The upper airway in sleep: Physiology of the pharynx

Sleep Medicine Reviews

Volumn 7, Issue 1, 2003, Pages 9-33

  Ayappa, Indu ^a   Rapoport, David M ^a,b  

^a NEW YORK UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b NEW YORK UNIVERSITY MEDICAL CENTER   (United States)

Author keywords

Obstructive sleep apnea hypopnea syndrome; Pharynx; Sleep disordered breathing; Snoring; Upper airway physiology; Upper airway resistance

Indexed keywords

AIRWAY RESISTANCE; DISEASE PREDISPOSITION; HUMAN; REVIEW; SLEEP; SLEEP APNEA SYNDROME; SLEEP DISORDER; SNORING; SOMNOLENCE; SYMPTOM; UPPER RESPIRATORY TRACT;

EID: 0037313903     PISSN: 10870792     EISSN: None     Source Type: Journal    
DOI: 10.1053/smrv.2002.0238     Document Type: Review

References (166)

1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328(17): 1230-1235.
2. Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P. A cause of excessive daytime sleepiness. The upper airway resistance syndrome. Chest 1993; 104(3): 781-787.
3. Guilleminault C, Stoohs R, Shiomi T, Kushida C, Schnittger I. Upper airway resistance syndrome, nocturnal blood pressure monitoring, and borderline hypertension. Chest 1996; 109(4): 901-908.
4. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000; 342(19): 1378-1384.
5. Phillipson EA. Sleep apnea - a major public health problem. N Engl J Med 1993; 328(17): 1271-1273.
6. Nishino T, Hiraga K. Coordination of swallowing and respiration in unconscious subjects. J Appl Physiol 1991; 70(3): 988-993.
7. Fouke JM, Teeter JP, Strohl KP. Pressure-volume behavior of the upper airway. J Appl Physiol 1986; 61(3): 912-918.
8. Strohl KP, Fouke JM. Dilating forces on the upper airway of anesthetized dogs. J Appl Physiol 1985; 58(2): 452-458.
9. Schwab RJ, Gupta KB, Gefter WB, Metzger LJ, Hoffman EA, Pack AI. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med 1995; 152(5 Pt 1): 1673-1689.
10. Rivlin J, Hoffstein V, Kalbfleisch J, McNicholas W, Zamel N, Bryan AC. Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis 1984; 129(3): 355-360.
11. Lyberg T, Krogstad O, Djupesland G. Cephalometric analysis in patients with obstructive sleep apnoea syndrome. I. Skeletal morphology. J Laryngol Otol 1989; 103(3): 287-292.
12. Brooks LJ, Strohl KP. Size and mechanical properties of the pharynx in healthy men and women. Am Rev Respir Dis 1992; 146(6): 1394-1397.
13. Brown IG, Zamel N, Hoffstein V. Pharyngeal cross-sectional area in normal men and women. J Appl Physiol 1986; 61(3): 890-895.
14. Bradley TD, Brown IG, Grossman RF, Zamel N, Martinez D, Phillipson EA, Hoffstein V. Pharyngeal size in snorers, nonsnorers, and patients with obstructive sleep apnea. N Engl J Med 1986; 315(21): 1327-1331.
15. Burger CD, Stanson AW, Daniels BK, Sheedy PF, Shepard JW. Fast-CT evaluation of the effect of lung volume on upper airway size and function in normal men. Am Rev Respir Dis 1992; 146(2): 335-339.
16. Suratt PM, Dee P, Atkinson RL, Armstrong P, Wilhoit SC. Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis 1983; 127(4): 487-492.
17. Kuna ST, Bedi DG, Ryckman C. Effect of nasal airway positive pressure on upper airway size and configuration. Am Rev Respir Dis 1988; 138(4): 969-975.
18. Shepard JW, Garrison M, Vas W. Upper airway distensibility and collapsibility in patients with obstructive sleep apnea. Chest 1990; 98(1): 84-91.
19. Schwab RJ, Gefter WB, Pack AI, Hoffman EA. Dynamic imaging of the upper airway during respiration in normal subjects. J Appl Physiol 1993; 74(4): 1504-1514.
20. Pevernagie DA, Stanson AW, Sheedy PF, Daniels BK, Shepard JW, Jr. Effects of body position on the upper airway of patients with obstructive sleep apnea. Am J Respir Crit Care Med 1995; 152(1): 179-185.
21. Fouke JM, Strohl KP. Effect of position and lung volume on upper airway geometry. J Appl Physiol 1987; 63(1): 375-380.
22. Anch AM, Remmers JE, Bunce H. Supraglottic airway resistance in normal subjects and patients with occlusive sleep apnea. J Appl Physiol 1982; 53(5): 1158-1163.
23. Martin SE, Mathur R, Marshall I, Douglas NJ. The effect of age, sex, obesity and posture on upper airway size. Eur Respir J 1997; 10(9): 2087-2090.
24. Isono S, Remmers JE, Tanaka A, Sho Y, Sato J, Nishino T. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol 1997; 82(4): 1319-1326.
25. Remmers JE, deGroot WJ, Sauerland EK, Anch AM. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol 1978; 44(6): 931-938.
26. Brouillette RT, Thach BT. A neuromuscular mechanism maintaining extrathoracic airway patency. J Appl Physiol 1979; 46(4): 772-779.
27. Morrison DL, Launois SH, Isono S, Feroah TR, Whitelaw WA, Remmers JE. Pharyngeal narrowing and closing pressures in patients with obstructive sleep apnea. Am Rev Respir Dis 1993; 148(3): 606-611.
28. Isono S, Feroah TR, Hajduk EA, Brant R, Whitelaw WA, Remmers JE. Interaction of cross-sectional area, driving pressure, and airflow of passive velopharynx. J Appl Physiol 1997; 83(3): 851-859.
29. Isono S, Morrison DL, Launois SH, Feroah TR, Whitelaw WA, Remmers JE. Static mechanics of the velopharynx of patients with obstructive sleep apnea. J Appl Physiol 1993; 75(1): 148-154.
30. Reed WR, Roberts JL, Thach BT. Factors influencing regional patency and configuration of the human infant upper airway. J Appl Physiol 1985; 58(2): 635-644.
31. Wilson SL, Thach BT, Brouillette RT, Abu-Osba YK. Upper airway patency in the human infant: influence of airway pressure and posture. J Appl Physiol 1980; 48(3): 500-504.
32. Koenig JS, Thach BT. Effects of mass loading on the upper airway. J Appl Physiol 1988; 64(6): 2294-2299.
33. Wolin AD, Strohl KP, Acree BN, Fouke JM. Responses to negative pressure surrounding the neck in anesthetized animals. J Appl Physiol 1990; 68(1): 154-160.
34. White DP, Lombard RM, Cadieux RJ, Zwillich CW. Pharyngeal resistance in normal humans: influence of gender, age, and obesity. J Appl Physiol 1985; 58(2): 365-371.
35. Fogel RB, Malhotra A, Shea SA, Edwards JK, White DP. Reduced genioglossal activity with upper airway anesthesia in awake patients with OSA. J Appl Physiol 2000; 88(4): 1346-1354.
36. Malhotra A, Fogel RB, Edwards JK, Shea SA, White DP. Local mechanisms drive genioglossus activation in obstructive sleep apnea. Am J Respir Crit Care Med 2000; 161(5): 1746-1749.
37. Sauerland EK, Mitchell SP. Electromyographic activity of intrinsic and extrinsic muscles of the human tongue. Tex Rep Biol Med 1975; 33(3): 444-455.
38. Malhotra A, Pillar G, Fogel RB, Beauregard J, Edwards JK, Slamowitz DI, Shea SA, White DP. GG but not palatal muscle activity relates closely to pharyngeal pressure. Am J Respir Crit Care Med 2000; 162(3 Pt 1): 1058-1062.
39. Van de Graaff WB, Gottfried SB, Mitra J, van Lunteren E, Cherniack NS, Strohl KP. Respiratory function of hyoid muscles and hyoid arch. J Appl Physiol 1984; 57(1): 197-204.
40. Kuna ST, Vanoye CR. Mechanical effects of pharyngeal constrictor activation on pharyngeal airway function. J Appl Physiol 1999; 86(1): 411-417.
41. Strohl KP, Hensley MJ, Hallett M, Saunders NA, Ingram RHJ. Activation of upper airway muscles before onset of inspiration in normal humans. J Appl Physiol 1980; 49(4): 638-642.
42. van Lunteren E, Van de Graaff WB, Parker DM, Mitra J, Haxhiu MA, Strohl KP, Cherniack NS. Nasal and laryngeal reflex responses to negative upper airway pressure. J Appl Physiol 1984; 56(3): 746-752.
43. Kobayashi I, Perry A, Rhymer J et al. Inspiratory coactivation of the genioglossus enlarges retroglossal space in laryngectomized humans. J Appl Physiol 1996; 80(5): 1595-1604.
44. Mathew OP, Abu-Osba YK, Thach BT. Genioglossus muscle responses to upper airway pressure changes: afferent pathways. J Appl Physiol 1982; 52(2): 445-450.
45. Horner RL, Innes JA, Murphy K, Guz A. Evidence for reflex upper airway dilator muscle activation by sudden negative airway pressure in man. J Physiol 1991; 436: 15-29.
46. Mathew OP. Upper airway negative-pressure effects on respiratory activity of upper airway muscles. J Appl Physiol 1984; 56(2): 500-505.
47. Akahoshi T, White DP, Edwards JK, Beauregard J, Shea SA. Phasic mechanoreceptor stimuli can induce phasic activation of upper airway muscles in humans. J Physiol 2001; 531(Pt 3): 677-691.
48. Smith PL, Wise RA, Gold AR, Schwartz AR, Permutt S. Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol 1988; 64(2): 789-795.
49. Condos R, Norman RG, Krishnasamy I, Peduzzi N, Goldring RM, Rapoport DM. Flow limitation as a non-invasive assessment of residual upper-airway resistance during continuous positive airway pressure therapy of obstructive sleep apnea. Am J Respir Crit Care Med 1994; 150(2): 475-480.
50. Issa FG, Sullivan CE. Upper airway closing pressures in snorers. J Appl Physiol 1984; 57(2): 528-535.
51. Gleadhill IC, Schwartz AR, Schubert N, Wise RA, Permutt S, Smith PL. Upper airway collapsibility in snorers and in patients with obstructive hypopnea and apnea. Am Rev Respir Dis 1991; 143(6): 1300-1303.
52. Issa FG, Sullivan CE. Upper airway closing pressures in obstructive sleep apnea. J Appl Physiol 1984; 57(2): 520-527.
53. Strohl KP, O'Cain CF, Slutsky AS. Alae nasi activation and nasal resistance in healthy subjects. J Appl Physiol 1982; 52(6): 1432-1437.
54. Gold AR, Smith PL, Schwartz AR. Effect of alae nasi activation on maximal nasal inspiratory airflow in humans. J Appl Physiol 1998; 84(6): 2115-2122.
55. White DP, Lombard RM, Cadieux RJ, Zwillich CW. Pharyngeal resistance in normal humans: influence of gender, age, and obesity. J Appl Physiol 1985; 58(2): 365-371.
56. Pillar G, Malhotra A, Fogel R, Beauregard J, Schnall R, White DP. Airway mechanics and ventilation in response to resistive loading during sleep: influence of gender. Am J Respir Crit Care Med 2000; 162(5): 1627-1632.
57. Popovic RM, White DP. Upper airway muscle activity in normal women: influence of hormonal status. J Appl Physiol 1998; 84(3): 1055-1062.
58. Popovic RM, White DP. Influence of gender on waking genioglossal electromyogram and upper airway resistance. Am J Respir Crit Care Med 1995; 152(2): 725-731.
59. Krol RC, Knuth SL, Bartlett D, Jr. Selective reduction of genioglossal muscle activity by alcohol in normal human subjects. Am Rev Respir Dis 1984; 129(2): 247-250.
60. Burger CD, Stanson AW, Sheedy PF, Daniels BK, Shepard JW. Fast-computed tomography evaluation of age-related changes in upper airway structure and function in normal men. Am Rev Respir Dis 1992; 145(4 Pt 1): 846-852.
61. Browne HA, Adams L, Simonds AK, Morrell MJ. Impact of age on breathing and resistive pressure in people with and without sleep apnea. J Appl Physiol 2001; 90(3): 1074-1082.
62. Worsnop C, Kay A, Kim Y, Trinder J, Pierce R. Effect of age on sleep onset-related changes in respiratory pump and upper airway muscle function. J Appl Physiol 2000; 88(5): 1831-1839.
63. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol 1959; 14: 760-764.
64. Strobel RJ, Rosen RC. Obesity and weight loss in obstructive sleep apnea: a critical review. Sleep 1996; 19(2): 104-115.
65. Hoffstein V, Zamel N, Phillipson EA. Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea. Am Rev Respir Dis 1984; 130(2): 175-178.
66. Van de Graaff WB. Thoracic influence on upper airway patency. J Appl Physiol 1988; 65(5): 2124-2131.
67. Breuer J. Die Selbststeurung der Atmung durch den Nervus vagus. S.B. Math Naturwiss Cl Akad Wiss Wien 1868; 58: 909-937.
68. Shelton RL, Bosma JF. Maintenance of the pharyngeal airway. J Appl Physiol 1962; 17: 209-214.
69. Orem J, Netick A, Dement WC. Increased upper airway resistance to breathing during sleep in the cat. Electro-encephalogr Clin Neurophysiol 1977; 43(1): 14-22.
70. Hudgel DW, Martin RJ, Johnson B, Hill P. Mechanics of the respiratory system and breathing pattern during sleep in normal humans. J Appl Physiol 1984; 56(1): 133-137.
71. Wiegand L, Zwillich CW, White DP. Collapsibility of the human upper airway during normal sleep. J Appl Physiol 1989; 66(4): 1800-1808.
72. Tangel DJ, Mezzanotte WS, White DP. Influence of sleep on tensor palatini EMG and upper airway resistance in normal men. J Appl Physiol 1991; 70(6): 2574-2581.
73. Skatrud JB, Dempsey JA. Airway resistance and respiratory muscle function in snorers during NREM sleep. J Appl Physiol 1985; 59(2): 328-335.
74. Trudo FJ, Gefter WB, Welch KC, Gupta KB, Maislin G, Schwab RJ. State-related changes in upper airway caliber and surrounding soft-tissue structures in normal subjects. Am J Respir Crit Care Med 1998; 158(4): 1259-1270.
75. Henke KG, Dempsey JA, Badr MS, Kowitz JM, Skatrud JB. Effect of sleep-induced increases in upper airway resistance on respiratory muscle activity. J Appl Physiol 1991; 70(1): 158-168.
76. Tangel DJ, Mezzanotte WS, Sandberg EJ, White DP. Influences of NREM sleep on the activity of tonic vs. inspiratory phasic muscles in normal men. J Appl Physiol 1992; 73(3): 1058-1066.
77. Pillar G, Malhotra A, Fogel RB, Beauregard J, Slamowitz DI, Shea SA, White DP. Upper airway muscle responsiveness to rising PCO(2) during NREM sleep. J Appl Physiol 2000; 89(4): 1275-1282.
78. Wiegand DA, Latz B, Zwillich CW, Wiegand L. Upper airway resistance and geniohyoid muscle activity in normal men during wakefulness and sleep. J Appl Physiol 1990; 69(4): 1252-1261.
79. Tangel DJ, Mezzanotte WS, White DP. Influences of NREM sleep on activity of palatoglossus and levator palatini muscles in normal men. J Appl Physiol 1995; 78(2): 689-695.
80. Berry RB, Gleeson K. Respiratory arousal from sleep: mechanisms and significance. Sleep 1997; 20(8): 654-675.
81. Sauerland EK, Harper RM. The human tongue during sleep: electromyographic activity of the genioglossus muscle. Exp Neurol 1976; 51(1): 160-170.
82. Henke KG. Upper airway muscle activity and upper airway resistance in young adults during sleep. J Appl Physiol 1998; 84(2): 486-491.
83. 2 rebreathing in humans. J Appl Physiol 1981; 50(5): 1052-1055.
84. Rowley JA, Williams BC, Smith PL, Schwartz AR. Neuromuscular activity and upper airway collapsibility. Mechanisms of action in the decerebrate cat. Am J Respir Crit Care Med 1997; 156(2 Pt 1): 515-521.
85. Trinder J, Kay A, Kleiman J, Dunai J. Gender differences in airway resistance during sleep. J Appl Physiol 1997; 83(6): 1986-1997.
86. Thurnheer R, Wraith PK, Douglas NJ. Influence of age and gender on upper airway resistance in NREM and REM sleep. J Appl Physiol 2001; 90(3): 981-988.
87. Ohayon MM, Guilleminault C, Priest RG, Caulet M. Snoring and breathing pauses during sleep: telephone interview survey of a United Kingdom population sample. BMJ 1997; 314(7084): 860-863.
88. Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W, Sullivan C. Snoring and sleep apnea. A population study in Australian men. Am J Respir Crit Care Med 1995; 151(5): 1459-1465.
89. Beck R, Odeh M, Oliven A, Gavriely N. The acoustic properties of snores. Eur Respir J 1995; 8(12): 2120-2128.
90. Cirignotta F, Lugaresi E. Some cineradiographic aspects of snoring and obstructive apneas. Sleep 1980; 3(3-4): 225-226.
91. Stoohs R, Guilleminault C. Snoring during NREM sleep: respiratory timing, esophageal pressure and EEG arousal. Respir Physiol 1991; 85(2): 151-167.
92. Liistro G, Stanescu DC, Veriter C, Rodenstein DO, Aubert-Tulkens G. Pattern of snoring in obstructive sleep apnea patients and in heavy snorers. Sleep 1991; 14(6): 517-525.
93. Rodenstein DO, Dooms G, Thomas Y, Liistro G, Stanescu DC, Culee C, Aubert-Tulkens G. Pharyngeal shape and dimensions in healthy subjects, snorers, and patients with obstructive sleep apnoea. Thorax 1990; 45(10): 722-727.
94. Shepard JWJ, Gefter WB, Guilleminault C, Hoffman EA, Hoffstein V, Hudgel DW, Suratt PM, White DP. Evaluation of the upper airway in patients with obstructive sleep apnea. Sleep 1991; 14(4): 361-371.
95. Zucconi M, Ferini-Strambi L, Palazzi S, Curci C, Cucchi E, Smirne S. Craniofacial cephalometric evaluation in habitual snorers with and without obstructive sleep apnea. Otolaryngol Head Neck Surg 1993; 109(6): 1007-1013.
96. Tsushima Y, Antila J, Svedstrom E, Vetrio A, Laurikainen E, Polo O, Kormano M. Upper airway size and collapsibility in snorers: evaluation with digital fluoroscopy. Eur Respir J 1996; 9(8): 1611-1618.
97. Reda M, Sims AJ, Collins MM, McKee GJ, Marshall H, Kelly PJ, Wilson JA. Morphological assessment of the soft palate in habitual snoring using image analysis. Laryngoscope 1999; 109(10): 1655-1660.
98. Lugaresi E, Cirignotta F, Montagna P. Pathogenic aspects of snoring and obstructive apnea syndrome. Schweiz Med Wochenschr 1988; 118(38): 1333-1337.
99. Hoffstein V. Snoring. Chest 1996; 109(1): 201-222.
100. Hoffstein V, Wright S, Zamel N, Bradley TD. Pharyngeal function and snoring characteristics in apneic and nonapneic snorers. Am Rev Respir Dis 1991; 143(6): 1294-1299.
101. Metes A, Ohki M, Cole P, Haight JS, Hoffstein V. Snoring, apnea and nasal resistance in men and women. J Otolaryngol 1991; 20(1): 57-61.
102. Brown IG, Bradley TD, Phillipson EA, Zamel N, Hoffstein V. Pharyngeal compliance in snoring subjects with and without obstructive sleep apnea. Am Rev Respir Dis 1985; 132(2): 211-215.
103. Steinhart H, Kuhn-Lohmann J, Gewalt K, Constantinidis J, Mertzlufft F, Iro H. Upper airway collapsibility in habitual snorers and sleep apneics: evaluation with drug-induced sleep endoscopy. Acta Otolaryngol 2000; 120(8): 990-994.
104. Wilson K, Stoohs RA, Mulrooney TF, Johnson LJ, Guilleminault C, Huang Z. The snoring spectrum: acoustic assessment of snoring sound intensity in 1, 139 individuals undergoing polysomnography. Chest 1999; 115(3): 762-770.
105. Series F, Cote C, Simoneau JA, Gelinas Y, St Pierre S, Leclerc J, Ferland R, Marc I. Physiologic, metabolic, and muscle fiber type characteristics of musculus uvulae in sleep apnea hypopnea syndrome and in snorers. J Clin Invest 1995; 95(1): 20-25.
106. Series FJ, Simoneau SA, St Pierre S, Marc I. Characteristics of the genioglossus and musculus uvulae in sleep apnea hypopnea syndrome and in snorers. Am J Respir Crit Care Med 1996; 153(6 Pt 1): 1870-1874.
107. Series F, Cote C, St Pierre S. Dysfunctional mechanical coupling of upper airway tissues in sleep apnea syndrome. Am J Respir Crit Care Med 1999; 159(5 Pt 1): 1551-1555.
108. Gavriely N, Jensen O. Theory and measurements of snores. J Appl Physiol 1993; 74(6): 2828-2837.
109. Skatvedt O. Localization of site of obstruction in snorers and patients with obstructive sleep apnea syndrome: a comparison of fiberoptic nasopharyngoscopy and pressure measurements. Acta Otoloryngol 1993; 113(2): 206-209.
110. Huang L, Williams JE. Neuromechanical interaction in human snoring and upper airway obstruction. J Appl Physiol 1999; 86(6): 1759-1763.
111. Young T, Finn L, Palta M. Chronic nasal congestion at night is a risk factor for snoring in a population-based cohort study. Arch Intern Med 2001; 161(12): 1514-1519.
112. Gastaut H, Tassinari CA, Duron B. Polygraphic study of the episodic diurnal and nocturnal (hypnic and respiratory) manifestations of the Pickwick syndrome. Brain Res 1966; 1(2): 167-186.
113. Walsh RE, Michaelson ED, Harkleroad LE, Zighelboim A, Sackner MA. Upper airway obstruction in obese patients with sleep disturbance and somnolence. Ann Intern Med 1972; 76(2): 185-192.
114. Hudgel DW. Variable site of airway narrowing among obstructive sleep apnea patients. J Appl Physiol 1986; 61(4): 1403-1409.
115. Shepard JW, Thawley SE. Localization of upper airway collapse during sleep in patients with obstructive sleep apnea. Am Rev Respir Dis 1990; 141(5 Pt 1): 1350-1355.
116. Hudgel DW, Hendricks C. Palate and hypopharynx sites of inspiratory narrowing of the upper airway during sleep. Am Rev Respir Dis 1988; 138(6): 1542-1547.
117. Don GW, Kirjavainen T, Broome C, Seton C, Waters KA. Site and mechanics of spontaneous, sleep-associated obstructive apnea in infants. J Appl Physiol 2000; 89(6): 2453-2462.
118. Isono S, Remmers JE, Tanaka A, Sho Y, Nishino T. Static properties of the passive pharynx in sleep apnea. Sleep 1996; 19(10 Suppl): S175-S177.
119. Sforza E, Bacon W, Weiss T, Thibault A, Petiau C, Krieger J. Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2000; 161(2 Pt 1): 347-352.
120. Shelton KE, Woodson H, Gay S, Suratt PM. Pharyngeal fat in obstructive sleep apnea. Am Rev Respir Dis 1993; 148(2): 462-466.
121. Ryan CF, Lowe AA, Li D, Fleetham JA. Three-dimensional upper airway computed tomography in obstructive sleep apnea. A prospective study in patients treated by uvulopalatopharyngoplasty. Am Rev Respir Dis 1991; 144(2): 428-432.
122. Schotland HM, Insko EK, Schwab RJ. Quantitative magnetic resonance imaging demonstrates alterations of the lingual musculature in obstructive sleep apnea. Sleep 1999; 22(5): 605-613.
123. Haponik EF, Smith PL, Bohlman ME, Allen RP, Goldman SM, Bleecker ER. Computerized tomography in obstructive sleep apnea. Correlation of airway size with physiology during sleep and wakefulness. Am Rev Respir Dis 1983; 127(2): 221-226.
124. Schellenberg JB, Maislin G, Schwab RJ. Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal structures. Am J Respir Crit Care Med 2000; 162(2 Pt 1): 740-748.
125. Schwab RJ. Properties of tissues surrounding the upper airway. Sleep 1996; 19(Suppl. 10): S170-S174.
126. Wasicko MJ, Erlichman JS, Leiter JC. Control of segmental upper airway resistance in patients with obstructive sleep apnea. J Appl Physiol 1993; 74(6): 2694-2703.
127. Rapoport DM, Rothenberg SA. An experimental model for inducing obstructive sleep apnea in normal human subjects. [Abstract] Am Rev Respir Dis 1986; 133: A309.
128. King ED, O'Donnell CP, Smith PL, Schwartz AR. A model of obstructive sleep apnea in normal humans. Role of the upper airway. Am J Respir Crit Care Med 2000; 161(6): 1979-1984.
129. Mezzanotte WS, Tangel DJ, White DP. Waking genioglossal electromyogram in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanism). J Clin Invest 1992; 89(5): 1571-1579.
130. Mezzanotte WS, Tangel DJ, White DP. Influence of sleep onset on upper-airway muscle activity in apnea patients versus normal controls. Am J Respir Crit Care Med 1996; 153(6 Pt 1): 1880-1887.
131. Badr MS, Toiber F, Skatrud JB, Dempsey J. Pharyngeal narrowing/occlusion during central sleep apnea. J Appl Physiol 1995; 78(5): 1806-1815.
132. 2 in sleeping dogs. American Review of Respiratory Disease 1977; 115(2): 251-259.
133. Martin RJ, Pennock BE, Orr WC, Sanders MH, Rogers RM. Respiratory mechanics and timing during sleep in occlusive sleep apnea. J Appl Physiol 1980; 48(3): 432-437.
134. Redline S, Kump K, Tishler PV, Browner I, Ferrette V. Gender differences in sleep disordered breathing in a community-based sample. Am J Respir Crit Care Med 1994; 149(3 Pt 1): 722-726.
135. Millman RP, Carlisle CC, McGarvey ST, Eveloff SE, Levinson PD. Body fat distribution and sleep apnea severity in women. Chest 1995; 107(2): 362-366.
136. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20(9): 705-706.
137. Young T, Hutton R, Finn L, Badr S, Palta M. The gender bias in sleep apnea diagnosis. Are women missed because they have different symptoms? Arch Intern Med 1996; 156(21): 2445-2451.
138. Quan SF, Howard BV, Iber C. et al. The sleep heart health study: design, rationale, and methods. Sleep 1997; 20(12): 1077-1085.
139. Norman RG, Ahmed MM, Walsleben JA, Rapoport DM. Detection of respiratory events during NPSG: nasal cannula/pressure sensor versus thermistor. Sleep 1997; 20(12): 1175-1184.
140. Hosselet JJ, Norman RG, Ayappa I, Rapoport DM. Detection of flow limitation with a nasal cannula/pressure transducer system. Am J Respir Crit Care Med 1998; 157(5 Pt 1): 1461-1467.
141. American Academy of Sleep Medicine. Sleep-related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. Sleep 1999; 22(5): 667-689.
142. Block AJ, Boysen PG, Wynne JW, Hunt LA. Sleep apnea, hypopnea and oxygen desaturation in normal subjects. A strong male predominance. N Engl J Med 1979; 300(10): 513-517.
143. Moser NJ, Phillips BA, Berry DT, Harbison L. What is hypopnea, anyway? Chest 1994; 105(2): 426-428.
144. Redline S, Sanders M. Hypopnea, a floating metric: implications for prevalence, morbidity estimates, and case finding. Sleep 1997; 20(12): 1209-1217.
145. Montserrat JM, Farre R, Ballester E, Felez MA, Pasto M, Navajas D. Evaluation of nasal prongs for estimating nasal flow. Am J Respir Crit Care Med 1997; 155(1): 211-215.
146. Ayappa I, Norman RG, Krieger AC, Rosen A, O'malley RL, Rapoport DM. Non-Invasive detection of respiratory effort-related arousals (REras) by a nasal cannula/pressure transducer system. Sleep 2000; 23(6): 763-771.
147. Tamisier R, Pepin JL, Wuyam B, Smith R, Argod J, Levy P. Characterization of pharyngeal resistance during sleep in a spectrum of sleep-disordered breathing. J Appl Physiol 2000; 89(1): 120-130.
148. Stradling JR, Davies RJ, Pitson DJ. New approaches to monitoring sleep-related breathing disorders. Sleep 1996; 19(9 Suppl): S77-S84.
149. Ballester E, Badia JR, Hernandez L, Farre R, Navajas D, Montserrat JM. Nasal prongs in the detection of sleep-related disordered breathing in the sleep apnoea/hypopnoea syndrome. Eur Respir J 1998; 11(4): 880-883.
150. Ayappa I, Norman RG, Hosselet JJ, Gruenke RA, Walsleben JA, Rapoport DM. Relative occurrence of flow limitation and snoring during continuous positive airway pressure titration. Chest 1998; 114(3): 685-690.
151. Meslier N, Boulay V, Meurice JC, et al. Snoring, flow limitation and airway resistance. [Abstract] Am J Respir Crit Care Med 1999; 159: (3)A792.
152. Meurice JC, Paquereau J, Denjean A, Patte F, Series F. Influence of correction of flow limitation on continuous positive airway pressure efficiency in sleep apnoea/hypopnoea syndrome. Eur Respir J 1998; 11(5): 1121-1127.
153. Ballester E, Badia JR, Hernandez L, Farre R, Navajas D, Montserrat JM. Nasal prongs in the detection of sleep-related disordered breathing in the sleep apnoea/hypopnoea syndrome. Eur Respir J 1998; 11(4): 880-883.
154. Guyatt AR, Parker SP, McBride MJ. Measurement of human nasal ventilation using an oxygen cannula as a pitot tube. Am Rev Respir Dis 1982; 126(3): 434-438.
155. Clark SA, Wilson CR, Satoh M, Pegelow D, Dempsey JA. Assessment of inspiratory flow limitation invasively and noninvasively during sleep. Am J Respir Crit Care Med 1998; 158(3): 713-722.
156. Pitson DJ, Sandell A, van den Hout R, Stradling JR. Use of pulse transit time as a measure of inspiratory effort in patients with obstructive sleep apnoea. Eur Respir J 1995; 8(10): 1669-1674.
157. Loube DI, Andrada T, Howard RS. Accuracy of respiratory inductive plethysmography for the diagnosis of upper airway resistance syndrome. Chest 1999; 115(5): 1333-1337.
158. Badia JR, Farre R, Montserrat JM, Ballester E, Hernandez L, Rotger M, Rodriguez-Roisin R, Navajas D. Forced oscillation technique for the evaluation of severe sleep apnoea/hypopnoea syndrome: a pilot study. Eur Respir J 1998; 11(5): 1128-1134.
159. Yen FC, Behbehani K, Lucas EA, Burk JR, Axe JR. A noninvasive technique for detecting obstructive and central sleep apnea. IEEE Trans Biomed Eng 1997; 44(12): 1262-1268.
160. Nieto FJ, Young TB, Lind BK et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 2000; 283(14): 1829-1836.
161. Trinder J, Van Beveren JA, Smith P, Kleiman J, Kay A. Correlation between ventilation and EEG-defined arousal during sleep onset in young subjects. J Appl Physiol 1997; 83(6): 2005-2011.
162. Pitson DJ, Stradling JR. Autonomic markers of arousal during sleep in patients undergoing investigation for obstructive sleep apnoea, their relationship to EEG arousals, respiratory events and subjective sleepiness. J Sleep Res 1998; 7(1): 53-59.
163. Pitson D, Chhina N, Knijn S, van Herwaaden M, Stradling J. Changes in pulse transit time and pulse rate as markers of arousal from sleep in normal subjects. Clin Sci (Colch) 1994; 87(2): 269-273.
164. Gleeson K, Zwillich CW, White DP. The influence of increasing ventilatory effort on arousal from sleep. Am Rev Respir Dis 1990; 142(2): 295-300.
165. Ayas NT, Brown R, Shea SA. Hypercapnia can induce arousal from sleep in the absence of altered respiratory mechanoreception. Am J Respir Crit Care Med 2000; 162(3 Pt 1): 1004-1008.
166. Hosselet JJ, Ayappa I, Norman RG, Krieger AC, Rapoport DM. Classification of sleep-disordered breathing. Am J Respir Crit Care Med 2001; 163(2): 398-405.