Advertisement

Functional Aspects and Upper Airway Control During Wakefulness and Sleep

  • Neriel KatzEmail author
  • Tamar Etzioni
  • Giora Pillar
Chapter
Part of the Respiratory Medicine book series (RM)

Abstract

Obstructive sleep apnea (OSA) is a disorder of recurrent upper airway obstruction occurring during sleep. This chapter reviews studies that have focussed on understanding the upper airway control and its functional aspects during wake, sleep onset, and sleep, in both adults and children.

Upper airway obstructions commonly occur due to a combination of anatomical and physiological factors. While convincing evidence supports deficient upper airway anatomy in afflicted patients, which requires increased neuromuscular activity during wakefulness as a compensatory response, the mechanism driving this response is still poorly defined. The neurochemical and physiological changes that occur at sleep onset leading to a loss of muscle activity and subsequent pharyngeal collapse are the subject of ongoing investigation, but may relate to diminished pharyngeal reflex control and a loss of the neuromuscular compensation present during wakefulness.

Keywords

Obstructive Sleep Apnea Continuous Positive Airway Pressure Down Syndrome Obstructive Sleep Apnea Patient Severe Obstructive Sleep Apnea 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Haponik EF, Smith PL, Bohlman ME, Allen RP, Goldman SM, Bleecker ER. Computerized tomography in obstructive sleep apnea. Correlation of airway size with physiology during sleep and wakefulness. Am Rev Respir Dis. 1983;127(2):221–6.PubMedGoogle Scholar
  2. 2.
    Schwab RJ, Pasirstein M, Pierson R, et al. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med. 2003;168(5):522–30.PubMedCrossRefGoogle Scholar
  3. 3.
    Whittle AT, Marshall I, Mortimore IL, Wraith PK, Sellar RJ, Douglas NJ. Neck soft tissue and fat distribution: comparison between normal men and women by magnetic resonance imaging. Thorax. 1999;54(4):323–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Macey PM, Macey KE, Henderson LA, et al. Functional magnetic resonance imaging responses to expiratory loading in obstructive sleep apnea. Respir Physiol Neurobiol. 2003;138(2–3):275–90.PubMedCrossRefGoogle Scholar
  5. 5.
    Sanner BM, Heise M, Knoben B, et al. MRI of the pharynx and treatment efficacy of a mandibular advancement device in obstructive sleep apnoea syndrome. Eur Respir J. 2002;20(1):143–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Ciscar MA, Juan G, Martinez V, et al. Magnetic resonance imaging of the pharynx in OSA patients and healthy subjects. Eur Respir J. 2001;17(1):79–86.PubMedCrossRefGoogle Scholar
  7. 7.
    Ikeda K, Ogura M, Oshima T, et al. Quantitative assessment of the pharyngeal airway by dynamic magnetic resonance imaging in obstructive sleep apnea syndrome. Ann Otol Rhinol Laryngol. 2001;110(2):183–9.PubMedGoogle Scholar
  8. 8.
    Morrell MJ, Arabi Y, Zahn B, Badr MS. Progressive retropalatal narrowing preceding obstructive apnea. Am J Respir Crit Care Med. 1998;158(6):1974–81.PubMedGoogle Scholar
  9. 9.
    Jager L, Gunther E, Gauger J, Reiser M. Fluoroscopic MR of the pharynx in patients with obstructive sleep apnea. AJNR Am J Neuroradiol. 1998;19(7):1205–14.PubMedGoogle Scholar
  10. 10.
    Schwab RJ. Upper airway imaging. Clin Chest Med. 1998;19(1):33–54.PubMedCrossRefGoogle Scholar
  11. 11.
    Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis. 1993;148(5):1385–400.PubMedGoogle Scholar
  12. 12.
    Hoffstein V, Weiser W, Haney R. Roentgenographic dimensions of the upper airway in snoring patients with and without obstructive sleep apnea. Chest. 1991;100(1):81–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Abbey NC, Block AJ, Green D, Mancuso A, Hellard DW. Measurement of pharyngeal volume by digitized magnetic resonance imaging. Effect of nasal continuous positive airway pressure. Am Rev Respir Dis. 1989;140(3):717–23.PubMedGoogle Scholar
  14. 14.
    Isono S, Feroah TR, Hajduk EA, Brant R, Whitelaw WA, Remmers JE. Interaction of cross-sectional area, driving pressure, and airflow of passive velopharynx. J Appl Physiol. 1997;83(3):851–9.PubMedGoogle Scholar
  15. 15.
    Isono S, Remmers JE, Tanaka A, Sho Y, Sato J, Nishino T. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol. 1997;82(4):1319–26.PubMedGoogle Scholar
  16. 16.
    Hoffstein V, Zamel N, Phillipson EA. Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea. Am Rev Respir Dis. 1984;130(2):175–8.PubMedGoogle Scholar
  17. 17.
    Horner RL, Shea SA, McIvor J, Guz A. Pharyngeal size and shape during wakefulness and sleep in patients with obstructive sleep apnoea. Q J Med. 1989;72(268):719–35.PubMedGoogle Scholar
  18. 18.
    Rodenstein DO, Dooms G, Thomas Y, et al. Pharyngeal shape and dimensions in healthy subjects, snorers, and patients with obstructive sleep apnoea. Thorax. 1990;45(10):722–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Leiter JC. Upper airway shape: is it important in the pathogenesis of obstructive sleep apnea? Am J Respir Crit Care Med. 1996;153(3):894–8.PubMedGoogle Scholar
  20. 20.
    Schwab RJ. Genetic determinants of upper airway structures that predispose to obstructive sleep apnea. Respir Physiol Neurobiol. 2005;147(2–3):289–98.PubMedCrossRefGoogle Scholar
  21. 21.
    Borys JM, Boute D. Obstructive sleep apnea syndrome: a frequent complication of obesity. Biomed Pharmacother. 1994;48(3–4):137–41.PubMedCrossRefGoogle Scholar
  22. 22.
    Carrera M, Barbe F, Sauleda J, et al. Effects of obesity upon genioglossus structure and function in obstructive sleep apnoea. Eur Respir J. 2004;23(3):425–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Grunstein RR, Wilcox I. Sleep-disordered breathing and obesity. Baillieres Clin Endocrinol Metab. 1994;8(3):601–28.PubMedCrossRefGoogle Scholar
  24. 24.
    White DP, Lombard RM, Cadieux RJ, Zwillich CW. Pharyngeal resistance in normal humans: influence of gender, age, and obesity. J Appl Physiol. 1985;58(2):365–71.PubMedGoogle Scholar
  25. 25.
    Ayappa I, Rapoport DM. The upper airway in sleep: physiology of the pharynx. Sleep Med Rev. 2003;7(1):9–33.PubMedCrossRefGoogle Scholar
  26. 26.
    Biddle C. Orocephalometry and airway control in obese sleep-disordered breathers, obese normals, and matched controls undergoing general anesthesia. Crna. 1994;5(3):97–103.PubMedGoogle Scholar
  27. 27.
    Fleetham JA. Upper airway imaging in relation to obstructive sleep apnea. Clin Chest Med. 1992;13(3):399–416.PubMedGoogle Scholar
  28. 28.
    Fogel RB, Malhotra A, Dalagiorgou G, et al. Anatomic and physiologic predictors of apnea severity in morbidly obese subjects. Sleep. 2003;26(2):150–5.PubMedGoogle Scholar
  29. 29.
    Gomez de Terreros FJ, Caballero P, Ana S, Soleto MJ, Martin-Duce A, Alvarez-Sala R. The upper airway and obstructive sleep apnea in morbidly obese women. Sleep. 2004;27(2):352; author reply 353.PubMedGoogle Scholar
  30. 30.
    Horner RL, Mohiaddin RH, Lowell DG, et al. Sites and sizes of fat deposits around the pharynx in obese patients with obstructive sleep apnoea and weight matched controls. Eur Respir J. 1989;2(7):613–22.PubMedGoogle Scholar
  31. 31.
    Koenig JS, Thach BT. Effects of mass loading on the upper airway. J Appl Physiol. 1988;64(6):2294–9.PubMedGoogle Scholar
  32. 32.
    Lam B, Ooi CG, Peh WC, et al. Computed tomographic evaluation of the role of craniofacial and upper airway morphology in obstructive sleep apnea in Chinese. Respir Med. 2004;98(4):301–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Lowe AA, Fleetham JA, Adachi S, Ryan CF. Cephalometric and computed tomographic predictors of obstructive sleep apnea severity. Am J Orthod Dentofacial Orthop. 1995;107(6):589–95.PubMedCrossRefGoogle Scholar
  34. 34.
    Martin SE, Mathur R, Marshall I, Douglas NJ. The effect of age, sex, obesity and posture on upper airway size. Eur Respir J. 1997;10(9):2087–90.PubMedCrossRefGoogle Scholar
  35. 35.
    O’Donnell CP, Schwartz AR, Smith PL. Upper airway collapsibility: the importance of gender and adiposity. Am J Respir Crit Care Med. 2000;162(5):1606–7.PubMedGoogle Scholar
  36. 36.
    Pillar G, Shehadeh N. Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care. 2008;31 Suppl 2:S303–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Richards A, Quaghebeur G, Clift S, Holland A, Dahlitz M, Parkes D. The upper airway and sleep apnoea in the Prader-Willi syndrome. Clin Otolaryngol Allied Sci. 1994;19(3):193–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Sakakibara H, Tong M, Matsushita K, Hirata M, Konishi Y, Suetsugu S. Cephalometric abnormalities in non-obese and obese patients with obstructive sleep apnoea. Eur Respir J. 1999;13(2):403–10.PubMedCrossRefGoogle Scholar
  39. 39.
    Charuzi I, Ovnat A, Peiser J, Saltz H, Weitzman S, Lavie P. The effect of surgical weight reduction on sleep quality in obesity-related sleep apnea syndrome. Surgery. 1985;97(5):535–8.PubMedGoogle Scholar
  40. 40.
    Davila-Cervantes A, Dominguez-Cherit G, Borunda D, et al. Impact of surgically-induced weight loss on respiratory function: a prospective analysis. Obes Surg. 2004;14(10):1389–92.PubMedCrossRefGoogle Scholar
  41. 41.
    Kansanen M, Vanninen E, Tuunainen A, et al. The effect of a very low-calorie diet-induced weight loss on the severity of obstructive sleep apnoea and autonomic nervous function in obese patients with obstructive sleep apnoea syndrome. Clin Physiol. 1998;18(4):377–85.PubMedCrossRefGoogle Scholar
  42. 42.
    Loube DI, Loube AA, Mitler MM. Weight loss for obstructive sleep apnea: the optimal therapy for obese patients. J Am Diet Assoc. 1994;94(11):1291–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Nahmias J, Kirschner M, Karetzky MS. Weight loss and OSA and pulmonary function in obesity. N J Med. 1993;90(1):48–53.PubMedGoogle Scholar
  44. 44.
    Pasquali R, Colella P, Cirignotta F, et al. Treatment of obese patients with obstructive sleep apnea syndrome (OSAS): effect of weight loss and interference of otorhinolaryngoiatric pathology. Int J Obes. 1990;14(3):207–17.PubMedGoogle Scholar
  45. 45.
    Peiser J, Lavie P, Ovnat A, Charuzi I. Sleep apnea syndrome in the morbidly obese as an indication for weight reduction surgery. Ann Surg. 1984;199(1):112–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Rubinstein I, Colapinto N, Rotstein LE, Brown IG, Hoffstein V. Improvement in upper airway function after weight loss in patients with obstructive sleep apnea. Am Rev Respir Dis. 1988;138(5):1192–5.PubMedGoogle Scholar
  47. 47.
    Schwartz AR, Gold AR, Schubert N, et al. Effect of weight loss on upper airway collapsibility in obstructive sleep apnea. Am Rev Respir Dis. 1991;144(3 Pt 1):494–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Smith PL, Gold AR, Meyers DA, Haponik EF, Bleecker ER. Weight loss in mildly to moderately obese patients with obstructive sleep apnea. Ann Intern Med. 1985;103(6 (Pt 1)):850–5.PubMedGoogle Scholar
  49. 49.
    Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Changes in breathing and the pharynx after weight loss in obstructive sleep apnea. Chest. 1987;92(4):631–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Effect of very-low-calorie diets with weight loss on obstructive sleep apnea. Am J Clin Nutr. 1992;56(1 Suppl):182S–4.PubMedGoogle Scholar
  51. 51.
    Pillar G, Peled R, Lavie P. Recurrence of sleep apnea without concomitant weight increase 7.5 years after weight reduction surgery. Chest. 1994;106(6):1702–4.PubMedCrossRefGoogle Scholar
  52. 52.
    Arens R, Muzumdar H. Childhood obesity and obstructive sleep apnea syndrome. J Appl Physiol. 2010;108(2):436–44.PubMedCrossRefGoogle Scholar
  53. 53.
    Ramos RT, Salles C, Gregorio PB, et al. Evaluation of the upper airway in children and adolescents with cystic fibrosis and obstructive sleep apnea syndrome. Int J Pediatr Otorhinolaryngol. 2009;73(12):1780–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Arens R, McDonough JM, Corbin AM, et al. Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2003;167(1):65–70.PubMedCrossRefGoogle Scholar
  55. 55.
    Finkelstein Y, Wexler D, Berger G, Nachmany A, Shapiro-Feinberg M, Ophir D. Anatomical basis of sleep-related breathing abnormalities in children with nasal obstruction. Arch Otolaryngol Head Neck Surg. 2000;126(5):593–600.PubMedGoogle Scholar
  56. 56.
    Marcus CL. Pathophysiology of childhood obstructive sleep apnea: current concepts. Respir Physiol. 2000;119(2–3):143–54.PubMedCrossRefGoogle Scholar
  57. 57.
    Isono S, Shimada A, Utsugi M, Konno A, Nishino T. Comparison of static mechanical properties of the passive pharynx between normal children and children with sleep-disordered breathing. Am J Respir Crit Care Med. 1998;157(4 Pt 1):1204–12.PubMedGoogle Scholar
  58. 58.
    Arens R, McDonough JM, Costarino AT, et al. Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2001;164(4):698–703.PubMedGoogle Scholar
  59. 59.
    Kohler MJ, Lushington K, van den Heuvel CJ, Martin J, Pamula Y, Kennedy D. Adenotonsillectomy and neurocognitive deficits in children with Sleep Disordered Breathing. PLoS One. 2009;4(10):e7343.PubMedCrossRefGoogle Scholar
  60. 60.
    Choi JH, Kim EJ, Choi J, et al. The effect of adenotonsillectomy on changes of position during sleep in pediatric obstructive sleep apnea syndrome. Am J Rhinol Allergy. 2009;23(6):e56–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Conley SF, Beecher RB, Delaney AL, Norins NA, Simpson PM, Li SH. Outcomes of tonsillectomy in neurologically impaired children. Laryngoscope. 2009;119(11):2231–41.PubMedCrossRefGoogle Scholar
  62. 62.
    Robb PJ, Bew S, Kubba H, et al. Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party. Ann R Coll Surg Engl. 2009;91(5):371–3.PubMedCrossRefGoogle Scholar
  63. 63.
    Friedman M, Wilson M, Lin HC, Chang HW. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2009;140(6):800–8.PubMedCrossRefGoogle Scholar
  64. 64.
    Greenfeld M, Tauman R, DeRowe A, Sivan Y. Obstructive sleep apnea syndrome due to adenotonsillar hypertrophy in infants. Int J Pediatr Otorhino­laryngol. 2003;67(10):1055–60.PubMedCrossRefGoogle Scholar
  65. 65.
    Goldstein NA, Post JC, Rosenfeld RM, Campbell TF. Impact of tonsillectomy and adenoidectomy on child behavior. Arch Otolaryngol Head Neck Surg. 2000;126(4):494–8.PubMedGoogle Scholar
  66. 66.
    Marcus CL, Loughlin GM. Obstructive sleep apnea in children. Semin Pediatr Neurol. 1996;3(1):23–8.PubMedCrossRefGoogle Scholar
  67. 67.
    Williams 3rd EF, Woo P, Miller R, Kellman RM. The effects of adenotonsillectomy on growth in young children. Otolaryngol Head Neck Surg. 1991;104(4):509–16.PubMedGoogle Scholar
  68. 68.
    Bannink N, Nout E, Wolvius EB, Hoeve HL, Joosten KF, Mathijssen IM. Obstructive sleep apnea in children with syndromic craniosynostosis: long-term respiratory outcome of midface advancement. Int J Oral Maxillofac Surg. 2010;39(2):115–21.PubMedCrossRefGoogle Scholar
  69. 69.
    Johnston C, Taussig LM, Koopmann C, Smith P, Bjelland J. Obstructive sleep apnea in Treacher-Collins syndrome. Cleft Palate J. 1981;18(1):39–44.PubMedGoogle Scholar
  70. 70.
    Mandell DL, Yellon RF, Bradley JP, Izadi K, Gordon CB. Mandibular distraction for micrognathia and severe upper airway obstruction. Arch Otolaryngol Head Neck Surg. 2004;130(3):344–8.PubMedCrossRefGoogle Scholar
  71. 71.
    Bravo G, Ysunza A, Arrieta J, Pamplona MC. Videonasopharyngoscopy is useful for identifying children with Pierre Robin sequence and severe obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2005;69(1):27–33.PubMedCrossRefGoogle Scholar
  72. 72.
    Cohen SR, Simms C, Burstein FD. Mandibular ­distraction osteogenesis in the treatment of upper airway obstruction in children with craniofacial deformities. Plast Reconstr Surg. 1998;101(2):312–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Rachmiel A, Aizenbud D, Pillar G, Srouji S, Peled M. Bilateral mandibular distraction for patients with compromised airway analyzed by three-dimensional CT. Int J Oral Maxillofac Surg. 2005;34(1):9–18.PubMedCrossRefGoogle Scholar
  74. 74.
    Dauvilliers Y, Stal V, Abril B, et al. Chiari malformation and sleep related breathing disorders. J Neurol Neurosurg Psychiatry. 2007;78(12):1344–8.PubMedCrossRefGoogle Scholar
  75. 75.
    Cook SP, Borkowski WJ. Obstructive sleep apnea in Schwartz-Jampel syndrome. Arch Otolaryngol Head Neck Surg. 1997;123(12):1348–50.PubMedCrossRefGoogle Scholar
  76. 76.
    Mogayzel Jr PJ, Carroll JL, Loughlin GM, Hurko O, Francomano CA, Marcus CL. Sleep-disordered breathing in children with achondroplasia. J Pediatr. 1998;132(4):667–71.PubMedCrossRefGoogle Scholar
  77. 77.
    Zucconi M, Weber G, Castronovo V, et al. Sleep and upper airway obstruction in children with achondroplasia. J Pediatr. 1996;129(5):743–9.PubMedCrossRefGoogle Scholar
  78. 78.
    de Miguel-Diez J, Alvarez-Sala JL, Villa-Asensi JR. Magnetic resonance imaging of the upper airway in children with Down syndrome. Am J Respir Crit Care Med. 2002;165(8):1187; author reply 1187.PubMedGoogle Scholar
  79. 79.
    Donaldson JD, Redmond WM. Surgical management of obstructive sleep apnea in children with Down syndrome. J Otolaryngol. 1988;17(7):398–403.PubMedGoogle Scholar
  80. 80.
    Jacobs IN, Gray RF, Todd NW. Upper airway obstruction in children with Down syndrome. Arch Otolaryngol Head Neck Surg. 1996;122(9):945–50.PubMedCrossRefGoogle Scholar
  81. 81.
    de Moura CP, Andrade D, Cunha LM, et al. Down syndrome: otolaryngological effects of rapid maxillary expansion. J Laryngol Otol. 2008;122(12):1318–24.PubMedCrossRefGoogle Scholar
  82. 82.
    Gozal D. Determinants of daytime hypercapnia in obstructive sleep apnea: is obesity the only one to blame? Chest. 2002;121(2):320–1.PubMedCrossRefGoogle Scholar
  83. 83.
    Gozal D, Kheirandish-Gozal L. Obesity and excessive daytime sleepiness in prepubertal children with obstructive sleep apnea. Pediatrics. 2009;123(1):13–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Verhulst SL, Van Gaal L, De Backer W, Desager K. The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev. 2008;12(5):339–46.PubMedCrossRefGoogle Scholar
  85. 85.
    Kohler M, Lushington K, Couper R, et al. Obesity and risk of sleep related upper airway obstruction in Caucasian children. J Clin Sleep Med. 2008;4(2):129–36.PubMedGoogle Scholar
  86. 86.
    Nixon GM, Brouillette RT. Sleep and breathing in Prader-Willi syndrome. Pediatr Pulmonol. 2002;34(3):209–17.PubMedCrossRefGoogle Scholar
  87. 87.
    Arens R, Sin S, McDonough JM, et al. Changes in upper airway size during tidal breathing in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2005;171(11):1298–304.PubMedCrossRefGoogle Scholar
  88. 88.
    Dayyat E, Kheirandish-Gozal L, Sans Capdevila O, Maarafeya MM, Gozal D. Obstructive sleep apnea in children: relative contributions of body mass index and adenotonsillar hypertrophy. Chest. 2009;136(1):137–44.PubMedCrossRefGoogle Scholar
  89. 89.
    Apostolidou MT, Alexopoulos EI, Chaidas K, et al. Obesity and persisting sleep apnea after adenotonsillectomy in Greek children. Chest. 2008;134(6):1149–55.PubMedCrossRefGoogle Scholar
  90. 90.
    Guilleminault C, Li KK, Khramtsov A, Pelayo R, Martinez S. Sleep disordered breathing: surgical outcomes in prepubertal children. Laryngoscope. 2004;114(1):132–7.PubMedCrossRefGoogle Scholar
  91. 91.
    Shine NP, Lannigan FJ, Coates HL, Wilson A. Adenotonsillectomy for obstructive sleep apnea in obese children: effects on respiratory parameters and clinical outcome. Arch Otolaryngol Head Neck Surg. 2006;132(10):1123–7.PubMedCrossRefGoogle Scholar
  92. 92.
    Malhotra A, Huang Y, Fogel RB, et al. The male predisposition to pharyngeal collapse: importance of airway length. Am J Respir Crit Care Med. 2002;166(10):1388–95.PubMedCrossRefGoogle Scholar
  93. 93.
    Ronen O, Malhotra A, Pillar G. Influence of gender and age on upper-airway length during development. Pediatrics. 2007;120(4):e1028–34.PubMedCrossRefGoogle Scholar
  94. 94.
    Malhotra A, Huang Y, Fogel R, et al. Aging influences on pharyngeal anatomy and physiology: the predisposition to pharyngeal collapse. Am J Med. 2006;119(1):72 e79–14.CrossRefGoogle Scholar
  95. 95.
    Segal Y, Malhotra A, Pillar G. Upper airway length may be associated with the severity of obstructive sleep apnea syndrome. Sleep Breath. 2008;12(4):311–6.PubMedCrossRefGoogle Scholar
  96. 96.
    Issa FG, Sullivan CE. Upper airway closing pressures in snorers. J Appl Physiol. 1984;57(2):528–35.PubMedGoogle Scholar
  97. 97.
    Issa FG, Sullivan CE. Upper airway closing pressures in obstructive sleep apnea. J Appl Physiol. 1984;57(2):520–7.PubMedGoogle Scholar
  98. 98.
    Smith PL, Wise RA, Gold AR, Schwartz AR, Permutt S. Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol. 1988;64(2):789–95.PubMedGoogle Scholar
  99. 99.
    Jordan AS, Wellman A, Edwards JK, et al. Respiratory control stability and upper airway collapsibility in men and women with obstructive sleep apnea. J Appl Physiol. 2005;99(5):2020–7.PubMedCrossRefGoogle Scholar
  100. 100.
    Schwartz AR, Smith PL, Wise RA, Bankman I, Permutt S. Effect of positive nasal pressure on upper airway pressure-flow relationships. J Appl Physiol. 1989;66(4):1626–34.PubMedGoogle Scholar
  101. 101.
    Schwartz AR, Smith PL, Wise RA, Gold AR, Permutt S. Induction of upper airway occlusion in sleeping individuals with subatmospheric nasal pressure. J Appl Physiol. 1988;64(2):535–42.PubMedGoogle Scholar
  102. 102.
    Sforza E, Petiau C, Weiss T, Thibault A, Krieger J. Pharyngeal critical pressure in patients with obstructive sleep apnea syndrome. Clinical implications. Am J Respir Crit Care Med. 1999;159(1):149–57.PubMedGoogle Scholar
  103. 103.
    Marcus CL, McColley SA, Carroll JL, Loughlin GM, Smith PL, Schwartz AR. Upper airway collapsibility in children with obstructive sleep apnea ­syndrome. J Appl Physiol. 1994;77(2):918–24.PubMedGoogle Scholar
  104. 104.
    Gleadhill IC, Schwartz AR, Schubert N, Wise RA, Permutt S, Smith PL. Upper airway collapsibility in snorers and in patients with obstructive hypopnea and apnea. Am Rev Respir Dis. 1991;143(6):1300–3.PubMedGoogle Scholar
  105. 105.
    van Lunteren E, Strohl KP. The muscles of the upper airways. Clin Chest Med. 1986;7(2):171–88.PubMedGoogle Scholar
  106. 106.
    Tangel DJ, Mezzanotte WS, White DP. Influence of sleep on tensor palatini EMG and upper airway resistance in normal men. J Appl Physiol. 1991;70(6):2574–81.PubMedGoogle Scholar
  107. 107.
    Onal E, Lopata M, O’Connor TD. Diaphragmatic and genioglossal electromyogram responses to CO2 rebreathing in humans. J Appl Physiol. 1981;50(5):1052–5.PubMedGoogle Scholar
  108. 108.
    Onal E, Lopata M, O’Connor TD. Diaphragmatic and genioglossal electromyogram responses to isocapnic hypoxia in humans. Am Rev Respir Dis. 1981;124(3):215–7.PubMedGoogle Scholar
  109. 109.
    Berry RB, White DP, Roper J, et al. Awake negative pressure reflex response of the genioglossus in OSA patients and normal subjects. J Appl Physiol. 2003;94(5):1875–82.PubMedGoogle Scholar
  110. 110.
    Malhotra A, Fogel RB, Edwards JK, Shea SA, White DP. Local mechanisms drive genioglossus activation in obstructive sleep apnea. Am J Respir Crit Care Med. 2000;161(5):1746–9.PubMedGoogle Scholar
  111. 111.
    Malhotra A, Pillar G, Fogel R, Beauregard J, Edwards J, White DP. Upper-airway collapsibility: measurements and sleep effects. Chest. 2001;120(1):156–61.PubMedCrossRefGoogle Scholar
  112. 112.
    Malhotra A, Pillar G, Fogel RB, et al. Pharyngeal pressure and flow effects on genioglossus activation in normal subjects. Am J Respir Crit Care Med. 2002;165(1):71–7.PubMedGoogle Scholar
  113. 113.
    Pillar G, Fogel RB, Malhotra A, et al. Genioglossal inspiratory activation: central respiratory vs mechanoreceptive influences. Respir Physiol. 2001;127(1):23–38.PubMedCrossRefGoogle Scholar
  114. 114.
    Fogel RB, Malhotra A, Shea SA, Edwards JK, White DP. Reduced genioglossal activity with upper airway anesthesia in awake patients with OSA. J Appl Physiol. 2000;88(4):1346–54.PubMedGoogle Scholar
  115. 115.
    Mezzanotte WS, Tangel DJ, White DP. Mechanisms of control of alae nasi muscle activity. J Appl Physiol. 1992;72(3):925–33.PubMedCrossRefGoogle Scholar
  116. 116.
    Tangel DJ, Mezzanotte WS, Sandberg EJ, White DP. Influences of NREM sleep on the activity of tonic vs. inspiratory phasic muscles in normal men. J Appl Physiol. 1992;73(3):1058–66.PubMedGoogle Scholar
  117. 117.
    Wheatley JR, Tangel DJ, Mezzanotte WS, White DP. Influence of sleep on response to negative airway pressure of tensor palatini muscle and retropalatal airway. J Appl Physiol. 1993;75(5):2117–24.PubMedGoogle Scholar
  118. 118.
    Wheatley JR, Mezzanotte WS, Tangel DJ, White DP. Influence of sleep on genioglossus muscle activation by negative pressure in normal men. Am Rev Respir Dis. 1993;148(3):597–605.PubMedCrossRefGoogle Scholar
  119. 119.
    Fogel RB, Malhotra A, Pillar G, et al. Genioglossal activation in patients with obstructive sleep apnea versus control subjects. Mechanisms of muscle ­control. Am J Respir Crit Care Med. 2001;164(11):2025–30.PubMedGoogle Scholar
  120. 120.
    Fogel RB, Trinder J, Malhotra A, et al. Within-breath control of genioglossal muscle activation in humans: effect of sleep-wake state. J Physiol. 2003;550(Pt 3):899–910.PubMedCrossRefGoogle Scholar
  121. 121.
    Malhotra A, Pillar G, Fogel RB, et al. Genioglossal but not palatal muscle activity relates closely to pharyngeal pressure. Am J Respir Crit Care Med. 2001;162(3 Pt 1):1058–62.Google Scholar
  122. 122.
    Fogel RB, White DP, Pierce RJ, et al. Control of upper airway muscle activity in younger versus older men during sleep onset. J Physiol. 2003;553(Pt 2):533–44.PubMedCrossRefGoogle Scholar
  123. 123.
    Shea SA, Edwards JK, White DP. Effect of wake-sleep transitions and rapid eye movement sleep on pharyngeal muscle response to negative pressure in humans. J Physiol. 1999;520(Pt 3):897–908.PubMedCrossRefGoogle Scholar
  124. 124.
    Fogel RB, Trinder J, White DP, et al. The effect of sleep onset on upper airway muscle activity in patients with sleep apnoea versus controls. J Physiol. 2005;564(Pt 2):549–62.PubMedCrossRefGoogle Scholar
  125. 125.
    Marcus CL, Katz ES, Lutz J, Black CA, Galster P, Carson KA. Upper airway dynamic responses in children with the obstructive sleep apnea syndrome. Pediatr Res. 2005;57(1):99–107.PubMedCrossRefGoogle Scholar
  126. 126.
    Gozal D, Burnside MM. Increased upper airway collapsibility in children with obstructive sleep apnea during wakefulness. Am J Respir Crit Care Med. 2004;169(2):163–7.PubMedCrossRefGoogle Scholar
  127. 127.
    Katz ES, Marcus CL, White DP. Influence of airway pressure on genioglossus activity during sleep in normal children. Am J Respir Crit Care Med. 2006;173(8):902–9.PubMedCrossRefGoogle Scholar
  128. 128.
    Katz ES, White DP. Genioglossus activity in children with obstructive sleep apnea during wakefulness and sleep onset. Am J Respir Crit Care Med. 2003;168(6):664–70.PubMedCrossRefGoogle Scholar
  129. 129.
    Onal E, Burrows DL, Hart RH, Lopata M. Induction of periodic breathing during sleep causes upper airway obstruction in humans. J Appl Physiol. 1986;61(4):1438–43.PubMedGoogle Scholar
  130. 130.
    Hudgel DW, Harasick T. Fluctuation in timing of upper airway and chest wall inspiratory muscle activity in obstructive sleep apnea. J Appl Physiol. 1990;69(2):443–50.PubMedGoogle Scholar
  131. 131.
    Younes M, Ostrowski M, Thompson W, Leslie C, Shewchuk W. Chemical control stability in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2001;163(5):1181–90.PubMedGoogle Scholar
  132. 132.
    Asyali MH, Berry RB, Khoo MC. Assessment of closed-loop ventilatory stability in obstructive sleep apnea. IEEE Trans Biomed Eng. 2002;49(3):206–16.PubMedCrossRefGoogle Scholar
  133. 133.
    White DP. Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med. 2005;172(11):1363–70.PubMedCrossRefGoogle Scholar
  134. 134.
    Wellman A, Malhotra A, Fogel RB, Edwards JK, Schory K, White DP. Respiratory system loop gain in normal men and women measured with ­proportional-assist ventilation. J Appl Physiol. 2003;94(1):205–12.PubMedGoogle Scholar
  135. 135.
    Browne HA, Adams L, Simonds AK, Morrell MJ. Ageing does not influence the sleep-related decrease in the hypercapnic ventilatory response. Eur Respir J. 2003;21(3):523–9.PubMedCrossRefGoogle Scholar
  136. 136.
    Wellman A, Jordan AS, Malhotra A, et al. Ventilatory control and airway anatomy in obstructive sleep apnea. Am J Respir Crit Care Med. 2004;170(11):1225–32.PubMedCrossRefGoogle Scholar
  137. 137.
    Bradley TD, Martinez D, Rutherford R, et al. Physiological determinants of nocturnal arterial oxygenation in patients with obstructive sleep apnea. J Appl Physiol. 1985;59(5):1364–8.PubMedGoogle Scholar
  138. 138.
    Gleeson K, Zwillich CW, White DP. Chemo­sensitivity and the ventilatory response to airflow obstruction during sleep. J Appl Physiol. 1989;67(4):1630–7.PubMedGoogle Scholar
  139. 139.
    Gleeson K, Zwillich CW, White DP. The influence of increasing ventilatory effort on arousal from sleep. Am Rev Respir Dis. 1990;142(2):295–300.PubMedGoogle Scholar
  140. 140.
    Younes M. Role of arousals in the pathogenesis of obstructive sleep apnea. Am J Respir Crit Care Med. 2004;169(5):623–33.PubMedCrossRefGoogle Scholar
  141. 141.
    Marcus CL. Obstructive sleep apnea syndrome: differences between children and adults. Sleep. 2000;23 Suppl 4:S140–1.PubMedGoogle Scholar
  142. 142.
    Marcus CL, Lutz J, Carroll JL, Bamford O. Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. J Appl Physiol. 1998;84(6):1926–36.PubMedGoogle Scholar
  143. 143.
    Gozal D, Arens R, Omlin KJ, et al. Ventilatory response to consecutive short hypercapnic challenges in children with obstructive sleep apnea. J Appl Physiol. 1995;79(5):1608–14.PubMedGoogle Scholar
  144. 144.
    Gozal D, Torres JE, Menendez AA. Longitudinal assessment of hypercapnic ventilatory drive after tracheotomy in a patient with the Prader-Willi ­syndrome. Eur Respir J. 1996;9(7):1565–8.PubMedCrossRefGoogle Scholar
  145. 145.
    Marcus CL, Gozal D, Arens R, et al. Ventilatory responses during wakefulness in children with obstructive sleep apnea. Am J Respir Crit Care Med. 1994;149(3 Pt 1):715–21.PubMedGoogle Scholar
  146. 146.
    Rapoport DM, Garay SM, Epstein H, Goldring RM. Hypercapnia in the obstructive sleep apnea syndrome. A reevaluation of the “Pickwickian syndrome”. Chest. 1986;89(5):627–35.PubMedCrossRefGoogle Scholar
  147. 147.
    Malhotra A, White DP. Obstructive sleep apnoea. Lancet. 2002;360(9328):237–45.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Newborn Department and Sleep LabWolfson HospitalHulonIsrael
  2. 2.Department of Pediatrics and Sleep LabCarmel Medical CenterHaifaIsrael
  3. 3.Pediatrics Department and Sleep LabRambam Medical Center and Technion Faculty of MedicineHaifaIsrael

Personalised recommendations