Adaptive support ventilation as an effective treatment option for central sleep apnea in an older adult with heart failure with preserved ejection fraction: a case report

Background Adaptive support ventilation (ASV) is a proposed treatment option for central sleep apnea (CSA). Although the effectiveness of ASV remains unclear, some studies have reported promising results regarding the use of ASV in patients with heart failure with preserved ejection fraction (HfpEF). To illustrate the importance of suspecting and diagnosing sleep-disordered breathing (SDB) in older adults unable to recognize symptoms, we discuss a case in which ASV was effective in a patient with CSA and HfpEF, based on changes in the Holter electrocardiogram (ECG). Case presentation. An 82-year-old man presented to our hospital with vomiting on April 19, 2021. Approximately 10 years before admission, he was diagnosed with type 1 diabetes mellitus and recently required full support from his wife for daily activities due to cognitive dysfunction. Two days before admission, his wife was unable to administer insulin due to excessively high glucose levels, which were displayed as “high” on the patient’s glucose meter; therefore, we diagnosed the patient with diabetic ketoacidosis. After recovery, we initiated intensive insulin therapy for glycemic control. However, the patient exhibited excessive daytime sleepiness, and numerous premature ventricular contractions were observed on his ECG monitor despite the absence of hypoglycemia. As we suspected sleep-disordered breathing (SDB), we performed portable polysomnography (PSG), which revealed CSA. PSG revealed a central type of apnea and hypopnea due to an apnea–hypopnea index of 37.6, which was > 5. Moreover, the patient had daytime sleepiness; thus, we diagnosed him with CSA. We performed ASV and observed its effect using portable PSG and Holter ECG. His episodes of apnea and hypopnea were resolved, and an apparent improvement was confirmed through Holter ECG. Conclusion Medical staff should carefully monitor adult adults for signs of or risk factors for SDB to prevent serious complications. Future studies on ASV should focus on older patients with arrhythmia, as the prevalence of CSA may be underreported in this population and determine the effectiveness of ASV in patients with HfpEF, especially in older adults.

Positional Therapy in a Patient With Refractory Treatment-Emergent Central Sleep Apnea

Treatment-emergent central sleep apnea (TE-CSA) is commonly encountered during the treatment for obstructive sleep apnea (OSA) with positive airway pressure (PAP) and usually remains self-limited. Persistent TE-CSA is sporadically seen with PAP therapy and has only rarely been described with hypoglossal nerve stimulation (HGNS). We report the case of a 60-year-old female patient with moderate OSA that progressed to TE-CSA with PAP therapy. A prolonged trial with PAP therapy was limited because the patient experienced recurrent aerophagia and subsequently underwent HGNS implantation. HGNS titration led to improved control of the patient’s OSA, but TE-CSA recurred and demonstrated a strong positional component. Lateral positional therapy was implemented with adequate control of respiratory events. TE-CSA can persist throughout different treatment modalities, including HGNS. The patient’s successful lateral sleep therapy for persistent and positionally exacerbated TE-CSA demonstrates the benefit of a well-known sleep apnea treatment for this poorly understood condition.

Delivery outcomes as a result of snoring as determined by standard sleep surveys

Background Sleep-disordered breathing (SDB), is an umbrella term that encompasses obstructive sleep apnea (OSA), central sleep apnea (CSA) and hypoventilation. is common but studies in the pregnant population are limited. Data suggests relationships between OSA and preeclampsia, but the relationship between snoring and pregnancy outcomes is unknown. Methods A prospective study of 2224 singleton pregnancies was undertaken. Women were questioned using the Berlin Questionnaire (BQ- 2 or more categories where the score is positive.) and the Epworth Sleepiness Scale (ESS >10/24), the results compared with pregnancy outcomes with regard to hypertension in pregnancy. Results Women having symptoms raising the possibility of OSA defined by the BQ with a score >7 was 45.5%, and using ESS with a score >10, was 36%. The birth and neonatal outcomes for self-reported snoring and increased daytime sleepiness showed increased adverse outcomes notably increased caesarean section rates and low APGAR scores but not birth before 37 weeks of gestation. Conclusion Using questionnaires designed for the general population, the prevalence of possible undiagnosed OSA is high in the pregnant population. The increased adverse delivery and neonatal outcomes for self-reported snoring and increased daytime sleepiness with these tools indicated the need for further investigation of the links between snoring SDB and pregnancy outcomes.

Obstructive Sleep Apnea (OSA), Overview and Treatment Options: A Review

There are different forms of sleep apnea, each with different causes. Fortunately, they are all treatable. 1] Obstructive sleep apnea (OSA) occurs when the muscles and soft tissues in the upper airways relax and become blocked during sleep. It is often accompanied by loud snoring or snorting. OSA is the most common form of sleep apnea, 2] Central sleep apnea (CSA) occurs when the brain stops sending signals to the respiratory muscles while sleeping. Although the airways remain open, breathing stops. CSA is less common than OSA, 3] Mixed sleep apnea is a combination of central and obstructive sleep apnea, and Common to all of these disorders is the occurrence of apneas and hypopneas. Apnea is when the muscles and soft tissues in the upper airways slacken and collapse to the point that they are completely blocked for 10 seconds or more. Hypopnea is a partial blockage of the airways that decreases airflow by more than 50% for 10 seconds or more.

Interaction Between Arousals and Ventilation During Cheyne-Stokes Respiration in Heart Failure Patients: Insights From Breath-by-Breath Analysis

Study Objectives: Arousals from sleep during the hyperpneic phases of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA) in patients with heart failure are thought to cause ventilatory overshoot and a consequent longer apnea, thereby sustaining and exacerbating ventilatory instability. However, data supporting this model are lacking. We investigated the relationship between arousals, hyperpnea and post-hyperpnea apnea length during CSR-CSA.Methods: Breath-by-breath changes in ventilation associated with the occurrence of arousal were evaluated in 18 heart failure patients with CSR-CSA, apnea-hypopnea index ≥15/h and central apnea index ≥5/h. The change in apnea length associated with the presence of arousal during the previous hyperpnea was also evaluated. Potential confounding variables (chemical drive, sleep stage) were controlled for.Results: Arousals were associated with a large increase in ventilation at the beginning of the hyperpnea (+76 ± 35%, p < 0.0001), that rapidly declined during its crescendo phase. Around peak hyperpnea, the change in ventilation was −8 ± 26% (p = 0.14). The presence of arousal during the hyperpnea was associated with a median increase in the length of the subsequent apnea of +4.6% (Q1, Q2: −0.7%, 20.5%; range: −8.5%, 36.2%) (p = 0.021). The incidence of arousals occurring at the beginning of hyperpnea and mean ventilation in the region around its peak were independent predictors of the change in apnea length (p = 0.004 and p = 0.015, respectively; R2 = 0.78).Conclusions: Arousals from sleep during CSR-CSA in heart failure patients are associated with a rapidly decreasing ventilatory overshoot at the beginning of the hyperpnea, followed by a tendency toward a slight ventilatory undershoot around its peak. On average, arousals are also associated with a modest increase in post-hyperpnea apnea length; however, large increases in apnea length (>20%) occur in about a quarter of the patients.

Central Sleep Apnea Is Associated with an Abnormal P-Wave Terminal Force in Lead V1 in Patients with Acute Myocardial Infarction Independent from Ventricular Function

Sleep-disordered breathing (SDB) is highly prevalent in patients with cardiovascular disease. We have recently shown that an elevation of the electrocardiographic (ECG) parameter P wave terminal force in lead V1 (PTFV1) is linked to atrial proarrhythmic activity by stimulation of reactive oxygen species (ROS)-dependent pathways. Since SDB leads to increased ROS generation, we aimed to investigate the relationship between SDB-related hypoxia and PTFV1 in patients with first-time acute myocardial infarction (AMI). We examined 56 patients with first-time AMI. PTFV1 was analyzed in 12-lead ECGs and defined as abnormal when ≥4000 µV*ms. Polysomnography (PSG) to assess SDB was performed within 3–5 days after AMI. SDB was defined by an apnea-hypopnea-index (AHI) >15/h. The multivariable regression analysis showed a significant association between SDB-related hypoxia and the magnitude of PTFV1 independent from other relevant clinical co-factors. Interestingly, this association was mainly driven by central but not obstructive apnea events. Additionally, abnormal PTFV1 was associated with SDB severity (as measured by AHI, B 21.495; CI [10.872 to 32.118]; p < 0.001), suggesting that ECG may help identify patients suitable for SDB screening. Hypoxia as a consequence of central sleep apnea may result in atrial electrical remodeling measured by abnormal PTFV1 in patients with first-time AMI independent of ventricular function. The PTFV1 may be used as a clinical marker for increased SDB risk in cardiovascular patients.

Combination of Obstructive and Central Sleep Apnea as a Non-Sleepy Phenotype of Obstructive Sleep Apnea (OSA): A Case Report and Literature Review

Background and Objective: Co-occurring central sleep apnea (CSA) and obstructive sleep apnea (OSA) are a developing apprehension because many patients referred to sleep studies have co-morbidities such as cardiovascular and/or neurological disorders which increase the possibility of central and obstructive episodes. Here, we report a patient without excessive daytime sleepiness and a combination of CSA and OSA. Case Report: We present a 16-year-old boy with a history of snoring, poor quality of sleep, nightmare, sleep walking, and sleep talking since he was two-years old. His STOP-Bang score was 7. Standard attended polysomnography (PSG) with audio-video monitoring was performed. The PSG results contained Apnea Hypopnea Index (AHI): 30.2 (number of OSAs was 50 and number of CSAs was 49 during sleep). Then, a titration study was performed and continuous positive airway pressure (CPAP) setting as low as eight cmH2O was effective in eliminating obstructive events, but there was emerging CSAs in favour of Treatment Emergent CSA (TCSA). Conclusion: This case represents a non-sleepy phenotype of OSA in combination with many CSAs in PSG. We suggest that further studies be performed on the association between the concomitant presence of CSA and OSA among nonsleepy patients with OSA.