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Arousal: Ontology, Functional Anatomy, Methodology, and Consequences

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Sleep Disordered Breathing in Children

Part of the book series: Respiratory Medicine ((RM))

Abstract

An arousal is considered a discrete event occurring within the context of sleep. The spectrum of arousal ranges from autonomic activation to complete awakening. Arousal is a graded phenomenon that may be associated with any combination of abrupt electroencephalogram (EEG) alterations (frequency and amplitude), blood pressure elevation, sympathetic activation, tachypnea, tachycardia, and movement. Though arousals may alleviate gas exchange abnormalities and normalize respiratory effort, they may do so with the untoward sequelae of sleep fragmentation. Thus, arousal must be viewed as both an essential protective mechanism and as an epiphenomenon adversely affecting sleep quality. This chapter will focus primarily on the role of arousal as a protective reflex, restoring airway patency in response to increased upper airway resistance.

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References

  1. Iber C, Ancoli-Israel S, Chesson AL, Quan SF, for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specifications. 1st ed. Westchester: American Academy of Sleep Medicine; 2007.

    Google Scholar 

  2. Davies RJO, Vardi-Visi K, Clarke M, Stradling JR. Identification of sleep disruption and sleep disordered breathing from the systolic blood pressure profile. Thorax. 1993;48:1242–7.

    Article  PubMed  CAS  Google Scholar 

  3. Somers VK, Dyken ME, Clary MP, Abboud FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest. 1995;96(4):1897–904.

    Article  PubMed  CAS  Google Scholar 

  4. Martin SE, Wraith PK, Deary IJ, Douglas NJ. The effect of nonvisible sleep fragmentation on daytime function. Am J Respir Crit Care Med. 1997;155: 1596–601.

    PubMed  CAS  Google Scholar 

  5. Sforza E, Jouny C, Ibanez V. Cardiac activation during arousal in humans: further evidence for hierarchy in the arousal response. Clin Neurophysiol. 2000; 111 :1611–9.

    Article  PubMed  CAS  Google Scholar 

  6. Morgan BJ, Crabtree DC, Puleo DS, et al. Neuro­circulatory consequences of abrupt change in sleep state in humans. J Appl Physiol. 1996;80: 1627–36.

    PubMed  CAS  Google Scholar 

  7. Davies RJO, Belt PJ, Roberts SJ, et al. Arterial blood pressure responses to graded transient arousal from sleep in normal humans. J Appl Phys. 1993;74:1123–30.

    CAS  Google Scholar 

  8. Tank J, Diedrich A, Hale N, et al. Relationship between blood pressure, sleep K-complexes, and muscle sympathetic nerve activity in humans. Am J Physiol Regul Integr Comp Physiol. 2003;285: R208–14.

    PubMed  CAS  Google Scholar 

  9. Bangash MF, Xie A, Skatrud JB, et al. Cerebrovascular response to arousal from NREM and REM sleep. Sleep. 2008;31:321–7.

    PubMed  Google Scholar 

  10. Baumert M, Kohler M, Kabir M, et al. Cardiorespiratory response to spontaneous cortical arousals during stage 2 and rapid eye movement sleep in healthy children. J Sleep Res. 2010;19(3):415–24.

    Article  PubMed  Google Scholar 

  11. McNamara F, Wulbrand H, Thach BT. Characteristics of the infant arousal response. J Appl Physiol. 1998;85:2314–21.

    PubMed  CAS  Google Scholar 

  12. Lijowska AS, Reed NW, Chiodini BA, Thach BT. Sequential arousal and airway-defensive behavior of infants in asphyxial sleep environments. J Appl Physiol. 1997;83:219–28.

    PubMed  CAS  Google Scholar 

  13. McNamara F, Lijowska AS, Thatch BT. Spontaneous arousal activity in infants during NREM and REM sleep. J Physiol. 2002;538:263–9.

    Article  PubMed  CAS  Google Scholar 

  14. Wulbrand H, McNamara F, Thatch BT. The role of arousal related brainstem reflexes in causing recovery from upper airway occlusion in infants. Sleep. 2008;31:833–40.

    PubMed  Google Scholar 

  15. Roberts JL, Reed WR, Mathew OP, Thatch BT. Control of respiratory activity of the genioglossus muscle in micrognathic infants. J Appl Physiol. 1986;61:1523–33.

    PubMed  CAS  Google Scholar 

  16. Younes M. Role of arousals in the pathogenesis of obstructive sleep apnea. Am J Respir Crit Care Med. 2004;169:623–33.

    Article  PubMed  Google Scholar 

  17. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677–84.

    Article  PubMed  CAS  Google Scholar 

  18. Pasquale-Styles MA, Tackitt PL, Schmidt CJ. Infant death scene investigation and the assessment of potential risk factors for asphyxia: a review of 209 sudden unexpected infant deaths. J Forensic Sci. 2007;52:924–9.

    Article  PubMed  Google Scholar 

  19. Leach CE, Blair PS, Fleming PJ, et al. Epidemiology of SIDS and explained sudden infant deaths. CESDI SUDI Research Group. Pediatrics. 1999;104:e43.

    Article  PubMed  CAS  Google Scholar 

  20. Vennemann MM, Bajanowski T, Brinkmann B, et al. Sleep environment risk factors for sudden infant death syndrome: The German Sudden Infant Death Syndrome Study. Pediatrics. 2009;123:1162–70.

    Article  PubMed  Google Scholar 

  21. Beal SM. Sudden infant death syndrome in South Australia 1968–97. Part I: changes over time. J Paediatr Child Health. 2000;36:540–7.

    Article  PubMed  CAS  Google Scholar 

  22. Mitchell EA, Brunt JM, Everard C. Reduction in mortality from sudden infant death syndrome in New Zealand: 1986–1992. Arch Dis Child. 1994;70:291–4.

    Article  PubMed  CAS  Google Scholar 

  23. Horne RSC, Ferens D, Watts AM, et al. The prone sleeping position impairs arousability in term infants. J Pediatr. 2001;138:811–6.

    Article  PubMed  CAS  Google Scholar 

  24. Horne RSC, Osborne A, Vitkovic J, et al. Arousal from sleep in infants is impaired following an infection. Early Hum Dev. 2002;66:89–100.

    Article  PubMed  Google Scholar 

  25. Franco P, Groswasser J, Hassid S, et al. Prenatal exposure to cigarette smoking is associated with a decrease in arousal in infants. J Pediatr. 1999;135:34–8.

    Article  PubMed  CAS  Google Scholar 

  26. Franco P, Scaillet S, Wermenbol V, et al. The influence of a pacifier on infants’ arousals from sleep. J Pediatr. 2000;136:775–9.

    PubMed  CAS  Google Scholar 

  27. Kahn A, Groswasser J, Rebuffat E, et al. Sleep and cardiorespiratory characteristics of infant victims of sudden death: a prospective case-control study. Sleep. 1992;15:287–92.

    PubMed  CAS  Google Scholar 

  28. Schechtman VL, Harper RM, Kluge KA, et al. Cardiac and respiratory patterns in normal infants and victims of the sudden infant death syndrome. Sleep. 1988;11: 413–24.

    PubMed  CAS  Google Scholar 

  29. Kato I, Franco P, Groswasser J, et al. Incomplete arousal processes in infants who were victims of sudden death. Am J Respir Crit Care Med. 2003;168:1298–303.

    Article  PubMed  Google Scholar 

  30. Duncan JR, Paterson DS, Hoffman JM, et al. Brainstem serotonergic deficiency in sudden infant death syndrome. JAMA. 2010;303:430–7.

    Article  PubMed  CAS  Google Scholar 

  31. The international paediatric work group on arousals. The scroring of arousals in healthy term infants (between the ages of 1 and 6 months). J Sleep Res. 2005;14:37–41.

    Article  Google Scholar 

  32. Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sleep and arousal in infants and children. J Clin Sleep Med. 2007;3:201–40.

    PubMed  Google Scholar 

  33. Bandla HP, Gozal D. Dynamic changes in EEG spectra during obstructive apnea in children. Pediatr Pulmonol. 2000;29:359–65.

    Article  PubMed  CAS  Google Scholar 

  34. Katz ES, Lutz J, Black C, Marcus CL. Pulse transit time as a measure of arousal and respiratory effort in children with sleep-disordered breathing. Pediatr Res. 2003;53:580–8.

    Article  PubMed  Google Scholar 

  35. Traeger N, Schultz B, Pollock AN, et al. Polysomno­graphic values in children 2–9 years old: additional data and review of the literature. Pediatr Pulmonol. 2005;40:22–30.

    Article  PubMed  Google Scholar 

  36. Montgomery-Downs HE, O’Brien LM, Gulliver TE, Gozal D. Polysomnographic characteristics in normal preschool and early school-aged children. Pediatrics. 2006;117:741–53.

    Article  PubMed  Google Scholar 

  37. Miano S, Villa MP, Blanco D, et al. Development of NREM sleep instability-continuity (cyclic alternating pattern) in healthy term infants aged 1 to 4 months. Sleep. 2009;32:83–90.

    PubMed  Google Scholar 

  38. O’Malley EB, Norman RG, Farkas D, et al. The addition of frontal EEG leads improves detection of cortical arousal following obstructive respiratory events. Sleep. 2003;26:435–9.

    PubMed  Google Scholar 

  39. Kaleyias J, Grant M, Darbari F, et al. Detection of cortical arousals in children using frontal EEG leads in addition to conventional leads. J Clin Sleep Med. 2006;2:305–8.

    PubMed  Google Scholar 

  40. Wong TK, Galster P, Lau TS, et al. Reliability of scoring arousals in normal children and children with obstructive sleep apnea syndrome. Sleep. 2004;27(6): 1139–45.

    PubMed  Google Scholar 

  41. Gora J, Trinder J, Pierce R, Colrain IM. Evidence of a sleep-specific blunted cortical response to inspiratory occlusions in mild obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2002;166:1225–34.

    Article  PubMed  Google Scholar 

  42. Chervin RD, Burns JW, Subotic NS, et al. Method for detection of respiratory cycle-related EEG changes in sleep-disordered breathing. Sleep. 2004;27:110–5.

    PubMed  Google Scholar 

  43. Chervin RD, Burns JW, Subotic NS, et al. Correlates of respiratory cycle-related EEG changes in children with sleep-disordered breathing. Sleep. 2004;27: 116–21.

    PubMed  Google Scholar 

  44. Chervin RD, Weatherly RA, Ruzicka DL, et al. Subjective sleepiness and polysomnographic correlates in children scheduled for adenotonsillectomy vs. other surgical care. Sleep. 2006;29:495–503.

    PubMed  Google Scholar 

  45. Goh DY, Galster P, Marcus CL. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir Crit Care Med. 2000;162:682–6.

    PubMed  CAS  Google Scholar 

  46. McNamara F, Issa F, Sullivan C. Arousal pattern following central and obstructive breathing abnormalities in infants and children. J Appl Physiol. 1996;81:2651–7.

    PubMed  CAS  Google Scholar 

  47. Mograss M, Ducharme F, Brouillette R. Movement/arousals. Description, classification and relationship to sleep apnea in children. Am J Respir Crit Care Med. 1994;150:1690–6.

    PubMed  CAS  Google Scholar 

  48. Scholle S, Zwacka G. Arousals and obstructive sleep apnea syndrome in children. Clin Neurophysiol. 2001;112:984–91.

    Article  PubMed  CAS  Google Scholar 

  49. Tauman R, O’Brien LM, Holbrook CR, Gozal D. Sleep pressure score: a new index of sleep disruption in snoring children. Sleep. 2004;27:274–8.

    PubMed  Google Scholar 

  50. Bruni O, Novelli L, Miano S, et al. Cyclic alternating pattern: a window into pediatric sleep. Sleep Med. 2010;11(7):628–36. Epub 2010 Apr 27.

    Article  PubMed  Google Scholar 

  51. Terzano MG, Parrino L, Sherieri A, et al. Atlas, rules, and recording techniques for the scoring of cyclic alternating pattern (CAP) in human sleep. Sleep Med. 2001;2:537–53.

    Article  PubMed  CAS  Google Scholar 

  52. Terzano MG, Parrino L, Boselli M, et al. CAP components and EEG synchronization in the first 3 sleep cycles. Clin Neurophysiol. 2000;111:283–90.

    Article  PubMed  CAS  Google Scholar 

  53. Bruni O, Ferri R, Miano S, et al. Sleep cyclic alternating pattern in normal school-age children. Clin Neurophysiol. 2002;113:1806–14.

    Article  PubMed  Google Scholar 

  54. Lopes MC, Guilleminault C. Chronic snoring and sleep in children: a demonstration of sleep disruption. Pediatrics. 2006;118:e741–6.

    Article  PubMed  Google Scholar 

  55. Parrino L, Boselli M, Spaggiari MC, et al. Cyclic alternating pattern (CAP) in normal sleep: polysomnographic parameters in different age groups. Electroencephalogr Clin Neurophysiol. 1998;107: 439–50.

    Article  PubMed  CAS  Google Scholar 

  56. Miano S, Rizzoli A, Evangelisti M, et al. NREM sleep instability changes following rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep Med. 2009;10:471–8.

    Article  PubMed  Google Scholar 

  57. Kheirandish-Gozal L, Miano S, Bruni O, et al. Reduced NREM sleep instability in children with sleep disordered breathing. Sleep. 2007;30:450–7.

    PubMed  Google Scholar 

  58. Guilleminault C, Lee JH, Chan A, et al. Non-REM sleep instability in recurrent sleepwalking in prepubertal children. Sleep Med. 2005;6:515–21.

    Article  PubMed  Google Scholar 

  59. Pollak MH, Obrist PA. Aortic-radial pulse transit time and ECG Q-wave to radial pulse wave interval as indices of beat-by-beat blood pressure changes. Psychophysiology. 1983;20:21–8.

    Article  PubMed  CAS  Google Scholar 

  60. Geddes L, Voelz MH, Babbs CF, et al. Pulse transit time as an indicator of arterial blood pressure. Psychophys. 1981;18:71–4.

    Article  CAS  Google Scholar 

  61. Payne RA, Symeonides CN, Webb DJ, Maxwell SRJ. Pulse transit time measured from the ECG: an unreliable marker of beat-to-beat blood pressure. J Appl Physiol. 2006;100:136–41.

    Article  PubMed  CAS  Google Scholar 

  62. Pitson DJ, Chhina N, Knijn S, et al. Changes in pulse transit time and pulse rate as markers of arousal from sleep in normal subjects. Clin Sci. 1994;87:269–73.

    PubMed  CAS  Google Scholar 

  63. O’Brien LM, Gozal D. Potential usefulness of noninvasive autonomic monitoring in recognition of arousals in normal healthy children. J Clin Sleep Med. 2007;3:41–7.

    PubMed  Google Scholar 

  64. Poyares D, Guilleminault C, Rosa A, et al. Arousal, EEG spectral power and pulse transit time in UARS and mild OSAS subjects. Clin Neurophysiol. 2002;113:1598–606.

    Article  PubMed  CAS  Google Scholar 

  65. Brietzke S, Katz ES, Roberson D. Pulse transit time as a screening test for pediatric sleep disordered breathing. Arch Otolaryngol Head Neck Surg. 2007;133: 980–4.

    Article  PubMed  Google Scholar 

  66. Pillar G, Bar A, Schlitner A, et al. Autonomic arousal index: an automated detection based on peripheral arterial tonometry. Sleep. 2002;25:543–9.

    PubMed  Google Scholar 

  67. Zou D, Grote L, Eder DN, et al. Obstructive apneic events induce alpha-receptor mediated digital vasoconstriction. Sleep. 2004;27:485–9.

    PubMed  Google Scholar 

  68. O’Donnell CP, Allan L, Atkinson P, Schwartz AR. The effect of upper airway obstruction and arousal on peripheral arterial tonometry in obstructive sleep apnea. Am J Respir Crit Care Med. 2002;166:965–71.

    Article  PubMed  Google Scholar 

  69. Bar A, Pillar G, Dvir I, et al. Evaluation of a portable device based on peripheral arterial tone for unattended home sleep studies. Chest. 2003;123:695–703.

    Article  PubMed  Google Scholar 

  70. Tauman R, O’Brien LM, Mast BT, et al. Peripheral arterial tonometry events and electroencephalographic arousals in children. Sleep. 2004;27:502–6.

    PubMed  Google Scholar 

  71. Gozal D, Kheirandish-Gozal L. Obesity and excessive daytime sleepiness in prepubertal children with obstructive sleep apnea. Pediatrics. 2009;123:13–8.

    Article  PubMed  Google Scholar 

  72. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102:616–20.

    Article  PubMed  CAS  Google Scholar 

  73. Urschitz MS, Wolff J, Sokollik C, et al. Nocturnal arterial oxygen saturation and academic performance in a community sample of children. Pediatrics. 2005;115:e204–9.

    Article  PubMed  Google Scholar 

  74. Gottlieb DJ, Vezina RM, Chase C, et al. Symptoms of sleep-disordered breathing in 5-year-old children are associated with sleepiness and problem behaviors. Pediatrics. 2003;112:870–7.

    Article  PubMed  Google Scholar 

  75. O’Brien LM, Tauman R, Gozal D. Sleep pressure correlates of cognitive and behavioral morbidity in snoring children. Sleep. 2004;27:279–82.

    PubMed  Google Scholar 

  76. Gozal D, Serpero LD, Kheirandish-Gozal L, et al. Sleep measures and morning plasma TNF-alpha levels in children with sleep-disordered breathing. Sleep. 2010;33:319–25.

    PubMed  Google Scholar 

  77. Katz ES, Marcus CL, White DP. Influence of airway pressure on genioglossus activity during sleep in normal children. Am J Respir Crit Care Med. 2006;173:902–9.

    Article  PubMed  Google Scholar 

  78. Gleeson K, Zwillich CW, White DP. The influence of increasing ventilatory effort on arousal from sleep. Am Rev Respir Dis. 1990;142:295–300.

    PubMed  CAS  Google Scholar 

  79. Kimoff RJ, Cheong TH, Olha AE, et al. Mechanisms of apnea termination in obstructive sleep apnea. Role of chemoreceptor and mechanoreceptor stimuli. Am J Respir Crit Care Med. 1994;149:707–14.

    PubMed  CAS  Google Scholar 

  80. Marcus CL, Bautista DB, Amihyia A, et al. Hypercapneic arousal responses in children with congenital central hypoventilation syndrome. Pediatrics. 1991;88:993–8.

    PubMed  CAS  Google Scholar 

  81. Ayas NT, Brown R, Shea SA. Hypercapnia can induce arousal from sleep in the absence of altered respiratory mechanoreception. Am J Respir Crit Care Med. 2000;162:1004–8.

    PubMed  CAS  Google Scholar 

  82. Davidson Ward SL, Bautista DB, Keens TG. Hypoxic arousal responses in normal infants. Pediatrics. 1992;89:860–4.

    Google Scholar 

  83. Parslow PM, Harding R, Cranage SM, et al. Arousal responses to somatosensory and mild hypoxic stimuli are depressed during quiet sleep in healthy term infants. Sleep. 2003;26:739–44.

    PubMed  Google Scholar 

  84. Berry RB, Asyali MA, McNellis MI, Khoo MC. Within-night variation in respiratory effort preceding apnea termination and EEG delta power in sleep apnea. J Appl Phys. 1998;85:1434–41.

    CAS  Google Scholar 

  85. Marcus CL, Moreira GA, Bamford O, Lutz J. Response to inspiratory resistive loading during sleep in normal children and children with obstructive apnea. J Appl Phys. 1999;87:1448–54.

    CAS  Google Scholar 

  86. Marcus CL, Lutz J, Carroll JL, Bamford O. Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. J Appl Phys. 1998;84:1926–36.

    CAS  Google Scholar 

  87. Moreira GA, Tufik S, Nery LE, et al. Acoustic arousal responses in children with obstructive sleep apnea. Pediatr Pulmonol. 2005;40:300–5.

    Article  PubMed  Google Scholar 

  88. Marcus CL, Katz ES, Lutz J, et al. Upper airway dynamic responses in children with the obstructive sleep apnea syndrome. Pediatr Res. 2005;57:99–107.

    Article  PubMed  Google Scholar 

  89. Huang J, Colrain IM, Melendres C, et al. Cortical processing of respiratory afferent stimuli during sleep in children with the obstructive sleep apnea syndrome. Sleep. 2007;31:403–10.

    Google Scholar 

  90. McNamara F, Sullivan CE. Effects of nasal CPAP therapy on respiratory and spontaneous arousals in infants with OSA. J Appl Physiol. 1999;87:889–96.

    PubMed  CAS  Google Scholar 

  91. Guilleminault C, Stoohs R, Clerk A, et al. A cause of excessive daytime sleepiness. The upper airway resistance syndrome. Chest. 1993;104:781–7.

    Article  PubMed  CAS  Google Scholar 

  92. Fuller PM, Gooley JJ, Saper CB. Neurobiology of the sleep-wake cycle: Sleep architecture, circadian regulation, and regulatory feedback. J Biol Rhythms. 2006;21(6):482–93.

    Article  PubMed  CAS  Google Scholar 

  93. Pepin JL, Tamisier R, Borel JC, et al. A critical review of peripheral arterial tone and pulse transit time as indirect diagnostic methods for detecting sleep disordered breathing and characterizing sleep structure. Curr Opin Pulm Med. 2009;15:550–8.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Pulmonary Department, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA

    Eliot S. Katz MD

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  1. Eliot S. Katz MD
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Correspondence to Eliot S. Katz MD .

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Editors and Affiliations

  1. Section of Sleep Medicine, Pritzker School of Medicine, Department of Pediatrics, S. Maryland Ave. 5721, Chicago, 60637, Illinois, USA

    Leila Kheirandish-Gozal

  2. Pritzker School of Medicine, Comer Children's Hospital, Department of Pediatrics, S. Maryland Ave. 5721, Chicago, 60637, Illinois, USA

    David Gozal

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Katz, E.S. (2012). Arousal: Ontology, Functional Anatomy, Methodology, and Consequences. In: Kheirandish-Gozal, L., Gozal, D. (eds) Sleep Disordered Breathing in Children. Respiratory Medicine. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60761-725-9_8

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