6 Sleep-disordered breathing and obesity

doi:10.1016/S0950-351X(05)80288-5

Baillière's Clinical Endocrinology and Metabolism

Volume 8, Issue 3, July 1994, Pages 601-628

https://doi.org/10.1016/S0950-351X(05)80288-5 Get rights and content

Summary

Recent epidemiological data indicate that obstructive sleep apnoea (OSA) and related conditions are extremely common in the middle-aged population. Obesity is an important aetiological factor in sleep-disordered breathing with a multifactorial role in the pathogenesis of upper airway occlusion. One extreme of the spectrum of sleep-disordered breathing is obesity-hypoventilation syndrome (one type of OSA with awake respiratory failure). Sleep-disordered breathing has a number of clinical consequences, including excess cardiovascular morbidity. Obesity is an important confounder of this association. Treatment of these disorders has been revolutionized by the use of nasal continuous positive airway pressure (CPAP). Weight reduction reduces apnoea severity but is not curative in most obese patients with sleep apnoea.

References (119)

CarlsonJ et al.
Augmented resting sympathetic activity in awake patients with obstructive sleep apnea
Chest
(1993)
FleethamJA
Upper airway imaging in relation to obstructive sleep apnoea
Clinics in Chest Medicine
(1992)
GislasonT et al.
Prevalence of sleep apnea syndrome amongst Swedish men
Journal of Clinical Epidemiology
(1988)
GislasonT et al.
Snoring, hypertension and the sleep apnea syndrome. An epidemiologic survey of middle aged women
Chest
(1993)
GrunsteinRR et al.
Hypothyroidism and sleep apnea. Mechanisms and management
American Journal of Medicine
(1988)
GuilleminaultC et al.
Women and the obstructive sleep apnea syndrome
Chest
(1988)
HeJ et al.
Mortality and apnea index in obstructive sleep apnea. Experience in 385 patients
Chest
(1988)
HungJ et al.
Association of sleep apnoea and myocardial infarction in men
Lancet
(1990)
IssaFG et al.
The immediate effects of nasal continuous positive airway pressure treatment on sleep pattern in patients with obstructive sleep apnea syndrome
Electroencephalography and Clinical Neurophysiology
(1986)
KissebahAH et al.
Health risks of obesity
Medical Clinics of North America
(1989)

KrygerMH

Fat, sleep, and Charles Dickens: literary and medical contributions to the understanding of sleep apnea

Clinics in Chest Medicine

(1985)

MalloryGB et al.

Sleep-associated breathing disorders in morbidly obese children and adolescents

Journal of Pediatrics

(1989)

PartinenM et al.

Daytime sleepiness and vascular morbidity at seven-year follow-up in obstructive sleep apnea patients

Chest

(1990)

PocetaJS et al.

Multiple wakefulness test in obstructive sleep apnea syndrome

Chest

(1992)

RochesterDF et al.

Current concepts in the pathogenesis of the obesity—hypoventilation syndrome

American Journal of Medicine

(1974)

SandersMH et al.

Obstructive sleep apnea treated by independently adjusted inspiratory and expiratory positive airway pressures via nasal mask: physiological and clinical implications

Chest

(1990)

SeidellJC et al.

Visceral fat accumulation in men is positively associated with insulin, glucose and C-peptide levels, but negatively with testosterone levels

Metabolism

(1990)

SmirneS et al.

Muscle fibre type and habitual snoring

Lancet

(1991)

AmbrogettiA et al.

Differences in the symptoms of men and women with obstructive sleep apnea

Australian and New Zealand Journal of Medicine

(1991)

BearparkH et al.

Home monitoring demonstrates a high prevalence of sleep disordered breathing in men in the Busselton (Western Australia) population

Sleep Research

(1991)

BearparkH et al.

Cognitive and psychological dysfunction in sleep apnea before and after treatment with CPAP

Sleep Research

(1987)

Berthon-JonesM

Feasibility of a self-setting CPAP machine

Sleep

(1993)

Berthon-JonesM et al.

Time course of change in ventilatory response to CO₂ with long-term CPAP therapy for obstructive sleep apnea

American Review of Respiratory Disease

(1987)

BrooksLJ et al.

Size and mechanical properties of the pharynx in healthy men and women

American Review of Respiratory Disease

(1992)

ChanCS et al.

Obstructive sleep apnea with severe chronic airflow limitation—comparison of hypercapnic and eucapnic patients

American Review of Respiratory Disease

(1989)

CistulliP et al.

Sleep apnea in Marfan's syndrome

American Review of Respiratory Disease

(1993)

CistulliPA et al.

Effect of short-term hormone replacement in postmenopausal women with obstructive sleep apnea

American Review of Respiratory Disease

(1993)

ClarkGT et al.

Effect of anterior mandibular positioning on obstructive sleep apnea

American Review of Respiratory Disease

(1993)

DaviesRJO et al.

The relationship between neck circumference, radiographic pharyngeal anatomy, and obstructive sleep apnoea

European Respiratory Journal

(1990)

DeanRT et al.

Possible atherogenic effects of hypoxia during obstructive sleep apnea

Sleep

(1993)

EdwardsLC et al.

The effect of transcutaneous electrical stimulation during wakefulness and sleep in patients with obstructive sleep apnea

American Review of Respiratory Disease

(1992)

EnziG et al.

Respiratory disturbances in visceral obesity

FindleyL et al.

Driving simulator performance in patients with sleep apnea

American Review of Respiratory Disease

(1989)

FletcherEC et al.

Carotid chemoreceptors, systemic blood pressure and chronic episodic hypoxia mimicking sleep apnea

Journal of Applied Physiology

(1992)

GouldGA et al.

The sleep hypopnea syndrome

American Review of Respiratory Disease

(1988)

GrunsteinRR

Endocrine and metabolic disturbances in obstructive sleep apnea

GrunsteinRR et al.

Neuroendocrine dysfunction in sleep apnea. Reversal by continuous nasal positive airway pressure

Journal of Clinical Endocrinology and Metabolism

(1989)

GrunsteinRR et al.

Growth hormone and sex steroids in sleep apnea

GrunsteinRR et al.

Treatment of sleep disordered breathing

Medical Journal of Australia

(1991)

GrunsteinRR et al.

Sleep apnea and acromegaly

Annals of Internal Medicine

(1991)

GrunsteinRR et al.

Sleep apnea is a risk factor for hypertension and hyperinsulinemia in obesity

International Journal of Obesity

(1993)

GrunsteinRR et al.

Snoring and sleep apnoea in men: association with central obesity and hypertension

International Journal of Obesity

(1993)

GrunsteinRR et al.

Growth hormone secretion is increased by nasal CPAP treatment of sleep apnea

American Review of Respiratory Disease

(1993)

GuilleminaultC et al.

From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness

Sleep

(1992)

HaffnerSM

Insulin and blood pressure: fact or fantasy?

Journal of Clinical Endocrinology and Metabolism

(1993)

HaraldssonP et al.

Driving vigilance simulator test

Acta Oto-laryngologica

(1990)

HednerJ et al.

Is high and fluctuating muscle nerve sympathetic activity in the sleep apnea syndrome of pathogenetic importance for the development of hypertension?

Journal of Hypertension

(1988)

HednerJ et al.

Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnea

Journal of Hypertension

(1990)

HednerJ et al.

A specific and potent pressor effect of hypoxia in patients with sleep apnea

American Review of Respiratory Disease

(1992)

HednerJ et al.

Sleep apnea, age and obesity. Independent risk factors for development of hypertension. High prevalence of hypertension in sleep apnea patients independently of obesity

American Review of Respiratory Disease

(1993)

Cited by (40)

Tirzepatide for the treatment of obstructive sleep apnea: Rationale, design, and sample baseline characteristics of the SURMOUNT -OSA phase 3 trial
2024, Contemporary Clinical Trials
Weight reduction is a standard recommendation for obstructive sleep apnea (OSA) treatment in people with obesity or overweight; however, weight loss can be challenging to achieve and maintain without bariatric surgery. Currently, no approved anti-obesity medication has demonstrated effectiveness in OSA management. This study is evaluating the efficacy and safety of tirzepatide for treatment of moderate to severe OSA in people with obesity.
SURMOUNT-OSA, a randomized, placebo -controlled, 52-week phase 3 trial, is investigating the efficacy and safety of tirzepatide for treatment of moderate to severe OSA (apnea hypopnea- index ≥15 events/h) in participants with obesity (body mass index ≥30 kg/m²) and an established OSA diagnosis. SURMOUNT-OSA is made of 2 intervention-specific appendices (ISAs): ISA-1 includes participants with no current OSA treatment, and ISA-2 includes participants using positive airway pressure therapy. Overall, 469 participants have been randomized 1:1 to receive tirzepatide or placebo across the master protocol (ISA-1, n = 234; ISA-2, n = 235). All participants are also receiving lifestyle intervention for weight reduction.
The primary endpoint for the individual ISAs is the difference in apnea hypopnea- index response, as measured by polysomnography, between tirzepatide and placebo arms at week 52. Secondary endpoints include sleep apnea-specific hypoxic burden, functional outcomes, and cardiometabolic biomarkers. The trial employs digital wearables, including home sleep testing to capture time to improvement and accelerometry for daily physical activity assessment, to evaluate exploratory outcomes.
SURMOUNT-OSA brings a novel design to investigate if tirzepatide provides clinically meaningful improvement in obesity-related OSA by targeting the underlying etiology.
Trial registration: ClinicalTrials.gov, NCT05412004
Sleep, anesthesia, and the upper airway
2007, Seminars in Anesthesia, Perioperative Medicine and Pain
Citation Excerpt :
There are a number of patient and other factors that predispose to sleep apnea either through their effects on morphology or neural control of the upper airway. Patient factors include: age23; male gender24; menopause25; obesity26; increased neck circumference27; macroglossia28; retrognathia29; maxillary constriction30; and nasal congestion.31 These morphological changes may be present to varying degrees in otherwise normal individuals or be part of a disease syndrome, such as acromegaly, Down’s syndrome, or Pierre-Robin syndrome or other syndromes associated with craniofacial abnormality.
Upper airway obstruction is a common problem during both sleep and anesthesia, and these tendencies are related in individuals. Patency of the upper airway is determined by the balance of forces across the pharyngeal wall. Airway narrowing, increased extra luminal tissue pressure, and increased airway wall compliance predispose to collapse, particularly during inspiration as negative intraluminal pressures are generated. The tendency to collapse is resisted by airway muscle activation, which is driven by a combination of influences including state-related wakeful stimulation, negative pressure reflexes, and respiratory neuronal activity. This activation decreases with both sleep and anesthesia increasing the tendency to obstruction, and there are substantial overlaps in the way in which these states modulate this neuronal compensatory activity. The common ground between sleep and anesthesia in all these considerations emphasizes the importance of seeking and applying information regarding breathing during sleep to everyday anesthesiology practice.
The Pathophysiology of Obesity and Its Implications for Anesthesia
2005, Foundations of Anesthesia: Basic Sciences for Clinical Practice
A pilot study to assess the possible methods of determining the burden of obstructive sleep apnoea syndrome in primary care
2005, Primary Care Respiratory Journal
A significant minority of otherwise healthy adults may suffer from disordered breathing during sleep. The commonest problem, known as Obstructive Sleep Apnoea Syndrome (OSAS), results in poor quality sleep, daytime hypersomnolence and excess risk of road traffic crashes. It is also associated with occupational injuries. OSAS can be successfully treated, reducing costs of hospitalisation. There is a gap in the literature regarding the burden of patients with OSAS in primary care, particularly because there is no agreed method for screening.
This pilot study was designed to determine the feasibility of screening for OSAS in a UK inner-city multi-ethnic primary care population, to investigate ways in which it might be detected, and to gain an awareness of the potential size of the burden of OSAS
We tested two methods of screening: firstly, postal questionnaires to a random sample of 240 patients from a subset of the population at highest risk of OSAS (men aged 35–65 years); and secondly, the same questionnaire plus two screening tools for detecting hypersomnolence, given to patients attending the practice for pre-registration health checks.
Despite reminders, only 40% of postal questionnaires were returned and there were only 67 (28%) usable responses. The prevalence of snoring was 55%. Almost half of those patients who responded (46%) had a Body Mass Index (BMI) associated with a high risk of OSAS. This was not a positive responder bias because there were no significant differences in BMI between responders and non-responders. 12% had a collar size of greater than 17.5, whilst 34% reported daytime sleepiness, and 24% reported witnessed apnoea.
Screening during pre-registration health checks proved both feasible and productive with 38 patients of differing linguistic abilities completing the assessment.
Screening for OSAS in primary care by means of a postal questionnaire produced a low response. Whilst there was no evidence of a responder bias in terms of BMI, the numbers reporting large collar size, daytime sleepiness and witnessed apnoea suggest that a sizeable proportion of the population is at risk of OSAS. Questionnaires used in this study provide a means of identifying patients with symptoms suggestive of OSAS, although the sensitivity, specificity and positive predictive value of a self-administered instrument needs to be confirmed by a larger study incorporating ventilatory monitoring during sleep. The addition of screening to pre-registration health checks is feasible, but it would take a long time to screen all those at risk for OSAS by this route.
Obstructive sleep apnoea and anaesthesia
2004, Sleep Medicine Reviews
Upper airway obstruction is common during both anaesthesia and sleep, as a result of loss of muscle tone present during wakefulness. Patients with obstructive sleep apnoea (OSA) are vulnerable during anaesthesia and sedation as the effects of loss of wakefulness are compounded by drug-induced depression of muscle activity and of arousal responses, so that they cannot respond to asphyxia. Conversely, those with ‘difficult’ airways during anaesthesia, either because of problems with maintenance of airway patency without tracheal intubation or because intubation itself is problematic, are at increased risk of OSA. These relationships have clinical importance. On the one hand identification of patients with OSA forewarns the anaesthetist of potential difficulty with airway maintenance intra- and postoperatively, influencing choice of anaesthetic technique and postoperative nursing environment. On the other hand difficulty with airway maintenance during anaesthesia should prompt further investigation for the possibility of OSA.
The extent of the problem of obesity
2002, American Journal of Surgery
Citation Excerpt :
Another important form of sleep-disordered breathing is obesity-hypoventilation syndrome. Less common but more pathogenic than OSA, it leads through chronic hypoxia and hypercapnia to pulmonary hypertension and right heart failure [21,22]. Asthma has only recently been recognized as an important comorbidity of obesity.
The prevalence of obesity is increasing worldwide. In the United States, in 1999, 27% of adults had a body mass index >30 kg/m², almost double the prevalence of 20 years earlier. The estimated mortality from obesity-related diseases in the United States is approximately 300,000 annually and growing. In the future, mortality related to obesity is expected to exceed that of smoking. Numerous diseases are caused or made worse by obesity. These include type 2 diabetes; hypertension; dyslipidemia; ischemic heart disease; stroke; obstructive sleep apnea; asthma; nonalcoholic steatohepatitis; gastroesophageal reflux disease; degenerative joint disease of the back, hips, knees, and feet; infertility and polycystic ovary syndrome; various malignancies; and depression. Type 2 diabetes is perhaps the most visible obesity-related problem. Present in at least 14 million Americans, it leads to serious complications and premature death. It is largely caused by obesity, and is generally cured by weight loss. The quality of life of the obese is markedly reduced, and the costs to health care systems are great. Preventive programs have yet to affect the rising prevalence. An effective solution is needed.

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6 Sleep-disordered breathing and obesity

Summary

Chest

Clinics in Chest Medicine

Journal of Clinical Epidemiology

Chest

American Journal of Medicine

Chest

Chest

Lancet

Electroencephalography and Clinical Neurophysiology

Medical Clinics of North America

Clinics in Chest Medicine

Journal of Pediatrics

Chest

Chest

American Journal of Medicine

Chest

Metabolism

Lancet

Differences in the symptoms of men and women with obstructive sleep apnea

Australian and New Zealand Journal of Medicine

Home monitoring demonstrates a high prevalence of sleep disordered breathing in men in the Busselton (Western Australia) population

Sleep Research

Cognitive and psychological dysfunction in sleep apnea before and after treatment with CPAP

Sleep Research

Feasibility of a self-setting CPAP machine

Sleep

Time course of change in ventilatory response to CO2 with long-term CPAP therapy for obstructive sleep apnea

American Review of Respiratory Disease

Size and mechanical properties of the pharynx in healthy men and women

American Review of Respiratory Disease

Obstructive sleep apnea with severe chronic airflow limitation—comparison of hypercapnic and eucapnic patients

American Review of Respiratory Disease

Sleep apnea in Marfan's syndrome

American Review of Respiratory Disease

Effect of short-term hormone replacement in postmenopausal women with obstructive sleep apnea

American Review of Respiratory Disease

Effect of anterior mandibular positioning on obstructive sleep apnea

American Review of Respiratory Disease

The relationship between neck circumference, radiographic pharyngeal anatomy, and obstructive sleep apnoea

European Respiratory Journal

Possible atherogenic effects of hypoxia during obstructive sleep apnea

Sleep

The effect of transcutaneous electrical stimulation during wakefulness and sleep in patients with obstructive sleep apnea

American Review of Respiratory Disease

Respiratory disturbances in visceral obesity

Driving simulator performance in patients with sleep apnea

American Review of Respiratory Disease

Carotid chemoreceptors, systemic blood pressure and chronic episodic hypoxia mimicking sleep apnea

Journal of Applied Physiology

The sleep hypopnea syndrome

American Review of Respiratory Disease

Endocrine and metabolic disturbances in obstructive sleep apnea

Neuroendocrine dysfunction in sleep apnea. Reversal by continuous nasal positive airway pressure

Journal of Clinical Endocrinology and Metabolism

Growth hormone and sex steroids in sleep apnea

Treatment of sleep disordered breathing

Medical Journal of Australia

Sleep apnea and acromegaly

Annals of Internal Medicine

Sleep apnea is a risk factor for hypertension and hyperinsulinemia in obesity

International Journal of Obesity

Snoring and sleep apnoea in men: association with central obesity and hypertension

International Journal of Obesity

Growth hormone secretion is increased by nasal CPAP treatment of sleep apnea

American Review of Respiratory Disease

From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness

Sleep

Insulin and blood pressure: fact or fantasy?

Journal of Clinical Endocrinology and Metabolism

Driving vigilance simulator test

Acta Oto-laryngologica

Is high and fluctuating muscle nerve sympathetic activity in the sleep apnea syndrome of pathogenetic importance for the development of hypertension?

Journal of Hypertension

Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnea

Journal of Hypertension

A specific and potent pressor effect of hypoxia in patients with sleep apnea

American Review of Respiratory Disease

Sleep apnea, age and obesity. Independent risk factors for development of hypertension. High prevalence of hypertension in sleep apnea patients independently of obesity

Time course of change in ventilatory response to CO₂ with long-term CPAP therapy for obstructive sleep apnea