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Original Research |

Periodic Leg Movement, Nasal CPAP, and Expiratory MusclesPeriodic Leg Movement and Positive Airway Pressure

Won Hee Seo, MD; Christian Guilleminault, MD, DBiol
Author and Funding Information

From Stanford University Sleep Medicine Division, Stanford Outpatient Medical Center, Redwood City, CA.

Correspondence to: Christian Guilleminault, MD, DBiol, Stanford University Sleep Medicine Division, Stanford Outpatient Medical Center, 450 Broadway M/C 5704, Redwood City, CA 94063; e-mail: cguil@stanford.edu

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Funding/Support: The authors have reported to CHEST that no funding was received for this study.


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(1):111-118. doi:10.1378/chest.11-1563
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Background:  Periodic leg movements (PLMs) may appear during nasal CPAP titration, persisting despite the elimination of hypopneas.

Methods:  Systematic recordings of expiratory abdominal muscles on the right and left sides with surface electromyographic (EMG) electrodes lateral to navel, and close from the lateral side of abdomen, were added during nasal CPAP titration for treatment of obstructive sleep apnea (OSA). Positive airway pressure was titrated during nocturnal polysomnography, based on analysis of the flow curve derived from the CPAP equipment and EEG analysis, including persistence of phases A2 and A3 of the cyclic alternating pattern (CAP). The requirement was to eliminate American Association of Sleep Medicine (AASM)-defined hypopnea and also flow limitation and abnormal EEG patterns. When CPAP reached valid results, it was lowered at the time of awakening by 2 or 3 cm H2O, and titration was performed again. Data collected during a 7-month period on adults with a prior diagnosis of OSA who had received treatment with nasal CPAP regardless of age and sex were rendered anonymous and were retrospectively rescored by a blinded investigator.

Results:  Eighty-one successively seen patients with PLMs during CPAP titration were investigated. Elimination of AASM-defined hypopnea was not sufficient to eliminate the PLMs observed during the titration; higher CPAP eliminated flow limitation and CAP phases A2 and A3 and persisting PLMs. PLMs were associated with simultaneous EMG bursts in expiratory abdominal muscles.

Conclusions:  The presence of PLMs during CPAP titration indicates the persistence of sleep-disordered breathing. PLMs during CPAP titration are related to the presence of abdominal expiratory muscle activity.

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