Treatment of obstructive sleep apnea, other than with continuous positive airway pressure

Evaluation of the Ocular Surface and Meibomian Gland in Obstructive Sleep Apnea Hypopnea Syndrome

Purpose

To assess the ocular surface and meibomian gland (MG) of patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and to explore the effects of surgery for OSAHS on the ocular surface and MG.

Methods

Based on the apnea hypopnea index (AHI), 21 patients with mild OSAHS (Group A, 5/h ≤ AHI < 15/h), 20 patients with moderate OSAHS (Group B, 15/h ≤ AHI < 30/h), 62 patients with severe OSAHS (Group C, AHI ≥ 30/h) were examined. The ocular surface and MG were evaluated using Keratograph 5M. In addition, detailed Ophthalmic examination including visual acuity, refraction, slit-lamp examination of the anterior segment, corneal fluorescein staining (CFS), ocular surface disease index (OSDI) scoring, Schirmer I test (SIT) and serum lipid measurement was performed. For OSAHS patients with dry eye syndrome (DES) who underwent uvulopalatopharyngoplasty for improving AHI, the conditions of the ocular surface and MG were compared before surgery and 3 months after surgery. Only the data of the right eyes were analyzed.

Results

There were no significantly different in the OSDI score, tear meniscus height (TMH), or loss ratio of the lower eyelid (LRLE) among these groups. The first non-invasive tear film breakup time (fNIBUT), average non-invasive tear film breakup time (avNIBUT), bulbar redness index (BRI), lipid layer grading (LLG), CFS, plugged orifices and distortion in MG, the loss ratio of upper eyelid (LRUE), and the incidence of DES, floppy eyelid syndrome (FES) and meibomian gland dysfunction (MGD) showed significant differences between Groups A and C (p = 0.015, p = 0.018, p < 0.001, p = 0.022, p = 0.036, p = 0.007, p = 0.019, p = 0.017, p = 0.045, p = 0.013, and p = 0.029, respectively). The SIT in the Group A was significantly higher than in Group B (p = 0.025) and in Group C (p < 0.001). In the correlation analyses, the fNIBUT, avNIBUT, SIT and LLG had negative correlations with the AHI (p = 0.013, p = 0.010, p = 0.003, p < 0.001, and p = 0.006, respectively). The BRI, CFS and LRUE were positively correlated with the AHI (p = 0.006, p = 0.007, and p = 0.046, respectively). Three months after surgery, there were no significant differences in the ocular surface or MG.

Conclusion

Patients with severe OSAHS have poor stability of tear film and are prone to lipid-deficient dry eye as a result of the loss of meibomian gland. By improving the AHI, the ocular surface damage of OSAHS patients cannot be reversed in a short time.

Obstructive sleep apnea treatment in adults

Sleep-related breathing disorders are complex problems that decrease quality of life and increase morbidity and mortality in patients. Comprehensive evaluation is essential for selecting and planning obstructive sleep apnea (OSA) treatments. However, the many proposed OSA treatments are rarely compared in the literature. The literature on OSA consists largely of case series studies, and the paucity of controlled studies makes comparisons of OSA treatments difficult. This article provides a brief overview of the most common OSA interventions. Because of the controversies and unanswered questions about OSA treatments, further studies are needed to define what treatments are best for specific OSA patients.

Controversies in Obstructive Sleep Apnea Surgery

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

Short-term effects of a mandibular advancement device on obstructive sleep apnoea: an open-label pilot trial

Obstructive sleep apnoea (OSA) is a common sleep disorder, which is, among others, associated with snoring. OSA has a considerable impact on a patient's general health and daily life. Nasal continuous positive airway pressure (nCPAP) is frequently used as a "gold standard" treatment for OSA. As an alternative, especially for mild/moderate cases, mandibular advancement devices (MADs) are prescribed increasingly. Their efficacy and effectiveness seem to be acceptable. Although some randomized clinical trials (RCTs) have been published recently, most studies so far are case studies. Therefore, our department is planning a controlled RCT, in which MADs are compared with both nCPAP and a control condition in a parallel design. As a first step, an adjustable MAD was developed with a small, more or less constant vertical dimension at different mandibular positions. To test the device and the experimental procedures, a pilot trial was performed with 10 OSA patients (six mild, four moderate; one women, nine men; mean age = 47.9 +/- 9.7 years). They all underwent a polysomnographic recording before as well as 2-14 weeks after insertion of the MAD (adjusted at 50% of the maximal protrusion). The apnoea-hypopnoea index (AHI) was significantly reduced with the MAD in situ (P = 0.017). When analysed as separate groups, the moderate cases showed a significantly larger decrease in AHI than the mild cases (P = 0.012). It was therefore concluded from this pilot study that this MAD might be an effective tool in the treatment of, especially, moderate OSA.

Caring for the bariatric patient with obstructive sleep apnea

Caring for the bariatric patient in the acute care environment poses many challenges to the team delivering care. The management of obstructive sleep apnea with noninvasive ventilation is one priority. Treatment options, including bi-level ventilation and continuous positive airway pressure, and delivery strategies are reviewed in conjunction with other aspects of care that ensure a holistic, comprehensive plan of care. The most effective plan of care for the bariatric patient is one that uses a multidisciplinary coordinated team effort.

Serotonin agonists and antagonists in obstructive sleep apnea: therapeutic potential

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a prevalent disorder associated with substantial cardiovascular and neurobehavioral morbidity. Yet this is a disorder for which there are no widely effective pharmacotherapies. The pathophysiology of obstructive sleep apnea namely, normal respiration in waking with disordered breathing only in sleep, suggests that this disorder should be readily amenable to drug therapy. Over the past 10 years, we have gained tremendous insight into the neurochemical mechanisms involved in state-dependent control of respiration. It is apparent from this work that there are many potential avenues for pharmacotherapies, including several seemingly conflicting directions for serotonergic therapies. Serotonin delivery is reduced to upper airway dilator motor neurons in sleep, and this contributes, at least in part, to sleep-related reductions in dilator muscle activity and upper airway obstruction. The dilator motor neuron post-synaptic serotonin receptors are 5-HT(2A) and 5-HT(2C) subtypes, and in adults the presynaptic 5-HT receptor in motor nuclei is 5-HT(1B), an inhibitory receptor. Serotonin receptors are also found within central respiratory neuronal groups, and these receptor subtypes include 5-HT(1A) (inhibitory) and 5-HT(2) receptors. Peripherally, stimulation of 5-HT(2A), 5-HT(2C) and 5-HT(3) receptor subtypes have an inhibitory effect on respiration via action at the nodose ganglion. Many of these receptor subtypes and their signal transduction pathways may be affected by oxidative stress in obstructive sleep apnea. These alterations will make finding drug therapies for sleep apnea more challenging, but not insurmountable. Future directions are suggested for elucidating safe, well-tolerated serotonergic drugs for this disorder. Tryptophan was one of the first serotonergic drugs tested for OSAHS. This drug was withdrawn from the market as a result of reports linking tryptophan use with eosinophilic myalgia syndrome and life-threatening pulmonary hypertension. Newer drugs with serotonergic activity tested in persons with sleep-disordered breathing include buspirone, fluoxetine and paroxetine. Trials are presently being conducted to evaluate the effects of 5-HT(2A) and 5-HT(3) antagonists on OSAHS. Many of the drugs tested have not shown significant improvement in sleep apnea. However, with continued effort to elucidate the pharmacology of neurochemical control of state-dependent changes in respiratory control, the availability of pharmacological therapy for this disorder is not too far away.

Uvulopalatopharyngoplasty for sleep apnea in mentally retarded obese 14-year-old: an anaesthetic challenge

Anaesthetic management of patients with obstructive sleep apnea for upper airway surgery has always been a challenging task. We report our anaesthetic approach for a young, mentally retarded obese patient with documented obstructive sleep apnea undergoing uvulopalatopharyngoplasty. The therapeutic intervention before, during and after operation is discussed.