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Ravesloot MJL. Positional Treatment of Obstructive Sleep Apnea. Otolaryngol Clin North Am 2024; 57:481-490. [PMID: 38311472 DOI: 10.1016/j.otc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Positional sleep apnea (POSA), a distinctive subtype of obstructive sleep apnea, underscores the critical influence of a patient's sleeping position on the severity of their condition. In the management of POSA, compliance with positional therapy (PT) is paramount, as it wields a profound impact on the treatment's efficacy and the overall alleviation of the disease. The advent of new-generation PT devices offers a promising alternative to conventional methods like the tennis ball technique, boasting higher compliance rates and substantial disease alleviation.
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Öner Ö, Ecevit MC, Gökmen AN. The relationship between bi-spectral index and VOTE score in evaluation of drug-induced sleep endoscopy: A systematic meta-analysis. Medicine (Baltimore) 2023; 102:e35209. [PMID: 37747022 PMCID: PMC10519450 DOI: 10.1097/md.0000000000035209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/19/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate both the presence and severity of collapse in anatomical regions defined by the VOTE score (velum, orofarinx, tongue, and epiglottis), during drug induced sleep endoscopy (DISE) in patients diagnosed with obstructive sleep apnea, based on the bi-spectral index (BIS) sedation level. METHODS In order to conduct a meta-analysis of articles examining the relationship between the VOTE score and BIS sedation level in determining the presence and severity of upper airway collapse during DISE, a literature review was performed. RESULTS As a result of the search made in the specified databases, a total of 1864 articles were reached. Five articles included in this review that had sufficient statistical data to be included in the meta-analysis were found. A statistically significant correlation was found between the BIS sedation level and the areas of obstruction in the VOTE score. The strongest association is at the epiglottis level, followed by the velum, oropharynx, and tongue, respectively (CC: 0.639, CC: 0.53, CC: 0.49, and CC: 0.346, P < .001). In the subgroup analysis of publications with BIS sedation levels in the range of 60 to 65, the distribution in the epiglottis region was heterogeneous, and it was found to be statistically significant according to the random effect model (P < .001). The distribution in the tongue was homogeneous, and it was found to be statistically significant according to the fixed effect model (P < .001). When the publications in which the BIS sedation level is in the range of 65 to 75 are examined according to the areas of obstruction; the distribution in 4 anatomical regions was homogeneous and statistically significant according to the fixed effect model (P < .001). CONCLUSION It was found that BIS sedation levels during DISE application in obstructive sleep apnea patients were associated with obstruction of the anatomical regions of the upper airway. The strongest association was found at the epiglottis level, followed by the velum, oropharynx, and tongue, respectively. It is helpful to monitor the sedation level with BIS in order to better define the collapsed areas during DISE application. However, more studies are needed to better understand the relationship between BIS sedation values and sleep stages.
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Affiliation(s)
- Özlem Öner
- Faculty of Medicine, Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Mustafa Cenk Ecevit
- Faculty of Medicine, Department of Otorihinolaryngology, Dokuz Eylül University, Izmir, Turkey
| | - Ali Necati Gökmen
- Faculty of Medicine, Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, Izmir, Turkey
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Every JD, Mackay SG, Sideris AW, Do TQ, Jones A, Weaver EM. Mean disease alleviation between surgery and continuous positive airway pressure in matched adults with obstructive sleep apnea. Sleep 2023; 46:zsad176. [PMID: 37395677 DOI: 10.1093/sleep/zsad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
STUDY OBJECTIVES Polysomnography parameters measure treatment efficacy for obstructive sleep apnea (OSA), such as reduction in apnea-hypopnea index (AHI). However, for continuous positive airway pressure (CPAP) therapy, polysomnography measures do not factor in adherence and thus do not measure effectiveness. Mean disease alleviation (MDA) corrects polysomnography measures for CPAP adherence and was used to compare treatment effectiveness between CPAP and multilevel upper airway surgery. METHODS This retrospective cohort study consisted of a consecutive sample of 331 patients with OSA managed with multilevel airway surgery as second-line treatment (N = 97) or CPAP (N = 234). Therapeutic effectiveness (MDA as % change or as corrected change in AHI) was calculated as the product of therapeutic efficacy (% or absolute change in AHI) and adherence (% time on CPAP of average nightly sleep). Cardinality and propensity score matching was utilized to manage confounding variables. RESULTS Surgery patients achieved greater MDA % than CPAP users (67 ± 30% vs. 60 ± 28%, p = 0.04, difference 7 ± 3%, 95% confidence interval 4% to 14%) in an unmatched comparison, despite a lower therapeutic efficacy seen with surgery. Cardinality matching demonstrated comparable MDA % in surgery (64%) and CPAP (57%) groups (p = 0.14, difference 8 ± 5%, 95% confidence interval -18% to 3%). MDA measured as corrected change in AHI showed similar results. CONCLUSIONS In adult patients with OSA, multilevel upper airway surgery and CPAP provide comparable therapeutic effectiveness on polysomnography. For patients with inadequate CPAP use, surgery should be considered.
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Affiliation(s)
- James D Every
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Stuart G Mackay
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
- Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Anders W Sideris
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Timothy Q Do
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Andrew Jones
- Department of Respiratory Medicine, The Wollongong Hospital, Wollongong, NSW. Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Edward M Weaver
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
- Surgery Service, Seattle Veterans Affairs Medical Center, Seattle, Washington, USA
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Erturk N, Celik A, CalikKutukcu E. High- and low-intensity expiratory muscle strength training in patients with severe obstructive sleep apnea syndrome using non-invasive mechanical ventilation: A double-blinded, randomized controlled trial. Heart Lung 2023; 61:29-36. [PMID: 37087896 DOI: 10.1016/j.hrtlng.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The effects of expiratory muscle strength training (EMST) with different intensity on stages of sleep were not examined in patients with obstructive sleep apnea syndrome (OSAS). OBJECTIVES The aim of this study was to compare the effects of high- and low-intensity EMST (H-EMST and L-EMST) on disease severity, sleep stages, disease-related symptoms, daytime sleepiness, fatigue severity, and sleep quality in adult patients with severe OSAS using non-invasive mechanical ventilation (NIMV). METHODS Thirty-one clinically stable patients with severe OSAS were included in this prospective, randomized controlled, double-blinded study. These were randomly divided into two groups. The H-EMST group underwent training at 60% of maximum expiratory pressure (MEP) and the L-EMST group at 30% of MEP, seven days a week for eight weeks. Apnea hypopnea index (AHI), sleep stages, and respiratory sleep parameters were recorded using polysomnographic sleep analysis. RESULTS AHI decreased by 34.57% and 20.20% in the H-EMST and L-EMST groups, respectively. A statistically significant improvement in disease severity classifications distributions was observed in the H-EMST group after training (p = 0.016). A greater number of symptoms improved in the H-EMST. The effects of training on respiratory muscle strength, daytime sleepiness, fatigue perception, and sleep quality levels were comparable between the two groups (p>0.05). CONCLUSIONS H-EMST training is more effective in reducing disease severity and disease-related symptoms than L-EMST. Further studies are warranted for evaluating the long-term effects of EMST with larger sample sizes in OSAS.
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Affiliation(s)
- Nurel Erturk
- Cardiopulmonary Rehabilitation Unit, University of Health Sciences, Ahi Evren Thoracic and Cardiovascular Surgery Training and Research Hospital, Trabzon, Turkey.
| | - Adem Celik
- Department of Chest Medicine and Sleep Center, University of Health Sciences, Ahi Evren Thoracic and Cardiovascular Surgery Training and Research Hospital, Trabzon, Turkey
| | - Ebru CalikKutukcu
- Department of Cardiorespiratory Physiotherapy and Rehabilitation, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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Suurna MV, Jacobowitz O, Chang J, Koutsourelakis I, Smith D, Alkan U, D'Agostino M, Boon M, Heiser C, Hoff P, Huntley C, Kent D, Kominsky A, Lewis R, Maurer JT, Ravesloot M, Soose R, Steffen A, Weaver E, Williams AM, Woodson T, Yaremchuk K, Ishman SL. Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum. J Clin Sleep Med 2021; 17:2477-2487. [PMID: 34279214 DOI: 10.5664/jcsm.9542] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea (OSA). Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction (STAR) trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, OSA phenotypes, individual health status, psychological conditions and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This manuscript presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel.
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Affiliation(s)
- Maria V Suurna
- Division of Sleep Surgery, Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY
| | | | - Jolie Chang
- Division of Sleep Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA
| | | | - David Smith
- Divisions of Pediatric Otolaryngology, Pulmonary Medicine, and the Sleep Center; Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Otolaryngology - Head and Neck Surgery of University of Cincinnati College of Medicine, Cincinnati, OH
| | - Uri Alkan
- Department of Otorhinolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mark D'Agostino
- Southern New England Ear, Nose, Throat and Facial Plastic Surgery Group and Middlesex Hospital, Middletown, CT
| | - Maurits Boon
- Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universität München, Munich, Germany
| | - Paul Hoff
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI
| | - Colin Huntley
- Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital
| | - David Kent
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN
| | - Alan Kominsky
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH
| | - Richard Lewis
- Perth Head & Neck Surgery, Hollywood Medical Centre, Nedlands, Australia
| | - Joachim T Maurer
- Division of Sleep Medicine, Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Ryan Soose
- Division of Sleep Surgery, Department of Otolaryngology, Pittsburgh School of Medicine, UPMC Mercy, University of Pittsburgh, Pittsburgh, PA
| | - Armin Steffen
- Department of otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Edward Weaver
- Department of Otolaryngology-Head and Neck Surgery, University of Washington; Surgery Service, Seattle Veterans Affairs Medical Center; Harborview Medical Center, Seattle, WA
| | - Amy M Williams
- Department of Otolaryngology - Head & Neck Surgery of Henry Ford Health System, Detroit, MI
| | - Tucker Woodson
- Division of Sleep Medicine and Sleep Surgery, Department of Otolaryngology and Human Communication of Medical College of Wisconsin, Milwaukee, WI
| | - Kathleen Yaremchuk
- Department of Otolaryngology - Head & Neck Surgery of Henry Ford Health System, Detroit, MI
| | - Stacey L Ishman
- Divisions of Pediatric Otolaryngology, Pulmonary Medicine, and the Sleep Center; Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Otolaryngology - Head and Neck Surgery of University of Cincinnati College of Medicine, Cincinnati, OH
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Neruntarat C, Wanichakorntrakul P, Khuancharee K, Saengthong P, Tangngekkee M. Upper airway stimulation vs other upper airway surgical procedures for OSA: a meta-analysis. Sleep Breath 2021; 26:407-418. [PMID: 33999362 DOI: 10.1007/s11325-021-02402-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim was to compare the outcomes of upper airway stimulation (Stim) and other upper airway surgical procedures (Surg) in the treatment of obstructive sleep apnea (OSA). METHODS Data sources included PubMed, Ovid MEDLINE, Cochrane Library, Web of Science, Scopus, and reference lists. Relevant articles were identified from various databases according to the PRISMA guidelines. RESULTS Five articles with a total of 990 patients were included. The mean cure rates in the Stim group and the Surg group was 63% and 22%, and the mean success rates was 86% and 51% which were higher in the Stim group (p < 0.001). The apnea-hypopnea index reduction was -23.9 events/ hour (MD, 95% CI -25.53, -22.29) in the Stim group and -15.5 events/hour (MD, 95% CI -17.50, -13.45) in the Surg group which was greater in the Stim group (P < 0.001). Epworth Sleepiness Scale decreased -4.9 (MD, 95% CI -5.45, -4.32) in the Stim group and -5.1 (MD 95% CI -5.88, -4.37) in the Surg group without significant difference between the groups (P = 0.62). Oxygen saturation nadir improvement was 8.5% (MD 95% CI 7.05%, 9.92%) in the Stim group and 2.2% (MD 95% CI-0.22%, 4.58%) in the Surg group which was higher in the Stim group (P < 0.001). Hospital stay and readmission rate were lower in the Stim group. The timing of follow-up ranged from 2 to 13 months. CONCLUSION Upper airway stimulation provides improved objective and similar subjective outcomes compared to other upper airway surgical procedures for selected patients with moderate to severe OSA with difficulty adhering to CPAP treatment. However, further studies are essential to confirm outcomes in the long term.
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Affiliation(s)
- Chairat Neruntarat
- Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Sukhumvit 23, Watana, Bangkok, Thailand.
| | - Pisit Wanichakorntrakul
- Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Sukhumvit 23, Watana, Bangkok, Thailand
| | - Kitsarawut Khuancharee
- Department of Preventive and Social Medicine, Faculty of Medicine, Srinakharinwirot University, Sukhumvit 23, Watana, Bangkok, Thailand
| | - Petcharat Saengthong
- Department of Otorhinolaryngology Head and Neck Surgery, Police General Hospital, 492/1 Rama 1 Road, Patumwan, Bangkok, Thailand
| | - Mongkol Tangngekkee
- Department of Otolaryngology, Faculty of Medicine, Thammasat University, 99/209 Moo 2, Klong Luang, Rasit, Prathumthani, Thailand
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Kooij L, Vos PJ, Dijkstra A, Roovers EA, van Harten WH. Video Consultation as an Adequate Alternative to Face-to-Face Consultation in Continuous Positive Airway Pressure Use for Newly Diagnosed Patients With Obstructive Sleep Apnea: Randomized Controlled Trial. JMIR Form Res 2021; 5:e20779. [PMID: 33973866 PMCID: PMC8150406 DOI: 10.2196/20779] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/25/2020] [Accepted: 04/13/2021] [Indexed: 01/29/2023] Open
Abstract
Background The effectiveness of continuous positive airway pressure (CPAP) is dependent on the degree of use, so adherence is essential. Cognitive components (eg, self-efficacy) and support during treatment have been found to be important in CPAP use. Video consultation may be useful to support patients during treatment. So far, video consultation has rarely been evaluated in thorough controlled research, with only a limited number of outcomes assessed. Objective The aim of the study was to evaluate the superiority of video consultation over face-to-face consultation for patients with obstructive sleep apnea (OSA) on CPAP use (minutes per night), adherence, self-efficacy, risk outcomes, outcome expectancies, expectations and experiences with video consultation, and satisfaction of patients and nurses. Methods A randomized controlled trial was conducted with an intervention (video consultation) and a usual care group (face-to-face consultation). Patients with confirmed OSA (apnea-hypopnea index >15), requiring CPAP treatment, no history of CPAP treatment, having access to a tablet or smartphone, and proficient in the Dutch language were recruited from a large teaching hospital. CPAP use was monitored remotely, with short-term (weeks 1 to 4) and long-term (week 4, week 12, and week 24) assessments. Questionnaires were completed at baseline and after 4 weeks on self-efficacy, risk perception, outcome expectancies (Self-Efficacy Measure for Sleep Apnea), expectations and experiences with video consultation (covering constructs of the unified theory of acceptance and use of technology), and satisfaction. Nurse satisfaction was evaluated using questionnaires. Results A total of 140 patients were randomized (1:1 allocation). The use of video consultation for OSA patients does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. A significant difference in change over time was found between groups for short-term (P-interaction=.008) but not long-term (P-interaction=.68) CPAP use. CPAP use decreased in the long term (P=.008), but no significant difference was found between groups (P=.09). Change over time for adherence was not significantly different in the short term (P-interaction=.17) or long term (P-interaction=.51). A relation was found between CPAP use and self-efficacy (P=.001), regardless of the intervention arm (P=.25). No significant difference between groups was found for outcome expectancies (P=.64), self-efficacy (P=.41), and risk perception (P=.30). The experiences were positive, and 95% (60/63) intended to keep using video consultation. Patients in both groups rated the consultations on average with an 8.4. Overall, nurses (n=3) were satisfied with the video consultation system. Conclusions Support of OSA patients with video consultation does not lead to superior results on CPAP use and adherence compared with face-to-face consultation. The findings of this research suggest that self-efficacy is an important factor in improving CPAP use and that video consultation may be a feasible way to support patients starting CPAP. Future research should focus on blended care approaches in which self-efficacy receives greater emphasis. Trial Registration Clinicaltrials.gov NCT04563169; https://clinicaltrials.gov/show/NCT04563169
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Affiliation(s)
- Laura Kooij
- Rijnstate, Arnhem, Netherlands.,Department of Health Technology and Services Research, University of Twente, Enschede, Netherlands
| | - Petra Je Vos
- Pulmonary Department, Rijnstate, Arnhem, Netherlands
| | | | | | - Wim H van Harten
- Rijnstate, Arnhem, Netherlands.,Department of Health Technology and Services Research, University of Twente, Enschede, Netherlands.,Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
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Van Tassel J, Chio E, Silverman D, Nord RS, Platter D, Abidin MR. Hyoid Suspension With UPPP for the Treatment of Obstructive Sleep Apnea. EAR, NOSE & THROAT JOURNAL 2021; 102:NP212-NP219. [PMID: 33734881 DOI: 10.1177/01455613211001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This retrospective evaluation of surgical outcomes for hyomandibular suspension when performed with uvulopalatopharyngoplasty (UPPP) for the treatment of obstructive sleep apnea (OSA). Thirty-nine patients with moderate-to-severe OSA were treated with hyoid myotomy and suspension and uvulopalatopharyngoplasty. Patients underwent hyoid advancement and suspension to the mandible (Encore System) with either staged or concurrent UPPP. The primary outcome was a successful surgical result, defined as an apnea hypopnea index (AHI) lower than 20, and a 50% or greater decline in AHI on postoperative polysomnography. Successful surgical results were achieved in 30 (76.9%) out of 39 patients. The mean preoperative AHI improved 69.2% from 49.9 ± 25.6 to 15.4 ± 14.9 (P < .001) postoperatively. All patients reported clinical improvement of symptoms. There were 4 wound complications and one infection requiring removal of hardware. For patients with multilevel obstructive sleep apnea, hyoid advancement and suspension to the mandible appears efficacious when performed in conjunction with uvulopalatopharyngoplasty.
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Affiliation(s)
| | - Eugene Chio
- 12306Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Dustin Silverman
- 12306Ohio State University, Wexner Medical Center, Columbus, OH, USA
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Standardized framework to report on the role of sleeping position in sleep apnea patients. Sleep Breath 2021; 25:1717-1728. [PMID: 33426584 DOI: 10.1007/s11325-020-02255-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea. METHODS We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these 5 main recommendations. RESULTS In this paper, we present the rationale behind this construct and present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patients should be reported separately for PP and NPP. CONCLUSION Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.
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Xi J, Wang J, Si XA, Zheng S, Donepudi R, Dong H. Extracting signature responses from respiratory flows: Low-dimensional analyses on Direct Numerical Simulation-predicted wakes of a flapping uvula. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2020; 36:e3406. [PMID: 33070467 DOI: 10.1002/cnm.3406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/05/2020] [Accepted: 10/11/2020] [Indexed: 06/11/2023]
Abstract
Uvula-induced snoring and associated obstructive sleep apnea is a complex phenomenon characterized by vibrating structures and highly transient vortex dynamics. This study aimed to extract signature features of uvula wake flows of different pathological origins and develop a linear reduced-order surrogate model for flow control. Six airway models were developed with two uvula kinematics and three pharynx constriction levels. A direct numerical simulation (DNS) flow solver based on the immersed boundary method was utilized to resolve the wake flows induced by the flapping uvula. Key spatial and temporal responses of the flow to uvula kinematics and pharynx constriction were investigated using continuous wavelet transform (CWT), proper orthogonal decomposition (POD), and dynamic mode decomposition (DMD). Results showed highly complex patterns in flow topologies. CWT analysis revealed multiscale correlations in both time and space between the flapping uvular and wake flows. POD analysis successfully separated the flows among the six models by projecting the datasets in the vector space spanned by the first three eigenmodes. Perceivable differences were also captured in the time evolution of the DMD modes among the six models. A linear reduced-order surrogate model was constructed from the predominant eigenmodes obtained from the DMD analysis and predicted vortex patterns from this surrogate model agreed well with the corresponding DNS simulations. The computational and analytical platform presented in this study could bring a variety of applications in breathing-related disorders and beyond. The computational efficiency of surrogate modeling makes it well suited for flow control, forecasting, and uncertainty analyses.
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Affiliation(s)
- Jinxiang Xi
- Department of Biomedical Engineering, University of Massachusetts, Lowell, Massachusetts, USA
| | - Junshi Wang
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Xiuhua April Si
- Department of Aerospace, Industrial, and Mechanical Engineering, California Baptist University, Riverside, California, USA
| | - Shaokuan Zheng
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ramesh Donepudi
- Sleep and Neurodiagnostic Center, Lowell General Hospital, Lowell, Massachusetts, USA
| | - Haibo Dong
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, Virginia, USA
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Hong SO, Poomkonsarn S, Millesi G, Liu SYC. Upper airway stimulation as an alternative to maxillomandibular advancement for obstructive sleep apnoea in a patient with dentofacial deformity: case report with literature review. Int J Oral Maxillofac Surg 2019; 49:908-913. [PMID: 31870520 DOI: 10.1016/j.ijom.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnoea (OSA) is characterized by repeated upper airway collapse leading to oxygen desaturation resulting in cardiovascular and neurocognitive sequelae. Upper airway surgeries such as palatopharyngoplasty, tongue base surgery, and maxillomandibular advancement can improve patient tolerance of continuous positive airway pressure, quality of life, and the severity of OSA. Upper airway stimulation (UAS) of the hypoglossal nerve is a contemporary US Food and Drug Administration-approved treatment modality for OSA with a fundamentally different mechanism. We report the case of a 65-year-old male with a high body mass index, hypertension, diabetes, dentofacial deformity, and severe OSA. He presented with a respiratory distress index (RDI) of 89.1 events per hour, apnoea-hypopnoea index (AHI) of 82.7 events per hour, and minimum oxygen saturation of 75%. He chose to undergo UAS. Initially, complete concentric collapse of the velum was found during drug-induced sedation endoscopy, which was converted by palatopharyngoplasty to meet inclusion criteria for UAS. The patient achieved surgical cure with postoperative RDI and AHI of 2 events per hour with minimum oxygen saturation of 83%, and resolution of daytime somnolence. UAS is an effective surgical option to broaden the surgeon's ability to treat OSA, especially if facial skeletal surgery is contraindicated or declined by the patient with dentofacial deformity.
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Affiliation(s)
- S O Hong
- Department of Oral and Maxillofacial Surgery (Dentistry), International St. Mary's Hospital, Catholic Kwandong University, Incheon, South Korea
| | - S Poomkonsarn
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA; Center of Excellence in Otolaryngology Head and Neck Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - G Millesi
- Department of Craniomaxillofacial and Oral Surgery, University Hospital, Medical University of Vienna, Vienna, Austria
| | - S Y C Liu
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA.
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Wang J, Xi J, Han P, Wongwiset N, Pontius J, Dong H. Computational analysis of a flapping uvula on aerodynamics and pharyngeal wall collapsibility in sleep apnea. J Biomech 2019; 94:88-98. [DOI: 10.1016/j.jbiomech.2019.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 07/01/2019] [Accepted: 07/14/2019] [Indexed: 01/15/2023]
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Kumar AT, Vasconcellos A, Boon M, Huntley C. Inclusion of the first cervical nerve does not influence outcomes in upper airway stimulation for treatment of obstructive sleep apnea. Laryngoscope 2019; 130:E382-E385. [PMID: 31461160 DOI: 10.1002/lary.28256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/12/2019] [Accepted: 08/07/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Upper airway stimulation (UAS) has demonstrated efficacy in the management of obstructive sleep apnea (OSA). Branches of the hypoglossal nerve that selectively activate tongue protrusor and stiffener muscles are included within the stimulation cuff electrode. The first cervical nerve (C1) is often also included to stimulate additional muscles contributing to tongue protrusion and stabilization. The purpose of this study was to determine whether inclusion of the C1 translates into treatment efficacy, decreased voltage requirement, and improved outcomes in patients utilizing UAS. STUDY DESIGN Single-center, retrospective cohort study. METHODS One hundred fourteen patients who received a UAS implant at our institution and underwent posttreatment polysomnography were evaluated. Stimulation cuff electrodes in 87 patients included the C1; those in the remaining 27 patients did not include the C1. Demographic data, voltage data, and pre- and posttreatment apnea-hypopnea index (AHI), O2 nadir, and Epworth Sleepiness Scale (ESS) data were collected for all patients. RESULTS There was no significant difference in stimulation voltage, or posttreatment AHI, O2 nadir, and ESS between the two cohorts. Treatment success, as measured by posttreatment AHI < 20 with a 50% reduction, was similar regardless of C1 inclusion. The same was seen for the percent of patients with AHI < 15 and AHI < 5 after treatment. The distributions of age and body mass index, as well as pre-treatment AHI, O2 nadir, and ESS were also not significantly different between treatment groups. CONCLUSIONS The current study has demonstrated that inclusion of the C1 in the stimulation cuff electrode of the upper airway stimulator may not provide any additional benefit in therapy for OSA. LEVEL OF EVIDENCE 4 Laryngoscope, 130:E382-E385, 2020.
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Affiliation(s)
- Ayan T Kumar
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Adam Vasconcellos
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
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Schlafendoskopie und komplett konzentrischer Weichgaumenkollaps bei CPAP-Nutzungsproblemen. HNO 2018; 66:837-842. [DOI: 10.1007/s00106-018-0550-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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15
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Patient experience with upper airway stimulation in the treatment of obstructive sleep apnea. Sleep Breath 2018; 23:235-241. [PMID: 29956103 DOI: 10.1007/s11325-018-1689-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/02/2018] [Accepted: 06/19/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Selective upper airway stimulation (sUAS) is a new treatment modality for patients with obstructive sleep apnea (OSA) and continuous positive airway pressure (CPAP) failure. The aim of this study was to analyze therapy adherence and to structure patient experience reports. METHODS Patients from two German implantation centers were included. Besides demographic and OSA characteristics of that cohort, patients answered a questionnaire on subjective sensation of the stimulation, use of different functions, side effects, and an inventory for the description of the attitude towards sUAS. The use of the sUAS was evaluated as a read-out of the implanted system. RESULTS The overall apnea-hypopnea-index (AHI) of that 102 assessed patients reduced from initially 32.8/h to 12.6/h at the last available assessment. The responder rate was 75%. There was an objective therapy usage of 5.7 h and subjective reports of 6.8 nights per week. The attitude resulted in strong agreement towards the statement "UAS reduces the problems caused by my sleep apnea". Information on sensing the stimulation and usage habits could be gathered such as that stimulation is only sensed by 67.9% of the patients upon waking in the morning and that 73.6% of the patients do not change the voltage in general. CONCLUSION This investigation on the sUAS therapy revealed a high adherence to the therapy. The AHI or daytime sleepiness do not have obvious influence on adherence. Patients expressed a positive attitude towards sUAS. These patient reports upon stimulation experiences are of great help to consult candidates for sUAS in future.
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Stuck BA, Ravesloot MJL, Eschenhagen T, de Vet HCW, Sommer JU. Uvulopalatopharyngoplasty with or without tonsillectomy in the treatment of adult obstructive sleep apnea - A systematic review. Sleep Med 2018; 50:152-165. [PMID: 30056286 DOI: 10.1016/j.sleep.2018.05.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/23/2017] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND The most commonly performed surgical procedure for obstructive sleep apnea (OSA) is uvulopalatopharyngoplasty with or without tonsillectomy (UPPP ± TE). However, there is currently no review solely focusing on clinically relevant effects of standard UPPP technique with or without tonsillectomy as a monotherapy in patients with OSA. METHODS A systematic review and meta-analysis were performed to assess the effects of isolated UPPP ± TE in patients with OSA. Studies of any design referring to adult patients with obstructive sleep apnea diagnosed via polysomnography or comparable objective measures were considered, in which isolated "standard" UPPP ± TE was performed. RESULTS Forty-eight studies were included for the qualitative analysis. All but one study demonstrated a reduction in the frequency of respiratory events and success/response rates ranged from 35 to 95.2%. In the six studies that reported pre- and postoperative mean scores of the Epworth Sleepiness Scale (ESS), a reduction in sleepiness scores was demonstrated. Data addressing the effect of UPPP ± TE in comparison to no treatment or control were available from two randomized controlled trials (RCT). When pooling the data, UPPP ± TE was significantly more effective in reducing the apnea-hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) (large effect): an AHI mean difference (MD) of -18.59 (95% CI -34.14, -3.04) and an ESS MD of -5.37 (95% CI -7,03, -3.72). Data addressing effect of UPPP ± TE in comparison to baseline was available from three RCT. When pooling the data, the AHI was reduced from a mean 35.4 to 17.9 (49.5% reduction); a MD of -20.41, 95% CI -32.78, -8.04 (-1.80, -1.15) (large effect). Various additional beneficial effects of UPPP ± TE were demonstrated including improvement in sexual function, ventricular function, sleep stages, serum lipid, depressive disorder and driving performance. CONCLUSION UPPP ± TE reduces respiratory events and daytime sleepiness in adult patients with OSA and UPPP ± TE is superior to non-treated controls in this regard. Further research is needed to establish the long-term benefit, the impact on cardiovascular morbidity and the role of UPPP ± TE in the variety of available treatment options for OSA.
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Affiliation(s)
- Boris A Stuck
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Germany
| | - Madeline J L Ravesloot
- Department of Otorhinolaryngology, Head and Neck Surgery, OLVG, Amsterdam, The Netherlands.
| | - Till Eschenhagen
- Department of Otorhinolaryngology Head and Neck Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - H C W de Vet
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - J Ulrich Sommer
- Department of Otorhinolaryngology Head and Neck Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
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Devita M, Zangrossi A, Marvisi M, Merlo P, Rusconi ML, Mondini S. Global cognitive profile and different components of reaction times in obstructive sleep apnea syndrome: Effects of continuous positive airway pressure over time. Int J Psychophysiol 2018; 123:121-126. [DOI: 10.1016/j.ijpsycho.2017.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/12/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022]
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Dhaliwal SS, Hesabgar SM, Haddad SMH, Ladak H, Samani A, Rotenberg BW. Constructing a patient-specific computer model of the upper airway in sleep apnea patients. Laryngoscope 2017; 128:277-282. [DOI: 10.1002/lary.26834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 05/10/2017] [Accepted: 06/16/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Sandeep S. Dhaliwal
- Department of Otolaryngology-Head and Neck Surgery; Western University; London Ontario Canada
| | - Seyyed M. Hesabgar
- Department of Medical Biophysics; Western University; London Ontario Canada
| | | | - Hanif Ladak
- Department of Medical Biophysics; Western University; London Ontario Canada
| | - Abbas Samani
- Department of Medical Biophysics; Western University; London Ontario Canada
| | - Brian W. Rotenberg
- Department of Otolaryngology-Head and Neck Surgery; Western University; London Ontario Canada
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Benoist L, de Ruiter M, de Lange J, de Vries N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep Med 2017; 34:109-117. [PMID: 28522078 DOI: 10.1016/j.sleep.2017.01.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/19/2017] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the effectiveness of positional therapy (PT) with the sleep position trainer (SPT) to oral appliance therapy (OAT) in patients with mild-to-moderate positional obstructive sleep apnea (POSA). METHODS Multicenter, prospective, randomized, controlled trial. Patients with mild-to-moderate POSA (apnea-hypopnea index (AHI) ≥5 ≤ 30/hour sleep) were randomized for PT or OAT. Polysomnography was repeated after 3 months. Efficacy, adherence, mean disease alleviation (MDA), quality of life, dropouts and adverse events were evaluated. RESULTS A total of 177 patients were screened for the study; 99 underwent randomization and 81 completed the study. Intention-to-treat (ITT) analysis of median [IQR] AHI showed a reduction in the PT group from 13.0 [9.7-18.5] to 7.0 [3.8-12.8], p < 0.001 and in the OAT group from 11.7 [9.0-16.2] to 9.1 [4.9-11.7], p < 0.001. Mean adherence (≥4 h/night, ≥5 days/week) was 89.3 ± 22.4% for SPT versus 81.3 ± 30.0% in OAT patients, p = 0.208. CONCLUSIONS Oral appliance therapy and positional therapy were equally effective in reducing the median AHI in patients with mild-to-moderate POSA. The results of this study have important implications for future OSA treatment guidelines and daily clinical practice. CLINICALTRIALS. GOV NUMBER NCT02045576.
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Affiliation(s)
- Linda Benoist
- Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands; Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Maurits de Ruiter
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Oral Kinesiology, Amsterdam, The Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Oral Kinesiology, Amsterdam, The Netherlands
| | - Nico de Vries
- Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands; Department of Oral Kinesiology, Amsterdam, The Netherlands; Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
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Sommer UJ, Heiser C, Gahleitner C, Herr RM, Hörmann K, Maurer JT, Stuck BA. Tonsillectomy with Uvulopalatopharyngoplasty in Obstructive Sleep Apnea. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:1-8. [PMID: 26931522 DOI: 10.3238/arztebl.2016.0001] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a very common disorder (prevalence 2-7% in women, 7-14% in men). It impairs the quality of life and increases mortality. Conservative treatment with continuous positive airway pressure is highly effective, but patient compliance is variable. Surgical treatments are controversial, as only a few are supported by evidence from controlled clinical trials. METHODS Adult patients with OSA, CPAP intolerance, and oropharyngeal obstruction were included in the trial. All underwent polysomnography (PSG) and were randomly allotted to one of two groups. Patients in the treatment group underwent tonsillectomy with uvulopalatopharyngoplasty (TE-UPPP) within one month. All patients had a follow-up PSG at three months, and all PSGs were evaluated in blinded fashion. The primary outcome variable was the apneahypopnea index (AHI) as determined by PSG. Other outcome variables were subjective symptoms (daytime sleepiness, quality of life), complications, and patient satisfaction. RESULTS 42 patents were included in the trial (23 in the treatment group, 19 in the control group). The baseline AHI was 35.7 ± 19.4/hr in the control group and 33.7 ± 14.6/hr in the treatment group. The corresponding figures at 3 months were 28.6 ± 19.4/hr in the control group and 15.4 ± 14.1/hr in the treatment group (p = 0.036). The intervention also led to significant improvement in daytime sleepiness and in snoring, according to the patients' and their bed partners' assessment. 97% of the patients who underwent surgery were satisfied with the outcome. 65% of them needed no further treatment for OSA. CONCLUSION TE-UPPP significantly improved apnea/hypopnea, daytime sleepiness, and snoring compared to control (i.e., no) treatment. It is a safe and effective treatment for OSA..
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Affiliation(s)
- Ulrich J Sommer
- Department of Otorhinolaryngology, Head and Neck Surgery, Sleep Disorders Center, University Hospital Mannheim, Department of Otorhinolaryngology, University Hospital Klinikum rechts der Isar, Technische Universität München, Mannheim Institute of Public Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Essen University Hospital-Department of Otorhinolaryngology, Head and Neck Surgery
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Devita M, Montemurro S, Ramponi S, Marvisi M, Villani D, Raimondi MC, Rusconi ML, Mondini S. Obstructive sleep apnea and its controversial effects on cognition. J Clin Exp Neuropsychol 2016; 39:659-669. [PMID: 27845600 DOI: 10.1080/13803395.2016.1253668] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Obstructive sleep apnea syndrome is a sleep disorder that may affect many brain functions. We are interested in the cognitive consequences of the condition with regard to the quality of life of individuals with this disorder. A debate is still underway as to whether cognitive difficulties caused by obstructive sleep apnea actually induce a "pseudodementia" pattern. This work provides a brief overview of the main controversies currently surrounding this issue. We report findings and opinions on structural and cognitive brain changes in individuals affected by obstructive sleep apnea by highlighting the involvement of executive functions and the possible reversibility of signs following-treatment with continuous positive airway pressure. Much research has been done on this issue but, to the best of our knowledge, a review of the present state of the literature evaluating different points of view has not yet been carried out.
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Affiliation(s)
- Maria Devita
- a Department of Human and Social Sciences , University of Bergamo , Bergamo , Italy
| | - Sonia Montemurro
- b Department of General Psychology , University of Padua , Padua , Italy.,c Human Inspired Technology Research Centre , University of Padua , Padua , Italy
| | - Sara Ramponi
- d Internal Medicine Unit , Figlie di S. Camillo , Cremona , Italy
| | - Maurizio Marvisi
- d Internal Medicine Unit , Figlie di S. Camillo , Cremona , Italy.,e Department of Internal Medicine and Pneumology , University of Parma , Parma , Italy
| | - Daniele Villani
- f Neuromotor Rehabilitation Unit , Figlie di S. Camillo , Cremona , Italy
| | | | - Maria Luisa Rusconi
- a Department of Human and Social Sciences , University of Bergamo , Bergamo , Italy
| | - Sara Mondini
- b Department of General Psychology , University of Padua , Padua , Italy.,c Human Inspired Technology Research Centre , University of Padua , Padua , Italy
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Heiser C, Knopf A, Bas M, Gahleitner C, Hofauer B. Selective upper airway stimulation for obstructive sleep apnea: a single center clinical experience. Eur Arch Otorhinolaryngol 2016; 274:1727-1734. [PMID: 27619823 DOI: 10.1007/s00405-016-4297-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/06/2016] [Indexed: 02/03/2023]
Abstract
Selective upper airway stimulation (UAS) is a novel therapy for patients with obstructive sleep apnea (OSA). The aim of this study was to analyze the application and outcome of UAS in patients with moderate to severe OSA in the clinical routine of a tertiary referral center. The design of this study is single-center, prospective clinical trial. Thirty-one patients who received a UAS device (Inspire Medical Systems) were included. Treatment outcome was evaluated at 2, 3, 6, and 12 months after surgery. Data collection included demographics, body mass index (BMI), apnea hypopnea index (AHI), oxygen saturation and desaturation index (ODI), Epworth Sleepiness Score (ESS), adverse events, and adherence to therapy. Sher criteria were used to evaluate treatment response. The mean age was 59.6 years with thirty patients being male. Mean BMI was 28.8 kg/m2. The mean pre-implantation AHI of 32.9/h could be reduced to 7.1/h after 12 months (p < 0.001). The mean pre-implantation ODI of 30.7/h could be reduced to 9.9/h after 12 months (p = 0.004). The mean pre-implantation ESS of 12.6 could be reduced to 5.9 after 12 months (p = 0.006). Serious adverse events did not occur. Therapy adherence was a usage of 6.6 h/night after 12 months. OSA severity and subjective daytime sleepiness were improved in patients with moderate to severe OSA after receiving UAS therapy. Patients maintained high adherence to therapy use after 12 months. It is encouraging that UAS has been shown to be successfully implemented in the routine clinical management of OSA outside of a clinical trial setting.
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Affiliation(s)
- Clemens Heiser
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Andreas Knopf
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Murat Bas
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Constanze Gahleitner
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Benedikt Hofauer
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
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Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg 2016; 45:43. [PMID: 27542595 PMCID: PMC4992257 DOI: 10.1186/s40463-016-0156-0] [Citation(s) in RCA: 412] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/11/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common disorder, and continuous airway positive pressure (CPAP) is considered to be the gold standard of therapy. CPAP however is known to have problems with adherence, with many patients eventually abandoning the device. The purpose of this paper is to assess secular trends in CPAP adherence over the long term to see if there have been meaningful improvements in adherence in light of the multiple interventions proposed to do so. METHODS A comprehensive systematic literature review was conducted using the Medline-Ovid, Embase, and Pubmed databases, searching for data regarding CPAP adherence over a twenty year timeframe (1994-2015). Data was assessed for quality and then extracted. The main outcome measure was reported CPAP non-adherence. Secondary outcomes included changes in CPAP non-adherence when comparing short versus long-term, and changes in terms of behavioral counseling. RESULTS Eighty-two papers met study inclusion/exclusion criteria. The overall CPAP non-adherence rate based on a 7-h/night sleep time that was reported in studies conducted over the twenty year time frame was 34.1 %. There was no significant improvement over the time frame. Behavioral intervention improved adherence rates by ~1 h per night on average. CONCLUSIONS The rate of CPAP adherence remains persistently low over twenty years worth of reported data. No clinically significant improvement in CPAP adherence was seen even in recent years despite efforts toward behavioral intervention and patient coaching. This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.
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Affiliation(s)
- Brian W Rotenberg
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Dorian Murariu
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON, Canada
| | - Kenny P Pang
- Asia Sleep Centre, Paragon, 290, Orchard Road, Unit 18-04, Singapore, 238859, Singapore.
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Hofauer B, Strohl K, Knopf A, Bas M, Wirth M, Stock K, Heiser C. Sonographic evaluation of tongue motions during upper airway stimulation for obstructive sleep apnea-a pilot study. Sleep Breath 2016; 21:101-107. [PMID: 27411337 DOI: 10.1007/s11325-016-1383-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/02/2016] [Accepted: 07/07/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The objective was to evaluate the feasibility of sonographic evaluation of functional tongue motion as a tool to evaluate postoperative outcomes in human subjects using breathing-synchronized stimulation of the hypoglossal nerve-a novel therapy option for patients with obstructive sleep apnea (OSA). MATERIAL AND METHODS Sixteen patients with OSA (n = 16, age 60.4 ± 10.2, BMI 28.7 ± 2.4, AHI 35.0 ± 11.8) underwent sonographic evaluation of tongue motion after initiation of therapy with the Inspire II Upper Airway Stimulation system. Sonographic examination was performed in four different planes (A = floor of the mouth frontal, B = base of the tongue horizontal, C = floor of the mouth parallel to mandible, and D = floor of the mouth median sagittal) in an attempt to visualize tongue surface, tongue and hyoid motion, and the distance of protrusion. RESULTS Identification of the tongue surface was achieved in all cases in planes B, C, and D and 81 % of patients in plane A. Tongue motion was evident on the right (implant) side in 63 % in plane A and 75 % in plane B. Distance of protrusion was measured in plane B at 1.04 cm (±0.51), in plane C at 1.08 cm (±0.47), and in plane D at 0.96 cm (±0.45). Hyoid protrusion was measured in plane C or D and was 0.57 cm (±0.39). Significant correlations among the three planes were observed, but there was no correlation to the reduction of apnea-hypopnea index. CONCLUSION The results indicate feasibility of sonography to identify tongue and hyoid motions during upper airway stimulation. Useful sonographic planes and landmarks, which allow visualization of dynamic effects of upper airway stimulation, could be established. The evaluation of the tongue in a horizontal (B) and in a sagittal plane (D) appears to be superior to the other investigated planes. The approximate tongue protrusion needed to generate a significant reduction of AHI and ODI was 1 cm.
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Affiliation(s)
- Benedikt Hofauer
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Kingman Strohl
- Division of Pulmonary, Critical Care, and Sleep Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center and Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Andreas Knopf
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Murat Bas
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Markus Wirth
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Konrad Stock
- Nephrology/II. Medical Department, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Clemens Heiser
- Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
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Strohl M D KP, Baskin M D J, Lance M D C, Ponsky M D D, Weidenbecher M D M, Strohl B A M, Yamauchi M D M. Origins of and implementation concepts for upper airway stimulation therapy for obstructive sleep apnea. Respir Investig 2016; 54:241-9. [PMID: 27424823 DOI: 10.1016/j.resinv.2016.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 01/16/2016] [Accepted: 01/21/2016] [Indexed: 11/24/2022]
Abstract
Upper airway stimulation, specifically hypoglossal (CN XII) nerve stimulation, is a new, alternative therapy for patients with obstructive sleep apnea hypopnea syndrome who cannot tolerate positive airway pressure, the first-line therapy for symptomatic patients. Stimulation therapy addresses the cause of inadequate upper airway muscle activation for nasopharyngeal and oropharyngeal airway collapse during sleep. The purpose of this report is to outline the development of this first-in-class therapy and its clinical implementation. Another practical theme is assessment of the features for considering a surgically implanted device and the insight as to how both clinical and endoscopic criteria increase the likelihood of safe and durable outcomes for an implant and how to more generally plan for management of CPAP-intolerant patients. A third theme is the team building required among sleep medicine and surgical specialties in the provision of individualized neurostimulation therapy.
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Affiliation(s)
- Kingman P Strohl M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Jonathan Baskin M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Colleen Lance M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Diana Ponsky M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Mark Weidenbecher M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
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Kirkham EM, Heckbert SR, Weaver EM. Relationship between Clinical and Polysomnography Measures Corrected for CPAP Use. J Clin Sleep Med 2015; 11:1305-12. [PMID: 26194734 DOI: 10.5664/jcsm.5192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 05/22/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The changes in patient-reported measures of obstructive sleep apnea (OSA) burden are largely discordant with the change in apnea-hypopnea index (AHI) and other polysomnography measures before and after treatment. For patients treated with continuous positive airway pressure (CPAP), some investigators have theorized that this discordance is due in part to the variability in CPAP use. We aim to test the hypothesis that patient-reported outcomes of CPAP treatment have stronger correlations with AHI when it is corrected for mean nightly CPAP use. METHODS This was a cross-sectional study of 459 adults treated with CPAP for OSA. Five patient-reported measures of OSA burden were collected at baseline and after 6 months of CPAP therapy. The correlations between the change in each patient-reported measure and the change in AHI as well as mean nightly AHI (corrected for CPAP use with a weighted average formula) were measured after 6 months of treatment. The same analysis was repeated for 4 additional polysomnography measures, including apnea index, arousal index, lowest oxyhemoglobin saturation, and desaturation index. RESULTS The change in AHI was weakly but significantly correlated with change in 2 of the 5 clinical measures. The change in mean nightly AHI demonstrated statistically significant correlations with 4 out of 5 clinical measures, though each with coefficients less than 0.3. Similar results were seen for apnea index, arousal index, lowest oxyhemoglobin saturation, and desaturation index. CONCLUSIONS Correction for CPAP use yielded overall small but significant improvements in the correlations between patient-reported measures of sleep apnea burden and polysomnography measures after 6 months of treatment.
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Affiliation(s)
- Erin M Kirkham
- Department of Otolaryngology/Head & Neck Surgery, University of Washington, Seattle, Washington
| | - Susan R Heckbert
- Cardiovascular Health Research Unit, Department of Epidemiology, University of Washington, Seattle, WA
| | - Edward M Weaver
- Department of Otolaryngology/Head & Neck Surgery, University of Washington, Seattle, Washington.,Surgery Service, Department of Veterans Affairs Medical Center, Seattle, Washington
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Com G, Carroll JL, Tang X, Melguizo MS, Bower C, Jambhekar S. Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea. J Clin Sleep Med 2015; 11:467-74. [PMID: 25665695 PMCID: PMC4365461 DOI: 10.5664/jcsm.4608] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/17/2014] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVES To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA). METHODS At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Presurgery and postsurgery OPSG indices were compared. We defined cure as an apneahypopnea index (AHI) < 1.5/h on the postsurgery OPSG, and we compared the cure rates of different surgeries. RESULTS A total of 143 children, median age 12.4 y (interquartile range [IQR] 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 y [IQR 9-15]) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT + turbinate trim ± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor. CONCLUSIONS Surgery improved OPSG indices in the majority of obese children with OSA.
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Affiliation(s)
- Gulnur Com
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, University of Arkansas Medical Sciences, Little Rock, AR
| | - John L. Carroll
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, University of Arkansas Medical Sciences, Little Rock, AR
| | - Xinyu Tang
- Department of Pediatrics, Biostatistics Program, University of Arkansas Medical Sciences, Little Rock, AR
| | - Maria S. Melguizo
- Department of Pediatrics, Biostatistics Program, University of Arkansas Medical Sciences, Little Rock, AR
| | - Charles Bower
- Department of Otolaryngology, University of Arkansas Medical Sciences, Little Rock, AR
| | - Supriya Jambhekar
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, University of Arkansas Medical Sciences, Little Rock, AR
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Bianchi MT, Alameddine Y, Mojica J. Apnea burden: efficacy versus effectiveness in patients using positive airway pressure. Sleep Med 2014; 15:1579-81. [PMID: 25441743 DOI: 10.1016/j.sleep.2014.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/29/2014] [Accepted: 07/05/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Modern continuous positive airway pressure (PAP) machines track hours of use and residual respiratory events while on treatment. A substantial portion of sleep apnea patients are partially compliant, emphasizing the need to distinguish between PAP efficacy and PAP effectiveness in chronic management of patients with sleep apnea. METHODS We used a combination of three data sources to estimate the sleep apnea burden in a convenience cohort of PAP users from our clinics that were compliant based on Medicare criteria: self-reported habitual total sleep time, and PAP usage times with residual apnea-hypopnea index (AHI) from compliance downloads. RESULTS Assuming that the off-PAP time consists of baseline AHI severity, an estimated apnea burden was calculated to estimate PAP effectiveness. Whereas 70% of patients in our cohort showed machine AHI values <5/h, the apnea burden calculations revealed that only one-third of patients are predicted to have an effective AHI <5. CONCLUSION Estimating PAP effectiveness through the concept of apnea burden has implications for clinical care as well as research trials.
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Affiliation(s)
- Matt T Bianchi
- Neurology Department, Massachusetts General Hospital, Boston, USA; Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - James Mojica
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
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Safiruddin F, Vanderveken OM, de Vries N, Maurer JT, Lee K, Ni Q, Strohl KP. Effect of upper-airway stimulation for obstructive sleep apnoea on airway dimensions. Eur Respir J 2014; 45:129-38. [PMID: 25186270 DOI: 10.1183/09031936.00059414] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Upper-airway stimulation (UAS) using a unilateral implantable neurostimulator for the hypoglossal nerve is an effective therapy for obstructive sleep apnoea patients with continuous positive airway pressure intolerance. This study evaluated stimulation effects on retropalatal and retrolingual dimensions during drug-induced sedation compared with wakefulness to assess mechanistic relationships in response to UAS. Patients with an implanted stimulator underwent nasal video endoscopy while awake and/or during drug-induced sedation in the supine position. The cross-sectional area, anterior-posterior and lateral dimensions of the retropalatal and retrolingual regions were measured during baseline and stimulation. 15 patients underwent endoscopy while awake and 12 underwent drug-induced sedation endoscopy. Increased levels of stimulation were associated with increased area of both the retropalatal and retrolingual regions. During wakefulness, a therapeutic level of stimulation increased the retropalatal area by 56.4% (p=0.002) and retrolingual area by 184.1% (p=0.006). During stimulation, the retropalatal area enlarged in the anterior-posterior dimension while retrolingual area enlarged in both anterior-posterior and lateral dimensions. During drug-induced sedation endoscopy, the same stimulation increased the retropalatal area by 180.0% (p=0.002) and retrolingual area by 130.1% (p=0.008). Therapy responders had larger retropalatal enlargement with stimulation than nonresponders. UAS increases both the retropalatal and retrolingual areas. This multilevel enlargement may explain reductions of the apnoea-hypopnoea index in selected patients receiving this therapy.
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Affiliation(s)
| | - Olivier M Vanderveken
- Dept of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Nico de Vries
- Sint Lucas Andreas Hospital, Amsterdam, The Netherlands Dept of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Kent Lee
- Inspire Medical Systems, Maple Grove, MN, USA
| | - Quan Ni
- Inspire Medical Systems, Maple Grove, MN, USA
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Rotenberg BW, Theriault J, Gottesman S. Redefining the timing of surgery for obstructive sleep apnea in anatomically favorable patients. Laryngoscope 2014; 124 Suppl 4:S1-9. [PMID: 24737140 DOI: 10.1002/lary.24720] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/09/2014] [Accepted: 04/11/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Healthcare remunerating agencies in North America require patients with obstructive sleep apnea (OSA) to undergo a continuous positive airway pressure (CPAP) trial before funding surgical therapy. The adherence rate of CPAP is problematic. This study's objective was to determine the proportion of surgically favorable patients who failed CPAP who subsequently benefitted from surgical therapy, and to explore consideration of surgical therapy as first-line treatment in this specific OSA subpopulation. STUDY DESIGN This was a prospective cohort study. METHODS Patients with moderate-severe OSA who had failed a minimum 6-month trial of CPAP were recruited. All had optimal anatomy for surgery and underwent tonsillectomy with palatoplasty ± septoplasty. Outcome measures included apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and Sleep Apnea Quality of Life Index (SAQLI-E), and blood pressure. Patients were followed for 1 year. RESULTS By AHI measurement, 85.7% of patients in the entire cohort were successfully treated by surgery. ESS while on CPAP was 13.7 ± 2.9, improving to 4.1 ± 2.5 after surgery. SAQLI-E scores on CPAP were 25.7 ± 5.8, improving to 10.2 ± 3.2 after surgery. Blood pressure remained elevated during CPAP but normalized after surgery. All changes were significant at P < .001. CONCLUSIONS Surgical intervention improved OSA severity as measured by the ESS, SAQLI-E, and blood pressure. These measures had not improved on CPAP. AHI improved as well. Our results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence and with only minor surgical risk. LEVEL OF EVIDENCE 2 Laryngoscope 124:S1-S9, 2014.
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Affiliation(s)
- Brian W Rotenberg
- Department of Otolaryngology-Head and Neck Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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De Vito A, Carrasco Llatas M, Vanni A, Bosi M, Braghiroli A, Campanini A, de Vries N, Hamans E, Hohenhorst W, Kotecha BT, Maurer J, Montevecchi F, Piccin O, Sorrenti G, Vanderveken OM, Vicini C. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 2014; 18:453-65. [PMID: 24859484 DOI: 10.1007/s11325-014-0989-6] [Citation(s) in RCA: 193] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 04/04/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting. METHODS The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique. RESULTS A proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system. CONCLUSIONS Although consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.
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Affiliation(s)
- Andrea De Vito
- Special Surgery Department, Ear-Nose-Throat Unit, Morgagni-Pierantoni Hospital, Via Forlanini 34, 47121, Forlì, Italy
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Crawford MR, Espie CA, Bartlett DJ, Grunstein RR. Integrating psychology and medicine in CPAP adherence – New concepts? Sleep Med Rev 2014; 18:123-39. [DOI: 10.1016/j.smrv.2013.03.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 12/11/2022]
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Pang KP, Rotenberg BW. Redefining successful therapy in obstructive sleep apnea: A call to arms. Laryngoscope 2014; 124:1051-2. [DOI: 10.1002/lary.24628] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/20/2014] [Accepted: 01/28/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Kenny P. Pang
- Medical Director, Asia Sleep Centre, Paragon Medical Centre; Singapore
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Dieltjens M, Braem MJ, Vroegop AVMT, Wouters K, Verbraecken JA, De Backer WA, Van de Heyning PH, Vanderveken OM. Objectively measured vs self-reported compliance during oral appliance therapy for sleep-disordered breathing. Chest 2014; 144:1495-1502. [PMID: 23928873 DOI: 10.1378/chest.13-0613] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Assessment of the overall therapeutic effectiveness of oral appliance therapy can only be realized through objectively measured compliance. The aims of this study were to assess objectively measured compliance during oral appliance therapy at 1-year follow-up and to compare these data with self-reported use. METHODS Fifty-one eligible patients were enrolled in this 1-year prospective clinical study (men, 61%; mean age, 49 ± 10 years; apnea-hypopnea index, 18.0 ± 11.9 events/h sleep; BMI, 26.6 ± 4.1 kg/m²). Objective compliance during oral appliance therapy at 1-year follow-up was assessed with a microsensor thermometer. Subjective compliance was assessed by self-report. Patients with a mean objectively measured use of ≥ 4 h/night on 70% of nights monitored were considered regular users. The mean disease alleviation was calculated as a measure of overall therapeutic effectiveness. RESULTS High agreement between objective and subjective compliance data at 1-year follow-up was reported (intraclass correlation coefficient, 0.8; 95% CI, 0.5-0.9), showing a mean subjective overestimation of 30 min (95% CI, -3.1 to 1.9; P = .02). The discontinuation rate at 1-year follow-up was 9.8%. The objective mean use rate was 6.4 ± 1.7 h/night at 1-year follow-up in continuing users, with a regular use rate of 83%. The mean disease alleviation was 54.9%. CONCLUSIONS This study is the first to our knowledge to report the 1-year results of objectively measured compliance during oral appliance therapy. In addition, a high agreement between objective and subjective compliance data were reported, with a mean subjective overestimation of 30 min. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01284881; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Marijke Dieltjens
- Department of Special Care Dentistry, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Marc J Braem
- Department of Special Care Dentistry, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Anneclaire V M T Vroegop
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Kristien Wouters
- Department of Scientific Coordination and Biostatistics, Antwerp University Hospital, Edegem
| | - Johan A Verbraecken
- Department of Pneumology, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Wilfried A De Backer
- Department of Pneumology, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Paul H Van de Heyning
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Olivier M Vanderveken
- Department of Otolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem; Multidisciplinary Sleep Disorders Center, Antwerp University Hospital, Edegem; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Scarlata S, Antonelli-Incalzi R. Comment on Grimaldi et al. Association of obstructive sleep apnea in rapid eye movement sleep with reduced glycemic control in type 2 diabetes: therapeutic implications. Diabetes Care 2014;37:355-363. Diabetes Care 2014; 37:e59. [PMID: 24558088 DOI: 10.2337/dc13-2429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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5-years APAP adherence in OSA patients--do first impressions matter? Respir Med 2013; 107:2046-52. [PMID: 24169074 DOI: 10.1016/j.rmed.2013.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although continuous positive airway pressure (CPAP) is effective in treating obstructive sleep apnoea (OSA), inadequate adherence remains a major cause of treatment failure. This study aimed to determine long term adherence to auto adjusting-CPAP (APAP) and its influencing factors including the role of initial compliance. METHODS Eighty-eight male patients with newly diagnosed moderate/severe OSA were included. After initiation of APAP treatment, patients had periodic follow-up appointments at 2 weeks, 6 months and then annually for at least 5 years. Patient's compliance to therapy was assessed in each appointment and predictors to treatment abandonment and poor compliance were evaluated. RESULTS The studied population had a mean age of 53.8 years and mean apnoea-hypopnoea index of 52.71/h. The mean time of follow-up was 5.2 (± 1.6) years, during that time 22 (25%) patients abandoned APAP, those who maintained treatment had good compliance to it since 94% of them used it more than 4 h/day for at least 70% of days. A significant negative association was found between age, % of days and mean time of APAP use on 12th day and 6th month and the risk of abandoning. APAP use lower than 33% and 57% of days at 12th day and 6th month, respectively had high specificity (≈ 100%) to detect treatment abandonment. CONCLUSIONS the majority of patients adheres to long term APAP treatment and has good compliance after 5-years of follow-up. Age and initial compliance (% days of use and mean hour/day) have the ability to predict future adherence, as soon as 12 days and 6 months after initiation.
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Ravesloot MJL, Vries N, Stuck BA. Treatment adherence should be taken into account when reporting treatment outcomes in obstructive sleep apnea. Laryngoscope 2013; 124:344-5. [DOI: 10.1002/lary.24302] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 06/19/2013] [Accepted: 06/19/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Madeline J. L. Ravesloot
- Department of Otolaryngology/Head and Neck SurgerySt. Lucas Andreas HospitalAmsterdam the Netherlands
| | - Nico Vries
- Department of Otolaryngology/Head and Neck SurgerySt. Lucas Andreas HospitalAmsterdam the Netherlands
| | - Boris A. Stuck
- Department of Otolaryngology/Head and Neck SurgeryUniversity Hospital MannheimMannheim Germany
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Handler E, Hamans E, Goldberg AN, Mickelson S. Tongue suspension: an evidence-based review and comparison to hypopharyngeal surgery for OSA. Laryngoscope 2013; 124:329-36. [PMID: 23729234 DOI: 10.1002/lary.24187] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/27/2013] [Accepted: 04/15/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Our first objective was to perform a systematic review of suture-based tongue suspension procedures as a stand-alone therapy for hypopharyngeal obstruction in obstructive sleep apnea (OSA). A second objective compared outcomes of tongue suspension as part of a multilevel approach to OSA surgery to genioglossus advancement (GA) with uvulopalatopharyngoplasty (UPPP), and to genioglossus advancement with hyoid suspension (GAHM) with UPPP. STUDY DESIGN Systematic review. METHODS The PubMed database was queried for English-language studies published after 1997 to create four cohorts: tongue suspension alone, tongue suspension with UPPP, GA + UPPP, and GAHM with UPPP. Chi-squared test was used to compare outcomes between cohorts. RESULTS Twenty-seven studies were included, broken down into cohorts based on our selection criteria. Six studies qualified for the tongue suspension-alone group with a surgical success rate of 36.6%. Eight studies qualified for our cohort of tongue suspension with UPPP with a surgical success rate of 62.3%. Eighteen studies qualified for our remaining two cohorts: GA + UPPP, and GAHM + UPPP. Their surgical success rates were both 61.1%. A chi-squared test to compare surgical outcomes showed that there was no difference between tongue suspension with UPPP, GA + UPPP, and GAHM + UPPP. CONCLUSION Tongue suspension is effective and safe as part of a multilevel surgical approach for patients with OSA. As a stand-alone procedure, its success rate is 36.6%, comparable to UPPP procedures for OSA success rates across the board. Tongue suspension should be considered in patients with OSA who demonstrate tongue base obstruction.
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Affiliation(s)
- Ethan Handler
- Department of Head and Neck Surgery, Kaiser Permanente, Oakland, California, U.S.A
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Functional short- and long-term effects of nasal CPAP with and without humidification on the ciliary function of the nasal respiratory epithelium. Sleep Breath 2013; 18:85-93. [PMID: 23657665 DOI: 10.1007/s11325-013-0853-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 04/15/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Continuous positive airway pressure (CPAP) is the gold standard in the treatment of obstructive sleep apnea (OSA), but its impact on ciliary function is unclear to date. Furthermore, CPAP is associated with numerous side effects related to the nose and upper airway. Humidified CPAP is used to relieve these symptoms, but again, little is known regarding its effect on ciliary function of the nasal respiratory epithelium. METHODS In this prospective, randomized, crossover trial, 31 patients with OSA (AHI >15/h) were randomized to two treatment arms: nasal continuous positive airway pressure (nCPAP) with humidification or nCPAP without humidification for one night in each modality to assess short-term effects of ciliary beat frequency (CBF) and mucus transport time (MTT) and consecutively for 8 weeks in each modality to assess long-term effects in a crossover fashion. RESULTS The baseline CBF was 4.8 ± 0.6 Hz, and baseline MTT was 540 ± 221 s. After one night of CPAP with and without humidification, ciliary function increased moderately yet with statistical significance (p <0.05). The short-term groups with and without humidification did not differ statistically significant. Regarding long-term effects of CPAP, a statistically significant increase in ciliary function above the baseline level and above the short-term level was shown without humidification (7.2 ± 0.4 Hz; 402 ± 176 s; p <0.01). The increase above baseline level was even more pronounced with humidification (9.3 ± 0.7 Hz; 313 ± 95 s; p <0.01). There was a statistically significant difference between both groups at long-term assessment with regard to CBF (p <0.01). CONCLUSIONS Independent of airway humidification, nCPAP has moderate effects on short-term ciliary function of the nasal respiratory epithelium. However, a significant increase in ciliary function-both in terms of an increased CBF and a decreased MTT-was detected after long-term use. The effect was more pronounced when humidification was used during nCPAP.
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Effectiveness of a group education session on adherence with APAP in obstructive sleep apnea—a randomized controlled study. Sleep Breath 2012. [DOI: 10.1007/s11325-012-0789-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Boyd SB, Walters AS. Effectiveness of treatment apnea-hypopnea index: a mathematical estimate of the true apnea-hypopnea index in the home setting. J Oral Maxillofac Surg 2012; 71:351-7. [PMID: 22771095 DOI: 10.1016/j.joms.2012.05.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 04/19/2012] [Accepted: 05/02/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To present a new measurement instrument, the Effectiveness of Treatment Apnea-Hypopnea Index (ET-AHI), which the authors developed to determine an estimate of the therapeutic control of obstructive sleep apnea (OSA). MATERIALS AND METHODS The authors retrospectively evaluated a cohort of patients with OSA who initially attempted to use continuous positive airway pressure (CPAP) therapy and subsequently underwent maxillomandibular advancement (MMA) surgery. The ET-AHI calculations were performed to estimate the level of CPAP adherence that would be necessary to achieve equivalence with the MMA surgical result and to reach effective AHIs of 5 and 15. RESULTS The sample was composed of 37 adult patients (mean age, 44.2 ± 9.0 yr; 73% men) with moderate to severe OSA (baseline AHI, 56.3 ± 22.6). CPAP therapy was highly efficacious (CPAP titration AHI, 4.3 ± 5.9), but no patient could adequately adhere to treatment. MMA produced a significant decrease in OSA (AHI after MMA, 11.6 ± 7.4). The ET-AHI calculations predicted that an 86% adherence rate with CPAP would be necessary to achieve equivalence with MMA, whereas adherence rates of 99% and 79% may be required to achieve effective AHIs of 5 and 15, respectively. CONCLUSIONS The ET-AHI has the potential to significantly affect the care of patients with OSA because it may provide the treating clinician with a valuable tool to estimate the control of OSA for any therapeutic intervention. How closely the ET-AHI predicts the true effective AHI in the home setting requires further validation.
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Affiliation(s)
- Scott B Boyd
- Department of Oral and Maxillofacial Surgery, Vanderbilt University School of Medicine, Nashville, TN 37232-2103, USA.
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Maurer JT, Sommer JU, Hein G, Hörmann K, Heiser C, Stuck BA. Palatal implants in the treatment of obstructive sleep apnea: a randomised, placebo-controlled single-centre trial. Eur Arch Otorhinolaryngol 2012; 269:1851-6. [PMID: 22228439 DOI: 10.1007/s00405-011-1920-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 12/29/2011] [Indexed: 01/19/2023]
Abstract
Palatal implants have been used to treat snoring and mild to moderate obstructive sleep apnea (OSA). Two previous controlled trials have published conflicting results regarding the effects of palatal implants on objective outcome measures, although they both could demonstrate superiority over placebo. The aim of the present study was to assess the effects of palatal implants in patients with mild to moderate sleep apnea in a randomised, placebo-controlled trial. Twenty-two patients with mild to moderate OSA (AHI 18 ± 5, BMI 28 ± 3, age 51 ± 13 years) due to palatal obstruction were enrolled in this randomised, double-blind, placebo-controlled trial. Respiratory parameters and sleep efficiency (evaluated by polysomnography), snoring (evaluated by the bed partner), and daytime sleepiness (evaluated by ESS) were assessed before and 90 days after surgery. One patient in each group did not show up for follow-up. The AHI, HI and LSAT showed statistically significant improvement in the treatment group (p < 0.05). Snoring as rated by bed partners also showed statistically significant improvement within the treatment group (p = 0.025). There was no statistical difference when comparing the means of the treatment group with the placebo group. There were no peri- or post-operative complications and no extrusions during the follow-up period. The study supports the idea that palatal implants lead to a reduction in respiratory events in patients with mild to moderate OSA, although a statistically significant superiority of palatal implants over placebo could not be demonstrated in this trial.
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Affiliation(s)
- J T Maurer
- Department of Otorhinolaryngology, Head and Neck Surgery, Sleep Disorders Centre, University Hospital Mannheim, 68135 Mannheim, Germany
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