Baclofen-Associated Onset of Central Sleep Apnea in Alcohol Use Disorder: A Case Report.

A 61-year-old patient with alcohol use disorder (AUD) was referred for suspicion of sleep apnea syndrome (SAS). He had incurred three road accidents attributed to sleepiness over the previous year, shortly after initiation of high-dose (100 mg b.i.d.) treatment with baclofen, a molecule increasingly used in the management of AUD. Polysomnography revealed a severe central SAS (CSAS) with an apnea-hypopnea index (AHI) of 81.6/h. Baclofen was suggested as a possible cause of the CSAS, and after its withdrawal, a second polysomnography was done, showing the disappearance of the central apneas and a shift to severe obstructive SAS (AHI 43.9/h), for which a positive airway pressure (CPAP) treatment was initiated. A third polysomnography was performed under CPAP after reintroduction of baclofen (50 mg b.i.d.) by the patient, showing reappearance of the CSAS (AHI 42.1/h). This case report illustrates the deleterious effect of baclofen on breathing physiology during sleep. Since it is typically prescribed off label at high doses to a population of patients potentially using other substances that inhibit the ventilatory drive, this possible adverse effect is a major concern. When considering the use of baclofen in patients with AUD, the potential for sleep-disordered breathing should be weighed and carefully monitored.

Underlying Mechanisms for Coexisting Central and Obstructive Sleep Apnea: Nocturnal PaCO2 and Poor Sleep Quality Are Key Issues.

Coexisting central and obstructive sleep apnea is a challenging clinical situation. We report a case exhibiting an overnight shift from obstructive to central events. The central sleep apnea component was related to sleep instability, hyperventilation and low nocturnal PaCO2. Both types of respiratory events were successfully treated with adaptive servoventilation.

Reliability of Apnea-Hypopnea Index Measured by a Home Bi-Level Pressure Support Ventilator Versus a Polysomnographic Assessment.

BACKGROUND: Ventilators designed for home care provide clinicians with built-in software that records items such as compliance, leaks, average tidal volume, total ventilation, and indices of residual apnea and hypopnea. Recent studies have showed, however, an important variability between devices regarding reliability of data provided. In this study, we aimed to compare apnea-hypopnea indices (AHI) provided by home ventilators (AHINIV) versus data scored manually during polysomnography (AHIPSG) in subjects on noninvasive ventilation (NIV) for obesity-hypoventilation syndrome. METHODS: Stable subjects with obesity-hypoventilation syndrome on NIV, all using the same device, underwent 3 consecutive polysomnographic sleep studies with different backup breathing frequencies (spontaneous mode, low and high backup breathing frequencies). During each recording, AHINIV was compared with AHIPSG. RESULTS: Ten subjects (30 polysomnogram tracings) were analyzed. For each backup breathing frequency (spontaneous mode, low and high backup breathing frequencies), AHI values were 62 ± 7/h, 26 ± 7/h, and 17 ± 5/h (mean ± SD), respectively. Correlation between AHINIV and AHIPSG was highly significant (r(2) = 0.89, P < .001). As determined by Bland-Altman analysis, mean bias was 6.5 events/h, and limits of agreement were +26.0 and -12.9 events/h. Bias increased significantly with higher AHI values. Using a threshold AHI value of 10/h to define appropriate control of respiratory events, the ventilator software had a sensitivity of 90.9%, a specificity and positive predictive value of 100%, and a negative predictive value of 71%. CONCLUSIONS: In stable subjects with obesity-hypoventilation syndrome, the home ventilator software tested was appropriate for determining if control of respiratory events was satisfactory on NIV or if further testing or adjustment of ventilator settings was required. (ClinicalTrials.gov registration NCT01130090.).

Spectral analysis of the sleep onset period in primary insomnia.

OBJECTIVE: To compare the EEG power spectra characteristics of the sleep onset period (SOP) in patients with sleep onset insomnia (SOI), sleep maintenance insomnia (SMI) and good sleepers (GS). METHODS: The time course of EEG power density (1-40Hz) during the SOP was examined in thirty subjects (SOI patients: N=10, SMI patients: N=10, GS: N=10). RESULTS: The EEG power of the beta2 frequency band (18-29.75 Hz) was significantly lower in SOI than in SMI in the period preceding sleep onset. The alpha power was significantly higher for the SMI group compared to GS before sleep onset. Despite the lack of statistical significance, several differences in EEG dynamics were observed in SOI compared to two other groups: delta power increased slower after sleep onset; beta2 and 3 (18-29.75 and 30-39.75 Hz) power decrease less abruptly before sleep onset; beta1 (15-17.75 Hz) power increase through the whole SOP. CONCLUSIONS: The lower level of beta2 frequency band in SOI and the differences in dynamics in delta and beta bands may suggest that a mechanism other than hyperarousal participates in etiology of SOI. SIGNIFICANCE: SOI and SMI patients have different spectral characteristics in SOP, thus future studies should avoid the inclusion of mixed insomnia samples.

Impact of different backup respiratory rates on the efficacy of noninvasive positive pressure ventilation in obesity hypoventilation syndrome: a randomized trial.

BACKGROUND: Unintentional leaks, patient-ventilatory asynchrony, and obstructive or central events (either residual or induced by noninvasive positive pressure ventilation [NPPV]) occur in patients treated with NPPV, but the impact of ventilator settings on these disturbances has been little explored. The objective of this study was to investigate the impact of backup respiratory rate (BURR) settings on the efficacy of ventilation, sleep structure, subjective sleep quality, and respiratory events in a group of patients with obesity hypoventilation syndrome (OHS). METHODS: Ten stable patients with OHS treated with long-term nocturnal NPPV underwent polysomnographic recordings and transcutaneous capnography on 3 consecutive nights with three different settings for BURR in random order: spontaneous (S) mode, low BURR, and high BURR. No other ventilator parameter was modified. RESULTS: The S mode was associated with the occurrence of a highly significant increase in respiratory events, mainly of central and mixed origin, when compared with both spontaneous/timed (S/T) modes. Accordingly, the oxygen desaturation index was significantly higher in the S mode than in either of the S/T modes. The results of nocturnal transcutaneous P(CO(2)) (Ptc(CO(2))) (mean value and time spent with Ptc(CO(2)) > 50 mm Hg) were similar over the three consecutive nocturnal recordings. The quality of sleep was perceived as slightly better, and the number of perceived arousals as lower with the low- vs high-BURR (S/T) mode. CONCLUSIONS: In a homogenous group of patients treated with long-term NPPV for obesity-hypoventilation, changing BURR from an S/T mode with a high or low BURR to an S mode was associated with the occurrence of a highly significant increase in respiratory events, of mainly central and mixed origin. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01130090; URL: www.clinicaltrials.gov

Polysomnography in stable COPD under non-invasive ventilation to reduce patient-ventilator asynchrony and morning breathlessness.

BACKGROUND: Stable severe chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure treated by nocturnal bi-level positive pressure non-invasive ventilation (NIV) may experience severe morning deventilation dyspnea. We hypothesised that in these patients, progressive hyperinflation, resulting from inappropriate ventilator settings, leads to patient-ventilator asynchrony (PVA) with a high rate of unrewarded inspiratory efforts and morning discomfort. METHODS: Polysomnography (PSG), diaphragm electromyogram and transcutaneous capnography (PtcCO(2)) under NIV during two consecutive nights using baseline ventilator settings on the first night, then, during the second night, adjustment of ventilator parameters under PSG with assessment of impact of settings changes on sleep, patient-ventilator synchronisation, morning arterial blood gases and morning dyspnea. RESULTS: Eight patients (61 ± 8 years, FEV(1) 30 ± 8% predicted, residual volume 210 ± 30% predicted) were included. In all patients, pressure support was decreased during setting adjustments, as well as tidal volume, while respiratory rate increased without any deleterious effect on nocturnal PtcCO(2) or morning PaCO(2). PVA index, initially high (40 ± 30%) during the baseline night, decreased significantly after adjusting ventilator settings (p = 0.0009), as well as subjective perception of PVA leaks, and morning dyspnea while quality of sleep improved. CONCLUSION: The subgroup of COPD patients treated by home NIV, who present marked deventilation dyspnea and unrewarded efforts may benefit from adjustment of ventilator settings under PSG or polygraphy.

Pulse wave amplitude drops during sleep are reliable surrogate markers of changes in cortical activity.

BACKGROUND: During sleep, sudden drops in pulse wave amplitude (PWA) measured by pulse oximetry are commonly associated with simultaneous arousals and are thought to result from autonomic vasoconstriction. In the present study, we determine whether PWA drops were associated with changes in cortical activity as determined by EEG spectral analysis. METHODS: A 20% decrease in PWA was chosen as a minimum for a drop. A total of 1085 PWA drops from 10 consecutive sleep recordings were analyzed. EEG spectral analysis was performed over 5 consecutive epochs of 5 seconds: 2 before, 1 during, and 2 after the PWA drop. EEG spectral analysis was performed over delta, theta, alpha, sigma, and beta frequency bands. Within each frequency band, power density was compared across the five 5-sec epochs. Presence or absence of visually scored EEG arousals were adjudicated by an investigator blinded to the PWA signal and considered associated with PWA drop if concomitant. RESULTS: A significant increase in EEG power density in all EEG frequency bands was found during PWA drops (P<0.001) compared to before and after drop. Even in the absence of visually scored arousals, PWA drops were associated with a significant increase in EEG power density (P<0.001) in most frequency bands. CONCLUSIONS: Drops in PWA are associated with a significant increase in EEG power density, suggesting that these events can be used as a surrogate for changes in cortical activity during sleep. This approach may prove of value in scoring respiratory events on limited-channel (type III) portable monitors.

No effect on cognitive function from daily mobile phone use.

The increasing use of mobiles phones (MP) has raised the problem of the effects of daily electromagnetic fields (EMF) exposure on human health. To date several studies have been published concerning the effects of acute MP exposure on psychomotor performances. This study investigated the effects of daily exposure to GSM 900 type MP on cognitive function. Fifty-five subjects (27 male and 28 female) were divided into two groups: a group with MP switched on and a group with MP switched off. The two groups were matched according to age, gender, and IQ. This double blind study lasted for 45 days and was divided in three periods: baseline (BLP, 2 days), exposure (EP, 27 days), and recovery (RP, 13 days). Subjects were exposed during EP and sham exposed during RP for 2 h/day, 5 days/week. The neuropsychological test battery composed of 22 tasks screened four neuropsychological categories: information processing, attention capacity, memory function, and executive function. This neuropsychological battery was performed four times on day 2 (BLP), day 15 (EP), day 29 (EP), and day 43 (RP). Our results indicate that daily MP use has no effect on cognitive function after a 13-h rest period.

Effect of cognitive behavioural therapy for insomnia on sleep architecture and sleep EEG power spectra in psychophysiological insomnia.

There is now an overwhelming preponderance of evidence that cognitive behavioural therapy for insomnia (CBT-I) is effective, as effective as sedative hypnotics during acute treatment (4-8 weeks), and is more effective in long term (following treatment). Although the efficacy of CBT-I in the treatment of chronic insomnia is well known, however there is little objective data on the effects of CBT-I on sleep architecture and sleep EEG power densities. The present study evaluated, first, subjective change in sleep quality and quantity, and secondly the modifications occurring in polysomnography and EEG power densities during sleep after 8 weeks of CBT-I. Nine free drug patients with psychophysiological insomnia, aged 33-62 years (mean age 47 +/- 9.7 years), seven female and two male participated in the study. Self-report questionnaires were administered 1 week before and 1 week after CBT-I, a sleep diary was completed each day 1 week before CBT-I, during CBT-I and 1 week after CBT-I. Subjects underwent two consecutive polysomnographic nights before and after CBT-I. Spectral analysis was performed the second night following 16 h of controlled wakefulness. After CBT-I, only scales assessing insomnia were significantly decreased, stages 2, REM sleep and SWS durations were significantly increased. Slow wave activity (SWA) was increased and the SWA decay shortened, beta and sigma activity were reduced. In conclusion CBT-I improves both subjective and objective sleep quality of sleep. CBT-I may enhance sleep pressure and improve homeostatic sleep regulation.

Arousal reactions in sleepwalking and night terrors in adults: the role of respiratory events.

STUDY OBJECTIVES: The aim of the study was to determine the role of respiratory events, assessed by means of esophageal pressure monitoring, during arousals from slow wave sleep in adult patients with parasomnias. DESIGN: N/A. SETTING: N/A. PATIENTS: Ten patients with parasomnias (sleepwalking, night terrors, or both) and 10 control subjects matched for gender and age underwent 3 consecutive nights of polysomnography. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: By increasing sleep fragmentation, esophageal pressure monitoring has a deleterious effect on sleep architecture in patients with parasomnias and in control subjects. Respiratory events occur more frequently in parasomniacs than in controls. Respiratory effort seems to be responsible for the occurrence of a great number of arousal reactions in parasomniacs and is involved in triggering the parasomnia episodes. CONCLUSION: Sleep-disordered breathing seems to be frequently associated with parasomnias during slow wave sleep, emphasizing the utility of performing esophageal pressure monitoring in cases of sleep walking or night terrors.

Insomnio crónico: diferencias entre diagnóstico inicial y definitivo / Chronic insomnia: the differences between definitive and inicial diagnosis

OBJETIVO: Mostrar las diferencias entre la impresión clínica inicial y el diagnóstico final en pacientes con insomnio crónico, Valorar la calidad del sueño durante la evolución y tratamiento en un grupo significativo de pacientes. METODOS: Seleccionamos 63 pacientes consecutivos con insomnio crónico seguido durante un périodo de 6 meses. se realizó entrevista personal, examen clínico neurológico, evaluación psicológica. de acuerdo a la impresión clínica alguno de los siguientes estudios fue realizado: test de personalidades por el Minnesota Multiphasic Personality Inventory (MMPI) (15 pacientes), el cuestionario circadiano de Horne y Ostberg (7 pacientes) y una o dos noches de polisomnografía (30 pacientes), Para evaluar y comparar la calidad del sueño se tomó como referencia el apartado 6 del cuestionario de calidad del sueño de Pittsburgh. El índice de calidad del sueño fue dividido en 4 grados (1: muy mala calidad del sueño, 2: mala calidad, 3: buena calidad, 4: muy buena calidad de sueño).RESULTADOS:A los 63 pacientes se les realizó el diagnóstico clínico presuntivo de acuerdo a la clasificación internacional de patologías del sueño. Con los distintos test de diagnósticos y polisomnográficos se modificó el diagnóstico de inicio en 17 pacientes (27 por ciento) valor considerado significativo dadas sus implincancias terapéuticas. El insomnio asociado a enfermedades psquiatricas fue el más frecuentemente sub-diagnosticado, en tanto el insomnio asociado a trastornos respiratorios fue el más sobre-diagnosticado. El insomnio por sindrome de piernas inquietas (RLS) y movimientos periódicos de los miembros (PLM) fue el grupo que tuvo mejor correlación entre la impresión clínica y el diagnóstico final. Luego de finalizado nuestro protocolo de estudio y seguimiento sólo 3 pacientes se mantuvieron sin diagnóstico. Un significativo número de pacientes (59 por ciento) presentaron más de un diagnóstico como causa de su trastorno del sueño. En el insomnio asociado a enfermedades psiquiátricas el índice de calidad de sueño tiende a mejorar sólo transitoriamente y las posibilidades de perder el contacto con los pacientes alcanzó un 25 por ciento a los 6 meses. En insomnio psicofisiológico, la calidad del sueño tuvo un índice de mejoría progresivo y estable durante los meses de tratamiento. CONCLUSIONES: 1) El insomnio crónico debido a enfermedades psiquiátricas, demostró ser la condición más frecuentemente subdiagnosticada...