0
September 11, 1991, Vol 266, No. 10 >
ARTICLE | September 11, 1991

Pathophysiology of Upper Airway Closure During Sleep FREE

Samuel T. Kuna, MD; Giuseppe Sant'Ambrogio, MD
[+] Author Affiliations

Reprint requests to Pulmonary Division, E-61, The University of Texas Medical Branch. Galveston, TX 77550-2778 (Dr Kuna).


JAMA. 1991;266(10):1384-1389. doi:10.1001/jama.1991.03470100076036
Text Size: A A A
Published online
Article
References

While the upper airway normally remains patent during quiet breathing in wakefulness and sleep, patients with obstructive sleep apnea have repetitive periods of upper airway closure during sleep. The upper airway closures usually occur at various sites in the pharynx. The patency of the potentially collapsible pharynx during inspiration depends on the balance between subatmospheric pressure in the pharyngeal airway and airway dilating forces generated by pharyngeal muscles. The pressure required to collapse the upper airway in the absence of upper airway muscle activity, ie, closing pressure, is normally subatmospheric. In obstructive sleep apnea, positive pressures are required to maintain patency of the passive upper airway. The pathophysiologic mechanisms underlying upper airway closures during sleep form the basis for the treatment of obstructive sleep apnea. In general, these treatment modalities attempt to (1) raise the pharyngeal pressure above the closing pressure, (2) decrease the closing pressure, or (3) increase upper airway muscle activity.

(JAMA. 1991;266:1384-1389)

REFERENCES

1 +
Wilson SL, Thach BT, Brouillette RT, Abu-Osba YK.  Upper airway patency in the human infant: influence of airway pressure and posture. J Appl Physiol . 1980;;48:500-504.
2 +
Kuna ST, Bedi DG, Ryckman C.  Effect of nasal airway positive pressure on upper airway size and configuration. Am Rev Respir Dis . 1988;;138: 969-975.
3 +
Chaban R, Cole P, Hoffstein V.  Site of upper airway obstruction in patients with idiopathic obstructive sleep apnea. Laryngoscope . 1988;;98: 641-647.
4 +
Suratt PM, Dee P, Atkinson RL, Armstrong P, Wilhoit SC.  Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis . 1983;;127:487-492.
5 +
Hudgel DW.  Variable site of upper airway narrowing among obstructive sleep apnea patients. J Appl Physiol . 1986;;61:1403-1409.
6 +
Launois SH, Feroah TR, Campbell WN, Whitelaw WA, Remmers JE.  Site of obstruction in obstructive sleep apnea: influence on the outcome of uvulopalatopharyngoplasty. Am Rev Respir Dis . 1990;;141:A861.
7 +
Shepard JW, Thawley SE.  Localization of upper airway collapse during sleep in patients with obstructive sleep apnea. Am Rev Respir Dis . 1990;;141:1350-1355.
8 +
Remmers JE, deGroot WJ, Sauerland EK, Anch AM.  Pathogenesis of upper airway occlusion during sleep. J Appl Physiol . 1978;;44:931-938.
9 +
Suratt PM, McTier R, Wilhoit SC.  Alae nasi electromyographic activity and timing in obstructive sleep apnea. J Appl Physiol . 1985;;58:1252-1256.
10 +
Anch AM, Remmers JE, Sauerland EK, deGroot WJ.  Oropharyngeal patency during waking and sleep in the pickwickian syndrome: electromyographic activity of the tensor veli palatini. Electromyogr Clin Neurophysiol . 1981;;21:317-330.
11 +
Jeffries B, Brouillette RT, Hunt CE.  Electromyographic study of some accessory muscles of respiration in children with obstructive sleep apnea. Am Rev Respir Dis . 1984;;129:696-702.
12 +
Hollowell DE, Jensen P, Funsten AW, Suratt PM.  Activation of masseter muscles during sleep in obstructive sleep apnea. Am Rev Respir Dis . 1989;;139:A448.
13 +
Brouillette RT, Thach BT.  A neuromuscular mechanism maintaining extrathoracic airway patency. J Appl Physiol . 1979;;46:772-779.
14 +
Strohl KP, Fouke JM.  Dilating forces on the upper airway of anesthetized dogs. J Appl Physiol . 1985;;58:452-458.
15 +
Van Lunteren E, Van De Graaff WB, Parker DM, et al.  Activity of upper airway muscles during augmented breaths. Respir Physiol . 1983;;53:87-98.
16 +
Van Lunteren E, Van de Graaff WB, Parker DM, et al.  Nasal and laryngeal reflex responses to negative upper airway pressure. J Appl Physiol . 1984;;56:746-752.
17 +
Hudgel DW, Chapman KR, Faulks C, Hendricks C.  Changes in inspiratory muscle electrical activity and upper airway resistance during periodic breathing induced by hypoxia during sleep. Am Rev Respir Dis . 1987;;135:899-906.
18 +
Onal E, Burrows DL, Hart RH, Lopata M.  Induction of periodic breathing during sleep causes upper airway obstruction in humans. J Appl Physiol . 1986;;61:1438-1443.
19 +
Hyland RH, Hutcheon MA, Perl A, et al.  Upper airway occlusion induced by diaphragm pacing for primary alveolar hypoventilation: implications for the pathogenesis of obstructive sleep apnea. Am Rev Respir Dis . 1981;;124:180-185.
20 +
Simonds AK, Branthwaite MA.  Efficiency of negative ventilatory equipment. Thorax . 1985;; 40:213.
21 +
Remmers JE.  Anatomy and physiology of upper airway obstruction.  In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine . Philadelphia, Pa: WB Saunders Co; 1989;:525-536.
22 +
Issa FG, Sullivan CE.  Arousal and breathing responses to airway occlusion in healthy sleeping adults. J Appl Physiol . 1983;;55:1113-1119.
23 +
Issa FG, Sullivan CE.  Upper airway closing pressures in snorers. J Appl Physiol . 1984;;57: 528-535.
24 +
Issa FG, Sullivan CE.  Upper airway closing pressures in obstructive sleep apnea. J Appl Physiol . 1984;;57:520-527.
25 +
Sant'Ambrogio FB, Mathew OP, Clark WD, Sant'Ambrogio G.  Laryngeal influences on breathing pattern and posterior cricoarytenoid muscle activity. J Appl Physiol . 1985;;58:1298-1304.
26 +
Mathew OP.  Upper airway negative-pressure effects on respiratory activity of upper airway muscles. J Appl Physiol . 1984;;56:500-505.
27 +
Kuna ST, Woodson G, Sant'Ambrogio G.  Effect of anesthetization of laryngeal receptors on pulmonary function testing in man. Am Rev Respir Dis . 1988;;137:656-661.
28 +
Basner R, Simon PM, Schwartzstein RM.  Breathing route influences upper airway muscle activity in awake normal adults. J Appl Physiol . 1989;;66:1766-1771.
29 +
Basner RC, Ringler J, Berkowitz S, et al.  Effect of inspired air temperature on genioglossus activity during nose breathing in awake humans. J Appl Physiol . 1990;;69:1098-1103.
30 +
Leiter JC, Daubenspeck JA.  Selective reflex activation of the genioglossus in humans. J Appl Physiol . 1990;;68:2581-2587.
31 +
Horner RL, Innes JA, Murphy K, Guz A.  Evidence for reflex upper airway dilator muscle activation by sudden negative airway pressure in man. J Physiol Lond . 1991;;436:15-29.
32 +
Homer RL, Innes JA, Holden HB, Guz A.  Afferent pathway(s) for pharyngeal dilator reflex to negative airway pressure in man: a study using upper airway anesthesia. J Physiol Lond . 1991;;436:31-44.
33 +
McNicholas WT, Coffey M, McDonnell T, O'Regan R, Fitzgerald MX.  Upper airway obstruction during sleep in normal subjects after selective topical oropharyngeal anesthesia. Am Rev Respir Dis . 1987;;135:1316-1319.
34 +
Cohen G, Henderson-Smart DJ.  Upper airway muscle activity during nasal occlusion in newborn babies. J Appl Physiol . 1987;;62:2026-2030.
35 +
Carlo WA, Miller MJ, Martin RJ.  Differential response of respiratory muscles to airway occlusion in infants. J Appl Physiol . 1985;;59:847-852.
36 +
Kuna ST, Smickley JS, Insalaco G.  Posterior cricoarytenoid muscle activity during wakefulness and sleep in normal adults. J Appl Physiol . 1990;;68:1746-1754.
37 +
Kuna ST, Smickley J.  Response of genioglossus muscle activity to nasal airway occlusion in normal sleeping adults. J Appl Physiol . 1988;; 65:1332-1339.
38 +
Hudgel DW, Hendricks C, Hamilton HB.  Characteristics of the upper airway pressure-flow relationship during sleep. J Appl Physiol . 1988;; 64:1930-1935.
39 +
Wiegand L, Zwillich CW, White DP.  Collapsibility of the human upper airway during normal sleep. J Appl Physiol . 1989;;66:1800-1808.
40 +
Hudgel DW, Hendricks C.  Palate and hypopharynx: sites of inspiratory airflow limitation within the upper airway during sleep. Am Rev Respir Dis . 1988;;138:1542-1547.
41 +
Sauerland EK, Harper RM.  The human tongue during sleep: electromyographic activity of the genioglossus muscle. Exp Neurol . 1976;;51:160-170.
42 +
Sauerland EK, Orr WC, Hairston LE.  EMG patterns of oropharyngeal muscles during respiration in wakefulness and sleep. Electromyogr Clin Neurophysiol . 1981;;21:307-316.
43 +
Wiegand DA, Latz B, Zwillich CW, Wiegand L.  Geniohyoid muscle activity in normal men during wakefulness and sleep. J Appl Physiol . 1990;;69:1262-1269.
44 +
Guilleminault C.  Clinical features and evaluation of obstructive sleep apnea . In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine . Philadelphia, Pa: WB Saunders Co; 1989;:525-536.
45 +
Sullivan CE, Issa FG, Berthon-Jones M, Eves L.  Reversal of obstructive sleep apnea by continuous positive pressure applied through the nares. Lancet . 1981;;1:862-865.
46 +
Sullivan CE, Berthon-Jones M, Issa FG, McCauley VB, Costas LJV.  Home treatment of obstructive sleep apnea with continuous positive airway pressure applied through a nose mask. Bull Eur Physiopathol Respir . 1984;;20:49-54.
47 +
Strohl KP, Redline S.  Nasal CPAP therapy, upper airway muscle activation, and obstructive sleep apnea. Am Rev Respir Dis . 1986;;134:555-558.
48 +
Fujita S, Conway W, Zorick F, Roth T.  Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg . 1981;;89: 923-934.
49 +
Dickson RI, Blokmanis A.  Treatment of obstruction sleep apnea by uvulopalatopharyngoplasty. Laryngoscope . 1987;;97:1054-1059.
50 +
Fujita S, Conway WA, Zorick FJ, et al.  Evaluation of the effectiveness of uvulopalatopharyngoplasty. Laryngoscope . 1985;;95:70-74.
51 +
Guilleminault C, Hayes B, Smoth FB.  Palatopharyngoplasty and obstructive sleep apnea: a review of 35 cases. Bull Eur Physiopathol Respir . 1983;;19:595-599.
52 +
Conway W, Fujita S, Zorick F, Roehrs T, Wittig R, Roth T.  Uvulopalatopharyngoplasty: 1 year follow-up. Chest . 1985;;88:385-387.
53 +
Gislason T, Lindholm C, Almqvist M, et al.  Uvulopalatopharyngoplasty in the sleep apnea syndrome: predictors of results. Arch Otolaryngol Head Neck Surg . 1988;;114:45-51.
54 +
Ryan CF, Dickson RI, Lowe AA, Blokmanis A, Fleetham JA.  Upper airway measurements predict response to uvulopalatopharyngoplasty in obstructive sleep apnea. Laryngoscope . 1990;;100: 248-253.
55 +
Olsen KD, Kern EB.  Nasal influences on snoring and obstructive sleep apnea. Mayo Clin Proc . 1990;;65:1095-1105.
56 +
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;;103:850-855.
57 +
Homer 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: 613-622.
58 +
Rivlin J, Hoffstein V, Kalbfleisch J, McNicholas W, Zamel N, Bryan AC.  Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis . 1984;;129:355-360.
59 +
Van de Graaff WB, Gottfried SB, Mitra J, van Lunteren E, Cherniack NS, Strohl KP.  Respiratory function of hyoid muscles and hyoid arch. J Appl Physiol . 1984;;57:197-204.
60 +
Guilleminault C, Korobkin R, Winkle R.  A review of 50 children with obstructive sleep apnea syndrome. Lung . 1981;;159:275-287.
61 +
Cravath RE, Pollack CP, Borowiecki B.  Hypoventilation during sleep in children who have lymphoid airway obstruction treated by nasopharyngeal tube T and A. Pediatrics . 1977;;59:865-867.
62 +
Rajagobal KR, Abbrecht PH, Derderias SS, et al.  Obstructive sleep apnea in hypothyroidism. Ann Intern Med . 1984;;101:491-494.
63 +
Perks WH, Horrocks PM, Cooper RA, et al.  Sleep apnea in acromegaly. BMJ . 1980;;280: 894-897.
64 +
Hudgel DW, Brooks LI, Harasick TM.  Measurements of awake upper airway caliber do not predict upper airway resistance during sleep. Am Rev Respir Dis . 1989;;139:A374.
65 +
Strohl KP, Saunders NA, Feldman NT, Hallett M.  Obstructive sleep apnea in family members. N Engl J Med . 1978;;299:969-973.
66 +
El Bayadi S, Millman RP, Tishler PV, et al.  A family study of sleep apnea. Chest . 1990;;98:554-559.
67 +
Bonora M, Shields GI, Knuth SL, Bartlett D Jr, St John WM.  Selective depression by ethanol of upper airway respiratory motor activity in cats. Am Rev Respir Dis . 1984;;130:156-161.
68 +
Bonora M, St John WM, Bledsoe TA.  Differential elevation by protriptyline and depression by diazepam of upper airway respiratory motor activity. Am Rev Respir Dis . 1985;;131:41-45.
69 +
Taasan VC, Block AJ, Boysen PG, Wynne JW.  Alcohol increases sleep apnea and oxygen desaturation in asymptomatic men. Am J Med . 1981;;71: 240-245.
70 +
Dolly FR, Block AJ.  Effect of flurazepam on sleep-disordered breathing and nocturnal oxygen. desaturation in asymptomatic subjects. Am J Med . 1982;;73:239-242.
71 +
Nishino T, Shirahata M, Yonezawa T, Honda Y.  Comparison of changes in the hypoglossal and phrenic nerve activity in response to increasing depth of anesthesia in cats. Anesthesiology . 1984;;60:19-24.
72 +
Remmers JE, Anch AM, deGroot WJ, Baker JP, Sauerland EK.  Oropharyngeal muscle tone in obstructive sleep apnea before and after strychnine. Sleep . 1980;;3:447-453.
73 +
Brownell LG, West P, Sweatman P, Acres JC, Kryger MH.  Protriptyline in obstructive sleep apnea: a double-blind trial. N Engl J Med . 1982;;307:1037-1042.
74 +
Gothe B, Strohl KP, Levin S, Chernick NS.  Nicotine: a different approach to treatment of obstructive sleep apnea. Chest . 1985;;87:11-17.
75 +
Miki H, Hida W, Kikuchi Y, et al.  Effect of hypoglossal stimulation and pharyngeal lubrication on the opening of obstructed upper airway. Am Rev Respir Dis . 1988;;137:A125.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Wilson SL, Thach BT, Brouillette RT, Abu-Osba YK.  Upper airway patency in the human infant: influence of airway pressure and posture. J Appl Physiol . 1980;;48:500-504.
2 +
Kuna ST, Bedi DG, Ryckman C.  Effect of nasal airway positive pressure on upper airway size and configuration. Am Rev Respir Dis . 1988;;138: 969-975.
3 +
Chaban R, Cole P, Hoffstein V.  Site of upper airway obstruction in patients with idiopathic obstructive sleep apnea. Laryngoscope . 1988;;98: 641-647.
4 +
Suratt PM, Dee P, Atkinson RL, Armstrong P, Wilhoit SC.  Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis . 1983;;127:487-492.
5 +
Hudgel DW.  Variable site of upper airway narrowing among obstructive sleep apnea patients. J Appl Physiol . 1986;;61:1403-1409.
6 +
Launois SH, Feroah TR, Campbell WN, Whitelaw WA, Remmers JE.  Site of obstruction in obstructive sleep apnea: influence on the outcome of uvulopalatopharyngoplasty. Am Rev Respir Dis . 1990;;141:A861.
7 +
Shepard JW, Thawley SE.  Localization of upper airway collapse during sleep in patients with obstructive sleep apnea. Am Rev Respir Dis . 1990;;141:1350-1355.
8 +
Remmers JE, deGroot WJ, Sauerland EK, Anch AM.  Pathogenesis of upper airway occlusion during sleep. J Appl Physiol . 1978;;44:931-938.
9 +
Suratt PM, McTier R, Wilhoit SC.  Alae nasi electromyographic activity and timing in obstructive sleep apnea. J Appl Physiol . 1985;;58:1252-1256.
10 +
Anch AM, Remmers JE, Sauerland EK, deGroot WJ.  Oropharyngeal patency during waking and sleep in the pickwickian syndrome: electromyographic activity of the tensor veli palatini. Electromyogr Clin Neurophysiol . 1981;;21:317-330.
11 +
Jeffries B, Brouillette RT, Hunt CE.  Electromyographic study of some accessory muscles of respiration in children with obstructive sleep apnea. Am Rev Respir Dis . 1984;;129:696-702.
12 +
Hollowell DE, Jensen P, Funsten AW, Suratt PM.  Activation of masseter muscles during sleep in obstructive sleep apnea. Am Rev Respir Dis . 1989;;139:A448.
13 +
Brouillette RT, Thach BT.  A neuromuscular mechanism maintaining extrathoracic airway patency. J Appl Physiol . 1979;;46:772-779.
14 +
Strohl KP, Fouke JM.  Dilating forces on the upper airway of anesthetized dogs. J Appl Physiol . 1985;;58:452-458.
15 +
Van Lunteren E, Van De Graaff WB, Parker DM, et al.  Activity of upper airway muscles during augmented breaths. Respir Physiol . 1983;;53:87-98.
16 +
Van Lunteren E, Van de Graaff WB, Parker DM, et al.  Nasal and laryngeal reflex responses to negative upper airway pressure. J Appl Physiol . 1984;;56:746-752.
17 +
Hudgel DW, Chapman KR, Faulks C, Hendricks C.  Changes in inspiratory muscle electrical activity and upper airway resistance during periodic breathing induced by hypoxia during sleep. Am Rev Respir Dis . 1987;;135:899-906.
18 +
Onal E, Burrows DL, Hart RH, Lopata M.  Induction of periodic breathing during sleep causes upper airway obstruction in humans. J Appl Physiol . 1986;;61:1438-1443.
19 +
Hyland RH, Hutcheon MA, Perl A, et al.  Upper airway occlusion induced by diaphragm pacing for primary alveolar hypoventilation: implications for the pathogenesis of obstructive sleep apnea. Am Rev Respir Dis . 1981;;124:180-185.
20 +
Simonds AK, Branthwaite MA.  Efficiency of negative ventilatory equipment. Thorax . 1985;; 40:213.
21 +
Remmers JE.  Anatomy and physiology of upper airway obstruction.  In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine . Philadelphia, Pa: WB Saunders Co; 1989;:525-536.
22 +
Issa FG, Sullivan CE.  Arousal and breathing responses to airway occlusion in healthy sleeping adults. J Appl Physiol . 1983;;55:1113-1119.
23 +
Issa FG, Sullivan CE.  Upper airway closing pressures in snorers. J Appl Physiol . 1984;;57: 528-535.
24 +
Issa FG, Sullivan CE.  Upper airway closing pressures in obstructive sleep apnea. J Appl Physiol . 1984;;57:520-527.
25 +
Sant'Ambrogio FB, Mathew OP, Clark WD, Sant'Ambrogio G.  Laryngeal influences on breathing pattern and posterior cricoarytenoid muscle activity. J Appl Physiol . 1985;;58:1298-1304.
26 +
Mathew OP.  Upper airway negative-pressure effects on respiratory activity of upper airway muscles. J Appl Physiol . 1984;;56:500-505.
27 +
Kuna ST, Woodson G, Sant'Ambrogio G.  Effect of anesthetization of laryngeal receptors on pulmonary function testing in man. Am Rev Respir Dis . 1988;;137:656-661.
28 +
Basner R, Simon PM, Schwartzstein RM.  Breathing route influences upper airway muscle activity in awake normal adults. J Appl Physiol . 1989;;66:1766-1771.
29 +
Basner RC, Ringler J, Berkowitz S, et al.  Effect of inspired air temperature on genioglossus activity during nose breathing in awake humans. J Appl Physiol . 1990;;69:1098-1103.
30 +
Leiter JC, Daubenspeck JA.  Selective reflex activation of the genioglossus in humans. J Appl Physiol . 1990;;68:2581-2587.
31 +
Horner RL, Innes JA, Murphy K, Guz A.  Evidence for reflex upper airway dilator muscle activation by sudden negative airway pressure in man. J Physiol Lond . 1991;;436:15-29.
32 +
Homer RL, Innes JA, Holden HB, Guz A.  Afferent pathway(s) for pharyngeal dilator reflex to negative airway pressure in man: a study using upper airway anesthesia. J Physiol Lond . 1991;;436:31-44.
33 +
McNicholas WT, Coffey M, McDonnell T, O'Regan R, Fitzgerald MX.  Upper airway obstruction during sleep in normal subjects after selective topical oropharyngeal anesthesia. Am Rev Respir Dis . 1987;;135:1316-1319.
34 +
Cohen G, Henderson-Smart DJ.  Upper airway muscle activity during nasal occlusion in newborn babies. J Appl Physiol . 1987;;62:2026-2030.
35 +
Carlo WA, Miller MJ, Martin RJ.  Differential response of respiratory muscles to airway occlusion in infants. J Appl Physiol . 1985;;59:847-852.
36 +
Kuna ST, Smickley JS, Insalaco G.  Posterior cricoarytenoid muscle activity during wakefulness and sleep in normal adults. J Appl Physiol . 1990;;68:1746-1754.
37 +
Kuna ST, Smickley J.  Response of genioglossus muscle activity to nasal airway occlusion in normal sleeping adults. J Appl Physiol . 1988;; 65:1332-1339.
38 +
Hudgel DW, Hendricks C, Hamilton HB.  Characteristics of the upper airway pressure-flow relationship during sleep. J Appl Physiol . 1988;; 64:1930-1935.
39 +
Wiegand L, Zwillich CW, White DP.  Collapsibility of the human upper airway during normal sleep. J Appl Physiol . 1989;;66:1800-1808.
40 +
Hudgel DW, Hendricks C.  Palate and hypopharynx: sites of inspiratory airflow limitation within the upper airway during sleep. Am Rev Respir Dis . 1988;;138:1542-1547.
41 +
Sauerland EK, Harper RM.  The human tongue during sleep: electromyographic activity of the genioglossus muscle. Exp Neurol . 1976;;51:160-170.
42 +
Sauerland EK, Orr WC, Hairston LE.  EMG patterns of oropharyngeal muscles during respiration in wakefulness and sleep. Electromyogr Clin Neurophysiol . 1981;;21:307-316.
43 +
Wiegand DA, Latz B, Zwillich CW, Wiegand L.  Geniohyoid muscle activity in normal men during wakefulness and sleep. J Appl Physiol . 1990;;69:1262-1269.
44 +
Guilleminault C.  Clinical features and evaluation of obstructive sleep apnea . In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine . Philadelphia, Pa: WB Saunders Co; 1989;:525-536.
45 +
Sullivan CE, Issa FG, Berthon-Jones M, Eves L.  Reversal of obstructive sleep apnea by continuous positive pressure applied through the nares. Lancet . 1981;;1:862-865.
46 +
Sullivan CE, Berthon-Jones M, Issa FG, McCauley VB, Costas LJV.  Home treatment of obstructive sleep apnea with continuous positive airway pressure applied through a nose mask. Bull Eur Physiopathol Respir . 1984;;20:49-54.
47 +
Strohl KP, Redline S.  Nasal CPAP therapy, upper airway muscle activation, and obstructive sleep apnea. Am Rev Respir Dis . 1986;;134:555-558.
48 +
Fujita S, Conway W, Zorick F, Roth T.  Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg . 1981;;89: 923-934.
49 +
Dickson RI, Blokmanis A.  Treatment of obstruction sleep apnea by uvulopalatopharyngoplasty. Laryngoscope . 1987;;97:1054-1059.
50 +
Fujita S, Conway WA, Zorick FJ, et al.  Evaluation of the effectiveness of uvulopalatopharyngoplasty. Laryngoscope . 1985;;95:70-74.
51 +
Guilleminault C, Hayes B, Smoth FB.  Palatopharyngoplasty and obstructive sleep apnea: a review of 35 cases. Bull Eur Physiopathol Respir . 1983;;19:595-599.
52 +
Conway W, Fujita S, Zorick F, Roehrs T, Wittig R, Roth T.  Uvulopalatopharyngoplasty: 1 year follow-up. Chest . 1985;;88:385-387.
53 +
Gislason T, Lindholm C, Almqvist M, et al.  Uvulopalatopharyngoplasty in the sleep apnea syndrome: predictors of results. Arch Otolaryngol Head Neck Surg . 1988;;114:45-51.
54 +
Ryan CF, Dickson RI, Lowe AA, Blokmanis A, Fleetham JA.  Upper airway measurements predict response to uvulopalatopharyngoplasty in obstructive sleep apnea. Laryngoscope . 1990;;100: 248-253.
55 +
Olsen KD, Kern EB.  Nasal influences on snoring and obstructive sleep apnea. Mayo Clin Proc . 1990;;65:1095-1105.
56 +
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;;103:850-855.
57 +
Homer 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: 613-622.
58 +
Rivlin J, Hoffstein V, Kalbfleisch J, McNicholas W, Zamel N, Bryan AC.  Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis . 1984;;129:355-360.
59 +
Van de Graaff WB, Gottfried SB, Mitra J, van Lunteren E, Cherniack NS, Strohl KP.  Respiratory function of hyoid muscles and hyoid arch. J Appl Physiol . 1984;;57:197-204.
60 +
Guilleminault C, Korobkin R, Winkle R.  A review of 50 children with obstructive sleep apnea syndrome. Lung . 1981;;159:275-287.
61 +
Cravath RE, Pollack CP, Borowiecki B.  Hypoventilation during sleep in children who have lymphoid airway obstruction treated by nasopharyngeal tube T and A. Pediatrics . 1977;;59:865-867.
62 +
Rajagobal KR, Abbrecht PH, Derderias SS, et al.  Obstructive sleep apnea in hypothyroidism. Ann Intern Med . 1984;;101:491-494.
63 +
Perks WH, Horrocks PM, Cooper RA, et al.  Sleep apnea in acromegaly. BMJ . 1980;;280: 894-897.
64 +
Hudgel DW, Brooks LI, Harasick TM.  Measurements of awake upper airway caliber do not predict upper airway resistance during sleep. Am Rev Respir Dis . 1989;;139:A374.
65 +
Strohl KP, Saunders NA, Feldman NT, Hallett M.  Obstructive sleep apnea in family members. N Engl J Med . 1978;;299:969-973.
66 +
El Bayadi S, Millman RP, Tishler PV, et al.  A family study of sleep apnea. Chest . 1990;;98:554-559.
67 +
Bonora M, Shields GI, Knuth SL, Bartlett D Jr, St John WM.  Selective depression by ethanol of upper airway respiratory motor activity in cats. Am Rev Respir Dis . 1984;;130:156-161.
68 +
Bonora M, St John WM, Bledsoe TA.  Differential elevation by protriptyline and depression by diazepam of upper airway respiratory motor activity. Am Rev Respir Dis . 1985;;131:41-45.
69 +
Taasan VC, Block AJ, Boysen PG, Wynne JW.  Alcohol increases sleep apnea and oxygen desaturation in asymptomatic men. Am J Med . 1981;;71: 240-245.
70 +
Dolly FR, Block AJ.  Effect of flurazepam on sleep-disordered breathing and nocturnal oxygen. desaturation in asymptomatic subjects. Am J Med . 1982;;73:239-242.
71 +
Nishino T, Shirahata M, Yonezawa T, Honda Y.  Comparison of changes in the hypoglossal and phrenic nerve activity in response to increasing depth of anesthesia in cats. Anesthesiology . 1984;;60:19-24.
72 +
Remmers JE, Anch AM, deGroot WJ, Baker JP, Sauerland EK.  Oropharyngeal muscle tone in obstructive sleep apnea before and after strychnine. Sleep . 1980;;3:447-453.
73 +
Brownell LG, West P, Sweatman P, Acres JC, Kryger MH.  Protriptyline in obstructive sleep apnea: a double-blind trial. N Engl J Med . 1982;;307:1037-1042.
74 +
Gothe B, Strohl KP, Levin S, Chernick NS.  Nicotine: a different approach to treatment of obstructive sleep apnea. Chest . 1985;;87:11-17.
75 +
Miki H, Hida W, Kikuchi Y, et al.  Effect of hypoglossal stimulation and pharyngeal lubrication on the opening of obstructed upper airway. Am Rev Respir Dis . 1988;;137:A125.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems