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Relationship between airflow limitation in response to upper airway negative pressure during wakefulness and obstructive sleep apnea severity

  • Sleep Breathing Physiology and Disorders • Original Article
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Abstract

Purpose

The objective was to determine if alteration in airflow induced by negative pressure (NP) applied to participants’ upper airways during wakefulness, is related to obstructive sleep apnea (OSA) severity as determined by the apnea–hypopnea index (AHI).

Methods

Adults 18 years of age or greater were recruited. All participants underwent overnight polysomnography to assess their apnea–hypopnea index (AHI). While awake, participants were twice exposed, orally, to -3 cm H2O of NP for five full breaths. The ratio of the breathing volumes of the last two breaths during NP exposure to the last two breaths prior to NP exposure was deemed the NP ratio (NPR).

Results

Eighteen participants were enrolled. A strong relationship between the AHI and the exponentially transformed NPR (ExpNPR) for all participants was observed (R2 = 0.55, p < 0.001). A multivariable model using the independent variable ExpNPR, age, body mass index and sex accounted for 81% of variability in AHI (p = 0.0006). A leave-one-subject-out cross-validation analysis revealed that predicted AHI using the multivariable model, and actual AHI from participants’ polysomnograms, were strongly related (R2 = 0.72, p < 0.001).

Conclusion

We conclude that ExpNPR, was strongly related to the AHI, independently of demographic factors known to be related to the AHI.

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Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. Eckert DJ, Malhotra A (2008) Pathophysiology of adult obstructive sleep apnea. Proc Am Thorac Soc 5:144–153. https://doi.org/10.1513/pats.200707-114MG

    Article  PubMed  PubMed Central  Google Scholar 

  2. Heinzer R, Vat S, Marques-Vidal P et al (2015) Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 3:310–318. https://doi.org/10.1016/s2213-2600(15)00043-0

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM (2013) Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 177:1006–1014. https://doi.org/10.1093/aje/kws342

    Article  PubMed  PubMed Central  Google Scholar 

  4. Young T, Evans L, Finn L, Palta M (1997) Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 20:705–706. https://doi.org/10.1093/sleep/20.9.705

    Article  CAS  PubMed  Google Scholar 

  5. Kee K, Dixon J, Shaw J et al (2018) Comparison of Commonly Used Questionnaires to Identify Obstructive Sleep Apnea in a High-Risk Population. J Clin Sleep Med 14:2057–2064. https://doi.org/10.5664/jcsm.7536

    Article  PubMed  PubMed Central  Google Scholar 

  6. Pini L, Magri R, Perger E et al (2022) Phenotyping OSAH patients during wakefulness. Sleep Breathing 26:1801–1807. https://doi.org/10.1007/s11325-021-02551-5

    Article  CAS  PubMed  Google Scholar 

  7. Romano S, Salvaggio A, Hirata RP, Lo Bue A, Picciolo S, Oliveira LV, Insalaco G (2011) Upper airway collapsibility evaluated by a negative expiratory pressure test in severe obstructive sleep apnea. Clinics (Sao Paulo) 66:567–572. https://doi.org/10.1590/s1807-59322011000400008

    Article  PubMed  Google Scholar 

  8. Brown IG, Bradley TD, Phillipson EA, Zamel N, Hoffstein V (1985) Pharyngeal compliance in snoring subjects with and without obstructive sleep apnea. Am Rev Respir Dis 132:211–215. https://doi.org/10.1164/arrd.1985.132.2.211

    Article  CAS  PubMed  Google Scholar 

  9. Gleadhill IC, Schwartz AR, Schubert N, Wise RA, Permutt S, Smith PL (1991) Upper airway collapsibility in snorers and in patients with obstructive hypopnea and apnea. Am Rev Respir Dis 143:1300–1303. https://doi.org/10.1164/ajrccm/143.6.1300

    Article  CAS  PubMed  Google Scholar 

  10. Haponik EF, Smith PL, Bohlman ME, Allen RP, Goldman SM, Bleecker ER (1983) Computerized tomography in obstructive sleep apnea. Correlation of airway size with physiology during sleep and wakefulness. Am Rev Respir Dis 127:221–226. https://doi.org/10.1164/arrd.1983.127.2.221

    Article  CAS  PubMed  Google Scholar 

  11. Isono S, Remmers JE, Tanaka A, Sho Y, Sato J (1985) Nishino T (1997) Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol 82:1319–1326. https://doi.org/10.1152/jappl.1997.82.4.1319

    Article  Google Scholar 

  12. Ferretti A, Giampiccolo P, Redolfi S, Mondini S, Cirignotta F, Cavalli A, Tantucci C (2006) Upper airway dynamics during negative expiratory pressure in apneic and non-apneic awake snorers. Respir Res 7:54

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Hirata RP, Schorr F, Kayamori F et al (2016) Upper Airway Collapsibility Assessed by Negative Expiratory Pressure while Awake is Associated with Upper Airway Anatomy. J Clin Sleep Med 12:1339–1346. https://doi.org/10.5664/jcsm.6184

    Article  PubMed  PubMed Central  Google Scholar 

  14. Liistro G, Veriter C, Dury M, Aubert G, Stanescu D (1999) Expiratory flow limitation in awake sleep-disordered breathing subjects. Eur Respir J 14:185–190. https://doi.org/10.1034/j.1399-3003.1999.14a31.x

    Article  CAS  PubMed  Google Scholar 

  15. Montemurro LT, Bettinzoli M, Corda L, Braghini A, Tantucci C (2010) Relationship between critical pressure and volume exhaled during negative pressure in awake subjects with sleep-disordered breathing. Chest 137:1304–1309. https://doi.org/10.1378/chest.09-2109

    Article  PubMed  Google Scholar 

  16. Baydur A, Vigen C, Chen Z (2012) Expiratory Flow Limitation in Obstructive Sleep Apnea and COPD: A Quantitative Method to Detect Pattern Differences Using the Negative Expiratory Pressure Technique. Open Respir Med J 6:111–120. https://doi.org/10.2174/1874306401206010111

    Article  PubMed  PubMed Central  Google Scholar 

  17. Guillot M, Costes F, Sforza E, Maudoux D, Bertoletti L, Barthelemy JC, Roche F (2010) Is tidal expiratory flow limitation predictive of sleep-related disorders in the elderly? Eur Respir J 36:842–848. https://doi.org/10.1183/09031936.00078009

    Article  CAS  PubMed  Google Scholar 

  18. Insalaco G, Romano S, Marrone O, Salvaggio A, Bonsignore G (2005) A new method of negative expiratory pressure test analysis detecting upper airway flow limitation to reveal obstructive sleep apnea. Chest 128:2159–2165. https://doi.org/10.1378/chest.128.4.2159

    Article  PubMed  Google Scholar 

  19. Rouatbi S, Tabka Z, Dogui M, Abdelghani A, Guenard H (2009) Negative expiratory pressure (NEP) parameters can predict obstructive sleep apnea syndrome in snoring patients. Lung 187:23–28. https://doi.org/10.1007/s00408-008-9122-6

    Article  PubMed  Google Scholar 

  20. Schwartz AR, Smith PL, Wise RA, Gold AR (1985) Permutt S (1988) Induction of upper airway occlusion in sleeping individuals with subatmospheric nasal pressure. J Appl Physiol 64:535–542. https://doi.org/10.1152/jappl.1988.64.2.535

    Article  Google Scholar 

  21. Smith PL, Wise RA, Gold AR, Schwartz AR, Permutt S (1988) Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol 64:789–795. https://doi.org/10.1152/jappl.1988.64.2.789

    Article  CAS  PubMed  Google Scholar 

  22. Berry RB, Budhiraja R, Gottlieb DJ et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 8:597–619. https://doi.org/10.5664/jcsm.2172

    Article  PubMed  PubMed Central  Google Scholar 

  23. Mendelson M, Lyons OD, Yadollahi A, Inami T, Oh P, Bradley TD (2016) Effects of exercise training on sleep apnoea in patients with coronary artery disease: a randomised trial. Eur Respir J 48:142–150. https://doi.org/10.1183/13993003.01897-2015

    Article  PubMed  Google Scholar 

  24. Young T, Skatrud J, Peppard PE (2004) Risk factors for obstructive sleep apnea in adults. JAMA 291:2013–2016. https://doi.org/10.1001/jama.291.16.2013

    Article  CAS  PubMed  Google Scholar 

  25. Chowdhury MZI, Turin TC (2020) Variable selection strategies and its importance in clinical prediction modelling. Fam Med Community Health 8:262. https://doi.org/10.1136/fmch-2019-000262

    Article  Google Scholar 

  26. Verin E, Tardif C, Portier F, Similowski T, Pasquis P, Muir JF (2002) Evidence for expiratory flow limitation of extrathoracic origin in patients with obstructive sleep apnoea. Thorax 57:423–428. https://doi.org/10.1136/thorax.57.5.423

    Article  PubMed  PubMed Central  Google Scholar 

  27. Gold AR, Marcus CL, Dipalo F, Gold MS (2002) Upper airway collapsibility during sleep in upper airway resistance syndrome. Chest 121:1531–1540. https://doi.org/10.1378/chest.121.5.1531

    Article  PubMed  Google Scholar 

  28. Malhotra A, Pillar G, Fogel R, Beauregard J, Edwards J, White DP (2001) Upper-airway collapsibility: measurements and sleep effects. Chest 120:156–161. https://doi.org/10.1378/chest.120.1.156

    Article  CAS  PubMed  Google Scholar 

  29. Sanders MH, Moore SE (1983) Inspiratory and expiratory partitioning of airway resistance during sleep in patients with sleep apnea. Am Rev Respir Dis 127:554–558. https://doi.org/10.1164/arrd.1983.127.5.554

    Article  CAS  PubMed  Google Scholar 

  30. Schneider H, Boudewyns A, Smith PL et al (1985) (2002) Modulation of upper airway collapsibility during sleep: influence of respiratory phase and flow regimen. J Appl Physiol 93:1365–1376. https://doi.org/10.1152/japplphysiol.00942.2001

    Article  Google Scholar 

  31. Morrell MJ (1985) Badr MS (1998) Effects of NREM sleep on dynamic within-breath changes in upper airway patency in humans. J Appl Physiol 84:190–199. https://doi.org/10.1152/jappl.1998.84.1.190

    Article  Google Scholar 

  32. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI (1993) Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis 148:1385–1400. https://doi.org/10.1164/ajrccm/148.5.1385

    Article  CAS  PubMed  Google Scholar 

  33. Remmers JE, deGroot WJ, Sauerland EK, Anch AM (1978) Pathogenesis of upper airway occlusion during sleep. J Appl Physiol Respir Environ Exerc Physiol 44:931–938. https://doi.org/10.1152/jappl.1978.44.6.931

    Article  CAS  PubMed  Google Scholar 

  34. Suratt PM, Wilhoit SC, Cooper K (1984) Induction of airway collapse with subatmospheric pressure in awake patients with sleep apnea. J Appl Physiol Respir Environ Exerc Physiol 57:140–146. https://doi.org/10.1152/jappl.1984.57.1.140

    Article  CAS  PubMed  Google Scholar 

  35. Tantucci C, Mehiri S, Duguet A et al (1998) Application of negative expiratory pressure during expiration and activity of genioglossus in humans. J Appl Physiol 84:1076–1082. https://doi.org/10.1152/jappl.1998.84.3.1076

    Article  CAS  PubMed  Google Scholar 

  36. Fogel RB, Malhotra A, Pillar G, Edwards JK, Beauregard J, Shea SA, White DP (2001) Genioglossal activation in patients with obstructive sleep apnea versus control subjects. Mechanisms of muscle control. Am J Respir Crit Care Med 164:2025–2030. https://doi.org/10.1164/ajrccm.164.11.2102048

    Article  CAS  PubMed  Google Scholar 

  37. Basner RC, Ringler J, Schwartzstein RM, Weinberger SE, Weiss JW (1991) Phasic electromyographic activity of the genioglossus increases in normals during slow-wave sleep. Respir Physiol 83:189–200. https://doi.org/10.1016/0034-5687(91)90028-h

    Article  CAS  PubMed  Google Scholar 

  38. Trinder J, Whitworth F, Kay A (1985) Wilkin P (1992) Respiratory instability during sleep onset. J Appl Physiol 73:2462–2469. https://doi.org/10.1152/jappl.1992.73.6.2462

    Article  Google Scholar 

  39. Findley LJ, Wilhoit SC, Suratt PM (1985) Apnea duration and hypoxemia during REM sleep in patients with obstructive sleep apnea. Chest 87:432–436. https://doi.org/10.1378/chest.87.4.432

    Article  CAS  PubMed  Google Scholar 

  40. Bouloukaki I, Kapsimalis F, Mermigkis C et al (2011) Prediction of obstructive sleep apnea syndrome in a large Greek population. Sleep Breath 15:657–664. https://doi.org/10.1007/s11325-010-0416-6

    Article  PubMed  Google Scholar 

  41. Deegan PC, McNicholas WT (1996) Predictive value of clinical features for the obstructive sleep apnoea syndrome. Eur Respir J 9:117–124. https://doi.org/10.1183/09031936.96.09010117

    Article  CAS  PubMed  Google Scholar 

  42. Santaolalla Montoya F, Iriondo Bedialauneta JR, Aguirre Larracoechea U, Martinez Ibargüen A, Sanchez Del Rey A, Sanchez Fernandez JM (2007) The predictive value of clinical and epidemiological parameters in the identification of patients with obstructive sleep apnoea (OSA): a clinical prediction algorithm in the evaluation of OSA. Eur Arch Otorhinolaryngol 264:637–643. https://doi.org/10.1007/s00405-006-0241-5

    Article  PubMed  Google Scholar 

  43. Hoffstein V, Szalai JP (1993) Predictive value of clinical features in diagnosing obstructive sleep apnea. Sleep 16:118–122

    CAS  PubMed  Google Scholar 

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Acknowledgements

This work was supported by a grant from the Ontario Lung Association.

T.D. Bradley was supported by the Godfrey S. Pettit Chair in Respiratory Medicine.

Funding

The Ontario Lung Association provided financial support in the form of grant funding. The sponsor had no role in the design or conduct of this research.

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Authors and Affiliations

  1. KITE Sleep Research Laboratory, Toronto Rehabilitation Institute of the University Health Network Toronto General Hospital, 200 Elizabeth St., Room 9N-943, Toronto, ON, M5G 2C4, Canada

    Jan Lim, Nasim Montazeri Ghahjaverestan & T. Douglas Bradley

  2. Pragmatic Innovation Inc., Toronto, ON, Canada

    Hisham Alshaer

  3. Department of Medicine, Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada

    Nasim Montazeri Ghahjaverestan

  4. Toronto General Hospital of the University Health Network, Toronto, ON, Canada

    T. Douglas Bradley

  5. Department of Medicine, University of Toronto, Toronto, ON, Canada

    T. Douglas Bradley

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  1. Jan Lim
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Correspondence to T. Douglas Bradley.

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Lim, J., Alshaer, H., Ghahjaverestan, N.M. et al. Relationship between airflow limitation in response to upper airway negative pressure during wakefulness and obstructive sleep apnea severity. Sleep Breath 28, 231–239 (2024). https://doi.org/10.1007/s11325-023-02892-3

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