Irregular Breathing Patterns: Causes and Solutions

Woman sleeping with CPAP mask When one's health changes and the person starts to breathe 2-3 times more than the medical norm (without noticing that), their breathing gets deeper and faster, but it still remains regular. During these transitions, from being healthy (with the normal breathing pattern) to mildly sick (with the ineffective respiratory pattern) and then severely sick (with the heavy breathing pattern), many people just breathe deeper and more often. However, low brain CO2 eventually can lead to appearance of irregular breathing patterns.

Hence, some people develop respiratory irregularities due to negative effects of hypocapnia (low CO2 level) and cell hypoxia (reduced cells oxygen level) in the breathing center. (It includes nerve cells located in the medulla oblongata of the brain.) As a result, such people can develop sleep apnea. This is logical to expect since CO2 is a powerful calmative and sedative agent of the nervous cells (for medical research, see CO2 Stabilizer of nerve cells), while low CO2 levels make nerve cells overexcited.

Hence, breathing normalization is the way to deal with irregular breathing patterns: the less and easier/slower you breathe, the more regular your breathing pattern naturally becomes. The application of the Buteyko breathing method for sleep apnea is a medically proven way to restore deep stages of sleep in sleep apnea patients with complete clinical remission of all symptoms related to this disease. There are other techniques to restore normal breathing. They are provided below.

Irregular respiratory patterns

Clinical manifestations and symptoms
of irregular respiratory patterns

- Apneic episodes during sleep
- Sighing and yawning
- Coughing
- Chest pain
- Sniffing air
- Panic and anxiety

Early signs and symptoms
of irregular breathing patterns

- Chest breathing
- Snoring
- Nocturnal sleep problems or agitated sleep
- Nasal obstruction or mouth breathing
- Sleeping on one's back

Healthy lifestyle factors

- Exercise effects
- Mouth taping at night
- Learning diaphragmatic breathing
- Relaxation and meditation exercises
- Good posture (straight spine 24/7)
- Eating, only when really hungry, and stopping in time
- Going to bed to sleep, only when really sleepy
- Getting out of the bed in the morning
- Sleeping on hard beds

Lifestyle risk factors

- Sleeping with mouth open
- Sleeping on one's back
- Lack of physical exercise
- Poor posture or slouching
- Stress, anger, and strong emotions
- Talking too much
- Overeating (especially of animal proteins)
- Deep breathing exercises and upper chest breathing
- Lack of essential nutrients and junk foods

Woman doctor and her patient Irregular breathing is a symptom of the chronic hyperventilation syndrome which is typical for most ordinary people and people with chronic diseases (see the Homepage for clinical studies). Chronic hyperventilation cannot increase normal oxygenation of the arterial blood (98%), but does cause hypocapnia causing reduced O2 delivery to body cells.

Clinical observation of patients with irregular respiratory patterns and periodic breathing suggests that their body oxygenation, measured using the DIY body oxygen level test (see instructions after the references below) is less than 20 s during daytime and less than 15 s immediately after waking up in the morning. These numbers are 2-3 times below normal, as clinical experience of Buteyko breathing medical practitioners indicate.

Reversing erratic breathing patterns

Group of 7 doctors Usual CP numbers (cells oxygen content) in sleep apnea patients are less than 20 s. Normal sleep structure with deep stages present (Buteyko Sleep Apnea Solution) and no symptoms is achieved when the patient has more than 30 s CP 24/7. Many sleep apnea patients can accomplish this goal within 2-4 weeks. There are following factors that make progress slower: obesity, prolonged use of the CPAP machine, medication used, and age of the student.

Medical research and science articles have shown that low level of CO2 disrupts and overexcites the nerve cells responsible for control of automatic breathing, while brain hypoxia makes uneven respiration worse. For research abstracts and clinical studies, especially relevant to Buteyko Sleep Apnea Solution, see the references below (especially medical quotes, which are in bold font).

Correction of lifestyle risk factors and breathing normalization are the key elements to treat erratic breathing. Positive changes and elimination of existing symptoms of irregular breathing are expected with the application of the following breathing therapies: the Buteyko breathing method, Frolov breathing device and Amazing DIY breathing device. Significant improvements are possible with Strelnikova paradoxical breathing gymnastic.


References and abstracts about healing powers of CO2 to restore regular breathing

J Appl Physiol. 1997 Mar;82(3):918-26.
Effects of inhaled CO2 and added dead space on idiopathic central sleep apnea.
Xie A, Rankin F, Rutherford R, Bradley TD.
Sleep Research Laboratory, Queen Elizabeth Hospital, Toronto, Ontario, Canada.
Abstract
We hypothesized that reductions in arterial PCO2 (PaCO2) below the apnea threshold play a key role in the pathogenesis of idiopathic central sleep apnea syndrome (ICSAS). If so, we reasoned that raising PaCO2 would abolish apneas in these patients. Accordingly, patients with ICSAS were studied overnight on four occasions during which the fraction of end-tidal CO2 and transcutaneous PCO2 were measured: during room air breathing (N1), alternating room air and CO2 breathing (N2), CO2 breathing all night (N3), and addition of dead space via a face mask all night (N4). Central apneas were invariably preceded by reductions in fraction of end-tidal CO2. Both administration of a CO2-enriched gas mixture and addition of dead space induced 1- to 3-Torr increases in transcutaneous PCO2, which virtually eliminated apneas and hypopneas; they decreased from 43.7 +/- 7.3 apneas and hypopneas/h on N1 to 5.8 +/- 0.9 apneas and hypopneas/h during N3 (P < 0.005), from 43.8 +/- 6.9 apneas and hypopneas/h during room air breathing to 5.9 +/- 2.5 apneas and hypopneas/h of sleep during CO2 inhalation during N2 (P < 0.01), and to 11.6% of the room air level while the patients were breathing through added dead space during N4 (P < 0.005). Because raising PaCO2 through two different means virtually eliminated central sleep apneas, we conclude that central apneas during sleep in ICSA are due to reductions in PaCO2 below the apnea threshold.


J Physiol. 1991;440:17-33.
The influence of induced hypocapnia and sleep on the endogenous respiratory rhythm in humans.
Datta AK, Shea SA, Horner RL, Guz A.
Department of Medicine, Charing Cross and Westminster Medical School, London.
Abstract
1. Ventilation has been studied during hypocapnia produced by passive mechanical ventilation in ten normal human subjects. 2. During wakefulness, disconnection of the ventilator led to inconsistent apnoea of only brief duration. During sleep, at a similar degree of hypocapnia, disconnection of the ventilator led more consistently to apnoea which was also of much longer duration; the deeper the sleep stage, the longer the apnoea. 3. The resumption of breathing during sleep could precede or follow arousal or be unaccompanied by arousal; in the absence of prior arousal, the evidence suggests that a starting end-tidal CO2 pressure (PET, CO2) less than 41 mmHg could result in an apnoea during sleep stages I and II. 4. Subjects did not report any common sensation which led them to breathe following an apnoea whilst awake. 5. Prior hyperoxia in one subject prolonged the apnoea duration in both slow-wave sleep and rapid eye movement sleep. 6. The results are interpreted as showing that even during light sleep, the maintenance of the respiratory rhythm is critically dependent on the arterial CO2 and O2 tensions. During wakefulness, other behavioural drives, which may not reach consciousness, supervene.


J Physiol. 2004 Oct 1;560(Pt 1):1-11. Epub 2004 Jul 29.
The ventilatory responsiveness to CO(2) below eupnoea as a determinant of ventilatory stability in sleep.
Dempsey JA, Smith CA, Przybylowski T, Chenuel B, Xie A, Nakayama H, Skatrud JB.
The John Rankin Laboratory of Pulmonary Medicine, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, 53726-2368, USA. jdempsey@wisc.edu.
Abstract
Sleep unmasks a highly sensitive hypocapnia-induced apnoeic threshold, whereby apnoea is initiated by small transient reductions in arterial CO(2) pressure (P(aCO(2))) below eupnoea and respiratory rhythm is not restored until P(aCO(2)) has risen significantly above eupnoeic levels. We propose that the 'CO(2) reserve' (i.e. the difference in P(aCO(2)) between eupnoea and the apnoeic threshold (AT)), when combined with 'plant gain' (or the ventilatory increase required for a given reduction in P(aCO(2))) and 'controller gain' (ventilatory responsiveness to CO(2) above eupnoea) are the key determinants of breathing instability in sleep. The CO(2) reserve varies inversely with both plant gain and the slope of the ventilatory response to reduced CO(2) below eupnoea; it is highly labile in non-random eye movement (NREM) sleep. With many types of increases or decreases in background ventilatory drive and P(aCO(2)), the slope of the ventilatory response to reduced P(aCO(2)) below eupnoea remains unchanged from control. Thus, the CO(2) reserve varies inversely with plant gain, i.e. it is widened with hyperventilation and narrowed with hypoventilation, regardless of the stimulus and whether it acts primarily at the peripheral or central chemoreceptors. However, there are notable exceptions, such as hypoxia, heart failure, or increased pulmonary vascular pressures, which all increase the slope of the CO(2) response below eupnoea and narrow the CO(2) reserve despite an accompanying hyperventilation and reduced plant gain. Finally, we review growing evidence that chemoreceptor-induced instability in respiratory motor output during sleep contributes significantly to the major clinical problem of cyclical obstructive sleep apnea.


J Appl Physiol. 1983 Sep;55(3):813-22.
Interaction of sleep state and chemical stimuli in sustaining rhythmic ventilation.
Skatrud JB, Dempsey JA.
Abstract
The effect of sleep state on ventilatory rhythmicity following graded hypocapnia was determined in two normal subjects and one patient with a chronic tracheostomy. Passive positive-pressure hyperventilation (PHV) was performed for 3 min awake and during nonrapid-eye-movement (NREM) sleep with hyperoxia [fractional inspired O2 concentration (FIO2) = 0.50], normoxia and hypoxia (FIO2 = 0.12). During wakefulness, no immediate posthyperventilation apnea was noted following abrupt cessation of PHV in 27 of 28 trials [mean hyperventilation end-tidal CO2 partial pressure (PETCO2) 29 +/- 2 Torr, range 22-35]. During spontaneous breathing in hyperoxia, PETCO2 rose from 40.4 +/- 0.7 Torr awake to 43.2 +/- 1.4 Torr during NREM sleep. PHV during NREM sleep caused apnea when PETCO2 was reduced to 3-6 Torr below NREM sleep levels and 1-2 Torr below the waking level. In hypoxia, PETCO2 increased from 37.1 +/- 0.1 awake to 39.8 +/- 0.1 Torr during NREM sleep. PHV caused apnea when PETCO2 was reduced to levels 1-2 Torr below NREM sleep levels and 1-2 Torr above awake levels. Apnea duration (5-45 s) was significantly correlated to the magnitude of hypocapnia (range 27-41 Torr). PHV caused no apnea when isocapnia was maintained via increased inspired CO2. Prolonged hypoxia caused periodic breathing, and the abrupt transition from short-term hypoxic-induced hyperventilation to acute hyperoxia caused apnea during NREM sleep when PETCO2 was lowered to or below the subject's apneic threshold as predetermined (passively) by PHV. We concluded that effective ventilatory rhythmogenesis in the absence of stimuli associated with wakefulness is critically dependent on chemoreceptor stimulation secondary to PCO2-[H+].


Am J Respir Crit Care Med. 2002 May 1;165(9):1251-60.
Effect of ventilatory drive on carbon dioxide sensitivity below eupnea during sleep.
Nakayama H, Smith CA, Rodman JR, Skatrud JB, Dempsey JA.
The John Rankin Laboratory of Pulmonary Medicine, Department of Population Health Sciences, University of Wisconsin School of Medicine, Madison 53705, USA.
Abstract
We determined the effects of changing ventilatory stimuli on the hypocapnia-induced apneic and hypopneic thresholds in sleeping dogs. End-tidal carbon dioxide pressure (PET(CO2)) was gradually reduced during non-rapid eye movement sleep by increasing tidal volume with pressure support mechanical ventilation, causing a reduction in diaphragm electromyogram amplitude until apnea/periodic breathing occurred. We used the reduction in PET(CO2) below spontaneous breathing required to produce apnea (DeltaPET(CO2)) as an index of the susceptibility to apnea. DeltaPET(CO2) was -5 mm Hg in control animals and changed in proportion to background ventilatory drive, increasing with metabolic acidosis (-6.7 mm Hg) and nonhypoxic peripheral chemoreceptor stimulation (almitrine; -5.9 mm Hg) and decreasing with metabolic alkalosis (-3.7 mm Hg). Hypoxia was the exception; DeltaPET(CO2) narrowed (-4.1 mm Hg) despite the accompanying hyperventilation. Thus, hyperventilation and hypocapnia, per se, widened the DeltaPET(CO2) thereby protecting against apnea and hypopnea, whereas reduced ventilatory drive and hypoventilation narrowed the DeltaPET(CO2) and increased the susceptibility to apnea. Hypoxia sensitized the ventilatory responsiveness to CO2 below eupnea and narrowed the DeltaPET(CO2); this effect of hypoxia was not attributable to an imbalance between peripheral and central chemoreceptor stimulation, per se. We conclude that the DeltaPET(CO2) and the ventilatory sensitivity to CO2 between eupnea and the apneic threshold are changeable in the face of variations in the magnitude, direction, and/or type of ventilatory stimulus, thereby altering the susceptibility for apnea, hypopnea, and periodic breathing in sleep.


Am J Respir Crit Care Med. 1995 Dec;152(6 Pt 1):1950-5.
Hypocapnia and increased ventilatory responsiveness in patients with idiopathic central sleep apnea.
Xie A, Rutherford R, Rankin F, Wong B, Bradley TD.
Sleep Research Laboratory, Queen Elizabeth Hospital, Toronto, Ontario, Canada.
Abstract
We previously demonstrated that central apneas during sleep in patients with idiopathic central sleep apnea (ICSA) are triggered by abrupt hyperventilation. In addition, baseline PCO2 at the time of augmented breaths which triggered central apneas was lower than for augmented breaths which did not trigger apneas. These observations led us to hypothesize that patients with ICSA chronically hyperventilate maintaining their PCO2 close to the threshold for apnea during sleep owing to increased chemical respiratory drive. To test these hypotheses, we recorded transcutaneous PCO2 (PtcCO2) during overnight sleep studies on nine consecutive patients with ICSA and nine sex-, age-, and body-mass-index-matched control subjects. Daytime PaCO2 as well as rebreathing and single breath ventilatory responses to CO2 were also measured. Compared with the control subjects, the patients had significantly lower mean PtcCO2 during sleep (37.8 +/- 1.2 versus 42.7 +/- 10.9 mm Hg, p < 0.01) and lower PaCO2 while awake (35.1 +/- 1.3 versus 38.8 +/- 0.9 mm Hg, p < 0.05). Furthermore, patients with ICSA had significantly higher ventilatory responses to CO2 for both the rebreathing (3.14 +/- 0.34 versus 1.60 +/- 0.32 L/min/mm Hg, p < 0.005) and single breath methods (0.51 +/- 0.10 versus 0.25 +/- 0.04 L/min/mm Hg, p < 0.05). We conclude that: (1) patients with ICSA chronically hyperventilate awake and asleep and (2) chronic hyperventilation is probably related to augmented central and peripheral respiratory drive which predisposes to respiratory control system instability.


Am Rev Respir Dis. 1993 Aug;148(2):330-8.
Role of hyperventilation in the pathogenesis of central sleep apneas in patients with congestive heart failure.
Naughton M, Benard D, Tam A, Rutherford R, Bradley TD.
Sleep Research Laboratory, Queen Elizabeth Hospital, Ontario, Canada.
Comment in:
Am J Respir Crit Care Med. 1994 Apr;149(4 Pt 1):1053; author reply 1053-4.
Am J Respir Crit Care Med. 1994 Apr;149(4 Pt 1):1053; author reply 1053-4.
Abstract
Periodic breathing with central apneas during sleep is typically triggered by hypocapnia resulting from hyperventilation. We therefore hypothesized that hypocapnia would be an important determinant of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA) in patients with congestive heart failure (CHF). To test this hypothesis, 24 male patients with CHF underwent overnight polysomnography during which transcutaneous PCO2 (PtcCO2) was measured. Lung to ear circulation time (LECT), derived from an ear oximeter as an estimate of circulatory delay, and CSR-CSA cycle length were determined. Patients were divided into a CSR-CSA group (n = 12, mean +/- SEM of 49.2 +/- 6.3 central apneas and hypopneas per h sleep) and a control group without CSR-CSA (n = 12, 4.9 +/- 0.8 central apneas and hypopneas per h sleep). There were no significant differences in left ventricular ejection fraction, awake PaO2, mean nocturnal SaO2, or LECT between the two groups. In contrast, the awake PaCO2 and mean sleep PtcCO2 were significantly lower in the CSR-CSA group than in the control group (33.0 +/- 1.2 versus 37.5 +/- 1.0 mm Hg, p < 0.01, and 33.2 +/- 1.2 versus 42.5 +/- 1.2 mm Hg, p < 0.0001, respectively). Neither group had significant awake or sleep-related hypoxemia. In addition, CSR-CSA cycle length correlated with LECT (r = 0.939, p < 0.001). We conclude that (1) hypocapnia is an important determinant of CSR-CSA in CHF and (2) circulatory delay plays an important role in determining CSR-CSA cycle length.


Am J Respir Crit Care Med. 1994 Aug;150(2):489-95.
Interaction of hyperventilation and arousal in the pathogenesis of idiopathic central sleep apnea.
Xie A, Wong B, Phillipson EA, Slutsky AS, Bradley TD.
Sleep Research Laboratory, Queen Elizabeth Hospital, Toronto, Ontario, Canada.
Abstract
Central apneas during sleep may arise as a result of reduction in PaCO2 below the apnea threshold. We therefore hypothesized that hyperventilation and arousals from sleep interact to cause hypocapnia and subsequent central apneas in patients with idiopathic central sleep apnea (ICSA). Accordingly, the relationships among preapneic ventilation, arousal from sleep, and the onset and duration of subsequent central apneas were examined during Stage 2 non-REM sleep in eight patients with ICSA (mean +/- SEM, 45.4 +/- 4.7 central apneas and hypopneas/h of sleep). During Stage 2 sleep, all episodes of periodic breathing with central apneas were triggered by hyperventilation. Minute ventilation (VI) was greater (6.3 +/- 0.7 versus 5.4 +/- 0.8 L/min, p < 0.05) and mean transcutaneous PCO2 (PtcCO2) was lower (37.8 +/- 1.3 versus 38.9 +/- 1.6 mm Hg, p < 0.05) during periodic breathing than during stable breathing. VI during the ventilatory phase of the periodic breathing cycle increased progressively with increasing grades of associated arousals from Grade 0 (no arousal) (10.3 +/- 1.4 L/min) to Grade 1 (EEG arousal) (12.6 +/- 1.6 L/min) to Grade 2 (movement arousal) (14.1 +/- 1.6 L/min, p < 0.01). There was a corresponding progressive increase in central apnea length following the ventilatory period from no arousal (14.1 +/- 2.0) to EEG arousal (16.4 +/- 1.8) to movement arousal (18.1 +/- 2.0 s, p < 0.01). We conclude that arousals and hyperventilation interact to trigger hypocapnia and central apneas in ICSA.


J Appl Physiol. 1996 Jun;80(6):2102-7.
Effects of inspired gas on sleep-related apnea in the rat.
Christon J, Carley DW, Monti D, Radulovacki M.
Department of Medicine, University of Illinois, Chicago 60612, USA.
Abstract
Central apneas have been reported to occur in the rat during all stages of sleep. Two types of apnea have been described: spontaneous and postsigh, which are immediately preceded by an augmented breath. We studied the effect of inspired gas on the number and type of apneas in nine adult male Sprague-Dawley rats that were surgically prepared with cortical electroencephalogram and nuchal electromyogram electrodes. In addition to the electroencephalogram and electromyogram, we recorded respiration by the barometric method by using a single-chamber plethysmograph. Each rat was recorded from 1000 until 1600 on 4 separate days by using different inspired gases: room air, 100% O2, 15% O2, and 5% CO2. We found that the sleep-related apnea index was significantly higher during 100% O2 compared with room air (P < 0.05) and was significantly lower during 15% O2 and 5% CO2 compared with room air (P < 0.05). Postsigh apneas occurred more frequently than did spontaneous apneas (P < 0.0001). The coupling between sighs and apneas was strengthened by hyperoxia and weakened by hypoxia and hypercapnia (P < 0.05 for each). We conclude that stimulation of chemoreceptors acts to oppose apnea in the rat.


J Appl Physiol. 2006 Jan;100(1):171-7. Epub 2005 Sep 22.
Influence of arterial O2 on the susceptibility to posthyperventilation apnea during sleep.
Xie A, Skatrud JB, Puleo DS, Dempsey JA.
Department of Medicine, University of Wisconsin, Madison, USA. axie@facstaff.wisc.edu
Abstract
To investigate the contribution of the peripheral chemoreceptors to the susceptibility to posthyperventilation apnea, we evaluated the time course and magnitude of hypocapnia required to produce apnea at different levels of peripheral chemoreceptor activation produced by exposure to three levels of inspired P(O2). We measured the apneic threshold and the apnea latency in nine normal sleeping subjects in response to augmented breaths during normoxia (room air), hypoxia (arterial O2 saturation = 78-80%), and hyperoxia (inspired O2 fraction = 50-52%). Pressure support mechanical ventilation in the assist mode was employed to introduce a single or multiple numbers of consecutive, sigh-like breaths to cause apnea. The apnea latency was measured from the end inspiration of the first augmented breath to the onset of apnea. It was 12.2 +/- 1.1 s during normoxia, which was similar to the lung-to-ear circulation delay of 11.7 s in these subjects. Hypoxia shortened the apnea latency (6.3 +/- 0.8 s; P < 0.05), whereas hyperoxia prolonged it (71.5 +/- 13.8 s; P < 0.01). The apneic threshold end-tidal P(CO2) (Pet(CO2)) was defined as the Pet(CO2)) at the onset of apnea. During hypoxia, the apneic threshold Pet(CO2) was higher (38.9 +/- 1.7 Torr; P < 0.01) compared with normoxia (35.8 +/- 1.1; Torr); during hyperoxia, it was lower (33.0 +/- 0.8 Torr; P < 0.05). Furthermore, the difference between the eupneic Pet(CO2) and apneic threshold Pet(CO2) was smaller during hypoxia (3.0 +/- 1.0 Torr P < 001) and greater during hyperoxia (10.6 +/- 0.8 Torr; P < 0.05) compared with normoxia (8.0 +/- 0.6 Torr). Correspondingly, the hypocapnic ventilatory response to CO2 below the eupneic Pet(CO2) was increased by hypoxia (3.44 +/- 0.63 l.min(-1).Torr(-1); P < 0.05) and decreased by hyperoxia (0.63 +/- 0.04 l.min(-1).Torr(-1); P < 0.05) compared with normoxia (0.79 +/- 0.05 l.min(-1).Torr(-1)). These findings indicate that posthyperventilation apnea is initiated by the peripheral chemoreceptors and that the varying susceptibility to apnea during hypoxia vs. hyperoxia is influenced by the relative activity of these receptors.


J Appl Physiol. 2010 Feb;108(2):369-77. Epub 2009 Nov 25.
Effect of episodic hypoxia on the susceptibility to hypocapnic central apnea during NREM sleep.
Chowdhuri S, Shanidze I, Pierchala L, Belen D, Mateika JH, Badr MS.
Medical Service, John D. Dingell Veterans Affairs Medical Center, Detroit, MI 48201, USA. schowdh@med.wayne.edu
Abstract
We hypothesized that episodic hypoxia (EH) leads to alterations in chemoreflex characteristics that might promote the development of central apnea in sleeping humans. We used nasal noninvasive positive pressure mechanical ventilation to induce hypocapnic central apnea in 11 healthy participants during stable nonrapid eye movement sleep before and after an exposure to EH, which consisted of fifteen 1-min episodes of isocapnic hypoxia (mean O(2) saturation/episode: 87.0 +/- 0.5%). The apneic threshold (AT) was defined as the absolute measured end-tidal PCO(2) (Pet(CO(2))) demarcating the central apnea. The difference between the AT and baseline Pet(CO(2)) measured immediately before the onset of mechanical ventilation was defined as the CO(2) reserve. The change in minute ventilation (V(I)) for a change in Pet(CO(2)) (DeltaV(I)/ DeltaPet(CO(2))) was defined as the hypocapnic ventilatory response. We studied the eupneic Pet(CO(2)), AT Pet(CO(2)), CO(2) reserve, and hypocapnic ventilatory response before and after the exposure to EH. We also measured the hypoxic ventilatory response, defined as the change in V(I) for a corresponding change in arterial O(2) saturation (DeltaV(I)/DeltaSa(O(2))) during the EH trials. V(I) increased from 6.2 +/- 0.4 l/min during the pre-EH control to 7.9 +/- 0.5 l/min during EH and remained elevated at 6.7 +/- 0.4 l/min the during post-EH recovery period (P < 0.05), indicative of long-term facilitation. The AT was unchanged after EH, but the CO(2) reserve declined significantly from -3.1 +/- 0.5 mmHg pre-EH to -2.3 +/- 0.4 mmHg post-EH (P < 0.001). In the post-EH recovery period, DeltaV(I)/DeltaPet(CO(2)) was higher compared with the baseline (3.3 +/- 0.6 vs. 1.8 +/- 0.3 l x min(-1) x mmHg(-1), P < 0.001), indicative of an increased hypocapnic ventilatory response. However, there was no significant change in the hypoxic ventilatory response (DeltaV(I)/DeltaSa(O(2))) during the EH period itself. In conclusion, despite the presence of ventilatory long-term facilitation, the increase in the hypocapnic ventilatory response after the exposure to EH induced a significant decrease in the CO(2) reserve. This form of respiratory plasticity may destabilize breathing and promote central apneas.


J Appl Physiol. 2000 Jul;89(1):192-9.
Effect of gender on the development of hypocapnic apnea/hypopnea during NREM sleep.
Zhou XS, Shahabuddin S, Zahn BR, Babcock MA, Badr MS.
John D. Dingell Veterans Affairs Medical Center, and Division of Pulmonary and Critical Care Medicine, Wayne State University School of Medicine, Detroit, Michigan 48201, USA.
Abstract
We hypothesized that a decreased susceptibility to the development of hypocapnic central apnea during non-rapid eye movement (NREM) sleep in women compared with men could be an explanation for the gender difference in the sleep apnea/hypopnea syndrome. We studied eight men (age 25-35 yr) and eight women in the midluteal phase of the menstrual cycle (age 21-43 yr); we repeated studies in six women during the midfollicular phase. Hypocapnia was induced via nasal mechanical ventilation for 3 min, with respiratory frequency matched to eupneic frequency. Tidal volume (VT) was increased between 110 and 200% of eupneic control. Cessation of mechanical ventilation resulted in hypocapnic central apnea or hypopnea, depending on the magnitude of hypocapnia. Nadir minute ventilation in the recovery period was plotted against the change in end-tidal PCO(2) (PET(CO(2))) per trial; minute ventilation was given a value of 0 during central apnea. The apneic threshold was defined as the x-intercept of the linear regression line. In women, induction of a central apnea required an increase in VT to 155 +/- 29% (mean +/- SD) and a reduction of PET(CO(2)) by -4.72 +/- 0.57 Torr. In men, induction of a central apnea required an increase in VT to 142 +/- 13% and a reduction of PET(CO(2)) by -3.54 +/- 0.31 Torr (P = 0.002). There was no difference in the apneic threshold between the follicular and the luteal phase in women. Premenopausal women are less susceptible to hypocapnic disfacilitation during NREM sleep than men. This effect was not explained by progesterone. Preservation of ventilatory motor output during hypocapnia may explain the gender difference in sleep apnea.


Can J Physiol Pharmacol. 2003 Aug;81(8):774-9.
The essential role of carotid body chemoreceptors in sleep apnea.
Smith CA, Nakayama H, Dempsey JA.
The John Rankin Laboratory of Pulmonary Medicine, Department of Population Health Sciences, University of Wisconsin School of Medicine, 504 North Walnut Street, Madison, WI 53726-2368. USA. casmith4@wisc.edu
Abstract
Sleep apnea is attributable, in part, to an unstable ventilatory control system and specifically to a narrowed "CO2 reserve" (i.e., the difference in P(a)CO2 between eupnea and the apneic threshold). Findings from sleeping animal preparations with denervated carotid chemoreceptors or vascularly isolated, perfused carotid chemoreceptors demonstrate the critical importance of peripheral chemoreceptors to the ventilatory responses to dynamic changes in P(a)CO2. Specifically, (i) carotid body denervation prevented the apnea and periodic breathing that normally follow transient ventilatory overshoots; (ii) the CO2 reserve for peripheral chemoreceptors was about one half that for brain chemoreceptors; and (iii) hypocapnia isolated to the carotid chemoreceptors caused hypoventilation that persisted over time despite a concomitant, progressive brain respiratory acidosis. Observations in both humans and animals are cited to demonstrate the marked plasticity of the CO2 reserve and, therefore, the propensity for apneas and periodic breathing, in response to changing background ventilatory stimuli.


Med Clin North Am. 1985 Nov;69(6):1205-19.
Central sleep apnea.
White DP.
Abstract
Central sleep apnea is a disorder characterized by apneic episodes during sleep with no associated ventilatory effort. More commonly than not these apneas are seen in patients who also have obstructive and mixed events. Although patients with this disorder frequently complain of insomnia and depression, frank hypersomnolence is rarely encountered. As these complaints are common ones seen in numerous clinical situations, and since sleep studies are rarely conducted to investigate their etiology, the true incidence of central sleep apnea has not been determined. The etiology of central apnea remains unknown, although the association between these breathing events and a number of other disease processes has increased our understanding of the disorder. Central apneas during sleep commonly occur after hyperventilation with the associated hypocapnic alkalosis. This occurs at high altitude when hyperventilation is induced by hypoxia and at sea level when spontaneous nocturnal hyperventilation occurs. This suggests that PCO2 is the primary stimulus to ventilation during sleep and that loss of this drive, as occurs with hypocapnia, may produce dysrhythmic breathing. Patients with complete absence of ventilatory chemosensitivity such as occurs with Ondine's curse (central alveolar hypoventilation) or the obesity-hypoventilation syndrome may also have central apneas. For reasons that remain unexplained, central sleep apnea is commonly seen in patients with congestive heart failure, nasal obstruction, and certain neurologic disorders. However, in most patients with central sleep apnea no obvious cause or association can be found. The treatment of this disorder is not entirely satisfactory. If it is severe, mechanical ventilation during sleep can be provided by any one of a number of techniques. However, for the patient who simply complains of insomnia and is found to have a moderate number of central apneas, the treatment choices are limited. Acetazolamide has been shown to decrease central apneas during short-term use, but results have been variable with prolonged administration. Other ventilatory stimulants seem to have little efficacy. Interestingly, oxygen administration has been shown to reduce central apneas considerably in a number of studies, although the explanation for its success is unknown. Central sleep apnea therefore remains a relatively rare disorder whose etiology is not fully understood and whose treatment is not completely satisfactory.


Am J Otolaryngol. 2010 May 11. [Epub ahead of print]
End-tidal carbon dioxide concentration monitoring in obstructive sleep apnea patients.
Weihu C, Jingying Y, Demin H, Yuhuan Z, Jiangyong W.
Department of Otorhinolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China.
Abstract
PURPOSE: The objective of this study was to investigate the end-tidal carbon dioxide concentration (ETco(2)) monitoring in obstructive sleep apnea (OSA) patients during sleep and to explore whether the ETco(2) value may explain a significant portion of the relationship between ETco(2) value and apnea/hypopnea index (AHI) and nocturnal oxygenation indices. MATERIALS AND METHODS: Thirty-eight consecutive patients underwent overnight polysomnography and were synchronously monitored for ETco(2) using an microstream capnometer. Mean and maximum values during wake time and different sleep stages were recorded. We grouped 38 OSA patients into 2 subgroups on the basis of their difference of mean total sleep time and wake time ETco(2) [(T - W) ETco(2)]; one group, 20 patients with (T - W) ETco(2) less than 0, and the other group,18 patients with (T - W) ETco(2) greater than 0. RESULTS: Group with (T - W) ETco(2) less than 0 patients exhibited higher AHI (mean +/- SD, 68.58 +/- 22.78 vs. 27.61 +/- 19.44 events/h) and lower nocturnal oxygenation indices (minimum Sao(2), 67.85 +/- 10.08 vs. 82.61% +/- 6.07%; mean Sao(2), 91.29 +/- 3.31 vs. 95.15% +/- 1.88%) compared with the other group. CONCLUSIONS: In summary, the study provides preliminary data showing that ETco(2) potentially can be used in continuous monitoring of OSA patients. And, (T - W) ETco(2) can indicate the severity of OSA. Copyright 2010 Elsevier Inc. All rights reserved.

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