Biomedical subjects
Publications and source records attributed to C Guilleminault.
Pediatric respiratory disorders during sleep are primarily apneic problems that can be associated with a number of abnormalities. When apnea is secondary to a disease process, the main focus should be on the identification of that disease process and on the institution of appropriate therapy. When the apnea persists or when it is idiopathic, additional evaluation may be required to identify an appropriate course of management.
Eight full-term infants between 3 and 8 weeks of age, who had had 24 to 48 hours of vague problems involving a congested upper airway and/or irritability, had a life-threatening respiratory episode at home, called a near-miss for sudden infant death syndrome event. Polygraphically monitored mixed apneas occurred in clusters during non-rapid eye movement (NREM) sleep with significant cardiac arrhythmias, predominantly sinus arrest. The cardiorespiratory problems continued during sleep in the following 8 to 12 weeks but did not recur after that time, and there were no long-term sequelae when the children were studied again 4 to 7 years later.
Four apparently healthy young adults with vague chest symptoms during the day, two of whom had infrequent syncope while ambulatory at night, had periods of asystole up to nine seconds in duration occurring repeatedly during rapid-eye-movement (REM) sleep. Extensive evaluations, including electrophysiologic studies in two patients, were normal. It is therefore suggested that the underlying pathophysiology involved autonomic dysfunction. REM sleep-related sinus arrests such as these, which may occur in apparently healthy subjects but are undetected, may explain some cases of sudden, unexpected death during sleep. Polygraphic monitoring during sleep may be helpful in delineating the pathophysiology of the sleep-related arrhythmia in persons with daytime cardiac arrhythmias thought to be secondary to abnormal vagal tone. The possibility of nocturnal asystole should be considered in patients such as those described here.
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The occurrence of episodes of obstructive apnoea during sleep is encouraged by a variety of factors: local anatomical abnormalities, degree of activation of the autonomous nervous system, obesity, central nervous system depression from alcohol or drug consumption, deprivation or fragmentation of sleep. Each of these factors can play a predominant role in the development of the syndrome and their demonstration can contribute to our understanding of the success or failure of the different treatments. The authors' therapeutic experience includes mainly healthy living associated with treatment of systemic disorders and use of medroxyprogesterone and protriptyline. These therapeutic measures can be supplemented, if needed, by palatopharyngoplasty with or without temporary tracheostomy.
400 sleep-apnoeic patients with an intact autonomic nervous system underwent twenty-four-hour electrocardiography with simultaneous polygraphy recording at night. At onset of sleep apnoea all showed progressive bradycardia, followed by abrupt tachycardia on resumption of breathing. The electrocardiographic pattern, which is identifiable by computer analysis, can be used as a screening tool for sleep apnoea; it was not seen in controls without sleep apnoea syndrome. A subgroup of patients with sleep apnoea and impairment of autonomic nervous control of the heart (heart transplants, autonomic neuropathy, Shy-Drager syndrome) did not show the cyclical heart rate pattern. In obstructive sleep apnoeic patients with normal autonomic nervous function, atropine sulphate blocked the pattern by eliminating the bradycardia component, while 100% oxygen, even at high rates of administration, caused only moderate blunting of the heart rate variation. The electrocardiographic changes observed in sleep apnoea syndrome are therefore mediated by the autonomic nervous system; hypoxia is not the only factor involved.
Five patients with nocturnal myoclonus (periodic leg movements during sleep), mean age 59.6 years, were monitored polygraphically for fifteen successive nights. Using a double-blind drug study design with placebo at baseline, we investigated the effect of baclofen on these patients. All patients had the repetitive sleep-related abnormal movements during both the baseline nights and those on which baclofen had been administered. The number of movements varied during the four baseline nights, but the movements induced sleep fragmentation, i.e., very short electroencephalographic changes. Baclofen increased the number of movements but decreased their amplitude during non-rapid eye movement (REM) sleep and shortened the interval between movements. Its effect on sleep was dose related: as dosages increased, delta sleep progressively increased and REM sleep decreased. Sleep fragmentation resulting from muscle twitches decreased, as indicated by the diminution in alpha electroencephalographic arousals and K complexes. Baclofen dosages of 20 mg and 40 mg were the most efficacious.
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One full-term and nine premature infants who had been or were about to be discharged from the hospital were studied to identify any breathing problems. While awake and when sucking and swallowing, the infants had central apnea accompanied by significant bradycardia and significant drops in transcutaneous oxygen values. These events occurred whether infants were breast-fed or ingested human milk, formula, or water by bottle, and were not associated with falls in esophageal pH. While awake, after occlusion of both nostrils, the infants responded with mouth breathing. Sleep-related apneic episodes were also found but were less significant. The long apneic events were related to poorly coordinated sucking and breathing while awake.
Ten nonobese, healthy elderly adults (M = 73.3 years) were monitored polygraphically during sleep for sleep state changes, breathing, and the development of cardiac arrhythmias. All participated in 2 baseline nights and 1 night of flurazepam 30 mg ingestion; six underwent 1 night of sleep deprivation; four received ethyl alcohol (.6 mg/kg); and four whose apnea worsened significantly with flurazepam 30 mg were pretreated for 3 days with acetazolamide, taking acetazolamide and flurazepam 30 mg on the fourth night. Elderly adults with an Apnea Index (the number of apneas per sleep hour) between 5 and 7 at baseline experienced a worsening of their apnea with each manipulation. Acetazolamide did not protect individuals whose Apnea Index increased after flurazepam ingestion. One person developed premature ventricular contractions in conjunction with an increased Apnea Index after each manipulation.
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A 24-year-old man with obstructive sleep apnea syndrome and secondary daytime somnolence and nocturnal arrhythmias underwent palatopharyngoplasty. When he did not improve significantly, he underwent a new surgical procedure combining hyoid bone and mandibular horizontal sliding osteotomy.
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Periods of sustained sleep were analyzed to assess the development of sleep-state organization and structure during the first six months of life. Infants first establish consolidated sleep and wakeful periods, which then become oriented to the 24-hour day/night cycle. As infants mature they gradually show greater sleep 'efficiency', and at onset of sleep, REM periods become less likely. The longest sleep period progressively becomes associated with the dark period of the 24-hour cycle. This study also assessed the sequences of NREM-REM sleep-cycle organization during the first six months of life. Although individual infants may have a significant correlation between duration of sleep and latency at onset of sleep, the over-all direction is not constant, nor is an 'age effect' apparent during the first six months. The data support the hypothesis that states of alterness , which develop independently in the perinatal period, become integrated in early infancy.
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We performed palatopharyngoplasty operations on 155 patients as of June 1, 1983, and have 4-month clinical follow-ups on 123 patients. Forty-nine have had repeat polysomnograms (through September 1983) that continue to show the operation is about 50% effective in curing or considerably improving obstructive sleep apnea. Symptomatic (clinical) results in these same patients are much better than 50% and may be the reason why we have had considerable difficulty in obtaining sleep study follow-ups. Snoring was eliminated or much improved in 93% of all patients and 95% of patients without serious obstructive sleep apnea. Daytime symptoms, if any, were improved in 64%. Some form of preoperative sleep study is mandatory in all patients. Two thirds of patients who present with the complaint of snoring and none of the classic symptoms of apnea actually do have total airway obstructions during sleep.
The position of the hyoid bone, which anchors much of the tongue musculature, is often abnormally low in patients with obstructive sleep apnea syndrome (OSAS). Cephalometric measurements, frequently used to measure SNA and SNB angles, can also provide information on the posterior airway space (PAS), the mandibular plane, and the hyoid bone. This information is useful in determining the appropriate surgical treatment for OSAS patients.