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Apnea

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M.Umer Tariq [2]

Synonyms and keywords: Apnoea

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Apnea, (Greek απνοια, from α-, privative, πνεειν, to breathe) is a technical term for suspension of external breathing. During apnea there is no movement of the muscles of respiration and the volume of the lungs initially remains unchanged. Depending on the patency (openness) of the airways there may or may not be a flow of gas between the lungs and the environment; gas exchange within the lungs and cellular respiration is not affected.

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Historical Perspective

Historical Perspective

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Classification

Classification

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Pathophysiology

Under normal conditions, humans cannot store much oxygen in the body. Apnea of more than approximately one minute’s duration therefore leads to severe lack of oxygen in the blood circulation. Permanent brain damage can occur after as little as three minutes and death will inevitably ensue after a few more minutes unless ventilation is restored. However, under special circumstances such as hypothermia, hyperbaric oxygenation, apneic oxygenation (see below), or extracorporeal membrane oxygenation, much longer periods of apnea may be tolerated without severe consequences.

Untrained humans cannot sustain voluntary apnea for more than one or two minutes. The reason for this is that the rate of breathing and the volume of each breath are tightly regulated to maintain constant values of CO2 tension and pH of the blood. In apnea, CO2 is not removed through the lungs and accumulates in the blood. The consequent rise in CO2 tension and drop in pH result in stimulation of the respiratory centre in the brain which eventually cannot be overcome voluntarily.

When a person is immersed in water, physiological changes due to the mammalian diving reflex enable somewhat longer tolerance of apnea even in untrained persons. Tolerance can in addition be trained. The ancient technique of free-diving requires breath-holding, and world-class free-divers can indeed hold their breath underwater up to depths of 223 metres and for more than eight minutes. An apneist, in this context, is someone who can hold their breath for a long time.

Apneic oxygenation

Because the exchange of gases between the blood and airspace of the lungs is independent of the movement of gas to and from the lungs, enough oxygen can be delivered to the circulation even if a person is apneic. This phenomenon (apneic oxygenation) is explained as follows:

With the onset of apnea, an underpressure develops in the airspace of the lungs, because more oxygen is absorbed than CO2 is released. With the airways closed or obstructed, this will lead to a gradual collapse of the lungs. However, if the airways are patent (open), any gas supplied to the upper airways will follow the pressure gradient and flow into the lungs to replace the oxygen consumed. If pure oxygen is supplied, this process will serve to replenish the oxygen stores in the lungs. The uptake of oxygen into the blood will then remain at the usual level and the normal functioning of the organs will not be affected.

However, no CO2 is removed during apnea. The partial pressure of CO2 in the airspace of the lungs will quickly equilibrate with that of the blood. As the blood is loaded with CO2 from the metabolism, more and more CO2 will accumulate and eventually displace oxygen and other gases from the airspace. CO2 will also accumulate in the tissues of the body, resulting in respiratory acidosis.

Under ideal conditions (i.e., if pure oxygen is breathed before onset of apnea to remove all nitrogen from the lungs, and pure oxygen is insufflated), apneic oxygenation could theoretically be sufficient to provide enough oxygen for survival of more than one hour’s duration in a healthy adult. However, accumulation of carbon dioxide (described above) would remain the limiting factor.

Apneic oxygenation is more than a physiologic curiosity. It can be employed to provide a sufficient amount of oxygen in thoracic surgery when apnea cannot be avoided, and during manipulations of the airways such as bronchoscopy, intubation, and surgery of the upper airways. However, because of the limitations described above, apneic oxygenation is inferior to extracorporal circulation using a heart-lung machine and is therefore used only in emergencies and for short procedures.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: : Ogheneochuko Ajari, MB.BS, MS [2] Marcelo R. Zacarkim, M.D. [3]

Overview

Causes

Life Threatening Causes

Common Causes

Causes by Organ System

Cardiovascular 1q21.1 deletion, acromegaly, Arnold-Chiari malformation, aromatic amino acid decarboxylase deficiency , arrythmias, atrial fibrillation, cardiac arrest, cyanotic congenital heart disease, diabetic autonomic neuropathy, Down syndrome, end stage renal disease, floppy eyelid syndrome, Guillain-Barré syndrome, heart failure, Hurler syndrome, hypothyroidism, Klippel-Feil syndrome, Marfan syndrome, myasthenia gravis, myocardial infarction, nonarteritic anterior ischemic optic neuropathy, Pickwickian syndrome, pulmonary atresia, pulmonary edema,pulmonary embolism, pulmonary hypertension, right ventricular hypertrophy, secondary hypertension, shock, sleep deprivation, toxidrome, trisomy 13, Werdnig-Hoffman disease
Chemical/Poisoning Ammonium chloride, camphor, chloral hydrate, cyanide, eucalyptus oil poisoning, pepper spray, strychnine, tetramethylammonium hydroxide
Dental Crouzon syndrome, mandibular hypoplasia, midfacial hypoplasia, narrow maxillary arch, Hallermann-Streiff syndrome, osteopetrosis, Treacher Collins syndrome
Dermatologic Acromegaly, Beckwith-Wiedemann syndrome, diabetic autonomic neuropathy, floppy eyelid syndrome, Gaucher’s disease, Hallermann-Streiff syndrome, SADDAN
Drug Side Effect Amobarbital sodium, Beractant, Benzodiazepines,bicisate dihydrochloride, bupivacaine, chlordiazepoxide, cytomegalovirus immune globulin, diazepam, general anesthetics, levobupivacaine, lidocaine, Meropenem, morphine, narcotic analgesics, oxymorphone, pancuronium, Paregoric, Pentobarbital, PGE1, Polymyxin B, pramipexole, propofol, pyrimidifen, ropivacaine, Secobarbital sodium, sertraline, sodium thiopental, Tiagabine, trazodone, use of sedatives (sleeping pills)
Ear Nose Throat Achondroplasia, adenoid hypertrophy, adenotonsillar hypertrophy, angina tonsillaris, Apert syndrome, auriculo-condylar syndrome, Beckwith-Wiedemann syndrome, campomelic syndrome, choanal stenosis, collapse of aryepiglottic folds, Crouzon syndrome, deviated septum, Down syndrome, edema of epiglottis, elongated and/or thickened palate and uvula, empty nose syndrome, Hallermann-Streiff syndrome, Hunter syndrome, Hurler syndrome, Joubert syndrome, Klippel-Feil syndrome, lingual cyst, lingual tonsillar hypertrophy, lymphoma of tonsils, macroglossia, Marfan syndrome, micrognathia, nasoseptal obstruction, oropharyngeal papillomatosis, osteopetrosis, Pierre Robin sequence, rhinitis, septal dislocation, septal hematoma, tracheal rupture, Treacher Collins syndrome, turbinate hypertrophy
Endocrine Acromegaly, Down syndrome, Hyperpituitarism, hypothyroidism, Joubert syndrome, polycystic ovary syndrome, testosterone deficiency
Environmental Smoking
Gastroenterologic Aberrant subclavian artery abnormality, acromegaly, amyotrophic lateral sclerosis, Arnold-Chiari malformation, alcohol, Beckwith-Wiedemann syndrome, Brun’s syndrome, chronic airway-digestive inflammatory disease (CAID), diabetic autonomic neuropathy, Down syndrome, gastroesophageal reflux disease, Gaucher’s disease, Guillain-Barré syndrome, Hunter syndrome, Hurler syndrome, hypothyroidism, Joubert syndrome, osteopetrosis, polyposis, pulmonary edema, toxidrome, Werdnig-Hoffman disease
Genetic 1q21.1 deletion, Crouzon syndrome, Down’s syndrome, Gaucher’s disease, Genetics, Hallermann-Streiff syndrome, Hunter syndrome, Hurler syndrome, Joubert syndrome, Marfan syndrome, osteopetrosis, Prader-Willi syndrome, Treacher Collins syndrome, trisomy 13, Werdnig-Hoffman disease
Hematologic Anemia of prematurity, Gaucher’s disease, iron deficiency anemia, neonatal anemia, osteopetrosis, sickle cell disease
Iatrogenic No underlying causes
Infectious Disease Botulism, Brain abscess, bronchiolitis, encephalitis, meningitis, meningoencephalitis, pertussis, respiratory syncytial viral infection, septicemia
Musculoskeletal/Orthopedic Achondroplasia, an acutely angled skull base, Acromegaly, Apert syndrome, Arnold-Chiari malformation, Aromatic amino acid decarboxylase deficiency , campomelic syndrome, chondrodystrophy, Crouzon syndrome, Down syndrome, Duchenne muscular dystrophy, flail chest, Gaucher’s disease,Guillain-Barré syndrome, Hallermann-Streiff syndrome, head and neck burns, Hunter syndrome, hypertonia, hypothyroidism, hypotonia , Joubert syndrome, Klippel-Feil syndrome, lipoma of the neck, Marfan syndrome, myotonic dystrophy, osteopetrosis, Pickwickian syndrome, pulmonary edema, Rett syndrome, SADDAN, sickle cell disease, spinal cord injury, Treacher Collins syndrome, trisomy 13, Werdnig-Hoffman disease
Neurologic 1q21.1 deletion, acromegaly, amyotrophic lateral sclerosis, aromatic amino acid decarboxylase deficiency , benign familial infantile convulsion, brain abscess, brain stem dysfunction, brain stem injury, brain tumor, Brun’s syndrome, cerebral hemorrhage, cerebral infarction, cerebral palsy, delayed sleep phase syndrome, diabetic autonomic neuropathy, down syndrome, encephalitis, excessive daytime sleepiness, fatigue, floppy eyelid syndrome, Gaucher’s disease, glycine encephalopathy, Guillain-Barré syndrome, Hallermann-Streiff syndrome, head trauma, Hurler syndrome, hypertonia,hypotonia , increased intracranial pressure, Joubert syndrome, Klippel-Feil syndrome, late-onset spinal muscular atrophy, leukomalacia, Marfan syndrome, medullary hemorrhage, medullary infarction, meningitis, meningoencephalitis, myasthenia gravis, myotonic dystrophy, myotubular myopathy, near drowning, nonarteritic anterior ischemic optic neuropathy, periodic limb movement disorder, Pickwickian syndrome, pontine hemorrhage, post-traumatic stress disorder, Prader-Willi syndrome, prenatal asphyxia, REM sleep, restless legs syndrome, Rett syndrome, SADDAN, seizures, sleep deprivation, spinal cord injury, sudden infant death syndrome, toxidrome, transtentorial herniation, trisomy 13, Werdnig-Hoffman disease
Nutritional/Metabolic Achondroplasia, alcohol, aromatic amino acid decarboxylase deficiency , body fat redistribution (BFR) syndrome, congenital central hypoventilation syndrome, gastroesophageal reflux disease, glycine encephalopathy, hypercapnia, hyperglycinemia , hypoventilation, iron deficiency anemia, neonatal anemia, obesity, organic acidemia, polycystic ovary syndrome, prenatal asphyxia, respiratory acidosis, septicemia, shock, Werdnig-Hoffman disease
Obstetric/Gynecologic Polycystic ovary syndrome
Oncologic 1q21.1 deletion, Down syndrome, lymphoma of tonsils
Ophthalmologic 1q21.1 deletion, Arnold-Chiari malformation, aromatic amino acid decarboxylase deficiency , Crouzon syndrome,

diabetic autonomic neuropathy, Down syndrome, floppy eyelid syndrome, Gaucher’s disease, Hallermann-Streiff syndrome, Hurler syndrome, hypothyroidism, Joubert syndrome, leukomalacia, Marfan syndrome, nonarteritic anterior ischemic optic neuropathy, osteopetrosis, secondary hypertension, Treacher Collins syndrome

Overdose/Toxicity Barium, disopyramide toxicity, toxidrome
Psychiatric Down syndrome, Prader-Willi syndrome, Pickwickian syndrome, post-traumatic stress disorder
Pulmonary 1q21.1 deletion, aberrant subclavian artery abnormality, achondroplasia, acromegaly, adenoid hypertrophy, adenotonsillar hypertrophy, adult respiratory distress syndrome, ammonium chloride, amyotrophic lateral sclerosis, an acutely angled skull base, anemia of prematurity, angina tonsillaris, Apert syndrome, apnea of prematurity, Arnold-Chiari malformation, aromatic amino acid decarboxylase deficiency , arrythmias, asthma, ataxic respiration, atrial fibrillation, auriculo-condylar syndrome, barium, Beckwith-Wiedemann syndrome, benign familial infantile convulsion, biot’s respiration, body fat redistribution (BFR) syndrome, botulism, brain abscess, brain stem dysfunction, brain stem injury, brain tumor, bronchial rupture, bronchiolitis,bronchospasm, brun’s syndrome, campomelic syndrome, cardiac arrest, central sleep apnea, cerebral hemorrhage, cerebral infarction, cerebral palsy, Cheyne-Stokes respiration, choanal stenosis, chondrodystrophy, chronic airway-digestive inflammatory disease (CAID), chronic bronchitis, chronic obstructive pulmonary disease, collapse of aryepiglottic folds, congenital central hypoventilation syndrome, Crouzon syndrome, cyanotic congenital heart disease, delayed sleep phase syndrome, deviated septum, diabetic autonomic neuropathy, diffuse pneumonia, Down syndrome, Duchenne muscular dystrophy, edema of epiglottis, elongated and/or thickened palate and uvula, encephalitis, end stage renal disease, flail chest, floppy eyelid syndrome, foreign body aspiration, gastroesophageal reflux disease, Gaucher’s disease, glycine encephalopathy, Guillain-Barré syndrome, Hallermann-Streiff syndrome, head trauma, hemothorax, hunter syndrome, hurler syndrome, hypercapnia, hyperglycinemia , hyperpituitarism, hypothyroidism, hypertonia, hypotonia , hypoventilation, increased intracranial pressure, infant respiratory distress syndrome, Joubert syndrome, Klippel-Feil syndrome, laryngomalacia, late-onset spinal muscular atrophy, leukomalacia, Marfan syndrome, meconium aspiration syndrome, medullary hemorrhage, medullary infarction, meningitis, meningoencephalitis, micrognathia, midfacial hypoplasia, mucus plug, myocardial infarction, myotonic dystrophy, myotubular myopathy, nasal congestion, near drowning, neonatal anemia, nonarteritic anterior ischemic optic neuropathy, obesity, open chest wounds, organic acidemia, oropharyngeal papillomatosis, [[osteopetrosis],parenchymal lung disease, periodic limb movement disorder, pertussis, Pickwickian syndrome, Pierre Robin sequence, pneumothorax, polycystic ovary syndrome, polyposis, pontine hemorrhage, post-traumatic stress disorder, Prader-Willi syndrome, prenatal asphyxia, pulmonary atresia, pulmonary edema, pulmonary embolism, pulmonary fibrosis, pulmonary hypertension, REM sleep, respiratory acidosis, respiratory syncytial viral infection, restless legs syndrome, Rett syndrome, rhinitis, right ventricular hypertrophy, SADDAN, secondary hypertension, seizures, septal dislocation, septal hematoma, septicemia, shock, sickle cell disease, sleep deprivation, smoking, spinal cord injury, sudden infant death syndrome, toxidrome, tracheal rupture, transtentorial herniation, Treacher Collins syndrome, trisomy 13, turbinate hypertrophy, upper airway obstruction, upper Airway Resistance Syndrome (UARS), vocal cord paralysis, Werdnig-Hoffman disease
Renal/Electrolyte 1q21.1 deletion, diabetic autonomic neuropathy, end stage renal disease, Joubert syndrome, Klippel-Feil syndrome, nonarteritic anterior ischemic optic neuropathy, secondary hypertension, shock, trisomy 13
Rheumatology/Immunology/Allergy Guillain-Barré syndrome, sleep deprivation
Sexual Down syndrome, Klippel-Feil syndrome
Trauma Head trauma, near drowning, septal dislocation, septal hematoma, tracheal rupture,
Urologic Diabetic autonomic neuropathy, Klippel-Feil syndrome, trisomy 13
Miscellaneous Aging, breastfeeding, fatigue, maternal beta blocker use, near drowning, smoking, sudden infant death syndrome

Causes in Alphabetical Order


References

  1. ↑ Julliand S, Boulé M, Baujat G; et al. (2012). “Lung function, diagnosis, and treatment of sleep-disordered breathing in children with achondroplasia”. Am. J. Med. Genet. A. 158A (8): 1987–93. doi:10.1002/ajmg.a.35441. PMID 22711495. Unknown parameter |month= ignored (help)
  2. ↑ Gałecki P, Florkowski A, Zboralski K, Pietras T, Szemraj J, Talarowska M (2011). “[Psychiatric and psychological complications in obstructive sleep apnea syndrome]”. Pneumonol Alergol Pol (in Polish). 79 (1): 26–31. PMID 21190150.
  3. ↑ Zagol K, Lake DE, Vergales B; et al. (2012). “Anemia, apnea of prematurity, and blood transfusions”. J. Pediatr. 161 (3): 417–421.e1. doi:10.1016/j.jpeds.2012.02.044. PMID 22494873. Unknown parameter |month= ignored (help)
  4. ↑ Zhao J, Gonzalez F, Mu D (2011). “Apnea of prematurity: from cause to treatment”. Eur. J. Pediatr. 170 (9): 1097–105. doi:10.1007/s00431-011-1409-6. PMC 3158333. PMID 21301866. Unknown parameter |month= ignored (help)
  5. ↑ Campisi R, Ciancio N, Bivona L, Folisi C, Maria G (2013). “Type I Arnold-Chiari Malformation with Bronchiectasis, respiratory failure, and sleep disordered breathing: a case report”. Multidiscip Respir Med. 8 (1): 15. doi:10.1186/2049-6958-8-15. PMID 23433005. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 Vitulano N, Di Marco Berardino A, Re A; et al. (2013). “Obstructive sleep apnea and heart disease: the biomarkers point of view”. Front Biosci (Schol Ed). 5: 588–99. PMID 23277071.
  7. ↑ Shi J, Lv J, Wu H (2012). “[Th1/Th2 cytokines and its clinical significance in obstructive sleep apnea hypopnea syndrome children without allergic rhinitis and asthma]”. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi (in Chinese). 26 (23): 1073–6. PMID 23451475. Unknown parameter |month= ignored (help)
  8. ↑ Sundar KM, Daly SE, Pearce MJ, Alward WT (2010). “Chronic cough and obstructive sleep apnea in a community-based pulmonary practice”. Cough. 6 (1): 2. doi:10.1186/1745-9974-6-2. PMC 2861010. PMID 20398333.
  9. ↑ Mansukhani MP, Calvin AD, Kolla BP; et al. (2013). “The association between atrial fibrillation and stroke in patients with obstructive sleep apnea: A population-based case-control study”. Sleep Med. 14 (3): 243–6. doi:10.1016/j.sleep.2012.08.021. PMID 23340087. Unknown parameter |month= ignored (help)
  10. ↑ McMahon M (1994). “Apnea in infantile botulism”. J. Pediatr. 124 (1): 161. PMID 8283369. Unknown parameter |month= ignored (help)
  11. ↑ 11.0 11.1 Hoogstraate SR, Lequin MH, Huysman MA, Ahmed S, Govaert PP (2009). “Apnoea in relation to neonatal temporal lobe haemorrhage”. Eur. J. Paediatr. Neurol. 13 (4): 356–61. doi:10.1016/j.ejpn.2008.07.005. PMID 18757218. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 Oldenburg O (2012). “Cheyne-stokes respiration in chronic heart failure. Treatment with adaptive servoventilation therapy”. Circ. J. 76 (10): 2305–17. PMID 22972365.
  13. ↑ Huntsman RJ, Sinclair DB, Bhargava R, Chan A (2005). “Atypical presentations of leigh syndrome: a case series and review”. Pediatr. Neurol. 32 (5): 334–40. doi:10.1016/j.pediatrneurol.2004.12.009. PMID 15866434. Unknown parameter |month= ignored (help)
  14. ↑ Kasai T, Motwani SS, Yumino D; et al. (2013). “Contrasting Effects of Lower Body Positive Pressure on Upper Airways Resistance and Partial Pressure of Carbon Dioxide in Men With Heart Failure and Obstructive or Central Sleep Apnea”. J. Am. Coll. Cardiol. doi:10.1016/j.jacc.2012.10.055. PMID 23375931. Unknown parameter |month= ignored (help)
  15. ↑ Rybczynski M, Koschyk D, Karmeier A; et al. (2010). “Frequency of sleep apnea in adults with the Marfan syndrome”. Am. J. Cardiol. 105 (12): 1836–41. doi:10.1016/j.amjcard.2010.01.369. PMID 20538140. Unknown parameter |month= ignored (help)
  16. ↑ Copland VS, Haskins SC, Patz JD (1987). “Oxymorphone: cardiovascular, pulmonary, and behavioral effects in dogs”. Am. J. Vet. Res. 48 (11): 1626–30. PMID 2449102. Unknown parameter |month= ignored (help)
  17. ↑ 17.0 17.1 Maciel RT, Fernandes FC, Pereira Ldos S (2008). “Anesthesia in a patient with multiple endocrine abnormalities. Case report”. Rev Bras Anestesiol. 58 (2): 172–8. PMID 19378536.
  18. ↑ Arnetz BB, Templin T, Saudi W, Jamil H (2012). “Obstructive sleep apnea, posttraumatic stress disorder, and health in immigrants”. Psychosom Med. 74 (8): 824–31. doi:10.1097/PSY.0b013e31826bf1ec. PMID 23023679. Unknown parameter |month= ignored (help)
  19. ↑ Galante D (2005). “Preoperative apnea in a preterm infant after caudal block with ropivacaine and clonidine”. Paediatr Anaesth. 15 (8): 708–9. doi:10.1111/j.1460-9592.2005.01683.x. PMID 16029411. Unknown parameter |month= ignored (help)
  20. ↑ Nice A, Leikin JB, Maturen A, Madsen-Konczyk LJ, Zell M, Hryhorczuk DO (1988). “Toxidrome recognition to improve efficiency of emergency urine drug screens”. Ann Emerg Med. 17 (7): 676–80. PMID 3382068. Unknown parameter |month= ignored (help)
  21. ↑ Heinzer RC, White DP, Jordan AS; et al. (2008). “Trazodone increases arousal threshold in obstructive sleep apnoea”. Eur. Respir. J. 31 (6): 1308–12. doi:10.1183/09031936.00067607. PMC 2732198. PMID 18256066. Unknown parameter |month= ignored (help)
  22. ↑ Gold AR, Broderick JE, Gold MS, Amin MM (2013). “A comparison of inspiratory airflow dynamics during sleep between upper airway resistance syndrome patients and healthy controls”. Sleep Breath. doi:10.1007/s11325-013-0817-4. PMID 23407917. Unknown parameter |month= ignored (help)

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Differentiating Apnea from other Diseases

Differentiating Apnea from other Diseases

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Epidemiology and Demographics

Epidemiology and Demographics

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Risk Factors

Risk Factors

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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Chest X Ray | CT | MRI | Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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