Sleep Apnea Syndrome
Raphael Heinzer
Brigham and Women's Hospital, Division of Sleep Medicine, Boston, Massachusetts
Search for more papers by this authorAmy Jordan
Brigham and Women's Hospital, Division of Sleep Medicine, Boston, Massachusetts
Search for more papers by this authorAtul Malhotra
Brigham and Women's Hospital, Division of Sleep Medicine, Boston, Massachusetts
Search for more papers by this authorRaphael Heinzer
Brigham and Women's Hospital, Division of Sleep Medicine, Boston, Massachusetts
Search for more papers by this authorAmy Jordan
Brigham and Women's Hospital, Division of Sleep Medicine, Boston, Massachusetts
Search for more papers by this authorAtul Malhotra
Brigham and Women's Hospital, Division of Sleep Medicine, Boston, Massachusetts
Search for more papers by this authorAbstract
Diseases affecting the respiratory system are usually present during the day and the night; however, sleep apnea/hypopnea syndrome is a disease manifesting only during sleep. It is defined as a cessation (apnea) or a reduction of breathing (hypopnea) of 10 seconds or more during sleep. Each of these apneas or hypopneas is usually terminated when the person awakens for a few seconds. Typically, patients do not remember these transient awakenings.
There are two general categories of apnea: central and obstructive. These categories are classified according to the presence or the absence of respiratory effort. Central sleep apnea is a result of the absence of nerve impulses from the brain to the respiratory muscles and therefore occurs in absence of respiratory effort. Obstructive sleep apnea is much more common. This condition is caused by repetitive obstruction of the upper airway (pharynx) during sleep. Therefore, respiratory efforts are still present during apnea and usually increase throughout the apnea. The individual makes larger and larger respiratory efforts until they arouse from sleep apnea and reopen their upper airway so breathing can resume. As will be discussed, some overlap exists between obstructive and central apnea in both disease presentation (so-called mixed apnea) and in pathogenesis.
Bibliography
- 1 AASM, Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in adults. Sleep 1999; 22(5): 667–689.
- 2R. B. Berry and K. Gleeson, Respiratory arousal from sleep: mechanisms and significance. Sleep 1997; 20(8): 654–675.
- 3T. Young, P. Peppard, and D. Gottlieb, The epidemiology of obstructive sleep apnea: a population health perspective. Am. J. Respir. Crit. Care Med. 2002; 165: 1217–1239.
- 4T. Young, M. Palta, J. Dempsey, J. Skatrud, S. Weber, and S. Badr, The occurrence of sleep-disordered breathing among middle-aged adults. N. Engl. J. Med. 1993; 32: 1230–1235.
- 5J. Teran-Santos, A. Jimenez-Gomez, and J. Cordero-Guevara, The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N. Engl. J. Med. 1999; 340(11): 847–851.
- 6J. W. Weiss, S. Remsburg, E. Garpestad, J. Ringler, D. Sparrow, and J. A. Parker, Hemodynamic consequences of obstructive sleep apnea. Sleep 1996; 19(5): 388–397.
- 7P. Peppard, T. Young, M. Palta, and J. Skatrud, Prospective study of the association between sleep disordered breathing and hypertension. N. Engl. J. Med. 2000; 342: 1378–1384.
- 8D. Brooks, R. L. Horner, L. F. Kozar, C. L. Render-Teixeira, and E. A. Phillipson, Obstructive sleep apnea as a cause of systemic hypertension. Evidence from a canine model [see comments]. J. Clin. Invest. 1997; 99(1): 106–109.
- 9P. Lavie, P. Here, and V. Hoffstein, Obstructive sleep apnea syndrome as a risk factor for hypertension. Brit. Med. J. 2000; 320: 479–482.
- 10J. C. Pepperell, S. Ramdassingh-Dow, N. Crosthwaite, R. Mullins, C. Jenkinson, J. R. Stradling, and R. J. Davies, Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised parallel trial. Lancet 2002; 359(9302): 204–210.
- 11J. E. Remmers, W. J. de Groot, E. K. Sauerland, and A. M. Anch, Pathogenesis of upper airway occlusion during sleep. J. Appl. Physiol. 1978; 44(6): 931–938.
- 12I. Kobayashi, A. Perry, J. Rhymer, B. Wuyam, P. Hughes, K. Murphy, J. Innes, J. McIvor, A. Cheesman, and A. Guz, Inspiratory coactivation of the genioglossus enlarges retroglossal space in laryngectomized humans. J. Appl. Physiol. 1996; 80(5): 1595–1604.
- 13W. B. Van de Graaff, Thoracic influence on upper airway patency. J. Appl. Physiol. 1988; 65: 2124–2131.
- 14W. B. Van de Graaff, Thoracic traction on the trachea: mechanisms and magnitude. J. Appl. Physiol. 1991; 70: 1328–1363.
- 15M. Stanchina, A. Malhotra, R. Fogel, J. Trinder, J. Edwards, K. Schory, and D. White, The influence of lung volume on pharyngeal mechanics, collapsibility, and genioglossus muscle activation during sleep. Sleep 2003; 26: 851–856.
- 16R. Schwab, M. Pasirstein, R. Pierson, A. Mackley, R. Hachadoorian, R. Arens, G. Maislin, and A. Pack, Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am. J. Respir. Crit. Care Med. 2003; 168: 522–530.
- 17A. A. Lowe, J. A. Fleetham, S. Adachi, and C. F. Ryan, Cephalometric and computed tomographic predictors of obstructive sleep apnea severity [see comments]. Am. J. Orthodont. Dentofac. Orthoped. 1995; 107(6): 589–595.
- 18S. Isono, J. E. Remmers, A. Tanaka, Y. Sho, J. Sato, and T. Nishino, Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J. Appl. Physiol. 1997; 82(4): 1319–1326.
- 19A. Malhotra, G. Pillar, R. Fogel, J. Beauregard, and D. White, Genioglossal but not palatal muscle activity relates closely to pharyngeal pressure. Am. J. Respir. Crit. Care Med. 2000; 162(3): 1058–1062.
- 20A. Malhotra, R. Fogel, J. Edwards, S. Shea, and D. White, Local mechanisms drive genioglossus muscle activation in obstructive sleep apnea. Am. J. Respir. Crit. Care Med. 2000; 161: 1746–1749.
- 21A. Malhotra, G. Pillar, R. B. Fogel, J. K. Edwards, N. Ayas, T. Akahoshi, D. Hess, and D. P. White, Pharyngeal pressure and flow effects on genioglossus activation in normal subjects. Am. J. Respir. Crit. Care Med. 2002; 165(1): 71–77.
- 22W.S. Mezzanotte, D. J. Tangel, and D. P. White, Waking and sleeping upper airway muscle activity in apnea patients versus normal control. Am. J. Respir. Crit. Care Med. 1996; 153: 1880–1887.
- 23J. Wheatley and D. White, The influence of sleep on pharyngeal reflexes. Sleep 1993; 16(8 Suppl): S87–S89.
- 24R. Horner, J. Innes, M. Morrell, S. Shea, and A. Guz, The effect of sleep on reflex genioglossus muscle activation by stimuli of negative airway pressure in humans. J. Physiol. (Lond). 1994; 476(1): 141–151.
- 25F. Series, Y. Cormier, N. Lampron, and J. La Forge, Influence of lung volume in sleep apnoea. Thorax. 1989; 44(1): 52–57.
- 26R. B. Berry and K. Gleeson, Respiratory arousal from sleep: mechanisms and significance. [Review] [83 refs]. Sleep 1997; 20(8): 654–675.
- 27K. Gleeson, C. W. Zwillich, and D. P. White, The influence of increasing ventilatory effort on arousal from sleep. Am. Rev. Respir. Dis. 1990; 142: 295–300.
- 28M. Younes, Contributions of upper airway mechanics and control mechanisms to severity of obstructive apnea. Am. J. Respir. Crit. Care Med. 2003; 148: 645–658.
- 29U. Eichenberger, E. Weiss, D. Riemann, O. Oelz, and P. Bartsch, Nocturnal periodic breathing and the development of acute high altitude illness. Am. J. Respir. Crit. Care Med. 1996; 154(6 Pt 1): 1748–1754.
- 30B. Wuyam, J. Pepin, F. Tremel, and P. Levy, Pathophysiology of central sleep apnea syndrome. Sleep 2000; 23: S213–S215.
- 31T. D. Bradley and J. S. Floras, Sleep apnea and heart failure: Part II: central sleep apnea. Circulation 2003; 107(13): 1822–1826.
- 32E. Lindberg, N. Carter, T. Gislason, and C. Janson, Role of snoring and daytime sleepiness in occupational accidents. Am. J. Respir. Crit. Care Med. 2001; 164(11): 2031–2035.
- 33H. M. Engleman, R. N. Kingshott, S. E. Martin, N. J. Douglas, Cognitive function in the sleep apnea/hypopnea syndrome. Sleep 2000; 23: S102–S107.
- 34C. Jenkinson, R. J. Davies, R. Mullins, and J. R. Stradling, Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial. Lancet 1999; 353(9170): 2100–2105.
- 35H. M. Engleman, R. N. Kingshott, P. K. Wraith, T. W. Mackay, I. J. Deary, and N. J. Douglas, Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep Apnea/Hypopnea syndrome. Am. J. Respir. Crit. Care Med. 1999; 159(2): 461–467.
- 36J. Montserrat et al., Effectiveness of CPAP treatment in daytime function in sleep apnea syndrome. A randomized controlled study with an optimized placebo. Am. J. Respir. Crit. Care Med. 2001; 164: 608–613.
- 37J. W. Weiss, E. Garpestad, T. Parker, S. Remsburg, and J. Ringler, Changes in left ventricular stroke volume during obstructive apneas. Sleep 1993; 16(8 Suppl): S39–S40.
- 38J. Krieger, E. Sforza, M. Apprill, E. Lampert, E. Weitzenblum, and J. Ratomaharo, Pulmonary hypertension, hypoxemia, and hypercapnia in obstructive sleep apnea patients. Chest 1989; 96(4): 729–737.
- 39J. Wright, R. Johns, I. Watt, A. Melville, and T. Sheldon, Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airway pressure: a systematic review of the research evidence. 1997; 314(7084):851–860.
- 40D. Mansfield, N. Gollogly, D. Kaye, M. Richardson, P. Bergin, and M. Naughton, Controlled trial of continuous positive airway pressure in obstructive sleep apnea and heart failure. Am. J. Respir. Crit. Care Med. 2004; 169: 361–366.
- 41Y. Kaneko, J. Floras, K. Usui, J. Plante, R. Tkacova, T. Kubo, S. Ando, and T. Bradley, Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. New Engl. J. Med. 2003; 348: 1233–1241.
- 42K. Fagan, Selected contribution: pulmonary hypertension in mice following intermittent hypoxia. J. Appl. Physiol. 2001; 90(6): 2502–2507.
- 43B. M. Sanner, C. Doberauer, M. Konermann, A. Sturm, and W. Zidek, Pulmonary hypertension in patients with obstructive sleep apnea syndrome. Arch. Internal Med. 1997; 157(21): 2483–2487.
- 44D. Sajkov, T. Wang, N. A. Saunders, A. J. Bune, A. M. Neill, and D. R. Mcevoy, Daytime pulmonary hemodynamics in patients with obstructive sleep apnea without lung disease. Am. J. Respir. Crit. Care Med. 1999; 159(5 Pt 1): 1518–1526.
- 45D. Sajkov, T. Wang, N. A. Saunders, A. J. Bune, and R. D. McEvoy, Continuous positive airway pressure treatment improves pulmonary hemodynamics in patients with obstructive sleep apnea. Am. J. Respir. Crit. Care Med. 2002; 165(2): 152–158.
- 46B. G. Phillips, K. Narkiewicz, C. A. Pesek, W. G. Haynes, M. E. Dyken, and V. K. Somers, Effects of obstructive sleep apnea on endothelin-1 and blood pressure. J. Hypertens. 1999; 17(1): 61–66.
- 47R. D. J. von Kanel, Hemostatic alterations in patients with obstructive sleep apnea and the implications for cardiovascular disease. Chest 2003; 124(5): 1956–1967.
- 48E. Shahar, C. W. Whitney, S. Redline, E. T. Lee, A. B. Newman, F. J. Nieto, G. T. O’Connor, L. Boland, J. E. Schwartz, and J. M. Samet, Sleep-disordered breathing and cardiovascular disease. Cross-sectional results of the sleep heart health study. Am. J. Respir. Crit. Care Med. 2001; 163: 19–25.
- 49P. Hanly and N. Zuberi-Khokhar, Daytime sleepiness in patients with congestive heart failure and Cheyne–Stokes respiration. Chest 1995; 107(4): 952–958.
- 50A. Tarasiuk and S. M. Scharf, Cardiovascular effects of periodic obstructive and central apneas in dogs. Am. J. Respir. Crit. Care Med. 1994; 150(1): 83–89.
- 51K. A. Franklin, E. Sandstrom, G. Johansson, and E. M. Balfors, Hemodynamics, cerebral circulation, and oxygen saturation in Cheyne–Stokes. J. Appl. Physiol. 1997; 83(4): 1184–1191.
- 52P. A. Lanfranchi, A. Braghiroli, E. Bosimini, G. Mazzuero, R. Colombo, C. F. Donner, and P. Giannuzzi, Prognostic value of nocturnal Cheyne–Stokes respiration in chronic heart failure. Circulation 1999; 99(11): 1435–1440.
- 53W. W. Flemons, M. R. Littner, J. A. Rowley, P. Gay, W. M. Anderson, D. W. Hudgel, R. D. McEvoy, and D. I. Loube, Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest 2003; 124(4): 1543–1579.
- 54J. M. Montserrat, R. Farre, E. Ballester, M. A. Felez, M. Pasto, and D. Navajas, Evaluation of nasal prongs for estimating nasal flow. Am. J. Respir. Crit. Care Med. 1997; 155(1): 211–215.
- 55E. Ballester, J. R. Badia, L. Hernandez, R. Farre, D. Navajas, and J. M. Montserrat, Nasal prongs in the detection of sleep-related disordered breathing in the sleep apnea/hypopnea syndrome: a pilot study. Eur. Respir. J. 1998; 11(4): 880–883.
- 56R. G. Norman, M. M. Ahmed, J. A. Walsleben, and D. M. Rapoport, Detection of respiratory events during NPSG: nasal cannula/pressure. Sleep 1997; 20(12): 1175–1184.
- 57R. Farre, J. Rigau, J. M. Montserrat, E. Ballester, and D. Navajas, Relevance of linearizing nasal prongs for assessing hypopneas and flow limitation during sleep. Am. J. Respir. Crit. Care Med. 2001; 163(2): 494–497.
- 58S. J. Heitman, R. S. Aktar, E. A. Hajduk, R. A. Wanner, and W. W. Flemons, Validation of nasal pressure for the identification of apneas/hypopneas during sleep. Am. J. Respir. Crit. Care Med. 2002; 166(3): 386–391.
- 59R. X. X. Thurnheer and K. E. Bloch, Accuracy of nasal cannula pressure recordings for assessment of ventilation during sleep. Am. J. Respir. Crit. Care Med. 2001; 164(10 Pt 1): 1914–1919.
- 60D. G. Davila, K. C. Richards, B. L. Marshall, P. S. O’Sullivan, T. G. Gregory, V. J. Hernandez, and S. I. Rice, Oximeter performance: the influence of acquisition parameters. Chest 2002; 122(5): 1654–1660.
- 61M. A. Baltzan, P. Verschelden, H. Al-Jahdali, A. E. Olha, and R. J. Kimoff, Accuracy of oximetry with thermistor (OxiFlow) for diagnosis of obstructive sleep apnea and hypopnea. Sleep 2000; 23(1): 61–69.
- 62J. C. Vazquez, W. H. Tsai, W. W. Flemons, A. Masuda, R. Brant, E. Hajduk, W. A. Whitelaw, and J. E. Remmers, Automated analysis of digital oximetry in the diagnosis of obstructive sleep apnoea. Thorax 2000; 55(4): 302–307.
- 63V. G. Kirk, S. G. Bohn, W. W. Flemons, and J. E. Remmers, Comparison of home oximetry monitoring with laboratory polysomnography in children. Chest 2003; 124(5): 1702–1708.
- 64S. Gyulay, L. G. Olson, M. J. Hensley, M. T. King, K. M. Allen, and N. A. Saunders, A comparison of clinical assessment and home oximetry in the diagnosis of obstructive sleep apnea. Am. Rev. Respir. Dis. 1993; 147(1): 50–53.
- 65E. Chiner, E. Perrin, J. M. Arriero, J. Marco, I. Fuentes, and A. Sergado, Nocturnal oximetry for the diagnosis of the sleep apnoea hypopnoea syndrome: a method to reduce the number of polysomnographies? Thorax 1999; 54(11): 968–971.
- 66J. P. Janssens, E.Perrin, I. Bennani, B. de Muralt, V. Titelion, and C. Picaud, Is continuous transcutaneous monitoring of PCO2 (TcPCO2) over 8 h reliable in adults? Respir. Med. 2001; 95(5): 331–335.
- 67T. S. Chadha, H. Watson, S. Birch, G. A. Jenouri, A. W. Schneider, M. A. Cohn, and M. A. Sackner, Validation of respiratory inductive plethysmography using different calibration procedures. Am. Rev. Respir. Dis. 1982; 125(6): 644–649.
- 68J. Siivola and A. Heikki Lang, Non-invasive piezoelectric transducer for recording of respiration at the level of diaphragm. Electroencephalogr. Clin. Neurophysiol. 1998; 106(6): 552–553.
- 69R. Banzett, S. T. Mahan, D. M. Garner, A. Brughera, S. H. Loring, A simple and reliable method to calibrate respiratory magnetometers and Respitrace. J. Appl. Physiol. 1995; 79(6): 2169–2176.
- 70M. J. Morrell, M. S. Badr, C. A. Harms, and J. A. Dempsey, The assessment of upper airway patency during apnea using cardiogenic oscillations in the airflow signal. Sleep 1995; 18(8): 651–658.
- 71P. de Chazal, H. C., E. Sheridan, R. Reilly, P. Nolan, and M. O’Malley. Automated processing of the single-lead electrocardiogram for the detection of obstructive sleep apnoea. IEEE Trans. Biomed. Eng. 2003; 50(6): 686–696.
- 72T. Penzel, J. McNames, A. Murray, P. de Chazal, G. Moody, and B. Raymond, Systematic comparison of different algorithms for apnoea detection based on electrocardiogram recordings. Med. Biol. Eng. Comput. 2002; 40(4): 402–407.
- 73M. Berthon-Jones, Feasibility of a self-setting CPAP machine. Sleep 1993; 16(8 Suppl): S120–S121; discussion S121–S123.
- 74J. He, M. H. Kryger, F. J. Zorick, W. Conway, and T. Roth, Mortality and apnea index in obstructive sleep apnea. Experience in 385 male patients. Chest 1988; 94(1): 9–14.
- 75S. Kajaste, B. P. Telakivi, T. Partinen, and M. Mustajoki, Cognitive-behavioral weight reduction program in the treatment of obstructive sleep apnea syndrome with or without initial nasal CPAP: a randomized study. Sleep Med. 2004; 5(2): 125–134.
- 76M. Hack, R. J. Davies, R. Mullins, S. J. Choi, S. Ramdassingh-Dow, C. Jenkinson, J. R. Stradling, Randomised prospective parallel trial of therapeutic versus subtherapeutic nasal continuous positive airway pressure on simulated steering performance in patients with obstructive sleep apnoea. Thorax. 2000; 55(3): 224–231.
- 77S.R. Patel, D. P. White, A. Malhotra, M. L. Stanchina, N. T. Ayas, Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Arch. Intern. Med. 2003; 163(5): 565–571.
- 78J. Faccenda, N. A. Boon, T. W. Mackay, and N. J. Douglas, CPAP effects on blood pressure in the sleep apnea/hypopnoea syndrome during a randomized controlled trial. Am. J. Respir. Crit. Care Med. 2001; 163: 344–348.
- 79C. A. Massie, R. W. Hart, K. Peralez, and G. N. Richards, Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest 1999; 116(2): 403–408.
- 80M. K. Reeves-Hoche, D. W. Hudgel, R. Meck, R. Witteman, A. Ross, and C. W. Zwillich, Continuous versus bilevel positive airway pressure for obstructive sleep apnea. Am. J. Respir. Crit. Care Med. 1995; 151(2 Pt 1): 443–449.
- 81C. A. Massie, N. Mc Ardle, R. W. Hart, W. W. Schmidt-Nowara, A. Lankford, D. W. Hudgel, N. Gordon, and N. J. Douglas, Comparison between automatic and fixed positive airway pressure therapy in the home. Am. J. Respir. Crit. Care Med. 2003; 167(1): 20–23.
- 82D. W. Hudgel and C. Fung, A long-term randomized, cross-over comparison of auto-titrating and standard nasal continuous airway pressure. Sleep 2000; 23(5): 645–648.
- 83D. W. Hudgel, Availability of a meta-analysis of the surgical treatment of obstructive sleep apnea [editorial]. Chest 1997; 111(2): 265–266.
- 84R. W. Riley, N. B. Powell, and C. Guilleminault, Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngol. Head Neck Surg. 1993; 108(2): 117–125.
- 85M. B. Blumen, S. Dahan, B. Fleury, C. Hausser-Hauw, and F. Chabolle, Laryngoscope 2002; 112(11): 2086–2092.
- 86K. A. Ferguson, T. Ono, A. A. Lowe, S. P. Keenan, and J. A. Fleetham, A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea [see comments]. Chest 1996; 109(5): 1269–1275.
- 87R. P. Millman, C. L. Rosenberg, C. C. Carlisle, N. R. Kramer, D. M. Kahn, and A. E. Bonitati, The efficacy of oral appliances in the treatment of persistent sleep apnea after uvulopalatopharyngoplasty. Chest 1998; 113(4): 992–996.
- 88C. Guilleminault, R. Stoohs, H. Schneider, T. Podszus, J. H. Peter, and P. von Wichert, Central alveolar hypoventilation and sleep. Treatment by intermittent positive-pressure ventilation through nasal mask in an adult. Chest 1989; 96(5): 1210–1212.
- 89F. G. Issa and C. E. Sullivan, Reversal of central sleep apnea using nasal CPAP. Chest 1986; 90(2): 165–171.
- 90M. T. Naughton, M. A. Rahman, K. Hara, J. S. Floras, and T. D. Bradley, Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Circulation 1995; 91(6): 1725–1731.
- 91H. Teschler, J. Dohring, Y. M. Wang, and M. Berthon-Jones, Adaptive pressure support servo-ventilation: a novel treatment for Cheyne–Stokes respiration in heart failure. Am. J. Respir. Crit. Care Med. 2001; 164(4): 614–619.
- 92P. J. Hanly, T. W. Millar, D. G. Steljes, R. Baert, M. A. Frais, and M. H. Kryger, The effect of oxygen on respiration and sleep in patients with congestive heart failure. Ann. Intern. Med. 1989; 111(10): 777–782.
- 93S. Javaheri, T. J. Parker, L. Wexler, J. D. Liming, P. Lindower, and G. A. Roselle, Effect of theophylline on sleep-disordered breathing in heart failure. N. Engl. J. Med. 1996; 335: 562–567.
- 94D. P. White, C. W. Zwillich, C. K. Pickett, N. J. Douglas, L. J. Findley, and J. V. Weil, Central sleep apnea. Improvement with acetazolamide therapy. Arch. Intern. Med. 1982; 142(10): 1816–1819.
- 95D. J. Pitson, A. Sandell, R. van den Hout, and J. R. Stradling, Use of pulse transit time as a measure of inspiratory effort in patients with obstructive sleep apnoea. Eur. Respir. J. 1995; 8(10): 1669–1674.
- 96J. Argod, J. L. Pepin, R. P. Smith, and P. Levy, Comparison of esophageal pressure with pulse transit time as a measure of respiratory effort for scoring obstructive nonapneic respiratory events. Am. J. Respir. Crit. Care Med. 2000; 162(1): 87–93.
- 97C. Guilleminault, N. Powell, B. Bowman, and R. Stoohs, The effect of electrical stimulation on obstructive sleep apnea syndrome. Chest 1995; 107(1): 67–73.
- 98H. Miki, W. Hida, T. Chonan, Y. Kikuchi, and T. Takishima, Effects of submental electrical stimulation during sleep on upper airway patency in patients with obstructive sleep apnea. Am. Rev. Respir. Dis. 1989; 140(5): 1285–1289.
- 99D. W. Eisele et al., Direct hypoglossal nerve stimulation in obstructive sleep apnea. Arch. Otolaryngol. Head Neck Surg. 1997; 123(1): 57–61.