Surgery for obstructive sleep apnoea

Three-dimensional Evaluation of Nasal Surgery in Patients with Obstructive Sleep Apnea

Background:

Obstructive sleep apnea (OSA) is a common sleep disorder and is characterized by airway collapse at multiple levels of upper airway. The effectiveness of nasal surgery has been discussed in several studies and shows a promising growing interest. In this study, we intended to evaluate the effects of nasal surgery on the upper airway dimensions in patients with OSA using three-dimensional (3D) reconstruction of cone-beam computed tomography (CT).

Methods:

Twelve patients with moderate to severe OSA who underwent nasal surgery were included in this study. All patients were diagnosed with OSA using polysomnography (PSG) in multi sleep health centers associated with Massachusetts General Hospital, Massachusetts Eye and Ear Infirmary and the Partners Health Care from May 31, 2011 to December 14, 2013. The effect of nasal surgery was evaluated by the examination of PSG, subjective complains, and 3D reconstructed CT scan. Cross-sectional area was measured in eleven coronal levels, and nasal cavity volume was evaluated from anterior nasal spine to posterior nasal spine. The thickness of soft tissue in oral pharynx region was also measured.

Results:

Five out of the 12 patients were successfully treated by nasal surgery, with more than 50% drop of apnea–hypopnea index. All the 12 patients showed significant increase of cross-sectional area and volume postoperatively. The thickness of soft tissue in oral pharynx region revealed significant decrease postoperatively, which decreased from 19.14 ± 2.40 cm² and 6.11 ± 1.76 cm² to 17.13 ± 1.91 cm² and 5.22 ± 1.20 cm².

Conclusions:

Nasal surgery improved OSA severity as measured by PSG, subjective complaints, and 3D reconstructed CT scan. 3D assessment of upper airway can play an important role in the evaluation of treatment outcome.

Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition)

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Effects of exercise training on sleep apnea: a meta-analysis

BACKGROUND

Several studies have shown a favorable effect of supervised exercise training on obstructive sleep apnea (OSA). This meta-analysis was conducted to analyze the data from these studies on the severity of OSA (primary outcome) in adults. Secondary outcomes of interest included body mass index (BMI), sleep efficiency, daytime sleepiness and cardiorespiratory fitness.

METHODS

Two independent reviewers searched PubMed and Embase (from inception to March 6, 2013) to identify studies on the effects of supervised exercise training in adults with OSA. Pre- and postexercise training data on our primary and secondary outcomes were extracted.

RESULTS

A total of 5 studies with 6 cohorts that enrolled a total of 129 study participants met the inclusion criteria. The pooled estimate of mean pre- to postintervention (exercise) reduction in AHI was −6.27 events/h (95 % confidence interval [CI] -8.54 to -3.99; p < 0.001). The pooled estimates of mean changes in BMI, sleep efficiency, Epworth sleepiness scale and VO2 peak were -1.37 (95 % CI −2.81 to 0.07; p = 0.06), 5.75 % (95 % CI 2.47-9.03; p = 0.001), -3.3 (95 % CI -5.57 to -1.02; p = 0.004), and 3.93 mL/kg/min (95 % CI 2.44-5.42; p < 0.001), respectively.

CONCLUSIONS

This meta-analysis shows a statistically significant effect of exercise in reducing the severity of sleep apnea in patients with OSA with minimal changes in body weight. Additionally, the significant effects of exercise on cardiorespiratory fitness, daytime sleepiness, and sleep efficiency indicate the potential value of exercise in the management of OSA.

Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is an independent risk factor for the development of hypertension. However the effect of continuous positive airway pressure (CPAP) on lowering systemic blood pressure (BP) in OSA patients has been conflicting. Oral appliance (OA) therapy is an important alternative therapy to CPAP for patients with mild to moderate OSA.

OBJECTIVE

To conduct a meta-analysis of studies which have evaluated the effect of OAs on BP in patients with OSA.

DATA SOURCES

Studies were retrieved by searching PubMed (all studies that were published until December 15, 2011)

STUDY SELECTION

Three independent reviewers screened citations to identify trials of the effect of OA on BP.

DATA EXTRACTION

Data from observational and randomized controlled trial (RCT) studies was extracted for pre- and post-treatment systolic, diastolic, and mean arterial blood pressure (SBP, DBP, and MAP).

DATA SYNTHESIS

A total of 7 studies that enrolled 399 participants met the inclusion criteria. The pooled estimate of mean changes and the corresponding 95% CIs for SBP, DBP, and MAP from each trial are -2.7 mm Hg (95% CI: -0.8 to -4.6), p-value 0.04; -2.7 mm Hg (95% CI: -0.9 to -4.6), p-value 0.004; and -2.40 mm Hg (95% CI: -4.01 to -0.80), p-value 0.003 (Figures 2-4). The pooled estimate of mean changes and the corresponding 95% CIs for nocturnal SBP, DBP, and MAP from each trial are -2.0 mm Hg (95% CI: 1.1 to -5.3), p-value 0.212; -1.7 mm Hg (95% CI: -0.1 to -3.2), p-value 0.03; and -1.9 mm Hg (95% CI: 1.3 to -5.1), p-value 0.255 (Figures 5-7) respectively.

CONCLUSIONS

The pooled estimate shows a favorable effect of OAs on SBP, MAP, and DBP. Most of the studies were observational. Therefore, more RCTs are warranted involving a larger number of patients and longer treatment periods to confirm the effects of OA on BP.

Obstructive Sleep Apnoea (OSA) Patterns in Bariatric Surgical Practice and Response of OSA to Weight Loss after Laparoscopic Adjustable Gastric Banding (LAGB)

Introduction: This study aims to evaluate the incidence of Obstructive Sleep Apnoea (OSA) in severely obese Asians and to study the impact of weight loss on OSA. Materials and Methods: We report the results of routine preoperative Polysomnograms in 350 Asian patients undergoing bariatric surgery in our institute. Polysomnograms were repeated in 75 randomly selected patients with moderate to severe OSA after target weight loss with the laparoscopically placed adjustable gastric band (LAGB). Results: The prevalence of OSA in obese Asians is high. Moderate OSA was found in 46% of patients and severe OSA was found in 33%. Severe OSA was significantly more in the Chinese (46%) compared to the Malays (29%) or Indians (21%) (P = 0.035). We identified other risk factors for severe OSA (male sex, higher body mass index and the presence of hypertension) but were unable to select identifying parameters for very low (<5%) likelihood of severe OSA such that routine sleep studies prior to bariatric surgery could be omitted. Apnoea Hypoapnoea Index (AHI) showed improvement of 50% at 20 kg excess weight loss with the cure of OSA in preoperatively severe cases (P <0.005). Mild to moderate cases reported similar improvements although a direct correlation could not be established. Desaturation events, apnoea episodes, work of breathing and subjective assessment of sleepiness scores and quality of life (QOL) showed improving trends, albeit not statistically significant. Similar improvements were seen in sleep architecture with increased rapid eye movement (REM) and stage 3 sleep. Conclusions: The incidence of OSA in Asians undergoing bariatric surgery is high. Routine sleep studies in Asian patients are justified. Weight loss brought about a significant improvement in AHI and continuous positive airway pressure requirements. LAGB placement should be considered a broadly effective therapy for sleep apnoea in the severely obese patient. Introduction: This study aims to evaluate the incidence of Obstructive Sleep Apnoea (OSA) in severely obese Asians and to study the impact of weight loss on OSA. Materials and Methods: We report the results of routine preoperative Polysomnograms in 350 Asian patients undergoing bariatric surgery in our institute. Polysomnograms were repeated in 75 randomly selected patients with moderate to severe OSA after target weight loss with the laparoscopically placed adjustable gastric band (LAGB). Results: The prevalence of OSA in obese Asians is high. Moderate OSA was found in 46% of patients and severe OSA was found in 33%. Severe OSA was significantly more in the Chinese (46%) compared to the Malays (29%) or Indians (21%) (P = 0.035). We identified other risk factors for severe OSA (male sex, higher body mass index and the presence of hypertension) but were unable to select identifying parameters for very low (<5%) likelihood of severe OSA such that routine sleep studies prior to bariatric surgery could be omitted. Apnoea Hypoapnoea Index (AHI) showed improvement of 50% at 20 kg excess weight loss with the cure of OSA in preoperatively severe cases (P <0.005). Mild to moderate cases reported similar improvements although a direct correlation could not be established. Desaturation events, apnoea episodes, work of breathing and subjective assessment of sleepiness scores and quality of life (QOL) showed improving trends, albeit not statistically significant. Similar improvements were seen in sleep architecture with increased rapid eye movement (REM) and stage 3 sleep. Conclusions: The incidence of OSA in Asians undergoing bariatric surgery is high. Routine sleep studies in Asian patients are justified. Weight loss brought about a significant improvement in AHI and continuous positive airway pressure requirements. LAGB placement should be considered a broadly effective therapy for sleep apnoea in the severely obese patient.

Obstructive sleep apnea - management update

Obstructive sleep apnea (OSA) is a highly significant condition based both on the high prevalence in community and significant consequences. Obstructive sleep apnea syndrome (OSAS), OSA together with hypersomnolence, is seen in 4% of middle-aged men and 2% of middle-aged women. OSA is associated with impaired quality of life and increased risks of motor vehicle accidents, cardiovascular disease (including hypertension and coronary artery disease), and metabolic syndrome. There is some evidence for the use of conservative interventions such as weight loss and position modification. CPAP remains the mainstay of treatment in this condition with high-level evidence supporting its efficacy. Continuous positive airway pressure (CPAP) is an intrusive therapy, with long-term adherence rates of less than 70%. Dental appliances have been shown to be effective therapy in some subjects but are limited by the inability to predict treatment responders. Alternative treatments are discussed but there is little role for upper airway surgery (except in a select few experienced institutions) or pharmacological treatment. The current levels of evidence for the different treatment regimens are reviewed.

Polysomnography before and after weight loss in obese patients with severe sleep apnea

OBJECTIVE

While obstructive sleep apnea (OSA) is strongly related to obesity, few studies have examined polysomnographic (PSG) changes with major weight loss. We examined the effect of weight loss following laparoscopic adjustable gastric banding (LAGB) on the PSG changes in patients with severe OSA. In addition, we studied daytime sleepiness, the metabolic syndrome and quality of life (QOL).

METHODS

A prospective study was conducted of 25 severely obese patients (17 men, eight women) with paired diagnostic PSG, biochemical and questionnaire studies, the first prior to LAGB and the second at least 1 y later. Subjects with a baseline apnea-hypopnea index (AHI) >25/h were included.

RESULTS

Subject baseline age was 44.7 y, weight 154 kg and body mass index 52.7 kg/m(2). The second PSG study was conducted 17.7+/-10 (range 12-42) months after surgery and mean percentage of excess loss and weight loss were 50.1+/-15% (range 24-80%) and 44.9+/-22 kg (range 18-103 kg), respectively. There was a significant fall in AHI from 61.6+/-34 to 13.4+/-13, improved sleep architecture with increased REM and stage III and IV sleep, daytime sleepiness, as measured by Epworth Sleepiness Scale, of 13+/-7.0 to 3.8+/-3.0, and fewer patients requiring nasal continuous positive airways pressure (CPAP). There were also major improvements in the metabolic syndrome, QOL, body image and fewer symptoms of depression (P<0.05 for all).

CONCLUSION

Weight loss provides major improvement or resolution of OSA and CPAP requirements. It also reduces daytime sleepiness, and improves the metabolic syndrome and QOL. LAGB placement should be considered a broadly effective therapy for sleep apnea in the severely obese patient.