Auto-adjusting positive airway pressure: the fine line between engineering and medicine

Sleep And Breathing · 2025-07-28 · 9 citations

Auto-adjusting positive airway pressure (APAP), unlike continuous PAP (CPAP), dynamically adjusts treatment pressure in response to events detected automatically from a derived flow signal. Introduced in the 90's, APAP quickly became a key tool in sleep clinics, initially serving as a faster alternative to manual titration for patients with obstructive sleep apnea (OSA), and later also as a long-term treatment option to expedite follow-up visits. APAP and CPAP are overall comparable in terms of adherence, efficacy and control of symptoms. However, concern remains that APAP offers less control of chronic health outcomes, such as blood pressure, kidney function and glycemic values. Other APAP-related challenges entail engineering aspects. A major issue is that APAP algorithms-which govern event detection/identification and pressure adjustments-are proprietary of and vary among manufacturers, making them poorly understood by clinicians. Furthermore, APAP algorithms do not always match-up well when compared to both manual titration or manually scored polysomnography, particularly in the presence of unintentional leak. Variability in event detection, leak compensation, and pressure adjustment algorithms among devices adds another layer of complexity to clinical decision-making. All this complicates the management of OSA patients, who could be left with substantial residual disordered breathing, high leak, and a wide pressure range.This review aims to bridge the gap between the clinical and engineering perspectives of APAP, providing an up-to-date overview of current knowledge and existing challenges that sleep clinicians should consider when managing OSA patients with PAP therapy.

Force control deficits in rapid eye movement behavior disorder and Parkinson’s disease

Clinical Neurophysiology · 2025-05-25 · 1 citations

OBJECTIVE: This study aimed to determine if there are deficits in force variability, force increase, force decrease and force errors in rapid eye movement behavior disorder (RBD) using established force control paradigms. METHODS: A cohort of 27 controls, 37 RBD and 37 early-stage Parkinson's disease (PD) were investigated. Individuals completed constant force and ballistic force control for the finger and ankle. RESULTS: There was greater force variability in RBD compared with controls and PD during the constant force tasks (p < 0.05). Additionally, we split the RBD group into those with mild and moderate motor impairments and found both groups had higher force variability compared with controls (p < 0.05). PD were slower at increasing and decreasing force (p < 0.05) and this was not observed in the RBD group. CONCLUSION: These findings provide new evidence that force variability may be one of the earliest markers of motor dysfunction in RBD before a subsequent diagnosis of neurological disease. SIGNIFICANCE: These findings provide new and important insights into the motor physiological changes in force control in RBD and PD, which may inform future biomarker studies.

Functional and free-water imaging in rapid eye movement behaviour disorder and Parkinson’s disease

Brain Communications · 2024-01-01 · 11 citations

It is established that one of the best predictors of a future diagnosis of Parkinson's disease is a current diagnosis of rapid eye movement behaviour disorder (RBD). In such patients, this provides a unique opportunity to study brain physiology and behavioural motor features of RBD that may precede early-stage Parkinson's disease. Based on prior work in early-stage Parkinson's disease, we aim to determine if the function of corticostriatal and cerebellar regions are impaired in RBD using task-based functional MRI and if structural changes can be detected within the caudate, putamen and substantia nigra in RBD using free-water imaging. To assess motor function, we measured performance on the Purdue Pegboard Test, which is affected in patients with RBD and Parkinson's disease. A cohort of 24 RBD, 39 early-stage Parkinson's disease and 25 controls were investigated. All participants were imaged at 3 Telsa. Individuals performed a unimanual grip force task during functional imaging. Participants also completed scales to assess cognition, sleep and motor symptoms. We found decreased functional activity in both RBD and Parkinson's disease within the motor cortex, caudate, putamen and thalamus compared with controls. There was elevated free-water-corrected fractional anisotropy in the putamen in RBD and Parkinson's disease and elevated free-water in the putamen and posterior substantia nigra in Parkinson's disease compared with controls. Participants with RBD and Parkinson's disease performed significantly worse on all tasks of the Purdue Pegboard Test compared with controls. The both hands task of the Purdue Pegboard Test was most sensitive in distinguishing between groups. A subgroup analysis of early-stage RBD (<2 years diagnosis) confirmed similar findings as those in the larger RBD group. These findings provide new evidence that the putamen is affected in early-stage RBD using both functional and free-water imaging. We also found evidence that the striatum, thalamus and motor cortex have reduced functional activity in early-stage RBD and Parkinson's disease. While the substantia nigra shows elevated free-water in Parkinson's disease, we did not observe this effect in early-stage RBD. These findings point to the corticostriatal and thalamocortical circuits being impaired in RBD patients.

A golfer with hypoventilation

Journal of Clinical Sleep Medicine · 2024-07-04

A case of central sleep apnea associated with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids

Journal of Clinical Sleep Medicine · 2024-08-16

Teenager with sleep and wakefulness at the wrong time

Journal of Clinical Sleep Medicine · 2023-02-21 · 1 citations

Atlas of Clinical Sleep Medicine

Elsevier eBooks · 2023 · 43 citations

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Patient with a concerning download

Journal of Clinical Sleep Medicine · 2023-03-07

A transition to the American Academy of Sleep Medicine–recommended hypopnea definition in adults: initiatives of the Hypopnea Scoring Rule Task Force

Journal of Clinical Sleep Medicine · 2022-02-24 · 53 citations

Detection of Common Arrhythmias by the Watch-PAT: Expression of Electrical Arrhythmias by Pulse Recording

Dove Medical Press (Taylor and Francis Group) · 2022-04-21 · 5 citations

Giora Pillar,1 Murray Berall,2 Richard B Berry,3 Tamar Etzioni,1 Yaakov Henkin,4 Dennis Hwang,5 Ibrahim Marai,6,7 Faheem Shehadeh,6 Prasanth Manthena,8 Anil Rama,9 Rebecca Spiegel,10 Thomas Penzel,11 Riva Tauman12 1Sleep Laboratory, Carmel Medical Center and Technion Faculty of Medicine, Haifa, Israel; 2Center of Sleep and Chronobiology, University of Toronto, Toronto, ON, Canada; 3UF Health Sleep Center, University of Florida, Gainesville, FL, USA; 4Cardiology Department, Soroka Medical Center, Be’er Sheva, Israel; 5Kaiser Permanente San Bernardino County Medical Center, Fontana, CA, USA; 6Cardiology Department, Rambam Medical Center, Haifa, Israel; 7Baruch Padeh Medical Center and the Azrieli Faculty of Medicine in the Galilee, Poriya, Israel; 8Sleep clinic, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA; 9Sleep Clinic, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA; 10Department of Neurology and Sleep Center, Stony Brook University Hospital, Stony Brook, NY, USA; 11Charite Universitätsmedizin Berlin, Sleep Medicine Center, Berlin, Germany; 12Sleep Disorders Center, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelCorrespondence: Giora Pillar, Sleep Laboratory, Carmel Medical Center and Technion Faculty of Medicine, Haifa, 31096, Israel, Tel +972 4 8250258, Fax +972 48250699, Email gpillar@technion.ac.ilBackground: The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea and is widely used worldwide as an ambulatory diagnostic tool. While it records peripheral arterial tone (PAT) and not electrocardiogram (ECG), the ability of it to detect arrhythmias is unknown and was not studied previously. Common arrhythmias such as atrial fibrillation (AF) or premature beats may be uniquely presented while recording PAT/pulse wave.Purpose: To examine the potential detection of common arrhythmias by analyzing the PAT amplitude and pulse rate/volume changes.Patients and Methods: Patients with suspected sleep disordered breathing (SDB) were recruited with preference for patients with previously diagnosed AF or congestive heart failure (CHF). They underwent simultaneous WP and PSG studies in 11 sleep centers. A novel algorithm was developed to detect arrhythmias while measuring PAT and was tested on these patients. Manual scoring of ECG channel (recorded as part of the PSG) was blinded to the automatically analyzed WP data.Results: A total of 84 patients aged 57± 16 (54 males) participated in this study. Their BMI was 30± 5.7Kg/m2. Of them, 41 had heart failure (49%) and 17 (20%) had AF. The sensitivity and specificity of the WP to detect AF segments (of at least 60 seconds) were 0.77 and 0.99, respectively. The correlation between the WP derived detection of premature beats (events/min) to that of the PSG one was 0.98 (p&amp;lt; 0.001).Conclusion: The novel automatic algorithm of the WP can reasonably detect AF and premature beats. We suggest that when the algorithm raises a flag for arrhythmia, the patients should shortly undergo ECG and/or Holter ECG study.Keywords: home sleep apnea test, WatchPAT, obstructive sleep apnea, arrhythmia, atrial fibrillation