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Published ahead of print on December 18, 2003, doi:10.1164/rccm.200307-1023OC

Am. J. Respir. Crit. Care Med., Volume 169, Number 5, March 2004, 623-633

A more recent version of this article appeared on March 1, 2004
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Submitted on July 24, 2003
Accepted on December 15, 2003

ROLE OF AROUSALS IN THE PATHOGENESIS OF OBSTRUCTIVE SLEEP APNEA

Magdy K Younes1*

1 Internal Medicine, University of Toronto, Toronto, Ontario, Canada; Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada

* To whom correspondence should be addressed. E-mail: mkyounes{at}sympatico.ca.

Arousal is believed needed for upper airway opening in obstructive hypopneas/apneas without compelling evidence to support this notion. The association may be incidental. I studied the temporal relation between arousal and opening, and impact of arousal on flow response at opening, in 82 patients (apnea-hypopnea-index 46±35 hour-1). Obstructive apneas/hypopneas were induced by dial-down of continuous-positive-airway-pressure. Obstructions and hypopneas occurred in 44% and 56% of dial-downs, respectively. When arousal occurred (83% of dial-downs), the temporal relation between arousal and opening was inconsistent between and within patients. Frequency of opening without/prior to arousal increased with milder obstructions (p<E-9) and with delta power of electroencephalogram (p<E-6). Time of opening was unaffected by whether arousal occurred before or after opening (18.0±9.8 VS 18.1±10.5second). Flow response was already excessive when opening occurred without/prior to arousal (180±148% of initial flow decline) and was considerably higher when arousal occurred (267±154%, p<E-10). Flow undershoot following first ventilatory response was greater if arousal occurred (p<0.01). Conclusions: Arousals are incidental events that occur when thresholds for arousal and for arousal-independent opening are close. They are not needed to initiate opening or to obtain adequate flow and they likely increase the severity of the disorder by promoting greater ventilatory instability.
Key words: OSA Mechanisms Ventilatory stability




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