Negative Expiratory Pressure (NEP) Technique and Anthropometric Derived Indices as Surrogate Markers for Predicting Obstructive Sleep Apnea Syndrome (OSAS)
DOI:
https://doi.org/10.12974/2312-5470.2017.04.1Keywords:
Negative expiratory pressure, obstructive sleep apnea syndrome, apnea hypopnea index, expiratory flow limitation, anthropometric data.Abstract
Introduction: We wondered whether anthropometric, lung function, arterial blood gas (ABG), tidal volume (VT), and Negative Expiratory Pressure (NEP) Technique data could be utilized alone or collectively for predicting the presence of obstructive sleep apnea syndrome (OSAS).
Methods: Thirty-eight consecutive subjects (29% females) were referred for symptoms suggestive of OSAS. They had no respiratory or any other system failure. Anthropometric data, VT and lung function measurements were obtained. All subjects underwent overnight polysomnogaphy (PSG). They were also subjected to the NEP technique (-5 cm H2O) in seated and supine positions, specifically investigating the usefulness of known NEP-acquired indices (EFL %, ΔV %, V, NEP 0.5, V0.2%). PSG classified subjects according to Apnea/Hypopnea Index (AHI).
Results: Eleven patients had AHI<15, whilst 27 had AHI≥15. Only ΔV % and V,NEP0.5 correlated with AHI in both positions. A Multiple Linear Regression (MLR) model using V,NEP 0.5 in the seated position (V,NEP 0.5se), Neck Circumference (NC), arterial oxygen tension (Pa02), Expiratory Reserve Volume (ERV,% pred), improves AHI prediction (R2 adj =0,814).
Conclusions: V,NEP0.5, could identify moderate and severe OSAS in stable patients. MLR models using additional parameters substantially improve AHI prediction.
References
Owens RL, Malhotra A. Sleep-Disordered Breathing and COPD: The Overlap Syndrome. Respir Care 2010; 55(10): 1333-1346.
Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis 2015; 7(5): 920-929.
Koulouris NG, Valta P, Lavoie A, Corbeil C, Chassé M, Braidy J, et al. A simple method to detect expiratory flow limitation during spontaneous breathing. Eur Respir J 1995; 8(2): 306-313. https://doi.org/10.1183/09031936.95.08020306
Guillot M, Costes F, Sforza E, Maudoux D, Bertoletti L, Barthelemy JC, et al. Is tidal expiratory flow limitation predictive of sleep-related disorders in the elderly?. Eur Respir J 2010; 36(4): 842-848. https://doi.org/10.1183/09031936.00078009
Ferretti A, Giampiccolo P, Redolfi S, Mondini S, Cirignotta F, Cavalli A, et al. Upper airway dynamics during negative expiratory pressure in apneic and non-apneic awake snorers. Respir Res 2006; 7(1): 54. https://doi.org/10.1186/1465-9921-7-54
Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14: 540-545. https://doi.org/10.1093/sleep/14.6.540
Iber C, Israel SA, Chesson AL, Quan SF, Westchester IL. American Academy of Sleep Medicine (2007). The AASM Manual for the scoring of sleep and associated events. Rules, terminology and technical specifications.
Angelo ED, Prandi E, Marazzini L, Milic-Emili J. Dependence of maximal flow-volume curves on time course of preceding inspiration in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1994; 150: 1581-1586. https://doi.org/10.1164/ajrccm.150.6.7952618
Standardized lung function testing. Official statement of the European Respiratory Society. Eur Respir J 1993; 16(Suppl): 1-100.
Farré R, Navajas D, Peslin R , Rotger M , Duvivier C. A correction procedure for the asymmetry of differential pressure transducers in respiratory impedance measurements. IEEE Trans Biomed Eng 1989; 36(11): 1137- 1140. https://doi.org/10.1109/10.40822
Peslin R, Felicio da Silva J, Chabot F , Duvivier C. Respiratory mechanics studied by multiple linear regression in unsedated ventilated patients. Eur Respir J 1992; 5: 871- 878.
Kim S, Park B, Park S, Shin K, Ha S, Park J, et al. Predictors for Presence and Severity of Obstructive Sleep Apnea in Snoring Patients: Significance of Neck Circumference. J Sleep Med 2015; 12(2): 34-38. https://doi.org/10.13078/jsm.15007
Pattanshetty R, Chopde C. Screening for Obstructive Sleep Apnea using modified Berlin questionnaire, Stop-bang questionnaire and anthropometric measurements in patients visiting various OPDs in a tertiary care set up. Int J Physiother Res 2016; 4(4): 1583-1588. https://doi.org/10.16965/ijpr.2016.139
Wilson RC, Jones PW. A comparison of the visual analogue scale and modified Borg scale for the measurement of dyspnea during exercise. Clin Sci (Lond) 1989; 76(3): 277- 282. https://doi.org/10.1042/cs0760277
Wilson RC, Jones PW. Long-term reproducibility of Borg scale estimates of breathlessness during exercise. Clin Sci (Lond) 1991; 80(4): 309-312. https://doi.org/10.1042/cs0800309
Jones PW. Measurement of breathlessness, in Hughes JMB, Pride NB, eds. Lung Function Tests: Physiological Principles and Clinical Applications. 1st ed. London: Saunders, pp 121- 131 1999.
Koulouris N, Mulvey DA, Laroche CM, Green M, Moxham J. Comparison of two different mouthpieces for the measurement of Pimax and Pemax in normal and weak subjects. Eur Respir J 1988; 1: 863-867.
Liistro G, Veriter C, Dury M, Aubert G, Stanescu D. Expiratory flow limitation in awake sleep-disordered breathing subjects. Eur Respir J 1999; 14: 185-190. https://doi.org/10.1034/j.1399-3003.1999.14a31.x
Insalaco G, Romano S, Marrone O, Salvaggio A, Bonsignore G. A New Method of Negative Expiratory Pressure Test Analysis Detecting Upper Airway Flow Limitation To Reveal Obstructive Sleep Apnea. Chest 2005; 128(4): 2159-2165. https://doi.org/10.1378/chest.128.4.2159
Montemurro LT, Bettinzoli M, Corda L, Braghini A, Tantucci C. Relationship Between Critical Pressure and Volume Exhaled During Negative Pressure in Awake Subjects With Sleep-Disordered Breathing. Chest 2010; 137(6): 1304-1309. https://doi.org/10.1378/chest.09-2109
Romano S, Salvaggio A, Bue AL, Marrone O, Insalaco G. A negative expiratory pressure test during wakefulness for evaluating the risk of obstructive sleep apnea in patients referred for sleep studies. Clinics 2011; 66(11): 1887-1894. https://doi.org/10.1590/S1807-59322011001100007
Franco de Oliveira LV, Romano S, Hirata RP, Santos de Faria Júnior N, Giannasi LC, Nacif SR, Studart Leitao Filho FS, Insalaco G. Negative expiratory pressure test: a new, simple method to identify patients at risk for obstructive sleep apnea. J Bras Pneumol 2011; 37(5): 659-663.
Romano S, Salvaggio A, Hirata RP, Bue AL, Picciolo S, Franco de Oliveira LV, et al. Upper airway collapsibility evaluated by a negative expiratory pressure test in severe obstructive sleep apnea. Clinics (Sao Paulo) 2011; 66(4): 567-572. https://doi.org/10.1590/S1807-59322011000400008
Owens RL, Eckert DJ, Yeh SY, Malhotra A. Upper airway function in the pathogenesis of obstructive sleep apnea: a review of the current literature. Curr Opin Pulm Med 2008; 14(6): 519-524. https://doi.org/10.1097/MCP.0b013e3283130f66
Chiu KL, Ryan CM, Shiota S. Fluid shift by lower body positive pressure increases pharyngeal resistance in healthy subjects. Am J Respir Crit Care Med 2006; 174: 1378-1383. https://doi.org/10.1164/rccm.200607-927OC
Bucca CB, Brussino L, Battisti A, Mutani R, Rolla G, Mangiardi L, et al. Diuretics in Obstructive Sleep Apnea With Diastolic Heart Failure. Chest 2007; 132(2): 440-446. https://doi.org/10.1378/chest.07-0311
Redolfi S, Yumino D, Ruttanaumpawan P, Yau B, Su MC, Lam J, et al. Relationship between Overnight Rostral Fluid Shift and Obstructive Sleep Apnea in Nonobese Men. Am J Respir Crit Care Med 2009; 179: 241-246. https://doi.org/10.1164/rccm.200807-1076OC
Sampson MG, Grassino AE. Load compensation in obese patients during quiet tidal breathing. J Applied Physiol Respir Environ Exerc Physiol 1983; 55(4): 1269-1276.
Pellegrini M, Hedenstierna G, Roneus A, Segelsjö M, Larsson A, Perchiazzi G. The diaphragm has an expiratory braking effect in spontaneously breathing lung injured animals as shown by electrical diaphragmatic activity. Intensive Care Med Exp 2015; 3(Suppl 1): A572. https://doi.org/10.1186/2197-425X-3-S1-A572
Schulze A, Mädler H, Gehrhardt B, Schaller P, Gmyrek D. Titration of continuous positive airway pressure by the pattern of breathing: Analysis of flow-volume-time relationships by a noninvasive computerized system. Pediatr Pulmonol 1990; 8(2): 96-103. https://doi.org/10.1002/ppul.1950080207
Chien MY, Wu YT, Lee PL, Chang YJ, Yang PC. Inspiratory muscle dysfunction in patients with severe obstructive sleep apnoea. Eur Respir J 2010; 35: 373-380. https://doi.org/10.1183/09031936.00190208
Cibella F, Marrone O, Sanci S, Bellia V, Bonsignore G. Expiratory timing in obstructive sleep apneas. Eur Respir J 1990; 3: 293-298.
Sasaki CT. Anatomy and development and physiology of the larynx. GI Motility online 2006; doi: 10.1038/gimo7.
Scheinherr A. Glottal motion and its impact on airflow and aerosol deposition in upper airways during human breathing. Fluids mechanics
[physics.class-ph]. Ecole Centrale Marseille 2015. English. .
Hoffstein V, Zamel N, Phillipson EA. Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea. Am Rev Respir Dis 1984; 130(2): 175-178.
Morris MJ, Lane DJ. Tidal expiratory flow patterns in airflow obstruction. Thorax 1981; 36(2): 135-142. https://doi.org/10.1136/thx.36.2.135
Morris MJ, Madgwick RG, Frew AJ, Lane DJ. Breathing muscle activity during expiration in patients with chronic airflow obstruction. Eur Respir J 1990; 3: 901-909.
Lee D, Badr S, Mateika J. Progressive augmentation and ventilatory long-term facilitation are enhanced in sleep apnoea patients and are mitigated by antioxidant administration. J Physiol 2009; 587(22): 5451-5467. https://doi.org/10.1113/jphysiol.2009.178053
Radwan L, Maszczyk Z, Koziorowski A, Koziej M, Cieslicki J, Sliwinski P, et al. Control of breathing in obstructive sleep apnoea and in patients with the overlap syndrome. Eur Respir J 1995; 8: 542-545.
Arens R, Sin S, McDonough JM, Palmer JM, Dominguez T, Meyer H, et al. Changes in Upper Airway Size during Tidal Breathing in Children with Obstructive Sleep Apnea Syndrome. Am J Respir Crit Care Med 2005; 171: 1298- 1304. https://doi.org/10.1164/rccm.200411-1597OC
Littleton SW. Impact of obesity on respiratory function. Respirology 2012; 17(1): 43-49. https://doi.org/10.1111/j.1440-1843.2011.02096.x
Chlif M, Keochkerian D, Mourlhon C, Choquet D, Ahmaidi S. Noninvasive assessment of the tension-time index of inspiratory muscles at rest in obese male subjects. Int J Obes (Lond) 2005; 29(12): 1478-1483. https://doi.org/10.1038/sj.ijo.0803030
Steier J, Jolley CJ, Seymour J, Roughton M, Polkey MI, Moxham J. Neural respiratory drive in obesity. Thorax 2009; 64: 719-725. https://doi.org/10.1136/thx.2008.109728
Chlif M, Keochkerian D, Feki Y, Vaidie A, Choquet D, Ahmaidi S. Inspiratory muscle activity during incremental exercise in obese men. Int J Obes (Lond) 2007; 31: 1456- 1463. https://doi.org/10.1038/sj.ijo.0803546
Ferretti A, Giampiccolo P, Cavalli A, et al. Expiratory flow limitation and orthopnea in massively obese subjects. Chest 2001; 119: 1401-1408. https://doi.org/10.1378/chest.119.5.1401
Holley HS, Milic-Emili J, Becklake MR, Bates DV. Regional distribution of pulmonary ventilation and perfusion in obesity. J Clin Invest 1967; 46(4): 475-481. https://doi.org/10.1172/JCI105549
Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol 2010; 108(1): 206- 211. https://doi.org/10.1152/japplphysiol.00694.2009
Abdeyrim A, Zhang Y, Li N, Zhao M, Wang Y, Yao Y, et al. Impact of obstructive sleep apnea on lung volumes and mechanical properties of the respiratory system in overweight and obese individuals. BMC Pulm Med 2015; 15(76). https://doi.org/10.1186/s12890-015-0063-6
Appelberg J, Nordahl G, Janson C. Lung volume and its correlation to nocturnal apnoea and desaturation. Respir Med 2000; 94: 233-239. https://doi.org/10.1053/rmed.1999.0730
Clark F, Euler C. On the regulation of depth and rate of breathing. J Physiol 1972; 222(2): 267-295. https://doi.org/10.1113/jphysiol.1972.sp009797
van Meerhaeghe A, Delpire P, Stenuit P, Kerkhofs M. Operating characteristics of the negative expiratory pressure technique in predicting obstructive sleep apnoea syndrome in snoring patients. Thorax 2004; 59(10): 883-888. https://doi.org/10.1136/thx.2003.015271
Tamisier R, Wuyam B, Nicolle I, Pepin JL, Orliaguet O, Perrin CP, et al. Awake flow limitation with negative expiratory pressure in sleep disordered breathing. Sleep Med 2005; 6(3): 205-213. https://doi.org/10.1016/j.sleep.2004.10.013
Baydur A, Vigen C, Chen Z. 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 2012; 6: 111-120. https://doi.org/10.2174/1874306401206010111
