Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015

Improving OSA screening and diagnosis in patients with hypertension in an academic safety net primary care clinic: quality improvement project

Obstructive sleep apnoea (OSA) is more prevalent in patients with hypertension (HTN), and associated morbidities include stroke, heart failure and premature death. In the Internal Medicine Clinic (IMC), over 70% of the patients had a diagnosis of HTN and obesity. We identified a lack of OSA screening in patients with HTN. The aim of this quality improvement (QI) was to increase OSA diagnosis to 5% from the baseline rate of less than 1% in patients with HTN between the ages of 18 and 75 years over 6 months at IMC. We used the Plan-Do-Study-Act (PDSA) method. The QI team performed root cause analysis to identify materials/methods, provider and patient-related barriers. PDSA cycle included: (1) integration of customised workflow of loud Snoring, Tiredness, Observed apnea, high blood Pressure (STOP)-Body mass index (BMI), Age, Neck circumference, and Gender (BANG) OSA screening tool in the electronic health record (EHR); (2) physician education of OSA and EHR workflow; and (3) completion of STOP survey by patients, which was facilitated by nursing staff. The outcome measure was the percentage of OSA diagnosis in patients with HTN. The process measures included the percentage of patients with HTN screened for OSA and the increase in sleep study referrals in hypertensive patients with STOP-BANG score of ≥3. Increase in patient wait time and cost of sleep study were the balance measures. Data analysis was performed using weekly statistical process control chart. The average increase in OSA screening rate using the STOP-BANG tool was 3.88%. The significant variation seen in relation to PDSA cycles was not sustainable. 32% of patients scored ≥3 on the STOP-BANG tool, and 10.4% had a confirmed diagnosis of OSA. STOP-BANG tool integration in the EHR and a team approach did not result in a sustainable increase in OSA screening. OSA diagnosis was increased to 3.3% in IMC patient population within the 6-month period. The team identified multiple barriers to screening and diagnosis of OSA in the IMC.

Non-surgical treatment of obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS), a pervasive disease, is closely associated with complications such as cardiovascular diseases, neurocognitive diseases, and metabolic syndromes. Continuous positive airway pressure (CPAP) is the standard treatment for OSAS, with low compliance due to multifarious factors. The two other modes of ventilation, bi-level positive airway pressure (BPAP) and autotitrating positive airway pressure (APAP), which were developed from CPAP, are slightly different from CPAP in specific groups, as well as the corresponding treatment effect and compliance. The compliance of traditional positional therapy is not high, but with the emergence of the neck-based position treatment device, its compliance and indications have changed. Although CPAP is superior to mandibular advancement device (MAD) in improving AHI, MAD seems to be comparable to CPAP in improving other indicators. Corticosteroids and leukotriene receptor antagonists are effective treatments for mild OSAS children. Whether corticosteroids can be used in other OSAS groups and their adjunctive functions to CPAP remains unclear. The combination of these two kinds of drugs appears to be more effective than single drug. Researches on transcutaneous electrical stimulation are still not enough. Its effectiveness and stimulation settings still need further study. This review summarized the various OSAS non-surgical treatments from indications, treatment outcomes, compliance, adverse reactions, and recent progress.

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

The purpose of this review is to conduct a systematic review and meta-analysis comparing the effects of continuous positive airway pressure (CPAP) with a mandibular advancement device (MAD) in improving the quality of life (sleepiness, cognitive, and functional outcomes) in patients diagnosed with obstructive sleep apnea (OSA). Authors identified randomized, placebo-controlled studies from MEDLINE through PubMed, Web of Science, and the Cochrane Library. Studies were assessed for inclusion and exclusion criteria, as well as risk of bias. Initial search yielded 240 unduplicated references, which the authors reduced to 12 relevant studies. Patients with CPAP therapy showed no statistically significant difference in the post-treatment quality of life measured with the SF-36 mental health component (p = .994), or the SF-36 physical functioning component (p = .827). There was no significant improvement in neither Functional Outcomes of Sleep Questionnaire (p = .788) nor cognitive performance (p = .395) compared to patients treated with oral appliances. However, the meta-analyses' overall results showed a significant improvement in the post-treatment apnea-hypopnea index (AHI) in favor of CPAP therapy as compared with the oral appliance group (p < .001). Meta-analyses showed unclear results for sleepiness with no significant differences in average post-treatment Epworth Sleepiness Scale [ESS] (p = .203), but significant differences in change in ESS from baseline favorable to CPAP treatment (p = .047). Further studies are needed. Compliance with treatment was 1.1 h per night significantly lower with CPAP than MAD (p = .004), which could explain why though efficacy (AHI) is better with CPAP, no significant results are shown for quality of life, cognitive, and functional outcomes. Though CPAP is significantly more efficient in reducing AHI (moderate quality of evidence), it has a significantly lower compliance resulting in no differences with MAD in quality of life, cognitive, or functional outcomes. Sleep medicine professionals should monitor treatment compliance and offer patients non-compliant with CPAP an oral appliance for treatment of OSA.

Interpretation of sleep studies for patients with sleep-disordered breathing: What the anesthesiologist needs to know

There is increased interest in the perioperative management of patients with sleep-disordered breathing (SDB). Anesthesiologists must distill information from clinical reports to make key decisions for optimizing perioperative care. A patient with SDB may present with a sleep study report at the time of surgery. Knowledge of the essential components of such a report can help the anesthesiologist evaluate the patient and optimize the perioperative management. In this narrative review, we describe how level I (i.e., laboratory-based) polysomnography (PSG) data are collected and scored using the recommended scoring guidelines, as well as the basic information and salient features of a typical PSG report relevant to the anesthesiologist. In addition, we briefly review the indications for sleep studies, including the types of laboratory-based studies, as well as the role and limitations of portable monitors (level II-IV studies) and examples of PSG reports in the clinical context.

Combining MAD and CPAP as an effective strategy for treating patients with severe sleep apnea intolerant to high-pressure PAP and unresponsive to MAD

Introduction

This study aimed to determine the effect of combining positive airway pressure (PAP) therapy and mandibular advancement device (MAD) in patients with severe obstructive sleep apnea (OSA) who were pressure intolerant for PAP and were unresponsive to MAD.

Methods

This retrospective study reviewed the medical records of severe OSA patients with apnea-hypopnea index (AHI) ≥ 30/hr who were diagnosed between October 1, 2008 and June 30, 2014. Patients were initially treated with 2 weeks of PAP, and those who were intolerant to high-pressure PAP (≥15 cm H₂O) were switched to 12 weeks of MAD, which is a monobloc designed at 75% of maximum protrusion. Patients who had high residual AHI (≥15/hr) on MAD underwent 12 weeks of combination therapy (CT) with MAD and CPAP and were enrolled in the present study. Enrolled subjects who completed the 12-week CT were followed-up until June 30, 2016.

Results

A total of 14 male patients were included. All three treatments effectively reduced AHI, oxygen desaturation index (ODI), and total sleep time with SpO₂ <90% (% TST-SpO₂<90%) compared to pretreatment values. The residual AHI and ODI on CT was lower than that on MAD or PAP. The residual % TST-SpO₂<90% was lower than that on MAD and similar to that on PAP. The therapeutic pressure on CT was on average 9.2 cm H₂O lower than that on PAP. For the 11 patients who completed CT, only CT reduced ESS compared to pretreatment value. No treatment had significant impact on % slow wave sleep or overnight change of blood pressure. For patients who completed CT, the average usage was 5.9±1.7 hr/night at 12th week and 6.4±1.5 hr/night at a median follow-up of 36.5-months.

Conclusions

Combining MAD and CPAP showed additive effects on reducing AHI and ODI, and lowered the therapeutic pressures.

Oral appliance treatment outcome can be predicted by continuous positive airway pressure in moderate to severe obstructive sleep apnea

Background

Studies show that the therapeutic CPAP pressure is associated with oral appliance (OA) treatment outcome in obstructive sleep apnea (OSA) patients. However, these studies included either CPAP adherent patients using fixed pressure devices, or partly CPAP non-adherent patients using fixed pressure or auto-adjusting (auto-CPAP) devices. In many countries, auto-CPAP is predominately used, and only those non-adherent to therapy need a change to OA. Therefore, studies examining the relationship between CPAP pressures and OA treatment outcome should focus on patients non-adherent to auto-CPAP.

Purpose

The purpose of this paper is to assess if CPAP pressures predicted OA treatment outcome in patients non-adherent to auto-CPAP therapy.

Methods

The OA treatment responders and non-responders were defined by two success criteria ((1) AHI < 5; (2) 5 ≤ AHI < 10 and > 50% AHI reduction). Logistic regression analyses were performed for CPAP pressures and baseline variables. ROC curve analyses were used to identify CPAP pressure cutoff values, alone and combined with other explanatory variables, predicting the OA treatment outcome.

Results

Eighty-seven patients with moderate or severe OSA were included. Maximum CPAP pressures (CPAPmax) were higher in non-responders by both criteria and were, together with baseline AHI, associated with the OA treatment outcome in multivariate regression analyses. ROC curves identified an optimal CPAPmax cutoff of 12 cm H₂O, corresponding to a positive predictive value (PPV) of 0.85 in predicting non-response using criterion 1. A prediction model combining CPAPmax > 12 and baseline AHI ≥ 30 had a PPV of 1.0 for non-response by both criteria.

Conclusions

Maximum CPAP pressure was a moderate predictor of OA treatment outcome, but combined with baseline AHI, the ability to identify OA non-responders was high.

Clinical Use of a Home Sleep Apnea Test: An American Academy of Sleep Medicine Position Statement

ABSTRACT

The diagnosis and effective treatment of obstructive sleep apnea (OSA) in adults is an urgent health priority. It is the position of the American Academy of Sleep Medicine (AASM) that only a physician can diagnose medical conditions such as OSA and primary snoring. Throughout this statement, the term "physician" refers to a medical provider who is licensed to practice medicine. A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of OSA in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. It is also the position of the AASM that: the need for, and appropriateness of, an HSAT must be based on the patient's medical history and a face-to-face examination by a physician, either in person or via telemedicine; an HSAT is a medical assessment that must be ordered by a physician to diagnose OSA or evaluate treatment efficacy; an HSAT should not be used for general screening of asymptomatic populations; diagnosis, assessment of treatment efficacy, and treatment decisions must not be based solely on automatically scored HSAT data, which could lead to sub-optimal care that jeopardizes patient health and safety; and the raw data from the HSAT device must be reviewed and interpreted by a physician who is either board-certified in sleep medicine or overseen by a board-certified sleep medicine physician.

Omega-3 Index and Obstructive Sleep Apnea: A Cross-Sectional Study

STUDY OBJECTIVES

Erythrocyte levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (Omega-3 Index) were previously found to be associated with obstructive sleep apnea (OSA) at very low levels (< 5.0%) in only one epidemiologic study. OSA has comorbidities, such as arterial hypertension, heart failure, or major depression, also associated with a low Omega-3 Index. These comorbidities can be improved by increasing intake of EPA and DHA, and thus the Omega-3 Index, preferably to its target range of 8% to 11%. Symptoms of OSA might improve by increasing the Omega-3 Index, but more research is needed.

METHODS

In our sleep laboratory, 357 participants with OSA were recruited, and data from 315 participants were evaluated. Three categories of OSA (none/ mild, moderate, severe) were defined based on apnea-hypopnea index. Anthropometrics and lifestyle characteristics (smoking, alcohol, fish intake, omega-3 supplementation) were recorded. Erythrocyte fatty acid compositions were assessed with the HS-Omega-3 Index methodology.

RESULTS

The mean Omega-3 Index in all 3 categories of OSA was 5.7%, and no association with OSA was found. There were more male participants with severe OSA (79.7%, P = .042) than females, and participants with severe OSA had a significantly higher body mass index (32.11 ± 6.39 kg/m², P = .009) than participants with mild or moderate OSA. Lifestyle characteristics were not significantly different.

CONCLUSIONS

In contrast to our hypothesis, an Omega-3 Index of 5.7% was not associated with OSA severity. Previously, an Omega-3 Index < 5.0% was associated. Although our results suggest aiming for an Omega-3 Index > 5.7% in an intervention trial with EPA and DHA in OSA, comorbidities of OSA suggest a target range of 8% to 11%.

Obstructive sleep apnea and rhonchopathy are associated with downregulation of trefoil factor family peptide 3 (TFF3)-Implications of changes in oral mucus composition

Study objectives

Trefoil factor family (TFF) peptides belong to the family of mucin-associated peptides and are expressed in most mucosal surfaces. TFF peptides carry out functions such as proliferation and migration enhancement, anti-apoptosis, and wound healing. Moreover, TFFs are associated with mucins and interact with them as “linker peptides”, thereby influencing mucus viscosity.

To test the hypothesis that in rhonchopathy and obstructive sleep apnea (OSA) changes occur in the expression of TFF3 and -2 that could contribute to changes in mucus viscosity, leading to an increase in upper airway resistance during breathing.

Methods

RT-PCR, Western-blot, immunohistochemistry and ELISA were performed to detect and quantify TFF3 and -2 in uvula samples. In addition, 99 saliva samples from patients with mild, moderate or severe OSA, as well as samples from rhonchopathy patients and from healthy volunteers, were analyzed by ELISA.

Results

TFF3 was detected in all uvula samples. Immunohistochemistry revealed a subjectively decreasing antibody reactivity of the uvula epithelia with increasing disease severity. ELISA demonstrated significantly higher TFF3 saliva protein concentrations in the healthy control group compared to cases with rhonchopathy and OSA. Predisposing factors of OSA such as BMI or age showed no correlation with TFF3. No significant changes were observed with regard to TFF2.

Conclusions

The results suggest the involvement of TFF3 in the pathogenesis of rhonchopathy and OSA and lead to the hypothesis that reduction of TFF3 production by the epithelium and subepithelial mucous glands of the uvula contribute to an increase in breathing resistance due to a change in mucus organization.

Updated clinical guidelines experience major reporting limitations

BACKGROUND

The Checklist for the Reporting of Updated Guidelines (CheckUp) was recently developed. However, so far, no systematic assessment of the reporting of updated clinical guidelines (CGs) exists. We aimed to examine (1) the completeness of reporting the updating process in CGs and (2) the inter-observer reliability of CheckUp.

METHODS

We conducted a systematic assessment of the reporting of the updating process in a sample of updated CGs using CheckUp. We performed a systematic search to identify updated CGs published in 2015, developed by a professional society, reporting a systematic review of the evidence, and containing at least one recommendation. Three reviewers independently assessed the CGs with CheckUp (16 items). We calculated the median score per item, per domain, and overall, converting scores to a 10-point scale. Multiple linear regression analyses were used to identify differences according to country, type of organisation, scope, and health topic of updated CGs. We calculated the intraclass coefficient (ICC) and 95% confidence interval (95% CI) for domains and overall score.

RESULTS

We included in total 60 updated CGs. The median domain score on a 10-point scale for presentation was 5.8 (range 1.7 to 10), for editorial independence 8.3 (range 3.3 to 10), and for methodology 5.7 (range 0 to 10). The median overall score on a 10-point scale was 6.3 (range 3.1 to 10). Presentation and justification items at recommendation level (respectively reported by 27 and 38% of the CGs) and the methods used for the external review and implementing changes in practice were particularly poorly reported (both reported by 38% of the CGs). CGs developed by a European or international institution obtained a statistically significant higher overall score compared to North American or Asian institutions (p = 0.014). Finally, the agreement among the reviewers on the overall score was excellent (ICC 0.88, 95% CI 0.75 to 0.95).

CONCLUSIONS

The reporting of updated CGs varies considerably with significant room for improvement. We recommend using CheckUp to assess the updating process in updated CGs and as a blueprint to inform methods and reporting strategies in updating.

Review of and Updates on Hypertension in Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a prevalent sleep disorder as is hypertension (HTN) in the 21st century with the rising incidence of obesity. Numerous studies have shown a strong association of OSA with cardiovascular morbidity and mortality. There is overwhelming evidence supporting the relationship between OSA and hypertension (HTN). The pathophysiology of HTN in OSA is complex and dependent on various factors such as sympathetic tone, renin-angiotensin-aldosterone system, endothelial dysfunction, and altered baroreceptor reflexes. The treatment of OSA is multifactorial ranging from CPAP to oral appliances to lifestyle modifications to antihypertensive drugs. OSA and HTN both need prompt diagnosis and treatment to help address the growing cardiovascular morbidity and mortality due to these two entities.

Treating OSA: Current and emerging therapies beyond CPAP

Continuous positive airway pressure (CPAP) is the standard treatment for moderate-to-severe obstructive sleep apnoea (OSA). However, adherence to CPAP is limited and non-CPAP therapies are frequently explored. Oral appliance (OA) therapy is currently widely used for the treatment of snoring, mild, moderate and severe OSA. The most commonly used and studied OA consists of a maxillary and mandibular splint which hold the lower jaw forward during sleep. The efficacy of OA is inferior to CPAP; however, the effectiveness as measured by sleepiness, quality of life, endothelial function and blood pressure is similar likely due to higher acceptance and subjective adherence. Upper airway stimulation augments neural drive by unilaterally stimulating the hypoglossal nerve. The Stimulation Therapy for Apnea Reduction (STAR) study enrolled 126 patients and demonstrated a 68% reduction in OSA severity. A high upfront cost and variable response are the main limitations. Oropharyngeal exercises consist of a set of isometric and isotonic exercises involving the tongue, soft palate and lateral pharyngeal wall. The collective reported trials (n = 120) showed that oropharyngeal exercises can ameliorate OSA and snoring (~30-40%). Nasal EPAP devices consist of disposable one-way resister valve. A systematic review (n = 345) showed that nasal EPAP reduced OSA severity by 53%. The Winx device consists of a mouthpiece placed inside the oral cavity that is connected by tubing to a console that generates negative pressure. Winx may provide successful therapy for ~30-40% of OSA patients. In conclusion, several non-CPAP therapies to treat OSA are currently available.

Sleep disordered breathing in older adults with heart failure with preserved ejection fraction

Heart failure in older adults is frequently accompanied by sleep disordered breathing (SDB). Treatment of SDB in persons with heart failure with preserved ejection fraction (HFpEF) is unclear because most data is on heart failure with reduced ejection fraction (HFrEF). The purpose of this paper was to evaluate studies that report on the effects of positive airway pressure on patient outcomes in older adults with HFpEF and comorbid SDB. A search of the literature found six data-based studies (N = 36 to 126). Treatment with positive airway pressure reduced nighttime SDB symptoms and improved daytime functional status in persons with HFPEF and SDB (New York Heart Association Functional Class: effect sizes = -0.67 to -1.60). Limitations (i.e. only two studies were randomized controlled trials, small sample sizes, and women were under-represented) suggest that additional evidence is needed to guide treatment of SDB in older adults with HFpEF.

Adjustable thermoplastic oral appliance versus positive airway pressure for obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To compare outcomes of continuous positive airway pressure (CPAP) and the adjustable thermoplastic mandibular advancement splint (AT-MAS) for obstructive sleep apnea treatment.

STUDY DESIGN

Randomized crossover, noninferiority, tertiary center setting.

METHODS

Fifty patients with a mean age of 49.5 ± 10.6 years were enrolled. Inclusion criteria were age ≥18 years, apnea-hypopnea index (AHI) ≥5 events/hour, and oxygen saturation ≥70%. Exclusion criteria were temporomandibular joint disorders, severe periodontitis, inadequate teeth, and unstable medical diseases. Treatment intolerance was considered a failure. Two-week periods without treatment were followed by questionnaires and randomization into two groups: CPAP/AT-MAS (25) and AT-MAS/CPAP (25). After 6 weeks of intervention, questionnaires and home WatchPAT monitoring were performed. Following each 2-week washout period, patients crossed over to the other treatment followed by similar procedures. Primary outcomes involved the scores from the Functional Outcomes of Sleep Questionnaire (FOSQ). Secondary outcomes were AHI, side effects, and treatment adherence.

RESULTS

Seven patients withdrew from this study: five (AT-MAS intolerance) and two (lost follow-up). There was no significant difference among FOSQ scores, particularly on global scores, between both treatments (0.57, 95% confidential interval of difference: -0.15 to 1.29). Mean AHI decreased from pretreatment 39.2 ± 2.53 to 2.56 ± 0.49 and 12.92 ± 2.05 events/hour while using CPAP and the AT-MAS, respectively (P < .05). Most common side effects of CPAP were dry throat and inconvenience to carry, whereas those of the AT-MAS were jaw pain and excessive salivation.

CONCLUSIONS

Both devices improved short-term quality of life similarly; however, the AT-MAS was not as efficacious as CPAP on resolving sleep-test parameters. The AT-MAS might be considered only a temporary treatment alternative.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:516-522, 2018.

Update on Oral Appliance Therapy for OSA

Purpose of Review

The majority of the adult population is affected by obstructive sleep apnea (OSA), according to recent epidemiological research. Oral appliance (OA) therapy is increasingly recommended, particularly for patients with milder OSA. This review updates the evidence in favor of OA therapy.

Recent Findings

A high level of evidence shows that OA is effective in the treatment of OSA, but continuous positive airway pressure (CPAP) is more efficient. Higher adherence with OAs may compensate for this difference. Daytime sleepiness is better treated with CPAP than with OA in patients with severe OSA. In patients with milder OSA, it is unclear whether sleepiness is significantly reduced. The long-term effectiveness of OAs is uncertain because of side-effects and the risk of OSA deterioration.

Summary

OAs are effective, but their efficacy is more variable than that of CPAP. More research is needed about the mechanism of action of OA, subjective effects and long-term health outcomes.

Oral Appliances for the Management of OSA: An Updated Review of the Literature

Oral appliances (OAs) are becoming increasingly recognized not only as an alternative to but also possibly as an adjunct treatment modality for OSA. Compared with CPAP, the gold standard therapy, OAs are less efficacious but are more accepted and tolerated by patients, which, in turn, may lead to a comparable level of therapeutic effectiveness. Different OA designs currently exist, and more are constantly emerging. Additionally, state-of-the-art technologies are being used in the fabrication of many; however, all the currently available OAs employ the same mechanism of action by targeting the anatomical component involved in the pathogenesis of the disease. Furthermore, the scope of use of OAs is expanding to include patients who are edentulous. For patients with OAs, the dentist is a member of an interdisciplinary team managing OSA, and constant communication and follow-up with the sleep physician and other team members is necessary for disease management.

Sleep-Disordered Breathing and Excessive Daytime Sleepiness

Sleep-related breathing disorders include obstructive sleep apnea (OSA), central sleep apnea, sleep-related hypoventilation, and sleep-related hypoxemia. Excessive daytime sleepiness (EDS) is frequently reported by patients with OSA but is not invariably present. The efficacy of positive airway pressure therapy in improving EDS is well established for OSA, but effectiveness is limited by suboptimal adherence. Non-OSA causes of sleepiness should be identified and treated before initiating pharmacotherapy for persistent sleepiness despite adequately treated OSA. Further research on the identification of factors that promote EDS in the setting of OSA is needed to aid in the development of better treatment options.

Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force

ABSTRACT

The American Academy of Sleep Medicine Sleep and Transportation Safety Awareness Task Force responded to the Federal Motor Carrier Safety Administration and Federal Railroad Administration Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA). The following document represents this response. The most salient points provided in our comments are that (1) moderate-to-severe OSA is common among commercial motor vehicle operators (CMVOs) and contributes to an increased risk of crashes; (2) objective screening methods are available and preferred for identifying at-risk drivers, with the most commonly used indicator being body mass index; (3) treatment in the form of continuous positive airway pressure (CPAP) is effective and reduces crashes; (4) CPAP is economically viable; (5) guidelines are available to assist medical examiners in determining whether CMVOs with moderate-to-severe OSA should continue to work without restrictions, with conditional certification, or be disqualified from operating commercial motor vehicles.

Therapeutic Efficacy of Twin-Block and Fixed Oral Appliances in Patients with Obstructive Sleep Apnea Syndrome

PURPOSE

To compare the efficacy of twin-block (i.e., allows mouth opening) and fixed (i.e., maintains mouth closure) mandibular advancement splints (MASs) for the treatment of obstructive sleep apnea-hypopnea syndrome (OSA).

MATERIALS AND METHODS

From 2011 to 2013, 23 patients with OSA in the twin-block group, and from 2013 to 2015, 29 patients in the fixed MAS group were included. All patients underwent polysomnography before and after 3 months of treatment. The two sets of polysomnographic and cephalometric variables were compared.

RESULTS

A significant difference (p < 0.001) was observed in the apnea-hypopnea index before and after MAS treatment in both groups (twin-block group: 20.6 ± 11.5 vs. 14.7 ± 9.4; fixed group: 21.4 ± 15.2 vs. 11.2 ± 9.7). In the twin-block group, 5 patients (21.7%) were complete responders, 9 (39.1%) were fair responders, and 9 (39.1%) were nonresponders; the corresponding figures for the fixed group were 14 (48.3%), 9 (31.0%), and 6 (20.7%) patients. A significant between-group difference was observed in the distribution of responders (p = 0.046). The fixed group showed a significant improvement in the snoring index (p = 0.003), arousal index (p = 0.036), and desaturation rate (p = 0.012). Finally, the change in incisal overjet was larger in the fixed group than in the twin-block group (p < 0.001).

CONCLUSIONS

These results suggest that fixed oral appliances are superior in treating OSA, based on their ability to prevent mouth opening and reduce incisal overjet.

Patient-centered care in obstructive sleep apnea: A vision for the future

Obstructive sleep apnea is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, but patient engagement is typically required for treatment to be effective. Patients with sleep apnea are phenotypically diverse and have individual needs, preferences, and values that impact treatment decisions. There has been a shift in obstructive sleep apnea management from diagnosis to chronic care management. Making treatment decisions that incorporate an individual patient's values and preferences and are personalized for that patient's biology has the potential to improve patient outcomes. A patient-centered care approach in obstructive sleep apnea is reviewed including 1) determining patient-specific needs to guide treatment decisions, 2) understanding patient values, preferences, and other factors impacting treatment decisions and using shared decision-making, 3) enhancing patient education and support to improve treatment adherence, 4) promoting patient engagement, 5) optimizing care coordination, continuity of care, and access to care, and 6) determining and assessing patient-centered outcomes.

Ready-Made Versus Custom-Made Mandibular Repositioning Devices in Sleep Apnea: A Randomized Clinical Trial

STUDY OBJECTIVES

To compare the effectiveness of a custom-made (MRDc) versus ready-made (MRDr) mandibular repositioning devices (MRD) in the management of obstructive sleep apnea (OSA).

METHODS

A randomized crossover trial design was adopted in which patients with a confirmed diagnosis of OSA were randomly allocated to receive either a 3-month period of ready-made or custom-made MRD, with an intervening washout period of 2 weeks, prior to crossover. Treatment outcomes included both objective sleep monitoring and patient-centered measures (daytime sleepiness, partner snoring and quality of life).

RESULTS

Twenty-five patients, with a mild degree of OSA (apnea-hypopnea index of 13.3 [10.9-25] events/h) and daytime sleepiness (Epworth Sleepiness Scale of 11 [6-16]), completed both arms of the trial. The MRDc achieved a complete treatment response in 64% of participants, compared with 24% with the MRDr (p < 0.001). A significant difference was observed in treatment failures, when comparing the MRDr (36%) with the MRDc (4%). Excessive daytime sleepiness (Epworth Sleepiness Scale ≥ 10) persisted in 33% (MRDc) and 66% (MRDr) of OSA subjects, following treatment. A statistically significant improvement was observed in quality of life scales following MRDc therapy only. Significant differences were observed in relation to both the number of nights per week (p = 0.004) and hours per night (p = 0.006) between the two different designs of device.

CONCLUSIONS

The study demonstrates the significant clinical effectiveness of a custom-made mandibular repositioning device, particularly in terms of patient compliance and tolerance, in the treatment of OSA.

Effect of jaw-opening exercise on prevention of temporomandibular disorders pain associated with oral appliance therapy in obstructive sleep apnea patients: A randomized, double-blind, placebo-controlled trial

PURPOSE

There are no studies on the prevention of temporomandibular joint and/or masticatory muscle pain (TMD pain) associated with oral appliance (OA) therapy in patients with obstructive sleep apnea (OSA). The aim of this study was to determine the effect of jaw-opening exercise on TMD pain associated with OA therapy in OSA patients.

METHODS

Twenty-five OSA patients without pain-related TMD were consecutively enrolled into a two-arm, randomized, double-blind, placebo-controlled trial. One group performed jaw-opening exercise (JE, n=13), and the other group performed placebo exercise (PE, n=12) for 1-month, and had started 2-weeks prior to insertion of an adjustable OA. TMD sign using the Research Diagnostic Criteria for Temporomandibular Disorders and TMD pain intensity using a visual analog scale (VAS) in the morning and daytime were evaluated at baseline (pre-exercise) and at 2-weeks, 1-month, and 3-months after OA insertion.

RESULTS

Pain-related TMD was not observed in the JE-group at all evaluation periods, although one subject in the PE-group was diagnosed with arthralgia at the 1-month evaluation. The JE-group showed lower morning and daytime VAS scores than the those of the PE-group at all evaluation periods, and significant group differences were found in terms of chewing pain and jaw-opening pain in the morning at the 1-month evaluation, and of jaw-opening pain during daytime at the 3-month evaluation (P<0.05).

CONCLUSIONS

Within the limitations of the study, jaw-opening exercise prior to OA therapy reduced the risk of TMD pain associated with OA use. Therefore, jaw-opening exercise may contribute to the prevention of TMD pain.

Zinc Is Indispensable in Exercise-Induced Cardioprotection against Intermittent Hypoxia-Induced Left Ventricular Function Impairment in Rats

In obstructive sleep apnea (OSA), recurrent obstruction of the upper airway leads to intermittent hypoxia (IH) during sleep, which can result in impairment of cardiac function. Although exercise can have beneficial effects against IH-induced cardiac dysfunction, the mechanism remains unclear. This study aimed to investigate the interactions of zinc and exercise on IH-triggered left ventricular dysfunction in a rat model that mimics IH in OSA patients. Nine-week-old male Sprague-Dawley rats were randomly assigned to either a control group (CON) or to a group receiving 10 weeks of exercise training (EXE). During weeks 9 and 10, half the rats in each group were subjected to IH for 8 h per day for 14 days (IHCON, IHEXE), whereas the remainder continued to breathe room air. Rats within each of the CON, IHCON, EXE, and IHEXE groups were further randomly assigned to receive intraperitoneal injections of either zinc chloride, the zinc chelator N,N,N',N'-tetrakis(2-pyridylmethyl) ethylenediamine (TPEN), or injection vehicle only. IH induced a lower left ventricular fractional shortening, reduced ejection fraction, higher myocardial levels of inflammatory factors, increased levels oxidative stress, and lower levels of antioxidative capacity, all of which were abolished by zinc treatment. IHEXE rats exhibited higher levels of cardiac function and antioxidant capacity and lower levels of inflammatory factors and oxidative stress than IHCON rats; however, IHEXE rats receiving TPEN did not exhibit these better outcomes. In conclusion, zinc is required for protecting against IH-induced LV functional impairment and likely plays a critical role in exercise-induced cardioprotection by exerting a dual antioxidant and anti-inflammatory effect.

Treatment options for obstructive sleep apnea

Purpose of review

Obstructive sleep apnea (OSA) is a global problem with implications for general health and quality of life, and is often encountered in patients with neurologic disease. This review outlines treatment modalities to consider for management of OSA in patients with neurologic disease.

Recent findings

New advances in positive airway pressure (PAP) devices, oral appliances, and surgical interventions offer a wide range of treatment options for patients with OSA.

Summary

PAP therapy remains the gold standard treatment for OSA. Other treatment modalities may be considered for OSA patients who decline or cannot tolerate PAP therapy. Some OSA patients may benefit from multimodal treatment.

Therapeutic outcomes of mandibular advancement devices as an initial treatment modality for obstructive sleep apnea

Although continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA), there is a need for alternative treatment options, such as sleep surgeries and mandibular advancement devices (MADs), to overcome the limitations of CPAP.This study aimed to analyze the therapeutic outcomes of OSA subjects who were treated with a MAD, and to estimate the clinical impact of MAD as a first-line treatment for OSA.Forty-seven patients diagnosed with OSA received an adjustable MAD as an initial treatment. Drug-induced sleep endoscopic findings and sleep parameters (both pre-MAD and post-MAD treatment), such as apnea index, oxygen saturation, and degree of daytime sleepiness, were assessed retrospectively.The MAD treatment resulted in a significant reduction in apnea-hypopnea index, and also a significant elevation in lowest oxygen saturation. Satisfactory results of MAD treatment as a first treatment modality were observed in 27 patients, and a successful outcome was reached in approximately 72% of patients. The OSA patients who had lower body mass index and upper airway narrowing at the level of palate and tongue base showed relatively higher rates of a satisfactory outcome even in cases of moderate or severe OSA.These results suggest that the use of a MAD may be an alternative treatment option in OSA patients with retropalatal and retroglossal area narrowing regardless of disease severity. Additionally, MADs can be recommended as an initial treatment modality, and the effectiveness of MADs in achieving success may not be inferior to CPAP.

Assessment of oral appliance for obstructive sleep apnea patients

Although oral appliances (OAs) have become widely used for the management of obstructive sleep apnea (OSA), side effects of OAs are generally related to poor utilization. The purpose of the present study was to evaluate relationship between utilization and treatment efficacy of a boil-and-bite appliance for OSA patients. A total of 135 patients with OSA who had used an OAs were mailed a questionnaire to determine whether they were currently using the OA. If so, they were asked about OA use, improvement of signs and subjective symptoms, and utilization. Otherwise, they were asked to indicate why and when they quit using the OA. Results of overnight polysomnography (PSG) before and after treatment were reviewed. Of the 48 responding patients, 33 patients were currently using the OA. The most common complication was excessive salivation (n = 11). All indices from PSG excluding arousal index were significantly improved after treatment (p < 0.05). Thirty patients showed improved signs and subjective symptoms. Eight out of 12 subjects (66.7%) were successfully treated, achieving an apnea-hypopnea index (AHI) < 10/h and >50% reduction in apnea-hypopnea index. Of the 15 patients no longer using the OA, the primary reason for quitting was "no treatment effect" (n = 5). No indices from PSG recording differed between before and after treatment in the not-using group. These results suggest that both subjective and objective signs and symptoms improved with use of the OA in the using group. However, no signs and subjective symptoms or indices of sleep quality differed between before and after treatment in the not-using group. Device improvements are needed to achieve better treatment efficacy, and thus improve compliance. The present study evaluated relationship between utilization and treatment efficacy of a boil -and bite appliance for OSA patients. Device improvements are needed to achieve better treatment efficacy, thus improve compliance.

Detection of exercise periodic breathing using thermal flowmeter in patients with heart failure

Exercise periodic breathing (EPB) is associated with exercise intolerance and poor prognosis in patients with heart failure (HF). However, EPB detection during cardiopulmonary exercise test (CPET) is difficult. The present study investigated the use of a wireless monitoring device to record the EPB during CPET and proposed quantization parameter estimates for the EPB. A total of 445 patients with HF were enrolled and underwent exercise tests. The ventilation data from the wearable device were compared with the data obtained during the CPET and were analyzed based on professional opinion and on 2 automated programs (decision tree [DT] and oscillatory pattern methods). The measurement accuracy was greater with the DT method (89 %) than with the oscillatory pattern method (75 %). The cutoffs for EPB recognition using the DT method were (1) an intercept of the regression line passing through the minute ventilation rate vs. the time curve during the recovery phase ≥64.63, and (2) an oscillatory phase duration to total exercise time ratio ≥0.5828. The wearable device was suitable for the assessment of EPB in patients with HF, and our new automated analysis system using the DT method effectively identified the EPB pattern.

Perceived Effectiveness, Self-efficacy, and Social Support for Oral Appliance Therapy Among Older Veterans With Obstructive Sleep Apnea

PURPOSE

Obstructive sleep apnea is a prevalent sleep disorder among older adults. Oral appliances are increasingly prescribed as therapy for obstructive sleep apnea. Adherence to oral appliance therapy is highly variable. Based on value-expectancy theory and other social-psychological theories, adherence to oral appliance therapy may be influenced by patients' perceived effectiveness of the therapy, self-efficacy, and availability of social support. We examined these perceptions among older adults with obstructive sleep apnea who were prescribed oral appliance therapy.

METHODS

We mailed surveys to all patients aged ≥65 years who had been prescribed oral appliance therapy for obstructive sleep apnea over the prior 36 months at a Veterans Affairs medical center. We examined frequencies of responses to items that assessed perceived effectiveness, self-efficacy, and social support for nightly use of oral appliances from friends, family, or health care staff.

FINDINGS

Thirty-nine individuals responded (response rate, 30%; mean [SD] age 71.4 [SD 6.3] years; 97% male). Thirty-six percent of the respondents perceived regular use of oral appliance therapy to be effective in managing obstructive sleep apnea; 39% agreed that they felt confident about using oral appliances regularly; 41% felt supported by people in their life in using oral appliance therapy; and 38% agreed that health care staff would help them to use their oral appliance regularly. These rates represented less than half of respondents despite the finding that 65% of patients believed that they would use their oral appliance regularly.

IMPLICATIONS

Although oral appliance therapy is increasingly prescribed for obstructive sleep apnea, only about one third of older adults prescribed it perceived it to be an effective treatment, were confident about oral appliance use, and/or believed that they would receive needed support. Future research is needed to better understand older adults' perceptions so that interventions can be designed to improve the effectiveness of oral appliances, their self-efficacy for using oral appliances, and their social support for this therapy, which may, in turn, improve oral appliance therapy adherence.

The Use of Remotely Controlled Mandibular Positioner as a Predictive Screening Tool for Mandibular Advancement Device Therapy in Patients with Obstructive Sleep Apnea through Single-Night Progressive Titration of the Mandible: A Systematic Review

STUDY OBJECTIVES

To perform a review of the current evidence regarding the use of a remotely controlled mandibular positioner (RCMP) and to analyze the efficacy of RCMP as a predictive selection tool in the treatment of obstructive sleep apnea (OSA) with oral appliances that protrude the mandible (OAm), exclusively relying on single-night RCMP titration.

METHODS

An extensive literature search is performed through PubMed.com, Thecochranelibrary.com (CENTRAL only), Embase.com, and recent conference meeting abstracts in the field.

RESULTS

A total of 254 OSA patients from four full-text articles and 5 conference meeting abstracts contribute data to the review. Criteria for successful RCMP test and success with OAm differed between studies. Study populations were not fully comparable due to range-difference in baseline apneahypopnea index (AHI). However, in all studies elimination of airway obstruction events during sleep by RCMP titration predicted OAm therapy success by the determination of the most effective target protrusive position (ETPP). A statistically significant association is found between mean AHI predicted outcome with RCMP and treatment outcome with OAm on polysomnographic or portable sleep monitoring evaluation (p < 0.05).

CONCLUSIONS

The existing evidence regarding the use of RCMP in patients with OSA indicates that it might be possible to protrude the mandible progressively during sleep under poly(somno)graphic observation by RCMP until respiratory events are eliminated without disturbing sleep or arousing the patient. ETPP as measured by the use of RCMP was significantly associated with success of OAm therapy in the reported studies. RCMP might be a promising instrument for predicting OAm treatment outcome and targeting the degree of mandibular advancement needed.

Oral Appliances in Obstructive Sleep Apnea

Oral appliance therapy (OAT) has become an increasingly popular nonsurgical option for the treatment of obstructive sleep disorders. Recent research supports its efficacy and high levels of compliance for patients with obstructive sleep disorders. Common side effects of OAT include temporomandibular joint-related symptoms, bite changes, and tooth movement. These side effects can be minimized by the use of exercises. The American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine have released joint clinical practice guidelines for the treatment of obstructive sleep apnea and snoring with OAT.

Sleep and airway assessment: A review for dentists

INTRODUCTION

Dentists can be the first professionals to recognize a patient's potential sleep problem since they typically have more frequent contact with their patients than do physicians. It is important that dentists have a reasonable understanding of sleep disorders and how to assess their patients if they suspect such a problem so that a timely referral can be made or treatment can be provided as appropriate.

OBJECTIVE

To review the key literature relevant to sleep-disordered breathing (SDB) characteristics and diagnosis, including history, examination, and investigation with an emphasis on radiographic airway analyses.

CONCLUSION

The authors present a concise explanation of SDB conditions and an outline for thorough patient examination and evaluation, including radiographic airway analyses. Limited two-dimensional and three-dimensional norms exist for adult patients with no SDB and even less so for children. Much more research is needed, particularly in the pediatric population.

Quality Assessment of Systematic Reviews on the Efficacy of Oral Appliance Therapy for Adult and Pediatric Sleep-Disordered Breathing

STUDY OBJECTIVES

To assess the methodological quality of published systematic reviews (SRs) and meta-analyses (MAs) about the efficacy of oral appliances (OA) in the management of adult and pediatric sleep-disordered breathing (SDB).

METHODS

SRs/MAs that evaluated the efficacy of OA therapy on the treatment of SDB in human subjects of all age groups were sought. Multiple electronic databases were searched for articles published in any language from the database's inception until January 2016. Two reviewers independently selected and then assessed the methodological quality of the studies using the Assessment of Multiple Systematic Reviews (AMSTAR) measurement tool.

RESULTS

Thirteen reviews on adult SDB were included (2 SRs and 11 SRs with MAs). Of those, seven were medium quality and six were high quality. Only four reviews were included on pediatric SDB (3 SRs and 1 SR with MA). Three of these were of high quality and one was medium quality. The identified limitations in the included reviews were failing to reference the excluded studies or describe reasons for exclusion, lack of applying valid criteria to assess the quality of included studies, lack of publication bias assessment, and absence of conflicts of interest reporting.

CONCLUSIONS

Overall, SRs/MAs on OA therapy for adult and pediatric SDB were conducted with acceptable methodological quality. High AMSTAR scores should not be extrapolated as a proxy of the methodological quality of the included evidence. There is a need for more primary studies and then that information can be used to be synthesized through SRs on pediatric SDB.

Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network meta-analysis

STUDY OBJECTIVE

To synthesize evidence from available studies on the relative efficacies of continuous positive airway pressure (CPAP), mandibular advancement device (MAD), supervised aerobic exercise training, and dietary weight loss in patients with obstructive sleep apnea (OSA).

DESIGN

Network meta-analysis of 80 randomized controlled trials (RCTs) short-listed from PubMed, SCOPUS, Web of science, and Cochrane register (inception - September 8, 2015).

PATIENTS

Individuals with OSA.

INTERVENTIONS

CPAP, MADs, exercise training, and dietary weight loss.

RESULTS

CPAP decreased apnea-hypopnea index (AHI) the most [by 25.27 events/hour (22.03-28.52)] followed by exercise training, MADs, and dietary weight loss. While the difference between exercise training and CPAP was non-significant [-8.04 (-17.00 to 0.92), a significant difference was found between CPAP and MADs on AHI and oxygen desaturation index (ODI) [-10.06 (-14.21 to -5.91) and -7.82 (-13.04 to -2.59), respectively]. Exercise training significantly improved Epworth sleepiness scores (ESS) [by 3.08 (0.68-5.48)], albeit with a non-significant difference compared to MADs and CPAP.

CONCLUSIONS

CPAP is the most efficacious in complete resolution of sleep apnea and in improving the indices of saturation during sleep. While MADs offer a reasonable alternative to CPAP, exercise training which significantly improved daytime sleepiness (ESS) could be used as adjunctive to the former two.

Novel Approaches to the Management of Sleep-Disordered Breathing

In the last several years, a variety of novel approaches to the treatment of sleep-disordered breathing have emerged. This new technology holds promise in serving to re-engage with patients who have previously been lost to follow-up due to continuous positive airway pressure intolerance. With more tools at our disposal, in turn more options can be offered to patients' growing demand for alternatives that are tailored to their individual needs. The key to proper deployment of alternative therapies will often depend on identification of certain phenotypic traits that trend toward a reasonable response to a given therapy.