Effect of continuous positive airway pressure on maximal exercise capacity in patients with obstructive sleep apnea: a systematic review and meta-analysis

Fletcher, Hannah; Cho, Peter Siu Pan; Loong, Stewart Lee; Estrada-Petrocelli, Luis; Patel, Amit; Birring, Surinder S.; Lee, Kai K.

doi:10.5664/jcsm.8686

Cited by 10 publications

(10 citation statements)

References 42 publications

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“…While other studies in patients with simple HF or simple OSA show opposite conclusions. [50][51][52] This may be due to OSA limiting the patient's ability to exercise 53 or HF limiting the patient's ability to use oxygen. 54 About this, one of the included studies inspired us that exercise may do good to this type of comorbidity, 29 since aerobic exercise also appears in the F I G U R E 5 Subgroup analysis of PAP efficacy to cardiac function in participants comorbid with HF and OSA.…”

Section: Discussionmentioning

confidence: 99%

Positive airway pressure therapy in heart failure patients comorbid with obstructive sleep apnea: Cardiovascular outcomes and nighttime‐duration effect

Lin

Yan

et al. 2022

Eur J Clin Investigation

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Background Comorbidity of obstructive sleep apnea (OSA) and heart failure (HF) is becoming increasingly common. This is a global analysis of positive airway pressure (PAP) efficacy for the cardiovascular outcomes in those HF Patients with comorbid OSA. Methods Related randomized controlled trials were included. Analysed indicators covered primary outcomes (cardiac function, motor ability and life quality) and secondary outcomes (blood pressure and OSA‐accompanying symptoms). Weighted mean difference was used to analyse the PAP‐control difference in different experimental phases and the baseline‐post difference in different groups. Results Compared with control group, PAP was associated with a 3.48% increase in left ventricle ejection fraction (LVEF) (p < .00001) and little decrease in heart rate (HR) (p = .67). Over 6 h of mean nighttime use was associated with a greater increase in LVEF of 5.21% (p = .0002) and a significant reduction in HR of 3.81 bpm (p = .03). There was no significant difference between PAP and control group in their association with change in motor ability and life quality. Besides, PAP was associated with a 13.08 mm Hg decrease in systolic blood pressure and great improvements in OSA‐accompanying symptoms: Apnea–Hypopnea Index, −23.73 e/h; mean oxygen saturation, 1.86%; minimum oxygen saturation, 8.78%; Epworth Sleepiness Scale, −1.39 point; arousal index, −16.41 e/h. There was also no significant difference in diastolic blood pressure. Conclusions Positive airway pressure treatment improves cardiac function in HF patients with comorbid OSA, but the improved magnitude is associated with the duration of nighttime use rather than the duration of treatment.

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Section: Discussionmentioning

confidence: 99%

Positive airway pressure therapy in heart failure patients comorbid with obstructive sleep apnea: Cardiovascular outcomes and nighttime‐duration effect

Lin

Yan

et al. 2022

Eur J Clin Investigation

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“…The continuous CPAP treatment effect on aerobic capacity in patients with OSA has been already described [ 2 ]. In fact, CPAP therapy for at least eight consecutive weeks was predominantly associated with significant improvements in VO 2 max [ 8 , 9 , 20 , 21 ]. CPAP therapy may normalize gas exchanges during sleep and contribute to structural and bio-energetic changes in skeletal muscles.…”

Section: Discussionmentioning

confidence: 99%

“…Most studies have shown reduced maximal aerobic exercise capacity in patients with OSA compared to control subjects [ 6 , 7 ]. Previous studies showed improvements in cardiac function and cardiorespiratory fitness in patients with OSA after eight weeks of nasal continuous positive airway pressure (CPAP) treatment [ 8 , 9 ]. Indeed, nasal CPAP is the gold-standard treatment for moderate to severe OSA and has been proven to reduce cardiovascular mortality and non-fatal cardiovascular events in this population [ 10 ].…”

Section: Introductionmentioning

confidence: 99%

Cardiopulmonary exercise testing in patients with moderate-severe obesity: a clinical evaluation tool for OSA?

et al. 2021

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Purpose Obstructive sleep apnea (OSA) is a widespread comorbidity of obesity. Nasal continuous positive airway pressure (CPAP) has been demonstrated very effective in treating patients with OSA. The aims of this study were to investigate whether or not cardiopulmonary exercise testing (CPET) can characterize patients with OSA and to evaluate the effect of nasal CPAP therapy. Methods An observational study was conducted on patients with moderate to severe obesity and suspected OSA. All patients underwent cardiorespiratory sleep study, spirometry, and functional evaluation with ECG-monitored, incremental, maximal CPET. Results Of the 147 patients, 94 presented with an apnea–hypopnea index (AHI) ≥ 15 events/h and were thus considered to have OSA (52 receiving nasal CPAP treatment; 42 untreated) while 53 formed a control group (AHI < 15 events/h). Patients with untreated OSA showed significantly lower oxygen uptake (VO2), heart rate, minute ventilation (VE), and end tidal carbon dioxide (PETCO2) at peak exercise compared to controls. Patients receiving nasal CPAP showed higher VE and VO2 at peak exercise compared to untreated patients. A difference in PETCO2 between the maximum value reached during test and peak exercise (ΔPETCO2 max-peak) of 1.71 mmHg was identified as a predictor of OSA. Conclusion Patients with moderate to severe obesity and untreated OSA presented a distinctive CPET-pattern characterized by lower aerobic and exercise capacity, higher PETCO2 at peak exercise associated with a lower ventilatory response. Nasal CPAP treatment was shown to positively affect these cardiorespiratory adaptations during exercise. ΔPETCO2 max-peak may be used to suggest OSA in patients with obesity.

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“…Among various comorbidities, OSA patients often experience muscle fatigue and reduced physical performance [ 7 ] resulting in limited daily activities and quality of life. In fact, recent meta-analyses showed that maximum oxygen uptake (aerobic capacity) under cycle ergometer test conditions is significantly reduced in patients with (severe) OSAS [ 8 , 9 ] compared to healthy controls and may be improved by continuous-positive-airway-pressure (CPAP) therapy [ 10 ]. The limiting factors of O 2 transport or muscle function responsible for an inverse relation between AHI and aerobic capacity have yet remained unclear, but may not include histomorphological muscle microvascularization, which was found to be increased at least in the tibialis anterior muscle [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

Effect of chronic intermittent hypoxia (CIH) on neuromuscular junctions and mitochondria in slow- and fast-twitch skeletal muscles of mice—the role of iNOS

et al. 2022

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Background Obstructive sleep apnea (OSA) imposes vascular and metabolic risks through chronic intermittent hypoxia (CIH) and impairs skeletal muscle performance. As studies addressing limb muscles are rare, the reasons for the lower exercise capacity are unknown. We hypothesize that CIH-related morphological alterations in neuromuscular junctions (NMJ) and mitochondrial integrity might be the cause of functional disorders in skeletal muscles. Methods Mice were kept under 6 weeks of CIH (alternating 7% and 21% O2 fractions every 30 s, 8 h/day, 5 days/week) compared to normoxia (NOX). Analyses included neuromuscular junctions (NMJ) postsynaptic morphology and integrity, fiber cross-sectional area (CSA) and composition (ATPase), mitochondrial ultrastructure (transmission-electron-microscopy), and relevant transcripts (RT-qPCR). Besides wildtype (WT), we included inducible nitric oxide synthase knockout mice (iNOS−/−) to evaluate whether iNOS is protective or risk-mediating. Results In WT soleus muscle, CIH vs. NOX reduced NMJ size (− 37.0%, p < 0.001) and length (− 25.0%, p < 0.05) together with fiber CSA of type IIa fibers (− 14%, p < 0.05) and increased centronucleated fiber fraction (p < 0.001). Moreover, CIH vs. NOX increased the fraction of damaged mitochondria (1.8-fold, p < 0.001). Compared to WT, iNOS−/− similarly decreased NMJ area and length with NOX (− 55%, p < 0.001 and − 33%, p < 0.05, respectively) or with CIH (− 37%, p < 0.05 and − 29%, p < 0.05), however, prompted no fiber atrophy. Moreover, increased fractions of damaged (2.1-fold, p < 0.001) or swollen (> 6-fold, p < 0.001) mitochondria were observed with iNOS−/− vs. WT under NOX and similarly under CIH. Both, CIH- and iNOS−/− massively upregulated suppressor-of-cytokine-signaling-3 (SOCS3) > 10-fold without changes in IL6 mRNA expression. Furthermore, inflammatory markers like CD68 (macrophages) and IL1β were significantly lower in CIH vs. NOX. None of these morphological alterations with CIH- or iNOS−/− were detected in the gastrocnemius muscle. Notably, iNOS expression was undetectable in WT muscle, unlike the liver, where it was massively decreased with CIH. Conclusion CIH leads to NMJ and mitochondrial damage associated with fiber atrophy/centronucleation selectively in slow-twitch muscle of WT. This effect is largely mimicked by iNOS−/− at NOX (except for atrophy). Both conditions involve massive SOCS3 upregulation likely through denervation without Il6 upregulation but accompanied by a decrease of macrophage density especially next to denervated endplates. In the absence of muscular iNOS expression in WT, this damage may arise from extramuscular, e.g., motoneuronal iNOS deficiency (through CIH or knockout) awaiting functional evaluation.

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Effect of continuous positive airway pressure on maximal exercise capacity in patients with obstructive sleep apnea: a systematic review and meta-analysis

Cited by 10 publications

References 42 publications

Positive airway pressure therapy in heart failure patients comorbid with obstructive sleep apnea: Cardiovascular outcomes and nighttime‐duration effect

Positive airway pressure therapy in heart failure patients comorbid with obstructive sleep apnea: Cardiovascular outcomes and nighttime‐duration effect

Cardiopulmonary exercise testing in patients with moderate-severe obesity: a clinical evaluation tool for OSA?

Effect of chronic intermittent hypoxia (CIH) on neuromuscular junctions and mitochondria in slow- and fast-twitch skeletal muscles of mice—the role of iNOS

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