Bilateral diaphragm paralysis and sleep apnoea without diurnal respiratory failure.

Stradling, John; Warley, A

doi:10.1136/thx.43.1.75

Cited by 25 publications

(17 citation statements)

References 7 publications

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“…This is consistent with the previous finding that patients with BDP have only REM sleep-related SDB [11,12]. Most of the events were hypopnoeas, although there was some obstruction in two patients that became worse during REM sleep.…”

Section: Discussionsupporting

confidence: 82%

“…However, the observed pathophysiology seems to be similar to that of patients with BDP in whom carbon dioxide retention has been measured and REM sleep hypoventilation confirmed [12,13]. Therefore, it is likely that the REM-related frequent hypopnoeas and apnoeas in UDP patients cause hypoventilation.…”

Section: Discussionmentioning

confidence: 87%

“…The results of studies looking at breathing patterns in unilateral or bilateral diaphragm paralysis (UDP and BDP, respectively) have been inconsistent [8][9][10][11][12][13]. Some studies have reported disturbed sleep, inadequate ventilation during sleep and daytime sleepiness caused by diaphragm dysfunction [8,11], while others have found little impact on the normal sleep pattern unless there is additional load on the ventilatory system [9,10,14].…”

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confidence: 99%

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Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness

Steier

Jolley

Seymour³

et al. 2008

Eur Respir J

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Few data exist concerning sleep in patients with hemidiaphragm paralysis or weakness. Traditionally, such patients are considered to sustain normal ventilation in sleep.In the present study, diaphragm strength was measured in order to identify patients with unilateral paralysis or severe weakness. Patients underwent polysomnography with additional recordings of the transoesophageal electromyogram (EMG) of the diaphragm and surface EMG of extra-diaphragmatic respiratory muscles. These data were compared with 11 normal, healthy subjects matched for sex, age and body mass index (BMI).In Patients with unilateral diaphragm dysfunction are at risk of developing sleep-disordered breathing during rapid eye movement sleep. The diaphragm electromyogram, reflecting neural respiratory drive, is doubled in patients compared with normal subjects, and increases further in rapid eye movement sleep.

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Section: Discussionsupporting

confidence: 82%

Section: Discussionmentioning

confidence: 87%

mentioning

confidence: 99%

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Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness

Steier

Jolley

Seymour³

et al. 2008

Eur Respir J

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“…This ability has never been estimated either, and so there are no data with which the present results can be compared. However, previous evaluations of subjects with complete, bilateral paralysis of the diaphragm have reported that such subjects generate ÄPao values between −9 and −40 cmHµO during maximum static inspiratory efforts (Kreitzer et al 1978;Celli et al 1987;Stradling & Warley, 1988;Laroche et al 1988). Although the muscles of the neck and the external intercostals are known to be involved, it is conventionally thought that these pressure changes are predominantly contributed by the action of the parasternal intercostals.…”

Section: Discussionmentioning

confidence: 99%

Mechanical advantage of the human parasternal intercostal and triangularis sterni muscles

Troyer

Legrand

Gevenois

et al. 1998

The Journal of Physiology

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Although the actions of most respiratory muscles on the chest wall in humans have been qualitatively described, the question of how much lung expansion (or deflation) each muscle can produce has not been answered. This is a difficult question because these muscles are inaccessible and cannot be maximally activated in isolation. However, recent theoretical studies by Wilson & De Troyer (1992, 1993 have proposed an indirect approach, based on the Maxwell reciprocity theorem. When applied to the respiratory system, this standard theorem of mechanics predicts that the potential change in airway pressure (ÄPao) produced by a particular muscle contracting alone against a closed airway is related to the mass (m) of the muscle, the maximal active muscle tension per unit cross-sectional area (ó), and the 1. Previous studies in dogs have demonstrated that the maximum change in airway pressure (ÄPao) produced by a particular respiratory muscle is the product of three factors, namely the mass of the muscle, the maximal active muscle tension per unit cross-sectional area (•3·0 kg cm¦Â), and the fractional change in muscle length per unit volume increase of the relaxed chest wall (i.e. the muscle's mechanical advantage). In the present studies, we have used this principle to infer the ÄPao values generated by the parasternal intercostal and triangularis sterni muscles in man. 2. The mass of the muscles and the direction of the muscle fibres relative to the sternum were first assessed in six cadavers. Seven healthy individuals were then placed in a computed tomographic scanner to determine the orientation of the costal cartilages relative to the sternum and their rotation during passive inflation to total lung capacity. The fractional changes in length of the muscles during inflation, their mechanical advantages, and their ÄPao values were then calculated. 3. Passive inflation induced shortening of the parasternal intercostals in all interspaces and lengthening of the triangularis sterni. The fractional shortening of the parasternal intercostals decreased gradually from 7·7% in the second interspace to 2·0% in the fifth, whereas the fractional lengthening of the triangularis sterni increased progressively from 5·9 to 13·8%. These rostrocaudal gradients were well accounted for by the more caudal orientation of the cartilages of the lower ribs. 4. Since these fractional changes in length corresponded to a maximal inflation, the inspiratory mechanical advantage of the parasternal intercostals was only 2·2-0·6 % l¢, and the expiratory mechanical advantage of the triangularis sterni was only 1·6-3·8 % l¢. In addition, whatever the interspace, parasternal and triangularis muscle mass was 3-5 and 1-3 g, respectively. As a result, the magnitude of the ÄPao values generated by a maximal contraction of the parasternal intercostals or triangularis sterni in all interspaces would be only 1-3 cmHµO. 5. These studies therefore confirm that the parasternal intercostals in man have an inspiratory action on the lung whereas the triangularis st...

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“…Whilst the majority of patients have obstructive sleep apnoea (OSA) [4,5], other causes of SDB may similarly cause health problems [6][7][8][9][10][11][12]. In the present study, we considered the group of patients with neuromuscular disease (NMD) who are affected by SDB because of weakness of the respiratory muscles [9,[13][14][15][16][17][18] influenced by posture and sleep stage [9,19] and who do not necessarily present with symptoms, such as daytime fatigue, that are measured by the Epworth Sleepiness scale (ESS) [20].…”

mentioning

confidence: 99%

Screening for sleep-disordered breathing in neuromuscular disease using a questionnaire for symptoms associated with diaphragm paralysis

Steier¹,

Jolley²,

Seymour³

et al. 2010

Eur Respir J

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Patients with neuromuscular disease (NMD) are at risk of developing sleepdisordered breathing (SDB) following respiratory muscle involvement. We hypothesised that a questionnaire based on clinical symptoms and signs of diaphragm weakness can be used to screen for SDB in such patients.We developed a self-administered multiple choice questionnaire containing five questions (Sleep-Disordered Breathing in Neuromuscular Disease Questionnaire (SiNQ)-5), scoring 0-10 points. 125 patients were enrolled: 32 with respiratory muscle weakness, 35 subjects with normal respiratory muscle strength and 58 patients with obstructive sleep apnoea (OSA). All subjects underwent full polysomnography.NMD patients with involvement of the respiratory muscles scored mean¡SD 6.8¡2.3 out of 10 points, significantly higher than both OSA patients 2.5¡2.3 and normal subjects 1.0¡2.0 (p,0.001). A score of five or more points in the SiNQ-5 had a sensitivity of 86.2%, specificity of 88.5%, positive predictive value of 69.4% and a negative predictive value of 95.5% to identify NMD with combined SDB.A short self-administered questionnaire, the SiNQ-5, based on clinical symptoms can reliably screen for SDB in patients with diaphragm weakness. However, comorbidities, such as heart failure, that have symptoms influenced by posture could alter diagnostic accuracy.

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Bilateral diaphragm paralysis and sleep apnoea without diurnal respiratory failure.

Cited by 25 publications

References 7 publications

Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness

Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness

Mechanical advantage of the human parasternal intercostal and triangularis sterni muscles

Screening for sleep-disordered breathing in neuromuscular disease using a questionnaire for symptoms associated with diaphragm paralysis

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