The influence of multilevel upper airway surgery on CPAP tolerance in non-responders to obstructive sleep apnea surgery

Anatomic Features of the Nasal and Pharyngeal Region Do Not Influence PAP Therapy Response

The objective of this study was to investigate to which extent anatomic features of the nasal and pharyngeal region contribute to the severity of obstructive sleep apnea (OSA) and positive airway pressure (PAP) therapy response. Therefore, 93 patients (mean age 57.5 ± 13.0 years, mean body mass index 32.2 ± 5.80 kg/m2, 75 males, 18 females) diagnosed with OSA who subsequently started PAP therapy were randomly selected from the databank of a sleep laboratory of a tertiary university medical center. Patients were subdivided based on nasal anatomy (septal deviation, turbinate hyperplasia, their combination, or none of the above), pharyngeal anatomy (webbing, tonsillar hyperplasia, their combination, or none of the above), and (as a separate group) tongue base anatomy (no tongue base hyperplasia or tongue base hyperplasia). Then, polysomnographic data (e.g., arousal index, ARI; respiratory disturbance index, RDI; apnea index, AI; hypopnea index, HI; and oxygen desaturation index, ODI) of diagnostic polysomnography (PSG) and PAP therapy control PSG were collected, grouped, and evaluated. Septal deviation, turbinate hyperplasia, or their combination did not significantly affect the assessed PSG parameters or the response to PAP therapy compared with patients without nasal obstruction (p > 0.05 for all parameters). Accordingly, most PSG parameters and the response to PAP therapy were not significantly affected by webbing, tonsil hyperplasia, or their combination compared with patients without pharyngeal obstruction (p > 0.05 for RDI, AI, HI, and ODI, respectively). However, in the pharyngeal anatomy group, ARI was significantly higher in patients with tonsil hyperplasia (p = 0.018). Further, patients with tongue base hyperplasia showed a significantly higher HI in the diagnostic PSG (p = 0.025) compared with patients with normal tongue base anatomy, but tongue base anatomy did not significantly affect the response to PAP therapy (p > 0.05 for all parameters). The influence of anatomic features of the nasal and pharyngeal region on PAP therapy response appears to be small, and generalizability of these results requires further studies.

The clinical influence of nasal surgery on PAP compliance and optimal application among OSA subjects uncomfortable with PAP device wear

This study aimed to evaluate the alteration of PAP compliance after nasal surgery and to determine the optimal indications of nasal surgery in obstructive sleep apnea (OSA) subjects. Among OSA subjects using PAP devices, 29 subjects who underwent septoturbinoplasty due to nasal obstruction were included and their pre- and postoperative medical and PAP records were reviewed retrospectively. Postoperative autoPAP usage data was further assessed by grouping the compliance (the percentage of days with usage ≥ 4 h) data (group 1: the good compliance group; group 2: the poor compliance group). The data showed that 56% of subjects in group 1 complained of nasal obstruction as the only barrier to using a PAP device and about 89% reported experiencing the efficacy of PAP usage. Both the mean and peak average PAP pressures were significantly reduced in group 1 following nasal surgery. Group 2 had multiple subjective problems that interfered with wearing a PAP device and reported a lack of experiencing the efficacy of PAP usage. Preoperative nasal cavity volume values were smaller and absolute blood eosinophil counts were significantly lower in group 1. The current data demonstrate that nasal surgery might increase the compliance of PAP device wear in OSA subjects who complained of only nasal obstruction as a barrier to wearing PAP and who had small nasal cavity volumes combined with allergic inflammation.

The Effect of Pharyngeal Surgery on Positive Airway Pressure Therapy in Obstructive Sleep Apnea: A Meta-Analysis

There is controversy about the effect of pharyngeal surgery for obstructive sleep apnea (OSA) on positive airway pressure (PAP) adherence, and the related results of meta-analysis have not yet been available. Therefore, the purpose of this meta-analysis was to assess the effect of pharyngeal OSA surgery on PAP therapy parameters such as optimal pressure levels and usage time. We selected studies investigating optimal PAP levels or usage time before and after pharyngeal OSA surgery, regardless of the study design. Pharyngeal OSA surgery included uvulopalatopharyngoplasty and its variants, tonsillectomy, Pillar implants, radiofrequency ablation, tongue base surgery and its variants, and genioglossus advancement. Studies in which isolated nasal surgery was performed were excluded. The random-effects model was used due to significant heterogeneity among the studies. Nine studies were included in the meta-analysis of optimal PAP levels, and five studies in the meta-analysis of PAP usage time. After pharyngeal OSA surgery, the summed optimal PAP level was significantly decreased (standardized mean difference (SMD), -1.113; 95% confidence interval (CI), -1.667 to -0.559)), and the summed usage time of PAP was significantly increased (SMD, 0.794; 95% CI, 0.259 to 1.329). This study illustrated that pharyngeal OSA surgery lowered optimal PAP levels and enhanced PAP usage time. The results of the meta-analysis contribute to our understanding of the role of pharyngeal OSA surgery in patients with PAP intolerance.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

ATS Core Curriculum 2021. Adult Sleep Medicine: Sleep Apnea

The American Thoracic Society Sleep Core Curriculum updates clinicians on important sleep topics, presented during the annual meeting, and appearing in summary here. This year’s sleep core theme is sleep-disordered breathing and its management. Topics range from pathophysiological mechanisms for the association of obstructive sleep apnea (OSA) and metabolic syndrome, surgical modalities of OSA treatment, comorbid insomnia and OSA, central sleep apnea, and sleep practices during a pandemic. OSA has been associated with metabolic syndrome, independent of the role of obesity, and the pathophysiology suggests a role for sleep fragmentation and intermittent hypoxia in observed metabolic outcomes. In specific patient populations, surgical treatment modalities for OSA have demonstrated large reductions in objective disease severity compared with no treatment and may facilitate adherence to positive airway pressure treatment. Patient-centered approaches to comorbid insomnia and sleep apnea include evaluating for both OSA and insomnia simultaneously and using shared-decision making to determine the order and timing of positive airway pressure therapy and cognitive behavioral therapy for insomnia. The pathophysiology of central sleep apnea is complex and may be due to the loss of drive to breathe or instability in the regulatory pathways that control ventilation. Pandemic-era sleep practices have evolved rapidly to balance safety and sustainability of care for patients with sleep-disordered breathing.

Endorsement of: "treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of Sleep Medicine Clinical Practice Guideline" by World Sleep Society

Guidelines for the evaluation and management of sleep disorders from national societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society's (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Taskforce reviewed the American Academy of Sleep Medicine's Clinical Practice Guideline on the Treatment of Adult Obstructive Sleep Apnea (OSA) with Positive Airway Pressure with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. To improve the evaluation of the guideline, surveys were sent by the senior author and the WSS to approximately 800 sleep doctors around the world to query the availability of OSA treatments in their respective region. The task force and the WSS guidelines committee endorsed the AASM's CPAP guidelines with respect to the indications for PAP therapy, utilization of different PAP modalities, and concurrent strategies to improve outcomes, noting appropriate caveats for universal applicability.

Impact of upper airway configuration on CPAP titration assessed by CT during Müller's maneuver in OSA patients

PURPOSE

Continuous positive airway pressure (CPAP) is the current gold-standard treatment for moderate to severe obstructive sleep apnea (OSA), and upper airway anatomy plays an increasingly important role in evaluating the efficacy of CPAP therapy. The aim of this observational study was to investigate the influence of upper airway anatomy on CPAP titration in OSA patients assessed by computed tomography (CT) during Müller's maneuver.

METHODS

Consecutive patients under investigation for OSA by undergoing polysomnography and CT scan of the upper airway while awake were enrolled. Successful full-night manual titration was performed to determine the optimal CPAP pressure level for OSA patients in supine position using a nasal mask.

RESULTS

A total of 157 subjects (134 males and 23 females) were included. Both apnea-hypopnea index (AHI) and LaSO2 significantly correlated with CPAP titration level, upper airway length (UAL), distance from mandibular plane to hyoid bone (MPH), and neck circumference (all p < 0.05). There were significant positive correlations between CPAP titration level and UAL (r = 0.348, p = 0.000) and MPH (r = 0.313, p = 0.002). Stepwise multiple linear regression analyses were performed to evaluate the independent predictors of AHI, LaSO2, and CPAP titration level. CPAP titration level was identified as an independent explanatory variable for AHI and LaSO2 after adjustment for confounders. Multiple linear regression analyses also indicated that body mass index (BMI) and UAL were independently associated with CPAP titration level (all p < 0.05).

CONCLUSIONS

Upper airway abnormalities combined with anthropometric parameters play important roles in CPAP titration for OSA patients, providing additional insight into the factors influencing OSA treatment strategies. UAL and BMI should be taken into consideration when choosing CPAP titration level to improve CPAP compliance.

Upper airway surgery to rescue the "untitratable" patient with OSA and obesity

None

This is a case report of an 41-year-old male with obesity (body mass index 90 kg/m²), severe obstructive sleep apnea (OSA), and an apnea-hypopnea index of 90 events/h despite high bilevel positive airway pressure (BPAP). He presented to the PAP Alternatives Clinic and underwent tonsillectomy, expansion sphincter pharyngoplasty, and partial uvulectomy to improve positive airway pressure effectiveness. Postoperative BPAP retitration resolved the patient's OSA. The patient is currently using BPAP therapy at home with improvement in both objective and self-reported OSA outcomes.

Intrapharyngeal surgery with integrated treatment for obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disease in adults, which influences human relations, quality of life and associates with major complications. Continuous positive airway pressure (CPAP) is the gold standard treatment modality in OSA patients. For patients incompliant or unwilling to CPAP therapy, surgery is an alternative treatment. Sleep surgery for OSA include intrapharyngeal surgery, extrapharyngeal surgery and bariatric surgery addressing upper airway soft tissue, maxillofacial bone, and obesity, respectively. Among sleep surgeries, intrapharyngeal surgery (soft tissue surgery) is widespread used and serves overwhelming majority in OSA surgical patients. Despite the popularity of intrapharyngeal surgery, its outcomes can be influenced by multiple factors and consequently need conjunctive remedy to enhance at the short-term and sustain in the long-term. In this article, we introduce updated indications for treating OSA, practical principle in decision-making between CPAP and surgery, hybrid procedures in treating obstruction at the nose, palate, tongue and epiglottis, and postoperative integrated treatment including oropharyngeal myofunctional therapy (local), positional therapy (regional), and body weight reduction (systemic), and circadian rhythm (central). In summary, intrapharyngeal surgery is a target-oriented procedure that needs to be performed precisely and combines with integrated treatment as a holistic care for OSA patients.

Combined Surgical Approach for Obstructive Sleep Apnea Patient

Obstructive sleep apnea (OSA) is a disease that is associated with high morbidity and mortality and can significantly impact the quality of life in a patient. OSA is strongly associated with obesity, and literature showed that weight loss will lead to improvement in OSA. The gold standard treatment for OSA is continuous positive airway pressure (CPAP). However, other methods of treatment are available. One of these methods is multilevel sleep surgery (MLS). Literature showed that bariatric surgery can also improve OSA. A common question is which surgical procedure of these two should be performed first. We present a 5-year follow-up of a patient who underwent simultaneously bariatric surgery and MLS. His apnea-hypopnea index (AHI) decreased from 53 episodes per hour to 5.2 per hour within the first 18 months, which was measured via a level 3 polysomnography. Five years after the surgery, a repeat level 3 polysomnography showed an AHI of 6.8 episodes per hour, and the patient is asymptomatic. The patient maintained his weight and did not use CPAP after the combined surgery during the five-year period.