Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis

Risk of Incident Obstructive Sleep Apnea Among Patients With Type 2 Diabetes

OBJECTIVE

This study compared the incidence of obstructive sleep apnea (OSA) in patients with and without type 2 diabetes and investigated risk factors for OSA in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective cohort study was performed to compare OSA incidence between adult patients with and without type 2 diabetes matched for age, sex, and BMI. Patients with a prevalent OSA diagnosis were excluded. The study cohort was derived from The Health Improvement Network (THIN), a U.K. primary care database, from 1 January 2005 to 31 December 2017.

RESULTS

There were 3,110 (0.88%) and 5,968 (0.46%) incident OSA cases identified in the 360,250 exposed and 1,296,489 unexposed patient cohorts, respectively. Adjusted incidence rate ratio (aIRR) of OSA in patients with type 2 diabetes compared with those without was 1.48 (95% CI 1.42-1.55; P < 0.001). In a multivariate regression analysis of patients with type 2 diabetes, significant predictors of OSA were diabetes-related foot disease (1.23 [1.06-1.42]; P = 0.005), being prescribed insulin in the last 60 days (1.58 [1.42-1.75]; P < 0.001), male sex (2.27 [2.09-2.46]; P < 0.001), being overweight (2.02 [1.54-2.64]; P < 0.001) or obese (8.29 [6.42-10.69]; P < 0.001), heart failure (1.41 [1.18-1.70]; P < 0.001), ischemic heart disease (1.22 [1.11-1.34]; P < 0.001), atrial fibrillation (1.23 [1.04-1.46]; P = 0.015), hypertension (1.32 [1.23-1.43]; P < 0.001), and depression (1.75 [1.61-1.91]; P < 0.001).

CONCLUSIONS

When considered alongside previous evidence, this study indicates that the association between type 2 diabetes and OSA is bidirectional. In addition to known predictors of OSA, diabetes-related foot disease and insulin treatment were identified as risk factors in patients with type 2 diabetes.

Oral Appliances in the Management of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a multifactorial condition, and an interdisciplinary approach to diagnosis forms the basis for effective treatment planning. Craniofacial structure and attached soft tissues and muscles play a central role in OSA. Evidence-based studies demonstrate the effectiveness of oral appliances for mandibular advancement and tongue stabilization in managing OSA, and current clinical standards of practice recommend the use of oral appliances to treat OSA when patients cannot tolerate continuous positive airway pressure (CPAP). Although effective, oral appliances are less predictable in managing OSA compared with CPAP therapy. Measures can be taken to improve predictability of oral appliance treatment.

Myofunctional Therapy: Role in Pediatric OSA

Myofunctional therapy (MFT) has been reported to be an alternative treatment to obstructive sleep apnea (OSA), but compliance and long-term outcome in the children were considered as an issue. A prospective study was performed on age-matched children submitted to MFT or to a functional oral device used during sleep (passive MFT) and compared with no-treatment control group. Compliance is a major problem of MFT, and MFT will have to take into consideration the absolute need to have continuous parental involvement in the procedure for pediatric OSA.

Difficult-to-treat OSAS: Combined continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) therapy. A case report

Background: Obstructive sleep apnea syndrome and is characterized by recurrent episodes of partial or complete upper airway collapse during sleep with consequent oxygen desaturations and cardiovascular, neurological, and metabolic impairment. Clinical presentation: The authors report the case of a 66-year-old male presenting "metabolic syndrome" (obesity, impaired glucose tolerance, dyslipidemia, multi-drug treated arterial hypertension), atopy, mouth breathing due to turbinate hypertrophy, and pathological daytime sleepiness. As patient's compliance to standard continuous positive airway pressure (CPAP) therapy was poor, he was treated using low-pressure CPAP combined with a mandibular advancement device (MAD). Conclusion: In selected patients, a treatment combining CPAP and MAD might be a more tolerable alternative to CPAP alone. The improved pharyngeal patency, promoted by mandibular advancement and stretching of the pharyngeal muscles, allows operating the CPAP at lower pressures when the MAD alone is not sufficient to induce a safe sleep profile.

Nocturia in Women With Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is underdiagnosed in women compared with men. Women have a tendency to underreport or present with atypical symptoms such as behavior changes, insomnia, fatigue, and depression. Nocturia, waking up from sleep 2 times or more to void, has been shown to be associated with OSA, but it is not an included symptom in commonly used screening questionnaires in primary provider offices. About 50% of patients with OSA have nocturia, and treatment of OSA improves it. Recognition of nocturia as a relevant symptom of OSA is important for primary providers to provide timely referral for the diagnosis of OSA.

Sleep Apnea in Heart Failure

PURPOSE OF REVIEW

In this review, we discuss the current treatment options for sleep-disordered breathing (SDB) in patients with heart failure (HF). We address the role of positive airway pressure (PAP) devices and other emerging therapies. The review includes discussion of recent trials that reported negative consequences for the PAP devices in patients with heart failure.

RECENT FINDINGS

Optimal guideline-directed medical therapies of HF and PAP devices have been the mainstay treatments for HF patients with SDB. Recently, randomized controlled trials (RCTs) evaluated the effect of PAP on clinical outcomes in patients with cardiovascular (CV) disease and heart failure and found no benefit in decreasing fatal and non-fatal CV events. The Sleep Apnea Cardiovascular Endpoints (SAVE) trial evaluated continuous positive airway pressure (CPAP) ventilation in patients with CV disease and obstructive sleep apnea (OSA) and did not observe any improvement in CV effect. In patients with HF and central sleep apnea (CSA), adaptive servo-ventilation (ASV) was hypothesized to help HF outcomes, but the Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure (SERVE-HF) trial did not show any mortality benefit. Instead, the trial suggested an increase in all-cause and CV mortality in the treatment arm. currently, studies have not shown the use of PAP therapy to improve any risks of CV outcomes or death in HF patients with sleep apnea, but some associations with improvements in symptoms from OSA have been observed.