Reversal of Ticagrelor-Induced Arrhythmias and Cheyne-Stokes Respiration With Aminophylline Infusion.

Dyspnea and bradyarrhythmias are frequent adverse effects (AEs) of ticagrelor. AEs commonly occur within the first week of therapy, are dose related and usually mild, but sometimes they may cause drug discontinuation. Currently, the exact mechanisms of ticagrelor-related AEs have not been definitively explained. In addition to the prevalent theory of adenosine overload, other reasonable mechanism like a direct central stimulation hypothesis was suggested. We present a case of incessant Cheyne-Stokes respiration associated with heart rate instability in patient with congestive heart failure and non-ST-segment elevation myocardial infarction, supporting the use of aminophylline as a potential reversal agent of ticagrelor-related AEs.

Sodium oxybate-induced central sleep apneas.

Sodium oxybate (γ-hydroxybutyric acid, GHB) is a neurotransmitter in the human brain which exerts sedative effects and is used therapeutically in the treatment of narcolepsy. Current safety recommendations have been formulated for the use of GHB in patients with preexisting breathing disorders. We report the case of a 39-year-old female with narcolepsy and cataplexy revealing the de novo emergence of central sleep apneas in a Cheyne-Stokes pattern under constant treatment with GHB. After discontinuation of GHB, polysomnographic re-evaluation demonstrated the disappearance of central sleep apneas. To our knowledge, this is the first report of de novo central sleep apneas induced by GHB in a patient without pre-existing sleep-disordered breathing, suggesting that there is a need for further investigation and potentially an extension of the safety guidelines to patients without a pre-existing breathing disorder.

Adaptive servoventilation (ASV) in patients with sleep disordered breathing associated with chronic opioid medications for non-malignant pain.

BACKGROUND: Adaptive servoventilation (ASV) can be effective therapy for specific types of central apnea such as Cheyne-Stokes respiration (CSR). Patients treated chronically with opioids develop central apneas and ataxic breathing patterns (Biot's respiration), but therapy with CPAP is usually unsuccessful. There are no published studies of ASV in patients with sleep apnea complicated by chronic opioid therapy. METHODS: Retrospective analysis of 22 consecutive patients referred for evaluation and treatment of sleep apnea who had been using opioid medications for at least 6 months, had an apnea-hypopnea index (AHI) > or = 20/h, and had been tested with ASV. Baseline polysomnography was compared with CPAP and ASV. OUTCOME VARIABLES: AHI, central apnea index (CAI), obstructive apnea index (OAI), hypopnea index (HI), desaturation index, mean SpO2, lowest SpO2, time SpO2 < 90%, and degree of Biot's respiration. RESULTS: Mean (SD) AHI measured 66.6/h (37.3) at baseline, 70.1/h (32.6) on CPAP, and 54.2/h (33.0) on ASV. With ASV, the mean OAI was significantly decreased to 2.4/h (p < 0.0001), and the mean HI increased significantly to 35.7/h (p < 0.0001). The decrease of CAI from 26.4/h to 15.6/h was not significant (p = 0.127). Biot's breathing persisted, and oxygenation parameters were unimproved with ASV. CONCLUSIONS: Due to residual respiratory events and hypoxemia, ASV was considered insufficient therapy in these patients. Persistence of obstructive events could be due to suboptimal pressure settings (end expiratory and/or maximal inspiratory). Residual central events could be related to fundamental differences in the pathophysiology of CSR compared to opioid induced breathing disturbances.

Exposure to retinoic acid at the onset of hindbrain segmentation induces episodic breathing in mice.

Hyperpnoeic episodic breathing (HEB), a cyclic waxing and waning of breathing, has been widely reported in pre-term neonates, patients with Joubert syndrome and adults (Cheyne-Stokes respiration) with congestive heart failure and brainstem infarction. We now provide a developmental mouse model of neonatal HEB. We used retinoic acid (RA) (0.5-10 mg/kg of maternal weight) to alter embryonic development of the respiratory neuronal network at the onset of hindbrain segmentation (7.5 days post-coitum). HEB was observed in vivo after RA treatment during post-natal days 1-7 but not in control animals. HEB persisted after reduction of the chemoafferent input by hypocapnic hyperoxia (100% O(2)). A large increase and decrease of the rhythm resembling an HEB episode was induced in vitro by stimulating the parafacial respiratory oscillator in treated but not in control neonates. Post-natal localization of the superior cerebellar peduncle and adjacent dorsal tegmentum was found to be abnormal in the pons of RA-treated juvenile mice. Thus, early developmental specifications in the rostral hindbrain are required for the development of neurones that stabilize the function of the respiratory rhythm generator, thereby preventing HEB during post-natal maturation.

The sedative and analgesic effects of detomidine-butorphanol and detomidine alone in donkeys.

Butorphanol and detomidine constitute an effective combination for sedation and analgesia in horses. This trial was undertaken to assess the effectiveness of this combination in donkeys. The detomidine and butorphanol were given intravenously one after the other. A dose of 10 microg/kg of detomidine and 25 microg/kg of butorphanol was used. Sedation is easily extended by additional doses of butorphanol. The average dose of detomidine was 11.24 microg/kg and that of butorphanol was 28.0 microg/kg. Four donkeys in the detomidine group required additional sedation and analgesia. Detomidine alone did not totally eliminate coronary band pain. Heart rates dropped significantly in the first minute after the injection of the combination. One donkey developed an atrioventricular block, while another developed a sino-atrial block. Four donkeys developed a Cheyne-Stokes respiratory pattern. The combination of detomidine and butorphanol is an effective combination for sedation and analgesia of donkeys for standing procedures.

[An experimental model of apneusis and periodic respiration]. / Eksperimental'naia model' apneizisa i periodicheskogo dykhaniia.

In experiments on sodium pentobarbital (40 mg/kg, i. p.) anesthetized mongrel cats of either sex weighting from 2.0 to 4.0 kg, it was stated, that sodium or lithium hydroxybutyrate (HOB) (200 mg/kg, i. v.) effectively slowed down breathing with inspiratory holdings. Thus 3-5 minutes after HOB administration, eupneic pattern of respiration was changed firstly to inspiratory apneustic one (100% of cats), and then to periodic one (80% of cats). This pattern persisted for 60-90 minutes, and after that the respiratory pattern usually changed its direction to the opposite one. In these conditions alterations of arterial blood composition (pH, pO2, pCO2, SO2) and hemodynamic variables (heart rate, arterial pressure) can not be considered as the cause of apneustic pattern of respiration. It is suggested, that HOB can be used for simulating such terminal respiratory patterns as apneustic and periodic ones.

Prenatal cocaine exposure is associated with respiratory pattern abnormalities.

As retrospectively determined, the rate of sudden infant death syndrome in 66 infants prenatally exposed to cocaine was 15%, compared with only 4% among infants exposed to opiates. This prospective evaluation of cardiorespiratory pattern in 32 cocaine-exposed and 18 methadone-exposed infants was therefore performed to further evaluate the effects of intrauterine exposure. The two groups were similar in maternal age, race, and cigarette, alcohol, and marijuana use and in gestational age, sex, and birth weight. Apnea density and episodes of periodic breathing exceeded the 95th percentile for normal infants in 12 (38%) of 32 of cocaine-exposed infants vs only 1 (6%) of 18 opiate-exposed infants. Five cocaine-exposed but no opiate-exposed infants had apnea of infancy, and all 5 of these infants had an abnormal cardiorespiratory pattern. In all 13 infants with an abnormal cardiorespiratory pattern, theophylline treatment resulted in normalization of the respiratory pattern and was associated with absence of any (further) clinical events. In summary, infants prenatally exposed to cocaine have a higher incidence of cardiorespiratory pattern abnormalities than do infants with methadone or no prenatal drug exposure.

Transplacentally acquired caffeine and the occurrence of apnea, bradycardia, and periodic breathing in preterm infants: preliminary communication.

Cord blood caffeine concentrations were measured by high-pressure liquid chromatography in 79 preterm infants. Eleven infants (14%) had detectable caffeine concentrations ranging from 1.1 to 3.7 micrograms/mL (means +/- SD = 2.5 +/- 0.8), and 68 infants had no measurable caffeine. Seven infants with detectable caffeine (group 1) had impedance pneumograms recorded before 2 weeks of age. Each infant in group 1 was matched with two infants without detectable caffeine by birthweight, gestational age, and chronologic age at pneumogram recording to yield a control group (group 2) of 14 infants. Comparison of the groups using quantitative measures of apnea, bradycardia, and periodic breathing obtained from pneumogram analysis and the incidence of monitor alarms on bedside nursing records showed no significant differences. Thus, caffeine was present infrequently and at low concentrations at birth in 79 preterm infants. The amount of apnea, bradycardia, and periodic breathing experienced before 2 weeks of age in 7 preterm infants with detectable cord blood caffeine was not different from that in 14 similar infants without caffeine. Future studies are planned to examine the relationship between postnatal changes in transplacentally acquired methylxanthine concentrations and quantitative measures of apnea, bradycardia, and periodic breathing in a larger number of preterm infants without cardiorespiratory disease.

Apneic spells associated with timolol therapy in a neonate.

A 2-week-old premature child with congenital glaucoma secondary to anterior cleavage syndrome was treated with timolol maleate and cyclocryotherapy. The patient had apneic spells of up to 30 seconds that stopped soon after timolol maleate therapy was discontinued. No apnea was seen before timolol maleate administration, and no further spells were noted after subsequent cyclocryotherapy without timolol maleate treatment. Possible central nervous system toxicity of timol maleate or its metabolic by-products in neonates with immature blood-brain barriers was noted.

Experimentally induced Cheyne-Stokes breathing.

We have studied the propensity for periodic breathing to occur in cats anaesthetized with pentobarbitone breathing either spontaneously or with the aid of a 'servo-respirator' governed continuously by the efferent phrenic nerve activity. Sustained periodic breathing could be induced increasing 'controller gain', either by increasing the gain of the respirator, or by lung deflation, which reflexly increased controller responses to both hypoxia and hypercapnia. Periodic breathing was potentiated both by hypoxia and by diminishing the central (CO2, H+)-drive by focal cooling at the ventral surface of the medulla, two procedures which increase the relative influence of hypoxic drive. Less hypoxia was needed to produce periodic breathing at high rather than low controller gains. Reducing controller gain to zero by constant artificial respiration always abolished periodic breathing. Periodic breathing was also eradicated when the relative importance of CO2 drive was enhanced by breathing the cats with CO2-enriched gas mixtures or with 100% O2. The results are consistent with theoretical predictions for the occurrence of oscillations in the mechanisms for the chemical control of breathing and indicate that increasing controller gas can produce periodic breathing. The results further emphasize the importance of the (CO2, H+)-drive in preserving ventilatory stability.

Dangers of treatment of status epilepticus with diazepam.

The results of treatment of 25 patients admitted from psychiatric institutions indicate that diazepam is the drug of first choice in the treatment of status epilepticus. The dangers of treatment appeared to result from combined use with other drugs. Respiratory depression occurred in one patient and hypotension in five patients, all of whom had been given intramuscular phenobarbitone in addition to intravenous diazepam. The two serious cases of hypotension had also been given parenteral paraldehyde.