Abstract
Study design
Prospective, double-blind, randomised, placebo-controlled, cross-over trial of nasal decongestion in tetraplegia.
Objectives
Tetraplegia is complicated by severe, predominantly obstructive, sleep apnoea. First-line therapy for obstructive sleep apnoea is nasal continuous positive airway pressure, but this is poorly tolerated. High nasal resistance associated with unopposed parasympathetic activation of the upper airway contributes to poor adherence. This preliminary study tested whether reducing nasal decongestion improved sleep.
Setting
Participants’ homes in Melbourne and Sydney, Australia.
Methods
Two sleep studies were performed in participants’ homes separated by 1 week. Participants were given a nasal spray (0.5 mL of 5% phenylephrine or placebo) in random order and posterior nasal resistance measured immediately. Outcomes included sleep apnoea severity, perceived nasal congestion, sleep quality and oxygenation during sleep.
Results
Twelve middle-aged (average (SD) 52 (12) years) overweight (body mass index 25.3 (6.7) kg/m2) men (C4-6, AIS A and B) participated. Nasal resistance was reduced following administration of phenylephrine (p = 0.02; mean between treatment group difference −5.20: 95% confidence interval −9.09, −1.32 cmH2O/L/s). No differences were observed in the apnoea hypopnoea index (p = 0.15; −6.37: −33.3, 20.6 events/h), total sleep time (p = 0.49; −1.33: −51.8, 49.1 min), REM sleep% (p = 0.50; 2.37: −5.6, 10.3), arousal index (p = 0.76; 1.15: −17.45, 19.75), 4% oxygen desaturation index (p = 0.88; 0.63: −23.5, 24.7 events/h), or the percentage of mouth breathing events (p = 0.4; −8.07: −29.2, 13.0) between treatments. The apnoea hypopnoea index did differ between groups, however, all except one participant had proportionally more hypopnoeas than apnoeas during sleep after decongestion.
Conclusions
These preliminary data found that phenylephrine acutely reduced nasal resistance but did not significantly change sleep-disordered breathing severity.
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References
AccessEconomics. The economic cost of spinal cord injury and traumatic brain injury in Australia. Report by Access Economics Pty Limited for the Victorian Neurotrauma Initiative, 2009.
Berlowitz DJ, Brown DJ, Campbell DA, Pierce RJ. A longitudinal evaluation of sleep and breathing in the first year after cervical spinal cord injury. Arch Phys Med Rehabil. 2005;86:1193–9.
Giannoccaro MP, Moghadam KK, Pizza F, Boriani S, Maraldi NM, Avoni P, et al. Sleep disorders in patients with spinal cord injury. Sleep Med Rev. 2013;17:399–409.
Berlowitz DJ, Spong J, Gordon I, Howard ME, Brown DJ. Relationships between objective sleep indices and symptoms in a community sample of people with tetraplegia. Arch Phys Med Rehabil. 2012;93:1246–52.
Biering-Sorensen F, Biering-Sorensen M. Sleep disturbances in the spinal cord injured: an epidemiological questionnaire investigation, including a normal population. Spinal Cord. 2001;39:505–13.
Spong J, Graco M, Brown DJ, Schembri R, Berlowitz DJ. Subjective sleep disturbances and quality of life in chronic tetraplegia. Spinal Cord. 2015;53:636–40.
Sajkov D, Marshall R, Walker P, Mykytyn I, McEvoy RD, Wale J, et al. Sleep apnoea related hypoxia is associated with cognitive disturbances in patients with tetraplegia. Spinal Cord. 1998;36:231–9.
Schembri R, Spong J, Graco M, Berlowitz DJ, team Cs. Neuropsychological function in patients with acute tetraplegia and sleep disordered breathing. Sleep 2017;40:zsw037.
Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med. 2013;188:996–1004.
Fuller DD, Lee KZ, Tester NJ. The impact of spinal cord injury on breathing during sleep. Respir Physiol Neurobiol. 2013;188:344–54.
Fang X, Goh MY, O’Callaghan C, Berlowitz D. Relationship between autonomic cardiovascular control and obstructive sleep apnoea in persons with spinal cord injury: a retrospective study. Spinal Cord Ser Cases. 2018;4:29.
Wijesuriya NS, Gainche L, Jordan AS, Berlowitz DJ, LeGuen M, Rochford PD, et al. Genioglossus reflex responses to negative upper airway pressure are altered in people with tetraplegia and obstructive sleep apnoea. J Physiol. 2018;596:2853–64.
Sankari A, Vaughan S, Bascom A, Martin JL, Badr MS. Sleep disordered breathing and spinal cord injury- a state of the art review. Chest 2018;155:438–45.
O’Donoghue FJ, Meaklim H, Bilston L, Hatt A, Connelly A, Jackson G, et al. Magnetic resonance imaging of the upper airway in patients with quadriplegia and obstructive sleep apnea. J Sleep Res. 2018;27:e12616.
Wijesuriya NS, Lewis C, Butler JE, Lee BB, Jordan AS, Berlowitz DJ, et al. High nasal resistance is stable over time but poorly perceived in people with tetraplegia and obstructive sleep apnoea. Respir Physiol Neurobiol. 2017;235:27–33.
Gainche L, Berlowitz DJ, LeGuen M, Ruehland WR, O’Donoghue FJ, Trinder J, et al. Nasal resistance is elevated in people with tetraplegia and is reduced by topical sympathomimetic administration. J Clin Sleep Med. 2016;12:1487–92.
Koutsourelakis I, Minaritzoglou A, Zakynthinos G, Vagiakis E, Zakynthinos S. The effect of nasal tramazoline with dexamethasone in obstructive sleep apnoea patients. Eur Respir J. 2013;42:1055–63.
Verse T, Pirsig W. Impact of impaired nasal breathing on sleep-disordered breathing. Sleep Breath. 2003;7:63–76.
Burns SP, Little JW, Hussey JD, Lyman P, Lakshminarayanan S. Sleep apnea syndrome in chronic spinal cord injury: associated factors and treatment. Arch Phys Med Rehabil. 2000;81:1334–9.
Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34:535–46.
Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012;8:597–619.
Stull DE, Meltzer EO, Krouse JH, Roberts L, Kim S, Frank L, et al. The congestion quantifier five-item test for nasal congestion: refinement of the congestion quantifier seven-item test. Am J Rhinol Allergy. 2010;24:34–8.
Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet. 2014;383:736–47.
Lung MA, Wang JC. Autonomic nervous control of nasal vasculature and airflow resistance in the anaesthetized dog. J Physiol. 1989;419:121–39.
Berlowitz DJ, Spong J, Pierce RJ, Ross J, Barnes M, Brown DJ. The feasibility of using auto-titrating continuous positive airway pressure to treat obstructive sleep apnoea after acute tetraplegia. Spinal Cord. 2009;47:868–73.
Kiely JL, Nolan P, McNicholas WT. Intranasal corticosteroid therapy for obstructive sleep apnoea in patients with co-existing rhinitis. Thorax. 2004;59:50–5.
Koutsourelakis I, Vagiakis E, Perraki E, Karatza M, Magkou C, Kopaka M, et al. Nasal inflammation in sleep apnoea patients using CPAP and effect of heated humidification. Eur Respir J. 2011;37:587–94.
Funding
This research project was proudly supported by the Transport Accident Commission (Sleep Health in Quadriplegia Program) and received National Health and Medical Research Council (NHMRC) project grant funding (1065913).
Author contributions
NSW was involved in the literature review, study design, data collection, analysis of data, manuscript preparation and review of the manuscript. DJE and ASJ were involved in study design, funding attainment, analysis of data and review of the manuscript. RS was involved in literature review, data collection, analysis of data, manuscript preparation and review of the manuscript. HM and LB were involved in data collection and review of the manuscript. CL and DB were involved in study design and review of the manuscript. MG was involved in study design, data collection, analysis of data and review of the manuscript. DJB was involved in literature review, study design, funding attainment, data collection, analysis of data, manuscript preparation and review of the manuscript.
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DJE is supported by a NHMRC Senior Research Fellowship (1116942). ASJ is supported by an Australian Research Council Future Fellowship (FT100100203). DJE has a Commonwealth Government of Australia Cooperative Research Centre grant (industry partner: Oventus Medical), serves as a consultant for Bayer and has research support from Apnimed. The remaining authors declare that they have no conflict of interest.
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Wijesuriya, N.S., Eckert, D.J., Jordan, A.S. et al. A randomised controlled trial of nasal decongestant to treat obstructive sleep apnoea in people with cervical spinal cord injury. Spinal Cord 57, 579–585 (2019). https://doi.org/10.1038/s41393-019-0256-6
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DOI: https://doi.org/10.1038/s41393-019-0256-6
