Adult enuresis is an unusual symptom of obstructivesleep apnea (OSA). Although it is described as aclassic symptom of childhood OSA, enuresis is en¬countered infrequently in adult sleep medicine. Fiveadults with enuresis associated with sleep apneapresented to our Sleep Disorders Center. In all fivecases, the onset of enuresis was associated with theprogression of sleep apnea symptoms. In each case,the enuresis resolved with treatment with nasal con¬tinuous positive airway pressure. Current medicalliterature on the postulated mechanisms of nocturiaand enuresis in sleep apnea is reviewed. Based onthe experience of the authors and review of themedical literature, one may conclude that severeOSA may lead to new-onset enuresis in adults andthat effective treatment of OSA is associated withresolution of enuresis.
2 3 G a r d n e r I D .Suppr e ssionof a n t ib a c t e r ia lim
m un it y b yin f e c t ion w it h in f l ue n z a v ir us.JI n f e
c t D is1 9 8 1 ;1 4 4 : 2 2 5 - 3 12 4 W a l shTJ ,Hie m e n zJ W
,Se ib e lN ,e t a l .Am ph ot e r ic inBl ipidc om pl e xin t h e
t r e a t m e n t of 2 2 8 c a se s of in v a siv em y c osis.Ab st
r a c t . I n :P r og r a ma n d a b st r a c t s of t h e 3 4 t h
I n t e r sc ie n c eC on f e r e n c e on An t im ic r ob ia lAg e
n t sa n dC h e m ot h e r a py( O r l a n d o, F L ) .W a sh in g
t on ,D C : Am e r ic a nSoc ie t yf or M ic r ob iol og y ,1 9 9
42 5 P e t r ik k osG ,Sa m b a t a k ouH,K or a n t z isJ ,e t a l
.Am ph ot e r ic inBl ipid c om pl e xf or t h em a n a g e m e n
tofsy st e m ic m y c osisinpa t ie n t sw it hn e ph r ot ox ic it
ya n d / or f a il ur e ofpr e v iousa n t if un g a lt r e a t m e
n t . Ab st r a c t 0 8 9 . I n : T h e 1 3 t hC on g r e ssof t h
eI n t e r n a t ion a lSoc ie t yf or Hum a n a n d An im a lM y c
ol og y ,P a r m a ,I t a l y ,1 9 9 72 6 K it a h a r aM ,Se t hV
K ,M e d of fG ,e t a l .Ac t iv it yofa m ph ot e r ic inB,5 - f l
uor oc y t osin e ,a n dr if a m pin a g a in stsix c l in ic a
lisol a t e s ofa spe r g il l us.An t im ic r obAg e n t sC h e m
ot h e r1 9 7 6 ;9 : 9 1 52 7 L a ue rBA,R e l l e rL B,Sc h r ot e
rG P J . Susc e pt ib il it yof a spe r g il l ust o5 - f l uor oc
y t osin ea n da m ph ot e r ic inB a l on e a n d inc om b in a t
ion .JAn t im ic r ob C h e m ot h e r1 9 7 8 ;4 : 3 7 52 8Hug h e
sC E ,Ha r r isC ,M ood y J A,e t a l . I n v it r o a c t iv it ie
s ofa m ph ot e r ic inB in c om b in a t ion w it h f oura n t if
un g a l a g e n t sa n dr if a m pin a g a in st Aspe r g il l us
spp.An t im ic r obAg e n t sC h e m ot h e r1 9 8 4 ;2 5 : 5 6 02
9Ar r oy o J ,M e d of fG ,K ob a y a sh iG S.Th e r a pyof m ur in
ea spe r g il l osisw it ha m ph ot e r ic inB in c om b in a t ion
w it h r if a m pinor5 - f l uor oc y t osin e .An t im ic r obAgC
h e m ot h e r1 9 7 7 ;1 1 : 2 13 0 P ol a k A. P h a r m a c ok in
e t ic s ofa m ph ot e r ic inB a n df l uc y t osin e .P ost g r a
dM e dJ1 9 7 9 ;5 5 : 6 6 73 1 C a r r iz osaJ ,L e v in sonM E ,L
a w r e n c eT ,e t a l . C ur e ofAspe r g il l usust us e n d oc
a r d it is on apr ost h e t icv a l v e . Ar c hI n t e r n M e d1
9 7 4 ;1 3 3 : 4 8 63 2D e n n in gD W ,St e v e n s D A.An t if un
g a la n dsur g ic a lt r e a t m e n tof in v a siv ea spe r g il
l osis:r e v ie w of2 , 1 2 1pub l ish e dc a se s. R e vI n f e c
t D is1 9 9 0 ;1 2 : 1 1 4 7 - 1 2 0 13 3D e n n in gD W ,T uc k e
rR M ,Ha n sonL H,e t a l . Tr e a t m e n t ofin v a siv ea spe r
g il l osisw it h it r a c on a z ol e . AmJM e d1 9 8 9 ;8 6 : 7 9
1 - 8 0 03 4D e n n in gD W ,L e eJ Y ,Host e t l e rJ S,e t a l .
N I AI Dm y c ose sst ud y g r oupm ul t ic e n t e r t r ia l of
or a l it r a c on a z ol et h e r a pyf orin v a siv ea spe r g il
l osis.AmJM e d1 9 9 4 ;9 7 : 1 3 5 - 4 43 5Sug a rAM . U se ofa m
ph ot e r ic inB w it h a z ol ea n t if un g a ld r ug s:w h a t a
r e w ed oin g ?An t im ic r obAg e n t sC h e m ot h e r1 9 9 5 ;3
9 : 1 9 0 7 - 1 23 6D e n n in gD W ,d e l F a v e r oA,G l uc k m
a nE ,e t a l . Th ee f f ic a c ya n dt ol e r a b il it yofU K1 0
9 , 4 9 6 ( v or ic on a z ol e )in t h e t r e a t m e n tof in v
a siv ea spe r g il l osis( I A) .Ab st r a c t P 5 5 2 . T h e 1 3
t h C on g r e ssof t h e I n t e r n a t ion a lSoc ie t yf or Hum
a n a n d An im a lM y c ol og y ,P a r m a ,I t a l y ,1 9 9 73 7
C a il l otD ,C a sa sn ov a sO , Be r n a r dA,e t a l .I m pr ov
e dm a n a g e m e n tof in v a siv epul m on a r y a spe r g il l
osisinn e ut r ope n icpa t ie n t s usin g e a r l yt h or a c icc
om put e d t om og r a ph icsc a n a n dsur g e r y . JC l in O n c
ol1 9 9 7 ;1 5 : 1 3 9 - 4 73 8 R oil id e sE ,Hol m e sA,Bl a k eC
,e t a l .An t if un g a l a c t iv it yofe l ut r ia t e d h um a
nm on oc y t e s a g a in st Aspe r g il l us f um ig a t ush y ph
a e :e n h a n c e m e n tb y g r a n ul oc y t e - m a c r oph a g
e c ol on yst im ul a t in gf a c t or a n din t e r f e r on - g a
m m a . JI n f e c t D is1 9 9 4 ;1 7 0 : 8 9 4 - 9 93 9 R oil id e
sE ,U h l igK ,V e n z onD ,e t a l . E n h a n c e m e n t ofox id
a t iv er e spon sea n dd a m a g ec a use db yh um a nn e ut r oph
il st oAspe r g il l us f um ig a t us h y ph a e b y g r a n ul oc
y t e c ol on yst im ul a t in gf a c t or a n dg a m m a - in t e
r f e r on .I n f e c t I m m un1 9 9 3 ;6 1 : 1 1 8 5 - 9 34 0 N e
um un a it isJ , M e y e r s J D ,Buc k n e rC D ,e t a l . P h a
se I t r ia l ofr e c om b in a n t h um a nm a c r oph a g e c ol
on y st im ul a t in gf a c t or inpa t ie n t sw it h in v a siv
ef un g a lin f e c t ion s. Bl ood1 9 9 1 ;7 8 :9 0 7 - 1 34 1 Be
r n h ise l - Br oa d b e n tJ , C a m a r g oE E ,J a f f eHS. R e
c om b in a n th um a nin t e r f e r on - g a m m aa sa d j un c t
t h e r a pyf orAspe r g il l usin f e c t ion in apa t ie n tw it
h c h r on icg r a n ul om a t ousd ise a se .JI n f e c t D is1 9
9 1 ;1 6 3 : 8 0 8 - 1 14 2C l a n c y C J ,D ia zL E ,N g uy e nM
H. I n v a siv ea spe r g il l ussin usit is in n or m a l h ost s:
v a l ue s ofa d j un c t iv e t h e r a pyw it h in t e r f e r on
a . 3 4 t h C on f e r e n c e of t h e I n f e c t ious D ise a
seSoc ie t yofAm e r ic a ,N e wO r l e a n s, L A,1 9 9 64 3 Sc h
a f f n e rA,D oug l a sH,Br a ud e A. Se l e c t iv epr ot e c t
iona g a in stc on id iab ym on on uc l e a r a n da g a in st m y
c e l ia b ypol y m or ph n uc l e a r ph a g oc y t e sin r e sist
a n c e t oAspe r g il l us:ob se r v a t ion s of t h e se t w o l
in e s of d e f e n se in v iv o a n d in v it r ow it h h um a n a
n d m ouseph a g oc y t e s. JC l in I n v e st1 9 8 2 ;6 9 : 6 1 7
- 3 14 4 C h usidM J ,Soh n l eP G ,F in kJ N ,e t a l . Ag e n e t
icd e f e c t ofg r a n ul oc y t em e t a b ol ism in a m a n w it
h d isse m in a t e da spe g il -l osis.JL a b C l in M e d1 9 8 1
;9 7 : 7 3 0 - 3 8E n ur e sis a n d O b st r uc t iv eSl e e pApn
e ain Ad ul t s*N a om i R .K r a m e r , M D ; Al ic e E .Bon it a
t i, M D , F C C P ;a n dR ic h a r d P .M il l m a n , M D , F C C
PAd ul t e n ur e sis is a n un usua lsy m pt omof ob st r uc t iv
esl e e p a pn e a( O SA) .Al t h oug hit is d e sc r ib e d a s ac
l a ssicsy m pt omof c h il d h oodO SA,e n ur e sis is e n c oun t
e r e din f r e que n t l yin a d ul tsl e e pm e d ic in e . F iv
ea d ul t s w it h e n ur e sis a ssoc ia t e d w it hsl e e p a pn
e apr e se n t e dt o ourSl e e pD isor d e r s C e n t e r . I n a
l l f iv ec a se s,t h e on se t of e n ur e sis w a s a ssoc ia t
e d w it h t h epr og r e ssionofsl e e p a pn e a sy m pt om s.I n
e a c hc a se ,t h e e n ur e sis r e sol v e d w it h t r e a t m
e n t w it h n a sa l c on t in uousposit iv e a ir w a y pr e ssur
e .C ur r e n t m e d ic a ll it e r a t ur e on t h epost ul a t e
dm e c h a n ism s of n oc t ur iaa n d e n ur e sis insl e e p a
pn e ais r e v ie w e d . Ba se d ont h ee x pe r ie n c eof t h e
a ut h or s a n d r e v ie w of t h em e d ic a ll it e r a t ur e
,on em a yc on c l ud e t h a t se v e r eO SAm a yl e a d t o n e
w - on se t e n ur e sis in a d ul t s a n dt h a t e f f e c t iv
e t r e a t m e n t of O SA is a ssoc ia t e d w it hr e sol ut ion
of e n ur e sis.( C HE ST 1 9 9 8 ; 1 1 4 : 6 3 4 - 6 3 7 )K e yw
or d s:a d ul t s; e n ur e sis;ob st r uc t iv esl e e p a pn e
aAb b r e v ia t ion s: AN P = a t r ia l n a t ur e t icpe pt id e
;C P AP = c on t in uousposit iv e a ir w a y pr e ssur e ;O SA=ob
st r uc t iv esl e e p a pn e a* F r om t h e D iv ision ofP ul m
on a r y , Sl e e p,a n d C r it ic a l C a r eM e d ic in e ,R h
od e I sl a n dHospit a la n d Br ow nU n iv e r sit ySc h oolofM e
d ic in e , P r ov id e n c e ,R LM a n usc r iptr e c e iv e dJ ul
y1 7 , 1 9 9 7 ;r e v isiona c c e pt e dD e c e m b e r2 6 ,1 9 9
7 .C or r e spon d e n c et o: N a om i R .K r a m e r , M D ,Sl e
e pD isor d e r sC e n t e r , R h od e I sl a n dHospit a l ,5 9
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Center Useron 01/10/2013A d ul t e n ur e sis is a n un usua lsy m
pt omof ob st r uc t iv e- ^ * -sl e e p a pn e a( O SA) .Al t h
oug hit is d e sc r ib e d a s a c l a ssicsy m pt omof c h il d h
oodO SA, 1 5e n ur e sis is e n c oun t e r e din f r e que n t l
yin t h e c l in ic a lpr a c t ic eof a d ul tsl e e pm e d ic in
e . F iv e a d ul t s w it h e n ur e sis a ssoc ia t e d w it hsl
e e p a pn e apr e se n t e dt o t h eSl e e pD isor d e r s C e n
t e rd ur in g1y e a r .T h epur poseof t h isst ud yis t o r e v
ie w t h ek e yc l in ic a lf e a t ur e s a n dpol y som n og r a
md a t a of t h e sepa t ie n t sinor d e r t o b e t t e r d e f
in e w h o isl ik e l yt od e v e l opt h ist r oub l in g sy m pt
om .C a se Se r ie sC l in ic a l D a t aAl l f iv epa t ie n t sw
e r e r e f e r r e d f or e v a l ua t ion ofsn or in gw it hw it
n e sse da pn e a sa n d e x c e ssiv esl e e pin e ss.Al l f iv
epa t ie n t sw e r em a l e . Th e m e a na g ea t t im e ofpr e
se n t a t ionw a s 3 8 9y e a r s.Al lt h epa t ie n t sw e r e ob
e se ,w it h m e a n( SE M )b od ym a ss in d e x of3 8 . 6 2 . 1k
g / m 2a n d n e c k siz e of 1 7 . 5 0 . 3 c m . C om or b idil l
n e sse s in c l ud e dh y pe r t e n sion( 2pa t ie n t s) ,m od e
r a t e C O P D( F E V j lof 1 . 6 9 in 1pa t ie n t ) ,m od e r a
t e a l c oh ol use( 3t o 6 a l c oh ol icb e v e r a g e s pe r n
ig h tin 2pa t ie n t s) ,a n d d ia b e t e s m e l l it us( 1pa t
ie n t ) .N opa t ie n t sw e r et a k in gd iur e t ic s. C a f f
e in e use w a squit ee x t e n siv e in m ostpa t ie n t sa n dr a
n g e df r om 1 6 oz of sod a t o3 2 oz of c of f e epl us1 2 oz of
sod ape r d a y .How e v e r ,n opa t ie n tuse d c a f f e in e in
t h ee v e n in ga f t e r d in n e r .Al t h oug ha l l of t h e
sepa t ie n t ssn or e d f orm a n y y e a r s,t h e r e h a db e e
n asig n if ic a n tin c r e a se insn or in g ,w it n e sse da pn
e a ,a n dsl e e pin e ssa ssoc ia t e d w it hw e ig h t g a inin
t h e m on t h spr iort opr e se n t a t ion .I n a l l f iv epa t
ie n t s,e n ur e sisd e v e l ope d d ur in gt h ist im epe r
iodofpr og r e ssiv e sl e e p a pn e a sy m pt om s. O n l yon e
oft h e sepa t ie n t sh a d apr ior h ist or yof e n ur e sis. Th
e e n ur e sis h a dpr e v iousl yr e sol v e d a ta g e1 9 a n d t
h e n r e c ur r e d a ta g e2 9 w h e nh ed e v e l ope d sy m pt
om sofsl e e p a pn e a .I n on e ot h e rpa t ie n t ,e n ur e sis
oc c ur r e dt r a n sie n t l y1y e a r pr iort opr e se n t a t
iona n dt h e n r e c ur r e d in t h e 2 t o 3 m on t h spr iort
opr e se n t a t ion .Hee x pe r ie n c e d m ul t ipl e e pisod e
s pe r n ig h t r e quir in gt h r e e t o f iv ec h a n g e sof un
d e r w e a rpe r n ig h ta n d t h e use ofpl a st icsh e e t s. I
nc on t r a st ,2 ot h e rpa t ie n t se a c he x pe r ie n c e d
on l y4e pisod e sofe n ur e sisoc c ur r in gov e r 4 t o 5 m on t
h s ofin c r e a sin g sn or in ga n dsl e e p a pn e a sy m pt om
s pr iort opr e se n t a t ion .I n t h e f if t hpa t ie n t ,t h
e e n ur e sis oc c ur r e din t e r m it t e n t l y .He w oul de
x pe r ie n c ee n ur e sis on an ig h t l yb a sis f or t h r e e
t o f ourn ig h t sa n d t h e n it w oul da b a t e f or se v e r
a ln ig h t s.Th ispa t ie n ta l so st a r t e dsl e e p w a l k
in g( n otin a ssoc ia t ion w it h e n ur e sispe rse ) ,w h ic h
h e h a d n ot d on ein c h il d h ood . Th epa t ie n tw it h t h
e m ost se v e r e e n ur e sis( m ul t ipl ee pisod e s pe r n ig
h t )d id n ot h a v e ah ig h e r a pn e a / h y popn e ain d e x
,l ow e rox y g e nsa t ur a t ion ,orl on g e rd ur a t ion ofr e
spir a t or ye v e n t s.Hed id , h ow e v e r ,h a v e t h eh ig h
e st b od ym a ss in d e x .T e st in gI n t h el a b or a t or y ,
spl it - n ig h t pol y som n og r a m sw e r e r e c or d e df or
a l l f iv epa t ie n t s. M on it or in gw a sa c c om pl ish e d
usin gt w o E E Gl e a d s,t w oe l e c t r o- oc ul og r a ml e a
d s,a sub m e n t a le l e c t r om y og r a m ,asn or in g m ic r
oph on e ,a n a ir f l owt h e r m ist or ,c h e st a n d a b d om
in a l P ie z o e l e c t r od eb a n d s,pul se ox im e t r y ,a
nE C G ,a n d b il a t e r a la n t e r ior t ib ia l ise l e c t r
om y og r a m .Al l 5pa t ie n t sh a d se v e r esl e e pa pn e a
d ur in ga b a se l in epe r iodof a m in im um 2 h ofsl e e p.T h
ea pn e a / h y popn e ain d e x w a s 1 0 7 . 4 7 . 7( m e a n SE
M )e v e n t spe rh our ofsl e e pw it h a n a d ir0 2sa t ur a t
ion of 7 5 . 2 2 . 7 % . T h ea pn e ad ur a t ionr a n g e df r om
1 0 t o 4 5 s. Th e m e a n d ur a t ion of t h el on g e ste v e n
t of e a c h r e c or d w a s 3 5 s. M e a nsl e e p e f f ic ie n
c yw a s8 4 % ,w it h ar a n g eof 6 0 t o 9 8 %d ur in gt h e b a
se l in epor t ionof t h er e c or d . I n t h r e e of t h e f iv
est ud ie s,r a pid e y em ov e m e n tsl e e pw a sn ot se e nd ur
in gt h e b a se l in epor t ionof t h er e c or d ; t h us,t h ed
e g r e eofsl e e p a pn e a m a yh a v e b e e n un d e r e st im
a t e d in t h e sepa t ie n t s.N a sa l c on t in uousposit iv e
a ir w a y pr e ssur e( C P AP )w a st it r a t e dd ur in gt h e
se c on d h a l f of t h est ud y .T h eopt im a l pr e ssur er a n
g e df r om 1 2 . 5 t o 2 0 c mH2 0 .T h ea pn e a / h y popn e ain
d e x a tt h eopt im a lC P APpr e ssur ew a s 1 0 . 6 2 . 7 w it h
a n a d ir0 2sa t ur a t ion of 9 1 . 2 1 . 2 %( Ta b l e 1 ) .R e
sul t sofTr e a t m e n tT h epa t ie n t sw e r e se e n 1 t o 2 w
e e k s a f t e r t h esl e e p st ud ya n dn a sa l C P AP w a s
st a r t e d a t h om e .Th e yw e r ea g a inse e n f orf ol l ow
- upe x a m in a t ion in 1 t o 4 m on t h s. Al l t h epa t ie n t
s r e por t e dc om pl e t er e sol ut ion ofsn or in g , d a y t
im e sl e e pin e ss,a n d e n ur e sisw it h use of C P AP .D I SC
U SSI O NTod a t e ,t h e r e a r e a m a x im um of 1 7 c a se s
of e n ur e sisa ssoc ia t e d w it hsl e e p a pn e a r e por t e
din a d ul t s. 5 1 1 T h ee a r l y r e por t sof e n ur e sis a r
e in c l ud e d in se v e r a lg e n e r a lr e v ie w s a n d c a
se se r ie s a b outsl e e p a pn e af r om t h esa m e in st it ut
ion .Th e r e f or e ,it ispossib l et h a t som epa t ie n t s m a
yh a v e b e e n in c l ud e d in m or e t h a n on er e por t .I t
is n otc l e a r , h ow e v e r ,w h oe x pe r ie n c e se n ur e
sis a n dw h y .Th isst ud y pr e se n t sf iv e m e n w it h O SA
a n de n ur e sis w h opr e se n t e dt o t h esl e e pc e n t e r
ov e r ape r iodof 1 2 m on t h s.D ur in gt h e c l ose st c a l e
n d a ry e a r ,1 ,5 6 1pol y som n og r a m sw e r e r e c or d e
d . O ft h e se ,7 7 5st ud ie s w e r e in it ia l st ud ie se st
a b l ish in gad ia g n osisofO SA in a n a d ul tpa t ie n t . Al
t h oug haposit iv e h ist or yofe n ur e sis un r e l a t e d t o
ot h e r m e d ic a l d isor d e r s w a s d oc um e n t e d inon l
yf iv epa t ie n t s,t h e a b se n c e of t h issy m pt omw a s n
ota l w a y sd oc um e n t e d in ot h e rpa t ie n t s.T h e r e f
or e ,t h e t r ue in c id e n c e of t h issy m pt omc a n n otAg
eT a b l e 1 . C l in ic a l F e a t ur e sofE n ur e sis a n d O b
st r uc t iv eSl e e p Apn e aBM I ,k g / m 2AHI ,Ba se l in eN a d
ir0 2 % ,Ba se l in eAHI W it hC P AP *N a d ir0 2 % ,W it h C P AP
*4 62 93 54 23 33 7 . 0 3 . 14 6 . 73 5 . 23 6 . 93 8 . 53 5 . 73 8
. 6 2 . 18 01 0 91 1 71 0 51 2 61 0 7 . 4 7 . 78 27 47 46 67 07 3 .
2 2 . 71 01 021 91 21 0 . 6 2 . 79 28 99 38 89 49 1 . 2 1 . 2*
p< 0 . 0 0 5 c om pa r e dt o b a se l in e . D a t a ise x pr e
sse da s M e a n SE M .BM I = b od ym a ss in d e x ;AHI = a pn e a
/ h y popn e ain d e xC HE ST/ 1 1 4 / 2 / AU G U ST, 1 9 9 8 6 3
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.How e v e r ,it isc l e a r l ya nin f r e que n t l yof f e r e
dc om pl a in tT h epa t ie n t sw e r e a l l ob e se w it hv e r
yse v e r e d ise a se . Th e e n ur e sisd e v e l ope dinc on j
un c t ionw it hw e ig h t g a ina n dw or se n in g sy m pt om sof
O SA. T h eon se t of e n ur e sis w it h t h e on se t ofsl e e p
a pn e a sy m pt om s a n d t h e r e sol ut ion of e n ur e sis w
it h C P AP t r e a t m e n t of O SAsug g e st st h a t t h esl e
e p a pn e a m a yb e t h ec a use of t h e e n ur e sis in t h e
sepa t ie n t s.Th e m e c h a n ism of e n ur e sis inpa t ie n t
sw it hsl e e p a pn e aispr ob a b l ym ul t if a c t or ia l . P
a t ie n t s w it h m a ssiv eob e sit yh a v e a n in c r e a se
dg l om e r ul a rf il t r a t ion r a t e . 1 2K r ie g e re ta l
1 3 d e m on st r a t e dh ig h e rf r a c t ion a lur in a r yf l
ow s,h ig h e rf r a c t ion a l sod ium a n d c h l or id ee x c r
e t ion ,a n d a l ow e rpe r c e n t a g eof f il t e r e d sod
iumr e a b sor pt ioninpa t ie n t sw it hsl e e p a pn e a c om pa
r e dw it h t h ose v a l ue s in n or m a lsub j e c t s.T r e a t
m e n t w it h n a sa l C P AP t e n d e d t o n or m a l iz et h e
r e n a l f un c t ion in t h epa t ie n t sw it h O SA.F ur t h e
r m or e ,t h e use of C P AP w a s a ssoc ia t e d w it h r e d uc
e dur in a iyout puta n d in c r e a se d N a +r e sor pt ion . Al
t h oug ht h isst ud yis l im it e d b e c a usepa t ie n t sa n d
n or m a lsub j e c t sw e r e n ota g e -a n dw e ig h t - m a t c
h e d ,ot h e r r e se a r c h h a s sh ow n sim il a r r e sul t
s. 1 4 1 6Sub se que n ta r t ic l e sb yt h e se a n d ot h e r a
ut h or ssug g e sta r ol e f or a t r ia l n a t ur e t icpe pt id
e( AN P )in t h e sec h a n g e sin r e n a l f un c t ion . 1 5 2
0N e g a t iv ein t r a t h or a c icpr e ssur e sw in g sa ssoc ia
t e d w it hr e spir a t or ye f f or ta g a in sta c l ose da ir w
a ya r e a ssoc ia t e d w it h in c r e a se dv e n ous r e t ur n
. I na d d it ion ,t h eh y pox iaa ssoc ia t e d w it ha na pn e
ice v e n tm a yin d uc epul m on a r yv a soc on st r ic -t ion ,w
h ic h c a n c a user ig h tv e n t r ic ul a r ov e r l oa d a n
dr ig h ta t r ia l d ist e n t ion . T h esub se que n ta t r ia l
d il a t a t ionm a yl e a d t o AN Pr e l e a se ,a n d t h is in
c r e a se in AN Pl e v e l s e n h a n c e sur in a r ye x c r e t
ion . I nsuppor toft h is,t h ew or kb y K r ie g e ra n d h isc ol
l e a g ue s1 7 sug g e st e dt h a t t h eAN P l e v e l s c or r
e l a t e d w it h t h ed e g r e eofh y pox e m iaa sw e l l a s t
h ed e g r e eofn e g a t iv ein t r a t h or a c icpr e ssur ea
ssoc ia t e d w it ha pn e a s.Al t h oug hse v e r a l a r t ic l
e s h a v e d e m on st r a t e d in c r e a se d AN P l e v e l s
inpa t ie n t sw it hsl e e p a pn e aa n d ad e c r e a se in AN P
l e v e l s w it h t r e a t m e n t w it h n a sa lC P AP , 1 6 1
8n ot a l l st ud ie s h a v e b e e n c on sist e n t in t h e irf
in d in g s.I n ast ud y b y W a r l e ye ta l ,2 1AN P l e v e l s
w e r en ot e l e v a t e d in n or m a lsub j e c t sw h e n O SA
w a s sim ul a t e d in n or m a lsub j e c t sw it h a nin spir a
t or yt h r e sh ol dl oa d . Th ed e g r e eofn e g a t iv e in
spir a t or y pr e ssur e sw in g sa n d t h ed e g r e eofh y pox
e m iaw e r e n ot a s se v e r e a s t h osese e n in a c t ua lpa
t ie n t sw it h O SA in t h e ot h e r st ud ie s.Bod e n st e in
e t a l 2 2 f oun dc h a n g e sin d iur e sis a n d n a t r i-ur e
sis inpa t ie n t sw it hsl e e p a pn e ab e f or e a n d a f t e
rt r e a t m e n t ,sim il a r t o t h ose d oc um e n t e db yot h
e r a ut h or s.How e v e r ,t h e yw e r e n ot a b l e t o d e m
on st r a t e ac h a n g ein AN P l e v e l s w it h C P AP . Som e
of t h e irpa t ie n t sd id h a v e l e f t v e n t r ic ul a rd y
sf un c t ion ,w h ic h c a n r a iseAN P l e v e l s. Th is r ise
in AN P w oul d n ot b ee x pe c t e dn e c e ssa r il yt oim pr ov
ew it h C P AP . I na d d it ion ,t h eb l oodsa m pl e st h e se a
ut h or s c ol l e c t e d w e r epe r iph e r a lv e n oussa m pl
e sd r a w n in t h em or n in g ,a f t e r t h epa t ie n t sw e r
e a w a k e .Al t h oug h K r ie g e re t a l 1 8 f oun d a t r e n
dt ow a r d s l ow e r AN P l e v e l s in O SApa t ie n t s r e c
e iv in gC P APt r e a t m e n t ,t h e d if f e r e n c e in AN P
l e v e l b e f or ea n d a f t e r C P APt h e r a py on l yr e a
c h e d st a t ist ic a lsig n if ic a n c e w h e npul m on a r y
a r t e r y sa m pl e sr a t h e r t h a npe r iph e r a lv e n
oussa m pl e sw e r ea n a l y z e d .AN P l e v e l sa r eh ig h e
rin t h epul m on a r y a r t e r yt h a n inpe r iph e r a lv e n
ous b l ood e v e n in n or m a lsub j e c t s.I na d d it ion ,AN
Ph a s av e r ysh or t h a l f - l if e( 2t o 3m in ) . Th e r e f
or e ,som ed isc r e pa n c yin r e sul t s b e t w e e n st ud ie
sm a yr e f l e c t t im ea n d sit e of AN Psa m pl in g .T y pic
a l l y , pa t ie n t sw it hsl e e p a pn e a c om pl a inoff r e
que n t a w a k e n in g st o ur in a t e . 2 3 ' 2 4 T h e f a c t
t h a t asm a l l sub se t ofpa t ie n t sd o n otf ul l ya w a k e
n t our in a t e ,b ut r a t h e r h a v ee n ur e sis,sug g e st
st h a t t h e r em a yb esom e t h in ga b n or m a l w it h t h e
ir a r ousa lr e spon se .P e r h a pst h ein or d in a t e l y h
ig hn um b e r of a r ousa l s t h a t t h e sepa t ie n t s e x pe
r ie n c e d m a yh a v e b l un t e d t h e ira b il it yt of ul l
yw a k eup.D a t a f r omBe r r ye t a l 2 5sug g e stt h a t O
SAit se l f( pe r h a psd ue t osl e e p f r a g m e n t a t ion )d
e c r e a se st h e a r ousa lr e spon set oa ir w a yoc c l usion
. T h ea pn e ad ur a t ion inpa t ie n t sin t h isst ud yw a s n
ot a sl on ga s t h a tse e nb y Be r r ye t a l . 2 5( Be r r ye t
a l f oun da pn e ad ur a t ionin c r e a se d a s a r ousa l t h r
e sh ol din c r e a se d . ) How e v e r ,t h isst ud yd id n ot m
e a sur ee soph a g e a l pr e ssur e sw in g sorr e spon se st o
ot h e rst im ul i,so d a t a on a r ousa l t h r e sh ol dpe rse c
a n n ot b epr ov id e d .T o d e t e r m in e if a n a l t e r e
da r ousa l t h r e sh ol d isr e a l l yt h ek e yf a c t or inc a
usin ge n ur e sis r a t h e r t h a nn oc t ur ia ,apr ospe c t iv
e st ud ye x a m in in gt h e d ur a t ion ofa pn e a , c h a n g e
sine soph a g e a lpr e ssur e ,a n d a r ousa lr e spon set o ot h
e rst im ul i,a m on got h e rv a r ia b l e s,isn e c e ssa r y .I
t h a s b e e nsh ow n ,h ow e v e r ,t h a tsl e e p f r a g m e n
t a t iona l on e( n ota ssoc ia t e dw it hr e spir a t or yd ist
ur b a n c e )im pa ir st h e a r ousa l r e spon set o a c oust ic
a n dr e spir a t or yst im ul i in h um a n sa n d a n im a l s. 2
6 ' 2 7 T h epa t ie n t s pr e se n t e din t h isst ud ya l lh a
dv e r yse v e r e O SA w it hf r e que n ta r ousa l s.I nsum m a
r y ,se v e r e O SAm a yl e a d t o n e w - on se t e n ur e sis
in a d ul t s. T h e e n ur e sis r e sol v e s w it h suc c e ssf
ul t r e a t m e n t of t h esl e e p a pn e a .F ur t h e r r e se
a r c h in h um a nsub j e c t sisn e c e ssa r yt of ul l ye l uc
id a t e t h epa t h oph y siol og icf e a t ur e s of t h is d
isor d e r .R e f e r e n c e s1 G uil l e m in a ul tC ,E l d r id
g eF L ,Sim m on sF B,e t a l .Sl e e pa pn e aine ig h tc h il d r
e n . P e d ia t r ic s1 9 7 6 ;5 8 : 2 3 - 3 02 W e id e rD J ,Sa
t e iaM J ,W e st R P . N oc t ur n a l e n ur e sis inc h il d r e
n w it huppe r a ir w a yob st r uc t ion .O t ol a r y n g olHe a
dN e c kSur g1 9 9 1 ;1 0 5 : 4 2 7 - 3 23 W e id e rD J ,Ha ur iP
J .N oc t ur n a l e n ur e sis in c h il d r e n w it huppe r a ir
w a yob st r uc t ion . I n tJP e d ia t rO t or h in ol a r y n g
ol1 9 8 5 ;9 : 1 7 3 - 8 24 T im m sD J . R a pid m a x il l a r y
e x pa n sionin t h e t r e a t m e n t ofn oc t ur n a l e n ur e
sis.An g l eO r t h od1 9 9 0 ;6 0 : 2 2 9 - 3 35 G uil l e m in a
ul tC ,D e m e n t W C .Sl e e p a pn e a sy n d r om e sa n dr e l
a t e dsl e e pd isor d e r s. I n : G uil l e m in a ul tC ,D e m
e n tW C ,e d s.Sl e e pd isor d e r s:d ia g n osisa n d t r e a t
m e n t . N e w Y or k :J oh n W il e y&Son s,1 9 7 8 : 9 - 2
86 E v e r a e r tK ,P e v e r n a g ieD ,O ost e r l in c k W . N
oc t ur n a l e n ur e sispr ov ok e d b ya n ob st r uc t iv esl e
e p a pn e a sy n d r om e . JU r ol1 9 9 5 ;1 5 3 : 1 2 3 67 G uil
l e m in a ul tC ,E l d r id g eF L , T il k ia nA,e t a l .Sl e e
p a pn e asy n d r om ed ue t ouppe r a ir w a yob st r uc t ion .
Ar c h I n t e r n M e d1 9 7 7 ;1 3 7 : 2 9 6 - 3 0 08Y ok oy a m
aO ,Am a n oT ,L e eS,e t a l . E n ur e sis in a n a d ul t6 3 6Se
l e c t e dR e por t sDownloaded From:
http://journal.publications.chestnet.org/ by a NYU Langone Medical
Center Useron 01/10/2013f e m a l e w it h ob st r uc t iv esl e e
p a pn e a . U r ol og y1 9 9 5 ;4 5 : 1 5 0 - 5 49U l f b e r g J
,T h um a n R . An on - ur ol og icc a use of n oc t ur ia a n de n
ur e sis. ob st r uc t iv esl e e p a pn e a sy n d r om e( O SAS)
.Sc a n dJU r olN e ph r ol1 9 9 6 ;3 0 : 1 3 5 - 3 71 0 Ar a iH,F
ur ut aH,K osh in oY ,e t a lL on g - t e r me f f e c t s of ad e
n t a la ppl ia n c e t h e r a py :a c a se of ob st r uc t iv esl
e e p a pn e asy n d r om ew it h e n ur e sis.Sl e e p1 9 9 7 ;2 0
: 1 5 8 - 5 91 1 G uil l e m in a ul tC ,Til k ia nA,D e m e n t W
C . Th esl e e p a pn e asy n d r om e .An n R e v M e d1 9 7 6 ;2
: 4 6 5 - 8 41 2 F l e t c h e r E C . O b st r uc t iv esl e e p a
pn e aa n d t h ek id n e y . JAmSocN e ph r ol1 9 9 3 ;4 : 1 1 1 1
- 2 11 3K r ie g e r J ,I m b sJ ,Sc h m id tM ,e t a l . R e n a l
f un c t ion inpa t ie n t sw it h ob st r uc t iv esl e e p a pn e
a :e f f e c t s of n a sa lc on t in uousposit iv e a ir w a y pr
e ssur e .Ar c h I n t e r n M e d1 9 8 8 ;1 4 8 : 1 3 3 7 - 4 01 4
F ol l e n iusM ,K r ie g e r J ,K r a ut hM O ,e t a l . O b st r
uc t iv esl e e pa pn e at r e a t m e n t :pe r iph e r a la n d c
e n t r a l e f f e c t s onpl a sm ar e n ina c t iv it ya n d a l
d ost e r on e .Sl e e p1 9 9 1 ;1 4 : 2 1 1 - 1 71 5K r ie g e r J
,Sc h m id tM ,Sf or z aE ,e t a l .U r in a r ye x c r e t ion ofg
ua n osin e 3 ' : 5 ' - c y c l ic m on oph osph a t e d ur in g sl
e e pin ob st r uc t iv esl e e p a pn e a pa t ie n t sw it h a n
d w it h out n a sa l c on t in uousposit iv e a ir w a y pr e ssur
et r e a t m e n t . C l in Sc i1 9 8 9 ;7 6 : 3 1 - 3 71 6W a r l
e yAR H,St r a d l in g J R .Ab n or m a l d iur n a l v a r ia t
ion in sa l ta n d w a t e r e x c r e t ion inpa t ie n t sw it h
ob st r uc t iv esl e e p a pn oe a .C l in Sc i1 9 8 8 ;7 4 : 1 8
3 - 8 51 7K r ie g e r J ,F ol l e n iusM ,Sf or z aE ,e t a l . E
f f e c t s of t r e a t m e n tw it h n a sa l c on t in uousposit
iv e a ir w a y pr e ssur eon a t r ia ln a t r iur e t icpe pt id
ea n da r g in in e v a sopr e ssinr e l e a sed ur in gsl e e
pinpa t ie n t sw it h ob st r uc t iv esl e e p a pn oe a .C l in
Sc i1 9 9 1 ;8 0 : 4 4 3 - 4 91 8K r ie g e r J ,L a k sL ,W il c
oxI ,e t a l . At r ia l n a t r iur e t icpe pt id er e l e a sed
ur in g sl e e pinpa t ie n t sw it h ob st r uc t iv esl e e p a
pn oe ab e f or e a n dd ur in gt r e a t m e n t w it h n a sa l c
on t in uousposit iv ea ir w a y pr e ssur e .C l in Sc i1 9 8 9 ;7
7 : 4 0 7 - 1 11 9 I c h iok aM ,Hir a t aY ,I n a seN ,e t a l .C
h a n g e sofc ir c ul a t in ga t r ia l n a t r iur e t icpe pt
id ea n d a n t id iur e t ic h or m on e inob st r uc t iv esl e e
p a pn e a sy n d r om e . R e spir a t ion1 9 9 2 ;5 9 :1 6 4 - 6
82 0 L inC ,T sa nK ,L in C . P l a sm a l e v e l s of a t r ia l
n a t r iur e t ic f a c t orin m od e r a t e t o se v e r e ob st
r uc t iv esl e e p a pn e a sy n d r om e .Sl e e p1 9 9 3 ;1 6 :
3 7 - 3 92 1W a r l e yAR H,F on t e sF ,W il sonM ,e t a l . L a c
k of e f f e c t of a nin spir a t or yt h r e sh ol d l oa d onpl
a sm aa t r ia l n a t r iur e t icpe pt id el e v e l s. C l in Sc
i1 9 9 0 ;7 8 : 3 1 1 - 1 32 2 R od e n st e inD O ,D ' O d e m on
tJ R ,P ie t e r sT ,e t a l . D iur n a l a n dn oc t ur n a l d
iur e sis a n d n a t r iur e sis in ob st r uc t iv esl e e p a pn
e a :e f f e c t s of n a sa l c on t in uousposit iv e a ir w a y
pr e ssur e t h e r a py .Am R e vR e spirD is1 9 9 2 ;1 4 5 : 1 3
6 7 - 7 12 3 P r e ssm a nM R ,F ig ue r oaW G ,K e n d r ic k - M
oh a m e dJ ,e t a l .N oc t ur ia : ar a r e l y r e c og n iz e d
sy m pt omofsl e e p a pn e aa n dot h e r oc c ul tsl e e pd isor
d e r s. Ar c h I n t e r n M e d1 9 9 6 ;1 5 6 :5 4 4 5 - 5 02 4K
r ie g e r J ,P e t ia uC ,Sf or z aE ,e t a l . N oc t ur n a lpol
l a k iur iais asy m pt omof ob st r uc t iv esl e e p a pn e a .U
r ol I n t1 9 9 3 ;5 0 : 9 3 - 9 72 5Be r r yR B,K ouc h iK G ,D e
rD E ,e t a l .Sl e e p a pn e a im pa ir st h e a r ousa lr e spon
set oa ir w a yoc c l usion . C h e st1 9 9 6 ;1 0 9 :1 4 9 0 - 9
62 6D ow n e yB,Bon n e t M H. P e r f or m a n c ed ur in g f r e
que n t sl e e pd isr upt ion . Sl e e p1 9 8 7 ;1 0 : 3 5 4 - 6 32
7P h il l ipsonE A,Bow e s G ,Sul l iv a nC E ,e t a l . T h e in f
l ue n c e ofsl e e p f r a g m e n t a t ionon a r ousa l a n dv e
n t il a t or y r e spon se st or e spir a t or yst im ul i.Sl e e
p1 9 8 0 ;3 : 2 8 1 - 8 8M ig r a t iona n dR ig h tAt r ia lP e r
f or a t ion of a n Ac c uf ix At r ia lL e a d R e t e n t ion W
ir eF ol l ow in gP a r t ia l L e a d R e m ov a lD ur in gM y om
e e t om y *E d w a r d P .G e r st e n f e l d ,M D ;Y og a r a j
a h Ba l a r a j a n ,M D ;R ob e r tC ook e , P AC ;a n d R ob e r
t S.M it t l e m a n ,M DA3 6 - y e a r - ol dm a n w it h ah ist
or yofh y pe r t r oph icob st r uc t iv ec a r d iom y opa t h y
pr e se n t e dt o t h e e m e r g e n c yr oom w it h" st a b b in
g "c h e stpa in .He h a dun d e r g on ed ua l - c h a m b e rpa c
e m a k e r im pl a n t a t ionin 1 9 9 3usin ga n a t r ia l l e a
d( Ac c uf ix ; Te l e c t r on ic s;E n g l e w ood ,C ol o)a n d
am y om e e t om yin 1 9 9 6d ur in gw h ic h t h e d ist a lpor t
ionof t h e a t r ia l l e a d w a s r e m ov e d .D ig it a l f l
uor osc opyr e v e a l e d t h a t t h e r e t e n t ion w ir e h a
dm ig r a t e dout of t h er e m a in in ga t r ia ll e a d a n dpe
r f or a t e dt h er ig h ta t r ium . T h e r e t e n t ionw ir e
w a ssuc c e ssf ul l yr e m ov e dpe r c ut a n e ousl y .T h en e
e d f orc om pl e t er e m ov a l of t h e r e t e n t ion w ir e
int h e Ac c uf ix l e a d a t t h e t im e ofope n - h e a r t sur
g e r yise m ph a siz e d .( C HE ST 1 9 9 8 ; 1 1 4 : 6 3 7 - 6 3
9 )K e yw or d s: a t r ia ll e a d ;h y pe r t r oph icob st r uc
t iv ec a r d iom y opa t h y ;l e a de x t r a c t ion ;pa c e m a
k e rApa t ie n tw h o h a dim pl a n t a t ionof a d ua l c h a m
b e r* * * * pa c e m a k e r e x pe r ie n c e d " st a b b in g "
pa int h a t r e sul t e df r omm ig r a t ionof t h e r e t e n t
ion w ir e out of t h e a t r ia l l e a da n dpe r f or a t ionof
t h er ig h ta t r ium . T h isr e por tr e c oun t st h e c l in
ic a l d a t ape r t in e n tt o t h epa t ie n t .C a se R e por
tA3 6 - y e a r - ol dm a n w it h ah ist or yofh y pe r t r oph
icob st r uc t iv ec a r d iom y opa t h y pr e se n t e dt o t h
ee m e r g e n c y d e pa r t m e n tc om pl a in in gofse v e r e
,pl e ur it icc h e stpa in r a d ia t in gt o h is b a c k . Ad ia
g n osisofh y pe r t r oph icob st r uc t iv ec a r d iom y opa t h
yh a db e e n m a d e w h e n t h epa t ie n tw a s a c h il d . Be
c a use ofsy m pt om sof e x e r t ion a ld y spn e aa n d c h e
stpa in r e f r a c t or yt o m e d ic a lt h e r a py ,h e un d e
r w e n tim pl a n t a t ionof a d ua l - c h a m b e rpa c e m a k
e r in 1 9 9 3 w it h t h e use of a n a t r ia l l e a d( Ac c uf
ix ;T e l e c t r on ic s;E n g l e w ood ,C O ) .Th e a t r ia l l
e a d is n ow k n ow n t ob esusc e pt ib l et o f r a c t ur e of
t h e r e t e n t ionw ir e ,l e a d in gt oc a r d ia cpe r f or a
t ionor e m b ol iz a t ion( J .W .D e n n is;Te l e c t r on ic
s;w r it t e nc om m un ic a t ion ;N ov e m b e r3 , 1 9 9 4 )
.Hissy m pt om spe r sist e d ,a n d h e w a s r e f e r r e d t o
a n out sid e in st it ut ionw h e r e h e un d e r w e n t am y om
e e t om yin 1 9 9 6 . At t h e t im e ofsur g e r y ,t h e a t r
ia l l e a d w a s c ut a t t h ej un c t ionof t h esupe r iorv e
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