sleep disordered breathing (SDB) and obstructive sleep apnea (OSA) increase risk for multiple morbidities such as cardiovascular events, diabetes mellitus, and hypertension. Association between SDB and incident cancer is unclear and studies that assessed this association have yielded conflicting results. Hypothesis: We systematically reviewed the literature and pooled available evidence that has associated SDP and incident cancer. Methods: Medline, Embase, Cochrane central library, and electronic databases were searched for relevant studies. Studies were included if: 1) they studied patients with SDB, and 2) reported rates of incident cancer. We excluded studies that reported cancers involving head and neck as we suspected reverse causation, since head and neck cancers can lead to SDP. Data were pooled using a random-effects model. Results: From 3522 retrieved citations, 7 observational studies were included in the review. Of these, 4 studies, representing 48,152 patients with SDB and 87,849 patients without SDB, were included in the meta-analysis. In total 6931 incident cancer cases were reported (2813 in SDB group and 4118 in non-SDB group). In the pooled analysis, patients with SDB experienced higher odds of incident cancer (OR: 1.30, 95% CI: 1.06 - 1.60, P = 0.01, I 2 : 75%, 4 included studies) compared to those without SDB. Data from 2 studies that assessed patients with OSA, showed that OSA increased risk for incident cancer at 5 years follow-up (OR: 1.90, 95% CI: 1.46 - 2.45, P < 0.001, I 2 : 0%) and 8 years follow-up (OR: 1.54, 95% CI: 1.25 - 1.88, P < 0.001, I 2 : 0%). Also, cancer risk (OR: 1.28, 95% CI: 1.09 - 1.51, P = 0.003, I 2 : 21%, 2 studies) and cancer mortality (OR: 1.84, 95% CI: 1.32 - 2.56, P = 0.003, I 2 : 0%, 2 studies) was significant only in patients with severe OSA [apnea-hypopnea index (AHI) > 30] and not in patients with mild to moderate OSA (AHI < 30). Factors namely; obesity, type of cancer, age and gender did not account for between study heterogeneity. Conclusions: SDB and OSA are associated with incident cancer. Though our study did not support the role of obesity in this association, strong mechanistic link exists, associating SDB, obesity and cancer. Future studies should assess the association between SDB and organ specific cancers.

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