Periodic Leg Movement, Nasal CPAP, and Expiratory Muscles

doi:10.1378/chest.11-1563

Chest

Volume 142, Issue 1, July 2012, Pages 111-118

https://doi.org/10.1378/chest.11-1563 Get rights and content

Background

Periodic leg movements (PLMs) may appear during nasal CPAP titration, persisting despite the elimination of hypopneas.

Methods

Systematic recordings of expiratory abdominal muscles on the right and left sides with surface electromyographic (EMG) electrodes lateral to navel, and close from the lateral side of abdomen, were added during nasal CPAP titration for treatment of obstructive sleep apnea (OSA). Positive airway pressure was titrated during nocturnal polysomnography, based on analysis of the flow curve derived from the CPAP equipment and EEG analysis, including persistence of phases A2 and A3 of the cyclic alternating pattern (CAP). The requirement was to eliminate American Association of Sleep Medicine (AASM)-defined hypopnea and also flow limitation and abnormal EEG patterns. When CPAP reached valid results, it was lowered at the time of awakening by 2 or 3 cm H₂O, and titration was performed again. Data collected during a 7-month period on adults with a prior diagnosis of OSA who had received treatment with nasal CPAP regardless of age and sex were rendered anonymous and were retrospectively rescored by a blinded investigator.

Results

Eighty-one successively seen patients with PLMs during CPAP titration were investigated. Elimination of AASM-defined hypopnea was not sufficient to eliminate the PLMs observed during the titration; higher CPAP eliminated flow limitation and CAP phases A2 and A3 and persisting PLMs. PLMs were associated with simultaneous EMG bursts in expiratory abdominal muscles.

Conclusions

The presence of PLMs during CPAP titration indicates the persistence of sleep-disordered breathing. PLMs during CPAP titration are related to the presence of abdominal expiratory muscle activity.

Section snippets

Research Protocol

All data collected during a 7-month period on successively seen adult patients with a prior diagnosis of obstructive sleep apnea (OSA), demonstrated by PSG, who had received treatment with nasal CPAP regardless of age and sex, were rendered anonymous. An individual not involved in the research protocol identified patients reported to have had PLMs during nasal CPAP titration, eliminating patients with a history of restless leg syndrome or other neurologic or clinical syndromes with a reported

Results

All successively monitored patients during a 7-month period who showed PLMs during nasal CPAP titration and who met the inclusion criteria were included in the study. Eighty-one patients were treated with nasal CPAP; the demographics are presented in Table 1.

Discussion

PLMs have been noted in patients with different types of SDB, including Cheyne-Stokes breathing.10, 11, 20, 21, 22, 23, 24 In 1989, Fry et al¹⁰ were the first to show that PLMs could be noted not only during baseline diagnostic recording but also during nasal CPAP titration, emphasizing that the PLM count was higher in the nasal CPAP titration night than during the baseline night and that the PLM count had increased between the initial nasal CPAP titration and the follow-up performed months

Acknowledgments

Author contributions: Dr Guilleminault takes responsibility for the integrity of the data and the accuracy of data analysis.

Dr Guilleminault: contributed to the study concept and design, subject recruitment, analysis of data, drafting of the manuscript, and study supervision.

Dr Seo: contributed to the study design, subject recruitment, analysis of data, and preparation of manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest

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These events can fragment and reduce the duration of sleep already compromised by OSA. Increasing evidence suggests that PLMS are associated with sympathetic activation, inflammation, endothelial dysfunction, and increased cardiovascular risk in those with OSA98–103 However, the pathophysiology of the relationship between PLMS and OSA and its clinical implications (independent vs synergistic effects) remain understudied, leaving uncertainty about consequences and management. PLMS often coexist with restless leg syndrome (RLS).
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In patients with Ehlers-Danlos syndrome, abnormal breathing during sleep is commonly unrecognized and is responsible for daytime fatigue and poor sleep. These patients are at particular risk for SDB because of genetically related cartilage defects that lead to the development of facial structures known to cause SDB. Ehlers-Danlos syndrome may be a genetic model for OSA because of abnormalities in oral-facial growth. Early recognition of SDB may allow treatment with orthodontics and myofacial reeducation.
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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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Chest

Original ResearchSleep DisordersPeriodic Leg Movement, Nasal CPAP, and Expiratory Muscles

Background

Methods

Results

Conclusions

Section snippets

Research Protocol

Results

Discussion

Acknowledgments

Am J Kidney Dis

Chest

Sleep Med

Sleep Med

Sleep Med

Measurement

Chest

Chest

Chest

International Classification of Sleep Disorders

Relationship of periodic movements in sleep (nocturnal myoclonus) and the Babinski sign

Sleep

Periodic arm movements in patients with the restless legs syndrome

Eur Neurol

The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications

EEG and cardiac activation during periodic leg movements in sleep: support for a hierarchy of arousal responses

Neurology

Original Research
Sleep Disorders
Periodic Leg Movement, Nasal CPAP, and Expiratory Muscles