Management of simple snoring, upper airway resistance syndrome, and moderate sleep apnea syndrome

Integrating the precision, sleep, and aerospace medicine fields: a systematic review of the genetic predisposition for obstructive sleep apnea in military aviation

PURPOSE

Obstructive sleep apnea (OSA) is the most common pathologic sleep disorder with an estimated prevalence in the USA of up to 25% of adult males. With military aviation being heavily comprised of adult men, the impact of OSA on flying operations is concerning as OSA is disqualifying for all flying classes in the US Air Force. In order to minimize the impact of OSA on operations, early identification of at-risk patients is critical in disease management. Individuals could be identified for whom regular polysomnography testing may reveal OSA while mild or sub-clinical, at which point treatment may be initiated in order to promote continued medical qualification for duty and career retention.

METHODS

We performed a keyword search of PubMed, EMBASE, and Google Scholar along with searches in the NHGRI/EBI GWAS Catalogue and the Atlas of GWAS Summary Statistics. We included primary research from candidate gene, GWAS, and meta-analyses. We also included other review articles in our search to confirm interpretations and implications of any genetic associations with OSA. Only studies related to OSA susceptibility or risk were included.

RESULTS

We identified 134 publications reporting or reviewing genetic associations with OSA risk. These papers reported 301 variants, of which 195 were unique and 33 were replicated in at least two papers. With respect to the strength of association, 43 variants exhibited odds ratios greater than 2. Finally, there were 84 null results reported, 51 of which were in conflict with reported associations.

CONCLUSION

There is ample evidence in the literature to confirm that genetics provide an important contribution to OSA development. The high number of strongly associated variants suggests that a polygenic risk model could be created with high predictive value for prognostic screening.

Effect of Modified Uvulopalatopharyngoplasty without Tonsillectomy on Obstructive Sleep Apnea: Polysomnographic Outcome and Correlation with Drug-Induced Sleep Endoscopy

OBJECTIVE

Uvulopalatopharyngoplasty (UPPP) is a common procedure for the treatment of obstructive sleep apnea (OSA) and is usually initiated with the resection of palatine tonsils. Because tonsillectomy potentially contributes to complications, minimally invasive upper airway surgeries have been proposed for OSA therapy. Whether tonsillectomy is always essential for UPPP remains unclear, particularly for patients with small tonsils. The purpose of this study was to present the effect of modified UPPP without tonsillectomy (UPsT) on patients with OSA and attempt to select the candidates for this procedure.

METHODS

This is a retrospective cohort study of patients with OSA, with tonsil size of grade 0-2, and with only retropalatal obstruction in drug-induced sleep endoscopy (DISE). The patients underwent UPsT at a tertiary center from November 2017 to December 2019. The sleep study was performed before and at least 3 months after surgery. The demographics, surgical outcomes, and staging patterns of preoperative DISE were recorded. The correlation between surgical outcome and DISE was also established.

RESULTS

A total of 22 adults with an average age of 46.5 years [interquartile range: 40 to 60 years] completed the follow-up study. Their apnea-hypopnea index (AHI) and Epworth sleepiness scale values improved significantly after surgery. Of the 17 patients with partial collapse and complete anteroposterior collapse (APC) at the velum, 16 presented good responses to UPsT. However, among the five patients with complete concentric collapse (CCC), only two (2/5, 40%) satisfied the criteria for surgical success. Furthermore, their follow-up AHI values were significantly higher than those of patients without CCC in DISE.

CONCLUSION

UPsT was demonstrated to be an effective therapy for patients with OSA who had small tonsils and retropalatal obstruction in DISE. CCC in sleep endoscopy indicates a poorer surgical outcome than does complete APC and partial collapse at the velum.

Prevalence and clinical impact of snoring in older community-dwelling adults

AIM

The prevalence and clinical impact of snoring in the independent older adult population is unknown. To address this, we carried out this cross-sectional epidemiological study of community-dwelling independent older adults.

METHODS

The study data were collected by the Japan Gerontological Evaluation Study 2013, a postal survey distributed to a large cohort of independent community-dwelling older adults (aged ≥65 years) in 2013, across 30 municipalities of 14 prefectures. We used data for 24 837 participants (13 135 women, mean age 73.5 years, and 11 702 men, mean age 73.3 years). The association of snoring with airway symptoms and history of hypertension, diabetes and heart disease were investigated using Poisson regression models.

RESULTS

The prevalence ratio (95% confidence intervals) for wheezing according to snoring frequency in men was 1.87 (1.45-2.43) among those who snored on 1-6 nights a week, and 2.95 (2.15-4.05) among those who snored every night. Similar relationships were observed for women. Expectoration, another airway symptom, was also associated with snoring frequency. Furthermore, snoring frequency was associated with a higher prevalence of hypertension, diabetes and heart disease. Both diabetes and heart disease were associated with snoring frequency in women independent of body mass index, but the association was only observed in men with a normal or lower body mass index.

CONCLUSIONS

Snoring is a highly prevalent and pathogenic symptom in adults aged ≥65 years. Geriatr Gerontol Int 2019; 19: 1165-1171.

Treatment of upper airway resistance syndrome in adults: Where do we stand?

OBJECTIVE

To evaluate the available literature regarding Upper Airway Resistance Syndrome (UARS) treatment.

METHODS

Keywords "Upper Airway Resistance Syndrome," "Sleep-related Breathing Disorder treatment," "Obstructive Sleep Apnea treatment" and "flow limitation and sleep" were used in main databases.

RESULTS

We found 27 articles describing UARS treatment. Nasal continuous positive airway pressure (CPAP) has been the mainstay therapy prescribed but with limited effectiveness. Studies about surgical treatments had methodological limitations. Oral appliances seem to be effective but their efficacy is not yet established.

CONCLUSION

Randomized controlled trials with larger numbers of patients and long-term follow-up are important to establish UARS treatment options.

Successful treatment of upper airway resistance syndrome with an oral appliance

This case report is the first description of the treatment response to an oral appliance (OA) in a patient with upper airway resistance syndrome (UARS). OAs are devices inserted into the mouth in order to modify the position of the mandible and tongue, thus relieving pharyngeal obstruction during sleep in obstructive sleep apnea (OSA) patients. Findings from this case report suggest that an OA may be a useful treatment option for UARS patients.

Drug therapy for obstructive sleep apnoea in adults

BACKGROUND

The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) applied via a mask during sleep. However, this is not tolerated by all individuals and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of rapid eye movement (REM) sleep, an increase in cholinergic tone during sleep, an increase in arousal threshold, a reduction in airway resistance and a reduction in surface tension in the upper airway.

OBJECTIVES

To determine the efficacy of drug therapies in the specific treatment of sleep apnoea.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2012.

SELECTION CRITERIA

Randomised, placebo controlled trials involving adult patients with confirmed OSA. We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. We excluded studies investigating treatment of associated conditions such as excessive sleepiness, hypertension, gastro-oesophageal reflux disease and obesity.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by The Cochrane Collaboration.

MAIN RESULTS

Thirty trials of 25 drugs, involving 516 participants, contributed data to the review. Drugs had several different proposed modes of action and the results were grouped accordingly in the review. Each of the studies stated that the participants had OSA but diagnostic criteria were not always explicit and it was possible that some patients with central apnoeas may have been recruited.Acetazolamide, eszopiclone, naltrexone, nasal lubricant (phosphocholinamine) and physiostigmine were administered for one to two nights only. Donepezil in patients with and without Alzheimer's disease, fluticasone in patients with allergic rhinitis, combinations of ondansetrone and fluoxetine and paroxetine were trials of one to three months duration, however most of the studies were small and had methodological limitations. The overall quality of the available evidence was low.The primary outcomes for the systematic review were the apnoea hypopnoea index (AHI) and the level of sleepiness associated with OSA, estimated by the Epworth Sleepiness Scale (ESS). AHI was reported in 25 studies and of these 10 showed statistically significant reductions in AHI.Fluticasone in patients with allergic rhinitis was well tolerated and reduced the severity of sleep apnoea compared with placebo (AHI 23.3 versus 30.3; P < 0.05) and improved subjective daytime alertness. Excessive sleepiness was reported to be altered in four studies, however the only clinically and statistically significant change in ESS of -2.9 (SD 2.9; P = 0.04) along with a small but statistically significant reduction in AHI of -9.4 (SD 17.2; P = 0.03) was seen in patients without Alzheimer's disease receiving donepezil for one month. In 23 patients with mild to moderate Alzheimer's disease donepezil led to a significant reduction in AHI (donepezil 20 (SD 15) to 9.9 (SD 11.5) versus placebo 23.2 (SD 26.4) to 22.9 (SD 28.8); P = 0.035) after three months of treatment but no reduction in sleepiness was reported. High dose combined treatment with ondansetron 24 mg and fluoxetine 10 mg showed a 40.5% decrease in AHI from the baseline at treatment day 28. Paroxetine was shown to reduce AHI compared to placebo (-6.10 events/hour; 95% CI -11.00 to -1.20) but failed to improve daytime symptoms.Promising results from the preliminary mirtazapine study failed to be reproduced in the two more recent multicentre trials and, moreover, the use of mirtazapine was associated with significant weight gain and sleepiness. Few data were presented on the long-term tolerability of any of the compounds used.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcomes. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24% and 45%. For donepezil and fluticasone, studies of longer duration with a larger population and better matching of groups are required to establish whether the change in AHI and impact on daytime symptoms are reproducible. Individual patients had more complete responses to particular drugs. It is possible that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.

Initial indication of treatment in 60 patients with sleep obstructive ventilatory disturbance

Aim

The author present a retrospective descriptive study of 60 patients with sleep obstructive ventilatory disturbance who have taken medical advice at the Centro Campinas de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço during a period of three years. All the patients have been examined after standardized protocol and decisions related to the treatment have been taken after systematic multidisciplinary discussion.

Study design

clinical retrospective.

Material and method

The patients were distributed into two groups according to the proposal of surgical and non-surgical treatment. After so, they were studied according to the model of treatment proposed and the main propaedeutic findings: respiratory disturbance index (RDI), body mass index (BMI), cephalometric analysis and Müller maneuver. The main features were compared - isolated or in association - with the model of treatment proposed.

Conclusion

Amongst several conclusions obtained, the most important were: surgical and non-surgical treatment were indicated almost in the same proportion for of snoring; surgical treatments were most indicated for snoring and Apnoea-Hipopnoea Syndrome, despite of its modality; RDI, BMI and cephalometric analysis and Müller maneuver had no influence at any therapeutic modality; the therapeutic decision was taken after standardized protocol and systematic multidisciplinary discussion, where each case was discussed individually.

Drug therapy for obstructive sleep apnoea in adults

BACKGROUND

The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) via a mask during sleep. However this is not tolerated by all patients and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of REM sleep, an increase in cholinergic tone during sleep, a reduction in airway resistance and a reduction in surface tension in the upper airway.

OBJECTIVES

To determine the efficacy of drug therapies in the treatment of sleep apnoea.

SEARCH STRATEGY

We carried out searches on the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2005.

SELECTION CRITERIA

Randomised, placebo controlled trials involving adult patients with confirmed OSA . We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. No restriction was placed upon publication language or trial duration.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, undertook data extraction according to pre-specified entry criteria, and quality assessment of studies. No response for further information was forthcoming from study authors. Results were expressed as mean differences and 95% Confidence Intervals (CI).

MAIN RESULTS

Twenty-six trials of 21 drugs, involving 394 participants contributed data to the review. Most of the studies were small and many trials had methodological limitations. Each of the studies states that the subjects had OSA but diagnostic criteria were not always explicit and it is possible that some patients with central apnoeas may have been recruited. Six drugs had some impact on OSA severity and two altered daytime symptoms. One study reported that apnoea hypopnea index (AHI) was lower following treatment with intranasal fluticasone compared with placebo (23.3 versus 30.3) in 24 participants with sleep apnoea and rhinitis. Subjective alertness in the daytime also improved. Physostigmine gave an AHI of 41 compared to 54 on placebo (10 participants) and in a similar study Mirtazipine 15 mg produced an AHI of 13 compared to 23.7 for placebo (10 participants). Topical nasal lubricant given twice overnight resulted in an AHI of 14 compared to 24 with placebo (10 participants). These three latter studies were of single night crossover design and so there are no data on the acceptability of these treatments or their effect on symptoms. Paroxetine was shown to reduce AHI to 23.3 compared to 30.3 for placebo, most of the 20 participants tolerated the treatment but there was no improvement in daytime symptoms. Acetazolamide also reduced the AHI (one crossover trial of nine patients, mean difference 24 (95% CI 4 to 44). However there was no symptomatic benefit from the drug and it was poorly tolerated in the long term. Protriptyline led to a symptomatic improvement (improved versus not improved) in two out of three crossover trials (13 participants, Peto Odds Ratio 29.2 (95% CI 2.8 to 301.1) but there was no change in the apnoea frequency. In one trial naltrexone did reduce AHI, but total sleep time favoured placebo. No significant beneficial effects were found for medroxy progesterone, clonidine, mibefradil, cilazapril, buspirone, aminophylline, theophylline doxapram, ondansetron or sabeluzole.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcome. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24 and 45%. For fluticasone, mirtazipine, physostigmine and nasal lubricant, studies of longer duration are required to establish whether this has an impact on daytime symptoms. Individual patients had more complete responses to particular drugs. It is likely that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.

The effect of a mandibular advancement splint in subjects with sleep-related breathing disorders

OBJECTIVE

This study assessed the effectiveness of a mandibular advancement splint (MAS) in subjects with sleep-related breathing disorders using both objective and subjective outcome measures.

DESIGN

The study was carried out as a retrospective analysis.

SETTING

The study was conducted within the Sleep Studies Unit at the Queen Victoria Hospital, East Grinstead, between May 1997 and March 2000.

SUBJECTS AND METHODS

Twenty subjects with obstructive sleep apnoea (OSA) and six with non-apnoeic snoring, diagnosed by overnight polysomnography, were fitted with a monobloc appliance between May 1997 and March 2000.

MAIN OUTCOME MEASURES

The subjects were analysed for changes in the respiratory disturbance index (RDI) and Epworth Sleepiness Scale (ESS) scores. In addition each subject completed an outcome questionnaire following fitting of the appliance.

RESULTS

Variability in response measured by the change in the respiratory disturbance index was found with no correlation to the baseline recording. Although median RDI values improved in both groups, significantly so in the obstructive sleep apnoea group (p<0.05), seven subjects exhibited an increased RDI score following mandibular advancement splint therapy. The median Epworth Sleepiness Scale scores decreased in both the OSA group and the non-apnoeic snorers although not significantly. Twenty-one of the 26 subjects completed the outcome questionnaire revealing an 81% reduction in snoring. Side-effects were generally transient and minor. Eighty-six per cent of the subjects' partners reported better quality of sleep as a result of MAS therapy.

CONCLUSIONS

The monobloc appliance significantly improved the Respiratory Disturbance Index in the obstructive sleep apnoea group. Some subjects had increased RDI scores following splint therapy. This supports the need for an objective assessment in the follow-up of patients treated with mandibular advancement splints.

Condutas terapêuticas para tratamento da Síndrome da Apnéia e Hipopnéia Obstrutiva do Sono (SAHOS) e da Síndrome da Resistência das Vias Aéreas Superiores (SRVAS) com enfoque no Aparelho Anti-Ronco (AAR-ITO)

Os autores apresentam uma revisão da literatura referente às alternativas de tratamento cirúrgicas e não-cirúrgicas para a Síndrome da Apnéia e Hipopnéia Obstrutiva do Sono (SAHOS) e para a Síndrome da Resistência das Vias Aéreas superiores (SRVAS) com enfoque no princípio de ação e evolução dos aparelhos de avanço mandibular e, em particular, no mecanismo dinâmico de ação do Aparelho Anti-Ronco® (AAR-ITO).

Improvement in Daytime Sleepiness by the Use of an Oral Appliance in a Patient with Upper Airway Resistance Syndrome

This case report details the treatment outcome of an oral appliance (OA) used in a patient suffering from excessive daytime sleepiness (EDS) caused by an upper airway resistance syndrome (UARS). The patient demonstrated significant improvement in the multiple sleep latency test (MSLT) and the maintenance of wakefulness test (MWT) after treatment with an OA. The presented case suggests that an OA may be considered as a further treatment option for UARS.

Drug treatments for obstructive sleep apnoea

BACKGROUND

The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airway pressure (CPAP) via a mask during sleep. However this is not tolerated by all patients and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea. The mechanisms by which drugs might reduce OSA include; a reduction in the proportion of rapid eye movement (REM) sleep (during which apnoeas tend to be more frequent), an increase in ventilatory drive or an increase in upper airway muscle tone during sleep.

OBJECTIVES

To determine the efficacy of drug therapies in the treatment of sleep apnoea.

SEARCH STRATEGY

Searches were carried out on the Cochrane Airways Group RCT Register. Additional hand searching was performed as relevant.

SELECTION CRITERIA

Double blind, randomised placebo controlled trials were included, involving patients with confirmed obstructive sleep apnoea. Trials were excluded if continuous positive airways pressure, mandibular devices or oxygen therapy were used. No restriction was placed upon publication language or trial duration.

DATA COLLECTION AND ANALYSIS

A total of 51 references were identified by electronic searches. 42 studies were retrieved for selection and 9 trials were included in the review. The results for 91 patients were available. No response for further information was forthcoming from the study authors. Results were expressed as (WMD) and 95% Confidence Intervals (95% CI) MAIN RESULTS: Only acetazolamide reduced the Hypopnoea Index (1 crossover trial of 9 patients, Weighted Mean Difference -24; 95%Confidence Intervals (95% CI): -4, -44). However there was no symptomatic response and the drug was poorly tolerated. Protriptyline led to a symptomatic improvement (improved vs not improved) in two out of three crossover trials (13 patients, Peto Odds Ratio 29.2; 95%CI 2.8, 301.1) but there was no change in the apnoea frequency. No beneficial effects were found for medroxy progesterone, clonidine, buspirone, aminophylline, theophylline or sabeluzole.

REVIEWER'S CONCLUSIONS

The data available do not support the use of drugs as a therapy for OSA. Although the studies examined had limitations there was little to justify further trials of these particular drugs.

Detection of upper airway resistance syndrome using a nasal cannula/pressure transducer

STUDY OBJECTIVES

To determine the diagnostic utility of a nasal cannula/pressure transducer (NC), in comparison to thermistor (TH), during routine, clinical nocturnal polysomnography (NPSG).

DESIGN

We analyzed the respiratory arousal index (RAI) using TH (RAI-TH) or NC (RAI-NC) in patients with suspected sleep-disordered breathing (SDB).

SETTING

Sleep disorders center of a university-affiliated teaching hospital.

PATIENTS

Fifty consecutive, nonselected patients referred for evaluation of suspected SDB.

MEASUREMENTS AND RESULTS

Twenty patients were found to have obstructive sleep apnea/hypopnea syndrome (OSA), 25 had upper airway resistance syndrome (UARS), and 5 had primary snoring (PS). Mean RAI-NC was greater than the mean RAI-TH by 25%, 302%, and 500% in OSA, UARS, and PS, respectively. RAI-NC was >/= 14 (mean, 25.2) in UARS and < 14 (mean, 9) in PS. Mean RAI-TH was 8.4 in UARS and 1.8 in PS, with significant overlap between the two groups.

CONCLUSIONS

NC is more sensitive than TH in detecting respiratory events during NPSG and may represent a simple, objective means to identify UARS among patients with a range of SDB.

Pediatric sleep-related breathing disorders

Sleep-related breathing disorders (SRBD) can occur at any age. Obstructive sleep apnea, upper airway resistance syndrome and obstructive hypopnea syndrome all lie on the pathological continuum of SRBD. These disorders can have a great impact on a child's quality of life and can progress to significant complications. The symptoms, signs, work-up, and treatment of SRBD in children are discussed.

The upper airway resistance syndrome

The upper airway resistance syndrome (UARS) is a recently described form of sleep-disordered breathing in which repetitive increases in resistance to airflow within the upper airway lead to brief arousals and daytime somnolence. This review will first describe the chronological progression of our understanding of UARS within the broader context of sleep-disordered breathing. The primary symptom, daytime somnolence, appears to result directly from repetitive EEG arousals. The level of negative intrathoracic pressure is the most likely stimulus for arousal, possibly mediated by mechanoreceptors in the upper airway. A general consensus regarding the exact clinical definitions and the physiologic measurement techniques leading to a diagnosis does not exist, although esophageal manometry and pneumotachographic airflow measurements taken during polysomnography are the "gold standard." Less invasive diagnostic modalities have been proposed, but none of them have been well-validated. Aside from daytime somnolence, hypertension is an important sequela of this disorder, likely resulting from autonomic and cardiovascular changes induced by increased negative intrathoracic pressure. Nasal continuous positive airway pressure is the most efficacious form of therapy, although low patient compliance may limit its practical application. The safety and efficacy of surgical treatments are poorly documented in the literature. Palatal tissue reduction by radiofrequency ablation and the use of oral appliances hold promise as safe and effective modalities, but these treatments require further study.

Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep apnea

LEARNING OBJECTIVES

The purpose of this review is to highlight fundamental aspects of obstructive sleep apnea (OSA), and to present an overview of the medical literature that pertains to the clinical interplay between various allergy-related disorders, nasal patency, and OSA. This should enable the reader to play a more proactive role in the diagnosis, management, and prevention of OSA.

DATA SOURCES

Relevant reviews, texts, and articles. The MEDLINE database was used to find related literature.

CONCLUSIONS

In predisposed individuals, OSA, sleep fragmentation, and the sequelae of disturbed sleep often result from nasal obstruction. Since breathing through the nose appears to be the preferred route during sleep, nasal obstruction frequently leads to nocturnal mouth breathing, snoring, and ultimately to OSA. Allergists can thus play a vital role in assessing sleep problems in their patients with allergic rhinitis and other upper respiratory disorders, in treating these problems more aggressively, and in some instances, in preventing them.