High nasal resistance is stable over time but poorly perceived in people with tetraplegia and obstructive sleep apnoea
Introduction
Obstructive sleep apnea (OSA) is highly prevalent (>60%) in people with tetraplegia (Berlowitz et al., 2005, Burns et al., 2000, Chiodo et al., 2016, Giannoccaro et al., 2013, Tran et al., 2010). The pathophysiological factors responsible for the high risk of OSA in people with tetraplegia are poorly understood. Increased nasal congestion, a risk factor for sleep-disordered breathing, is common in people with tetraplegia. Injury to the cervical spinal cord disrupts the supraspinal inputs to spinal sympathetic neurons below the level of injury (Weaver et al., 2006), while the parasympathetic drive remains largely unopposed. The result is diminished sympathetic activity overall. This increases vasodilation and mucosal thickening in the nose which may reduce nasal patency and increase nasal resistance (Baraniuk, 2008).
Nasal resistance is estimated to account for 30–50% of total upper airway resistance in non-neurologically impaired, able-bodied populations (Verin et al., 2002). Increased nasal resistance increases upper airway collapsibility (Dawson et al., 1997, Schwartz et al., 1989) and reduces compliance to therapies such as continuous positive airway pressure (CPAP) therapy in able-bodied people with OSA (Sugiura et al., 2007, Zeng et al., 2008) and in people with tetraplegia and OSA (Berlowitz et al., 2005, Burns et al., 2000). While increased nasal congestion is widely recognized clinically following tetraplegia, quantitative assessment of nasal resistance in people with tetraplegia and its potential role in pathogenesis of OSA had not been investigated until recently. The present study aimed to quantify nasal resistance in people with tetraplegia to establish whether strategies to reduce nasal congestion might be warranted as a therapeutic target to reduce OSA in this population. As such, it is important to know if nasal resistance is stable over time and how it compares to able-bodied controls.
Furthermore, there are inconsistencies between current measures of nasal congestion. Both objective and subjective measures have been used. However, it remains unclear whether the different approaches yield similar information (André et al., 2009, Clement et al., 2014, Schumacher, 2002). Therefore, the present study used three common measures of nasal congestion: (i) airway resistance measured via a choanal pressure transducer – laboratory gold standard technique to objectively quantify nasal resistance, (ii) anterior rhinomanometry – a routinely used tool to measure nasal obstruction in clinical practice and (iii) self-report nasal congestion to also determine how well the objective and subjective measures of nasal congestion correlate with one another.
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Participants
Participants with tetraplegia were recruited from the Prince of Wales Hospital Spinal Cord Unit and the community. Able-bodied participants were recruited from the local community alone via advertisement. Participants were recruited for the tetraplegia group if they: (i) had an injury to the cervical spinal cord, (ii) had a level of injury completeness according to the ASIA (American Spinal Injury Association) impairment scale (AIS) of either AIS A or AIS B, (Kirshblum et al., 2011), and (iii)
Participant characteristics
Eight people with tetraplegia (1 female) (see Table 1 for participant characteristics) and 6 able-bodied controls (1 female) completed the study. Tetraplegia and control groups were well-matched for age (50 ± 9 vs. 48 ± 10, p = 0.8) and body mass indices (26 ± 8 vs. 26 ± 4 kg/m2, p = 0.9). The tetraplegia group had moderate to severe OSA with a mean apnea/hypopnea index of 36 ± 14 events/h sleep. One of the tetraplegia participants was on continuous positive airway pressure (CPAP) therapy at the time of the
Discussion
The main findings of this study are that objectively measured nasal resistance via the gold standard choanal pressure technique is higher in people with tetraplegia compared to non-neurologically impaired controls yet perceived nasal blockage is similar between groups. These findings indicate poor perception of elevated nasal resistance in the tetraplegia population. High nasal resistance is consistent with autonomic dysfunction associated with high spinal cord injury. Poor perception of high
Disclosures
The authors do not have any conflicts of interest to disclose.
Acknowledgments
This work was supported by the National Health and Medical Research Council (NHMRC) of Australia (1065913). DJE is supported by a NHMRC RD Wright Fellowship (1049814). ASJ is supported by an ARC Future Fellowship (FT100100203). JEB is supported by NHMRC Fellowship (1042646). The authors would like to thank the participants of the study for their contribution and the Department of Respiratory Medicine, Prince of Wales hospital, Sydney for loaning their anterior rhinomanometer for the study.
References (53)
Neural regulation of mucosal function
Pulm. Pharmacol. Ther.
(2008)- et al.
A longitudinal evaluation of sleep and Breathing in the first year after cervical spinal cord injury
Arch. Phys. Med. Rehabil.
(2005) - et al.
Sleep apnea syndrome in chronic spinal cord injury: associated factors and treatment
Arch. Phys. Med. Rehabil.
(2000) - et al.
Forty-second Annual MeetingComparison of sequential anterior and posterior rhinomanometry
J. Allergy Clin. Immunol.
(1985) - et al.
THe influence of obstructive sleep apnea and gender on genioglossus activity during rapid eye movement sleep
Chest
(2009) - et al.
Sleep disorders in patients with spinal cord injury
Sleep Med. Rev.
(2013) MEchanisms of obstructive sleep apnea
Chest
(1992)- et al.
Olfactory ensheathing cells reduce duration of autonomic dysreflexia in rats with high spinal cord injury
Auton. Neurosci.
(2010) Autonomic function following cervical spinal cord injury
Respir. Physiol. Neurobiol.
(2009)- et al.
Spinal-cord injury
Lancet
(2002)
Rhinomanometry
J. Allergy Clin. Immunol.
Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients
Respir. Physiol.
Autonomic dysreflexia after spinal cord injury: central mechanisms and strategies for prevention
Correlation between subjective and objective evaluation of the nasal airway: a systematic review of the highest level of evidence
Clin. Otolaryngol.
Symptom perception and respiratory sensation in asthma
Am. J. Respir. Crit. Care Med.
The effects of camphor, eucalyptus and menthol vapour on nasal resistance to airflow and nasal sensation
Acta Otolaryngol. (Stockh.)
Assessing nasal air flow
Proc. Am. Thorac. Soc.
Sleep disordered breathing in spinal cord injury: a systematic review
J. Spinal Cord Med.
The role of mucosal receptors in the nasal sensation of airflow
Clin. Otolaryngol. Allied Sci.
Critical evaluation of different objective techniques of nasal airway assessment: a clinical review
Eur. Arch. Otorhinolaryngol.
Effect of bedtime alcohol on inspiratory resistance and respiratory drive in snoring and nonsnoring men
Alcohl. Clin. Exp. Res.
The effects of oral administration of (−)-menthol on nasal resistance to airflow and nasal sensation of airflow in subjects suffering from nasal congestion associated with the common cold
J. Pharm. Pharmacol.
Blunted sensation of dyspnoea and near fatal asthma
Eur. Respir. J.
Alcohol alters sensory processing to respiratory stimuli in healthy men and women during wakefulness
Sleep
Effects of pentobarbital on upper airway patency during sleep
Eur. Respir. J.
Nasal Resistance Is Elevated in People with Tetraplegia and Is Reduced by Topical Sympathomimetic Administration
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