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Serghani MM, Heiser C, Schwartz AR, Amatoury J. Exploring hypoglossal nerve stimulation therapy for obstructive sleep apnea: A comprehensive review of clinical and physiological upper airway outcomes. Sleep Med Rev 2024; 76:101947. [PMID: 38788518 DOI: 10.1016/j.smrv.2024.101947] [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: 11/06/2023] [Revised: 04/17/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of upper airway collapse during sleep, which can lead to serious health issues like cardiovascular disease and neurocognitive impairments. While positive airway pressure serves as the standard treatment, intolerance in some individuals necessitates exploration of alternative therapies. Hypoglossal nerve stimulation (HGNS) promises to mitigate OSA morbidity by stimulating the tongue muscles to maintain airway patency. However, its effectiveness varies, prompting research for optimization. This review summarizes the effects of HGNS on upper airway obstruction from human and animal studies. It examines physiological responses including critical closing pressure, maximal airflow, nasal and upper airway resistance, compliance, stiffness, and geometry. Interactions among these parameters and discrepant findings in animal and human studies are explored. Additionally, the review summarizes the impact of HGNS on established OSA metrics, such as the apnea-hypopnea index, oxygen desaturation index, and sleep arousals. Various therapeutic modalities, including selective unilateral or bilateral HGNS, targeted unilateral HGNS, and whole unilateral or bilateral HGNS, are discussed. This review consolidates our understanding of HGNS mechanisms, fostering exploration of under-investigated outcomes and approaches to drive advancements in HGNS therapy.
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Affiliation(s)
- Marie-Michèle Serghani
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon
| | - Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department ENT-HNS, Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Alan R Schwartz
- Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jason Amatoury
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon.
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Braun M, Stoerzel M, Wollny M, Schoebel C, Ulrich Sommer J, Heiser C. Patient-reported outcomes with hypoglossal nerve stimulation for treatment of obstructive sleep apnea: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2023; 280:4627-4639. [PMID: 37354340 PMCID: PMC10477259 DOI: 10.1007/s00405-023-08062-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/09/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Hypoglossal nerve stimulation (HNS) has recently been introduced as an alternative treatment for patients with OSA. A large number of studies have demonstrated substantial changes in OSA with this therapy by reducing respiratory events and improving symptoms such as daytime sleepiness and quality of life. The objective of this review was to conduct a systematic review and meta-analysis to evaluate patient-reported outcomes and experience with HNS therapy. METHODS A systematic literature search of MEDLINE, Cochrane, and Web of Science was performed to identify randomized controlled and observational studies reporting subjective outcomes with different HNS systems in patients with OSA. Abstracts of 406 articles were screened and a subset of 55 articles were reviewed for eligibility. Risk of bias was assessed using the ROBINS-I tool. Meta-analysis using RevMan was performed when > 2 studies were identified that reported data on a specific outcome. RESULTS Thirty-four publications reporting data on 3785 patients with a mean follow-up of 11.8 ± 12.2 months were identified and included in the meta-analysis. The analysis revealed a pooled effect of 4.59 points improvement in daytime sleepiness as measured by the ESS questionnaire (Z = 42.82, p < .001), 2.84 points improvement in daytime functioning as measured by the FOSQ score (Z = 28.38, p < .001), and 1.77 points improvement in sleep quality as measured by the PSQI questionnaire (Z = 2.53, p = .010). Patient-reported experience was consistently positive and revealed additional relevant aspects from this perspective. CONCLUSION HNS therapy significantly improves quality of life in patients with OSA and reliably produces clinically meaningful effects on daytime sleepiness, daytime functioning, and sleep quality. Treatment regularly meets or exceeds the minimum clinically important differences defined for the respective instruments. Additional research is needed to further investigate effects on quality of life beyond improvements in daytime sleepiness and daytime functioning.
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Affiliation(s)
- Marcel Braun
- Department of Pneumology, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Duisburg, Germany.
- Faculty of Sleep and Telemedicine, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239, Essen, Germany.
| | - Manuel Stoerzel
- German Cancer Research Center (DKFZ), Heidelberg, BW, Germany
| | | | - Christoph Schoebel
- Department of Pneumology, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Duisburg, Germany
- Faculty of Sleep and Telemedicine, University Medicine Essen - Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239, Essen, Germany
| | - J Ulrich Sommer
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- ENT-Center Mangfall-Inn, Bad Aibling, Germany
| | - Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ni YN, Thomas RJ. Predictors and consequences of residual apnea during positive airway pressure therapy. Sleep Med 2023; 106:42-51. [PMID: 37044000 DOI: 10.1016/j.sleep.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023]
Abstract
STUDY OBJECTIVES Determine the risk factors for, and consequences of, residual apnea during long-term positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA). METHODS A prospective cohort study of 195 subjects after a split-night polysomnogram. Estimation of residual respiratory events on PAP were done by both automated and manual scoring of data in EncoreAnywhere™. Clinical and polysomnographic predictors of residual apnea were estimated. RESULTS There were 166 and 101 patients still on PAP at the 3 and 12 months, respectively. Seventy four (44.6%) and 46 (45.5%) had a residual scored respiratory event index-flow (sREIFLOW) ≥ 15/hour of use and 46 (45.5%) at the 3rd and 12th month, respectively. Treatment phase central apnea hypopnea index (TCAHI), a surrogate of high loop gain, was the main predictor for residual sREIFLOW (β = 0.345, p: 0.025) at the 3rd and 12th month (β = 0.147, p: 0.020). TCAHI also predicted unstable breathing (U) %. The body mass index (hazard ratio [HR] 1.034, 95% CI 1.008-1.062, p: 0.012) and effective sREIFLOW>15/hour in the first month (HR 2.477, 95% CI 1.510-4.065, p < 0.001) were the key predictors for drop out of PAP use at the 12th month. Effective sREIFLOW>15/hour in the first month was also a predictor for median usage duration >4 h for 70% of the night at both the 3rd month (odds ratio [OR] 0.947, 95% CI 0.909-0.986, p: 0.008) and 12th month (OR 0.973, 95% CI 0.951-0.994, p: 0.014). CONCLUSIONS Treatment-phase CAHI predicts long-term residual apnea on PAP. High residual disease adversely impacts adherence.
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Martínez Deltoro A, Gamboa Martínez J, Soler-Cataluña JJ. Calidad de vida relacionada con la salud y adhesión terapéutica a la presión positiva continua en la vía aérea (CPAP) en pacientes con apnea obstructiva del sueño (AOS). OPEN RESPIRATORY ARCHIVES 2023. [PMID: 37497254 PMCID: PMC10369567 DOI: 10.1016/j.opresp.2022.100214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction The benefits of CPAP in patients with obstructive sleep apnea (OSA) are not achieved without therapeutic adherence (TA). The perception of benefit is one of the main predictors of adherence. However, it is unknown whether the impact of CPAP on health-related quality of life (HRQoL) is related to TA. Objective 1) To evaluate whether changes in HRQoL after initiating CPAP are associated with AT. 2) To analyze the influence of various TA determinants, including baseline HRQoL. Methods Prospective observational and longitudinal study on a cohort of patients with moderate-severe OSA and indication of CPAP. Baseline and after-therapy HRQoL were evaluated using the Quebec Sleep Questionnaire (QSQ), as well as other possible AT determinants. A multivariate analysis was performed. Results A total of 364 patients (78% men) were included, with mean age of 55 ± 11 years and apnea-hypopnea index of 42 ± 19/hour. 33.3% without TA. There was no association between HRQoL changes after 3 months of CPAP and AT and between QSQ baseline score and AT. A higher ODI4%, a global improvement and social interactions (QSQ), were associated with AT. Baseline anxiety-depressive symptoms, worsening anxiety, and side effects with CPAP were associated with worse AT. Conclusions The impact of CPAP on HRQoL with respect to the perception of social interactions seems to condition TA. The basal impact of the disease, in terms of HRQoL, is not associated with AT.
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Hypoglossal nerve stimulation versus positive airway pressure therapy for obstructive sleep apnea. Sleep Breath 2022; 27:693-701. [DOI: 10.1007/s11325-022-02663-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/22/2022] [Accepted: 06/09/2022] [Indexed: 10/17/2022]
Abstract
Abstract
Purpose
Hypoglossal nerve stimulation (HNS) has been shown to treat obstructive sleep apnea (OSA) effectively. The aim of this study was to compare HNS with positive airway pressure (PAP) treatment regarding outcome parameters: (1) sleepiness, (2) apnea–hypopnea index (AHI), and (3) effectiveness.
Methods
Propensity score matching with nearest neighbor algorithm was used to compare outcomes of HNS and PAP therapy in a real-world setting. Data were collected at baseline and 12 months after initiating OSA treatment including demographics, Epworth Sleepiness Scale (ESS), AHI, and objective adherence data. To account for overall treatment efficacy, the mean disease alleviation (MDA) was calculated.
Results
Of 227 patients who received treatment consecutively, 126 could be matched 1:1 with regard to age, body mass index, and AHI. After matching, no statistically significant differences between the groups were found. A clinically important symptom improvement was seen at 12 months in both cohorts, though there was a greater difference in ESS improvement in patients treated with HNS (8.0 ± 5.1 points vs. 3.9 ± 6.8 points; p = 0.042). In both groups, mean posttreatment AHI was significantly reduced (HNS: 8.1 ± 6.3/h; PAP: 6.6 ± 8.0/h; p < 0.001). Adherence after 12 months among patients treated with HNS was higher than in those receiving PAP therapy (5.0 ± 2.6 h/night; 4.0 ± 2.1 h/night) but not with statistical significance. Overall effectiveness calculated with the MDA was 59% in patients treated with HNS compared to 51% receiving PAP.
Conclusion
Patients treated with HNS therapy had significantly greater improvements in daytime sleepiness compared to PAP therapy, while the mean reduction of AHI and overall effectiveness were comparable for both treatments.
Trial registration
ClinicalTrial.gov Identifier: NCT03756805.
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Baptista PM, Prieto-Matos C, Alegre-Esteban M, Urrestarazu-Bolumburu E, Alcade Navarrete J. Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea in Spain: Implementation Strategy and Early Results in a Tertiary Care Center. Indian J Otolaryngol Head Neck Surg 2022; 74:158-165. [DOI: 10.1007/s12070-021-02503-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/02/2021] [Indexed: 11/29/2022] Open
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Can Weight Loss Improve the Cardiovascular Outcomes of Patients with Obesity and Obstructive Sleep Apnea? HEARTS 2022. [DOI: 10.3390/hearts3020008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular events are the primary cause of mortality in patients with obstructive sleep apnea and obesity. The rising prevalence of obstructive sleep apnea in recent decades has been linked to increasing rates of obesity. Obstructive sleep apnea has also been linked with many different cardiovascular diseases including coronary artery disease, stroke, heart failure, hypertension, and atrial fibrillation. Obesity is an increasing health concern globally, in part because obesity complications such as hypertension, diabetes, and obstructive sleep apnea increase the risk of cardiovascular diseases. More than 10% weight loss may be required to prevent or reverse obesity complications. Treatment approaches to obesity include nutritional therapy, exercise therapy, pharmacotherapy, and surgical therapies. This review intends to identify the effects of weight loss on cardiovascular outcomes in patients with obesity and obstructive sleep apnea. Despite the strong association between cardiovascular diseases and obstructive sleep apnea, randomized trials have failed to demonstrate that treatment of obstructive sleep apnea reduces cardiovascular events, even in patients with established cardiovascular diseases. Weight loss in patients with obstructive sleep apnea improves HbA1c, systolic blood pressure, HDL cholesterol, and triglycerides, but thus far no changes in cardiovascular events have been shown. The combination of weight loss with continuous positive airway pressure (CPAP) appears more beneficial than either treatment in isolation. Large well-controlled trials in patients with obstructive sleep apnea to assess the effects of different weight reduction programs on cardiovascular disease are still needed.
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Pascoe M, Bena J, Andrews ND, Auckley D, Benca R, Billings ME, Kapur VK, Iber C, Zee PC, Redline S, Rosen CL, Foldvary-Schaefer N. Dose response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study. J Clin Sleep Med 2021; 18:1027-1034. [PMID: 34870587 DOI: 10.5664/jcsm.9792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Clinical benefits of PAP therapy for OSA are assumed to require adherent PAP usage, as defined by CMS as ≥ 4 hours of use ≥ 70% of nights. However, this is based on early data and does not necessarily capture improvements at subthreshold adherence. We explored dose-response relationships between PAP adherence measures and EDS from the HomePAP RCT. METHODS Participants ≥18 years with apnea hypopnea index ≥ 15 and baseline sleepiness (Epworth Sleepiness Scale (ESS) ≥ 12) received PAP therapy. Data were collected at baseline, 1-month, and 3-months follow-up. Regression models and receiver operating characteristic curves evaluated PAP measures as predictors of ESS change and normalization (ESS < 10). RESULTS In 119 participants (age 49.4 ± 12.6 years, 66.4% male, 72.3% white), > 50% were PAP non-adherent per CMS criteria at 3 months. Percent of nights with PAP use ≥ 4 hours predicted ESS change (p = 0.023), but not when controlling for AHI. Percent of nights with ≥ 4 hours and average PAP use provided the best discrimination for predicting ESS normalization; each 10% increase in PAP use ≥ 4 hours increased the odds of ESS normalization by 22% (p = 0.007); those using PAP ≥ 4 hours had nearly 3-fold greater odds of ESS normalization (p = 0.025). At least 4 hours and 70% of nights provided the best balance between specificity (0.50) and sensitivity (0.73). CONCLUSIONS Although sub-adherent PAP usage may still confer some benefit for OSA patients, adherence to current criteria confers the highest likelihood for ESS change and normalization. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP); Identifier: NCT00642486; URL: http://clinicaltrials.gov/show/NCT00642486.
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Affiliation(s)
- Maeve Pascoe
- Cleveland Clinic Sleep Disorders Center, Cleveland, OH
| | - James Bena
- Cleveland Clinic Sleep Disorders Center, Cleveland, OH
| | | | - Dennis Auckley
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland OH
| | - Ruth Benca
- University of California Irvine, Irvine, CA
| | | | - Vishesh K Kapur
- Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Phyllis C Zee
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Susan Redline
- Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Carol L Rosen
- Case Western Reserve University School of Medicine, Cleveland, OH
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Braun M, Dietz-Terjung S, Taube C, Schoebel C. Treatment preferences and willingness to pay in patients with obstructive sleep apnea: relevance of treatment experience. SOMNOLOGIE 2021; 26:1-11. [PMID: 34785988 PMCID: PMC8579724 DOI: 10.1007/s11818-021-00331-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
Background Patients with obstructive sleep apnea (OSA) most commonly receive positive airway pressure therapy (PAP) as primary treatment, which is highly effective when used consistently. Little is known about the preferences for and relevance of attributes of OSA treatments, especially of non-PAP alternatives. The aim of this study was to evaluate treatment preferences and willingness to pay (WTP) among patients with and without previous experience of OSA therapies. Methods A discrete choice experiment and a structured survey were applied to patients presenting for overnight polysomnography at a tertiary sleep center. Medical variables were obtained from hospital case records. Results Over a period of 4 months, 241 subjects were enrolled and answered the questionnaire (61.8% with an existing diagnosis, 38.2% with a new diagnosis). The most preferred treatment among all patients was PAP therapy (51.1%), followed by mandibular advancement devices (18.1%), hypoglossal nerve stimulation (17.2%), and medication (13.7%). Approval for the different treatments varied by gender as well as by OSA therapy experience. The importance of attributes of OSA treatment varied too, with low rates of treatment-related side effects being equally important, independent of the preferred therapy. The most often stated monthly WTP for optimal sleep was € 50, with increasing age leading to lower WTP values. Conclusion Preferences for OSA therapies vary among patients and patient subgroups. PAP therapy is the most preferred treatment, though non-PAP interventions receive high approval ratings too, particularly in treatment-naïve patients. The importance of treatment attributes varies as well, depending on the choice of preferred treatment.
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Affiliation(s)
- Marcel Braun
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Essen, Germany.,Faculty of Sleep and Telemedicine, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239 Essen, Germany.,Inspire Medical Systems, Inc., Golden Valley, MN USA
| | - Sarah Dietz-Terjung
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Essen, Germany.,Faculty of Sleep and Telemedicine, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239 Essen, Germany
| | - Christian Taube
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Essen, Germany
| | - Christoph Schoebel
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Essen, Germany.,Faculty of Sleep and Telemedicine, University Medicine Essen-Ruhrlandklinik, West German Lung Center, University Duisburg-Essen, Tueschener Weg 40, 45239 Essen, Germany
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11
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Penzel T, Dietz-Terjung S, Woehrle H, Schöbel C. New Paths in Respiratory Sleep Medicine: Consumer Devices, e-Health, and Digital Health Measurements. Sleep Med Clin 2021; 16:619-634. [PMID: 34711386 DOI: 10.1016/j.jsmc.2021.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sleep health and tracking sleep with contemporary wearables have become more popular. Sleep disorders, in particular, sleep-disordered breathing, have a higher prevalence than estimated previously. Many patients with apnea and hypopnea events suffer whereas others do not report complaints or show cardiovascular consequences. Assessment with wearables may support efforts to distinguish which type of apnea is related to aging and which to cardiovascular comorbidities. Innovative methods offer smart solutions for problems that are insufficiently addressed. Telemedical concepts help bring patients to sleep medicine expertise at an early stage. To use these methods clinically, they must be certified as medical devices.
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Affiliation(s)
- Thomas Penzel
- Interdisciplinary Sleep Medicine Center, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany; Department of Biology, Saratov State University, Astrakhanskaya Str. 12, Saratov 410012, Russia.
| | - Sarah Dietz-Terjung
- Universitätsmedizin Essen, Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Tüschener Weg 40, 45239 Essen, Germany
| | | | - Christoph Schöbel
- Universitätsmedizin Essen, Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätsklinikum Essen gGmbH, Tüschener Weg 40, 45239 Essen, Germany
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12
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Vecchierini MF, Attali V, Collet JM, d'Ortho MP, Goutorbe F, Kerbrat JB, Leger D, Lavergne F, Monaca C, Monteyrol PJ, Mullens E, Pigearias B, Martin F, Khemliche H, Lerousseau L, Meurice JC. Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data. J Clin Sleep Med 2021; 17:1695-1705. [PMID: 34165074 DOI: 10.5664/jcsm.9308] [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] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVES Mandibular advancement devices (MADs) are an alternative to continuous positive airway pressure for the management of obstructive sleep apnea (OSA). The ORthèse d'avanCée mAndibulaire dans le traitement en DEuxième intention du SAHOS sévère (ORCADES) study is investigating the long-term effectiveness of MAD therapy in patients with OSA who refused or were intolerant of continuous positive airway pressure. Five-year follow-up data are presented. METHODS Data were available in 172 of 331 patients treated with a custom-made computer-aided design/computer-aided manufacturing biblock MAD (Narval CC; ResMed, Saint-Priest, France). The primary end point was treatment success (≥50% decrease in apnea-hypopnea index from baseline). RESULTS Five-year treatment success rates were 52% overall and 25%, 52%, and 63%, respectively, in patients with mild, moderate, or severe OSA. This reflects a decline over time vs 3-6 months (79% overall) and 2 years (68%). Rates declined in all patient subgroups but to the greatest extent in patients with mild OSA. The slight worsening of respiratory parameters over time was not associated with any relevant changes in sleepiness and symptoms. Moderate or severe OSA at baseline, treatment success at 3-6 months, and no previous continuous positive airway pressure use were significant independent predictors of 5-year treatment success on multivariate analysis. No new safety signals emerged during long-term follow-up. The proportion of patients using their MAD for ≥4 h/night on ≥4 days/wk was 93.3%; 91.3% of patients reported device use of ≥6 h/night at 5 years. At 5-year follow-up, 96.5% of patients reported that they wanted to continue MAD therapy. CONCLUSIONS Long-term MAD therapy remained effective after 5 years in >50% of patients, with good levels of patient satisfaction and adherence. CITATION Vecchierini MF, Attali V, Collet JM, et al. Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data. J Clin Sleep Med. 2021;17(8):1695-1705.
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Affiliation(s)
- Marie-Françoise Vecchierini
- AP-HP, Hôpital Hôtel Dieu, Centre du Sommeil et de la Vigilance, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Valérie Attali
- AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service des Pathologies du Sommeil (Département "R3S"), Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Jean-Marc Collet
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Stomatologie et Chirurgie Maxillo-Faciale, Paris, France
| | - Marie-Pia d'Ortho
- Physiologie Clinique- Explorations Fonctionnelles et Centre du Sommeil, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France.,Université de Paris, INSERM, UMR 1141 NeuroDiderot, Paris, France
| | - Frederic Goutorbe
- Centre Médecine du Sommeil, Centre Hospitalier de Béziers, Béziers, France
| | - Jean-Baptiste Kerbrat
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Stomatologie et Chirurgie Maxillo-Faciale, Paris, France.,Hôpital Charles Nicolle, Stomatologie et Chirurgie Maxillo-Faciale, Rouen, France
| | - Damien Leger
- AP-HP, Hôpital Hôtel Dieu, Centre du Sommeil et de la Vigilance, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | | | | | | | - Eric Mullens
- Fondation Bon Sauveur, Laboratoire du Sommeil, Albi, France
| | | | - Francis Martin
- AP-HP Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service des Pathologies du Sommeil (Département "R3S"), Paris, France
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13
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Yılmaz Kara B, Kalcan S, Özyurt S, Gümüş A, Özçelik N, Karadoğan D, Şahin Ü. Weight Loss as the First-Line Therapy in Patients with Severe Obesity and Obstructive Sleep Apnea Syndrome: the Role of Laparoscopic Sleeve Gastrectomy. Obes Surg 2020; 31:1082-1091. [PMID: 33108591 DOI: 10.1007/s11695-020-05080-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The objective of this study is to investigate the effects of laparoscopic sleeve gastrectomy (LSG) on the polysomnographic parameters related to OSAS. MATERIALS AND METHODS We conducted this 3-year prospective cohort study in a tertiary care center between December 2016 and December 2019. In total, we enrolled 31 patients with severe obesity who underwent full-night polysomnography (PSG) before LSG. Later, the patients were re-evaluated by full-night PSG 12 months after the surgery. RESULTS The mean age of the patients was 44.1 ± 9.6 years. The mean body mass index (BMI) decreased significantly from a mean value of 49.8 ± 8.5 kg/m2 at baseline to 33.2 ± 8.2 kg/m2 and a percent BMI (%BMI) reduction of 33.8 ± 10.4% and a percent total weight loss (%TWL) of 35.4 ± 10.8% was achieved on the same day of the postsurgical PSG (p < 0.001). There was a remarkable improvement in the AHI (baseline: 36.1 ± 27.1, 12 months after the surgery: 10.3 ± 11.8; difference: 25.8 ± 22.8 events per hour) (p < 0.001). Importantly, there was a decrease in the percentage of non-rapid eye movement (NREM) 2 (p < 0.001), whereas NREM 3 and REM stages witnessed a significant increase (p = 0.001 and p < 0.001, respectively) after the surgery. CONCLUSION The results of this study showed that weight loss after LSG yields improvement not only in AHI but also in many polysomnographic parameters such as sleep quality and desaturation indices.
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Affiliation(s)
- Bilge Yılmaz Kara
- Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey.
| | - Süleyman Kalcan
- Department of General Surgery, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Songül Özyurt
- Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Aziz Gümüş
- Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Neslihan Özçelik
- Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Dilek Karadoğan
- Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Ünal Şahin
- Department of Pulmonology, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
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14
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Telemedicine for Continuous Positive Airway Pressure in Sleep Apnea. A Randomized, Controlled Study. Ann Am Thorac Soc 2020; 16:1550-1557. [PMID: 31310575 DOI: 10.1513/annalsats.201901-013oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Rationale: Continuous positive airway pressure (CPAP) is the standard treatment for the obstructive sleep apnea syndrome (OSAS), but long-term adherence remains a challenge. In a pilot study, we observed that telemedicine combined with telemetrically triggered interventions was associated with improved CPAP adherence in the first month of treatment.Objectives: In the current randomized, controlled phase III trial, we aimed to collect pivotal data for the use of telemedicine in CPAP treatment of patients with OSAS.Methods: Symptomatic patients with OSAS were randomized to a telemedicine or control arm and initiated CPAP treatment. Phone calls were triggered in the telemedicine group during the first month of treatment upon either poor use or excessive mask leakage. Patients were followed for 6 months. Measures of CPAP use at 6 months were the main study endpoints.Results: Among 240 patients enrolled, 71 (30%) discontinued CPAP treatment over the course of the study. The primary outcome measure, the proportion of nights with CPAP use greater than 1 hour, was not statistically different in the telemedicine group (92.0%) versus the control group (88.2%) (P = 0.565). The daily hours of CPAP use at 6 months also did not differ significantly between the telemedicine group (5.6 h) and the control group (4.8 h) (P = 0.663). However, in a post hoc analysis, telemedicine led to increased device use in a subgroup of patients with a mild form of disease (5.6 h vs. 3.4 h; P = 0.026). The telemedicine-based intervention had a positive impact on sleep-related quality of life as measured with the Quebec Sleep Questionnaire (5.55 vs. 5.49 at 1 mo [P = 0.020]; 5.61 vs. 5.46 at 6 mo [P = 0.013]).Conclusions: A telemetrically triggered intervention in the first month of treatment did not improve CPAP use in the study population overall, but it had positive effects in patients with a mild form of OSAS and led to an improvement in sleep-related quality of life.Clinical trial registered with www.clinicaltrials.gov (NCT01715194).
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15
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Luo K, Zhang L, Zhang X, Han T, Li Y, Wang C. Acceptance of and six-month adherence to continuous positive airway pressure in patients with moderate to severe obstructive sleep apnea. CLINICAL RESPIRATORY JOURNAL 2020; 15:56-64. [PMID: 32939997 DOI: 10.1111/crj.13269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is the most effective treatment for moderate to severe obstructive sleep apnea (OSA). Acceptance of and adherence to CPAP are crucial for optimal treatment outcomes. The aim of this study was to investigate the factors influencing patients' acceptance of and adherence to CPAP treatment. METHODS One hundred eighty-eight patients with moderate to severe OSA who had received CPAP titration from October 2017 to September 2018 were recruited. They were interviewed at 2 weeks and at 6 months to assess CPAP use and barriers to acceptance and adherence. RESULTS One hundred fourteen patients (60.6%) accepted CPAP treatment. Disease severity, assessed by apnea-hypopnea index (AHI) (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.08), subjective satisfaction of titration (OR, 12.83; 95% CI, 3.83-42.99), initial intention of CPAP therapy (OR, 3.33; 95% CI, 1.05-10.51) and short-term home CPAP trial (OR, 9.40; 95% CI, 2.85-31.08) were associated with acceptance of CPAP treatment. Two-third of the 98 CPAP acceptors reported good CPAP adherence at 6 months follow-up. Average hours of CPAP use per day for the first 2 weeks (OR, 1.88; 95% CI, 1.28-3.04) and the global problems associated with CPAP use (OR, 0.82; 95% CI, 0.73-0.91) were independent predictors of the six-month CPAP adherence. CONCLUSIONS Nearly 40% of patients with moderate to severe OSA did not accept CPAP treatment, and one-third of those CPAP acceptors had poor adherence to CPAP treatment. Improvement in disease awareness, comfortable titration experience, short-term home CPAP trial may be of help to increase CPAP acceptance and early experience with CPAP is important for long-term adherence. The differences in predicting factors for CPAP acceptance and adherence highlight the importance of focusing on specific aspects during the whole process management of OSA.
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Affiliation(s)
- Kun Luo
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,First Hospital of Qinhuangdao, Beijing, China
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,China-Japan Friendship School of Clinical Medicine, Peking University, Beijing, China
| | - Xiaolei Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,China-Japan Friendship School of Clinical Medicine, Peking University, Beijing, China.,Capital Medical University, Beijing, China.,the Graduate School of Peking Union Medical College, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Teng Han
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yiming Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,China-Japan Friendship School of Clinical Medicine, Peking University, Beijing, China.,Capital Medical University, Beijing, China.,the Graduate School of Peking Union Medical College, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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16
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Digitale respiratorische Schlafmedizin – Teil II: Therapie. SOMNOLOGIE 2020. [DOI: 10.1007/s11818-020-00263-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Nakase-Richardson R, Hoffman JM, Magalang U, Almeida E, Schwartz DJ, Drasher-Phillips L, Ketchum JM, Whyte J, Bogner J, Dismuke-Greer CE. Cost-Benefit Analysis From the Payor's Perspective for Screening and Diagnosing Obstructive Sleep Apnea During Inpatient Rehabilitation for Moderate to Severe TBI. Arch Phys Med Rehabil 2020; 101:1497-1508. [PMID: 32376325 DOI: 10.1016/j.apmr.2020.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective. DESIGN A cost-benefit analysis of phased approaches to sleep apnea diagnosis. SETTING Six TBI Model System Inpatient Rehabilitation Centers. PARTICIPANTS Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5). INTERVENTION Not applicable. MAIN OUTCOME Cost benefit. RESULTS At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness. CONCLUSIONS The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.
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Affiliation(s)
- Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, Defense and Veterans Brain Injury Center at James A. Haley Veterans' Hospital, Morsani College of Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida, Tampa, Florida.
| | - Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ulysses Magalang
- Division of Pulmonary, Critical Care, and Sleep Medicine and Neuroscience Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Emily Almeida
- Research Department, Craig Hospital, Englewood, Colorado
| | - Daniel J Schwartz
- Medicine Service, James A. Haley Veterans' Hospital, Morsani College of Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida, Tampa, Florida
| | - Leah Drasher-Phillips
- Research and Development Service, James A. Haley Veterans' Hospital, Morsani College of Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida, Tampa, Florida
| | | | - John Whyte
- Moss Rehabilitation Research Institute, Albert Einstein Healthcare Network, Elkins Park, Pennsylvania
| | - Jennifer Bogner
- Division of Rehabilitation Psychology, Research and Academic Affairs, Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, Ohio
| | - Clara E Dismuke-Greer
- Health Economics Resource Center (HERC), Palo Alto VA Health Care System, Palo Alto, California; Division of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
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18
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Silva MA, Calvo D, Brennan EM, Reljic T, Drasher-Phillips L, Schwartz DJ, Kumar A, Cotner BA, Taylor DJ, Nakase-Richardson R. Incidence and predictors of adherence to sleep apnea treatment in rehabilitation inpatients with acquired brain injury. Sleep Med 2020; 69:159-167. [PMID: 32088352 DOI: 10.1016/j.sleep.2020.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI). METHODS A 2012-2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed. RESULTS ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (β = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023). CONCLUSIONS In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.
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Affiliation(s)
- Marc A Silva
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, 13000 Bruce B. Downs Blvd. (116-B), FL, 33612, USA; Dept. of Psychiatry and Behavioral Neurosciences, University of South Florida, 3515 E. Fletcher Ave Tampa, FL, 33613, USA; Dept. of Psychology, University of South Florida, 4202 East Fowler Ave, PCD4118G, Tampa, FL, 33620, USA; Defense and Veterans Brain Injury Center (DVBIC), James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (117), FL, 33612, USA.
| | - Dayana Calvo
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, 13000 Bruce B. Downs Blvd. (116-B), FL, 33612, USA.
| | - Erin M Brennan
- Dept. of Educational and Psychological Studies, University of South Florida, 4202 E Fowler Ave Ste 105, Tampa, FL, 33620, USA; Research Service, James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (151-R), Tampa, FL, 33612, USA.
| | - Tea Reljic
- Research Service, James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (151-R), Tampa, FL, 33612, USA; Office of Research, USF Health, University of South Florida, 12901 Bruce B Downs Blvd, MDC 19, Tampa, FL, 33612, USA; Department of Internal Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, MDC 27, Tampa, FL, 33612, USA.
| | - Leah Drasher-Phillips
- Research Service, James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (151-R), Tampa, FL, 33612, USA.
| | - Daniel J Schwartz
- Medicine Service, James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd., Tampa, FL, 33612, USA; Division of Pulmonary, Critical Care & Sleep Medicine, Dept. of Internal Medicine, University of South Florida, 12901 Bruce B Downs Blvd Ste MDC19, Tampa, FL, 33612, USA.
| | - Ambuj Kumar
- Research Service, James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (151-R), Tampa, FL, 33612, USA; Office of Research, USF Health, University of South Florida, 12901 Bruce B Downs Blvd, MDC 19, Tampa, FL, 33612, USA; Department of Internal Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, MDC 27, Tampa, FL, 33612, USA.
| | - Bridget A Cotner
- Research Service, James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (151-R), Tampa, FL, 33612, USA; Dept. of Anthropology, University of South Florida, 4202 E Fowler Ave, SOC107, Tampa, FL, 33620, USA.
| | - Daniel J Taylor
- Dept. of Psychology, University of Arizona, 1503 E University Blvd., Tucson, AZ, 85721, USA.
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, 13000 Bruce B. Downs Blvd. (116-B), FL, 33612, USA; Defense and Veterans Brain Injury Center (DVBIC), James A. Haley Veterans' Hospital, 13000 Bruce B. Downs Blvd. (117), FL, 33612, USA; Division of Pulmonary, Critical Care & Sleep Medicine, Dept. of Internal Medicine, University of South Florida, 12901 Bruce B Downs Blvd Ste MDC19, Tampa, FL, 33612, USA.
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Van Ryswyk E, Anderson CS, Antic NA, Barbe F, Bittencourt L, Freed R, Heeley E, Liu Z, Loffler KA, Lorenzi-Filho G, Luo Y, Margalef MJM, McEvoy RD, Mediano O, Mukherjee S, Ou Q, Woodman R, Zhang X, Chai-Coetzer CL. Predictors of long-term adherence to continuous positive airway pressure in patients with obstructive sleep apnea and cardiovascular disease. Sleep 2019; 42:5581969. [DOI: 10.1093/sleep/zsz152] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 05/12/2019] [Indexed: 11/12/2022] Open
Abstract
AbstractStudy ObjectivesPoor adherence to continuous positive airway pressure (CPAP) commonly affects therapeutic response in obstructive sleep apnea (OSA). We aimed to determine predictors of adherence to CPAP among participants of the Sleep Apnea and cardioVascular Endpoints (SAVE) trial.MethodsSAVE was an international, randomized, open trial of CPAP plus usual care versus usual care (UC) alone in participants (45–75 years) with co-occurring moderate-to-severe OSA (≥12 episodes/h of ≥4% oxygen desaturation) and established cardiovascular (CV) disease. Baseline sociodemographic, health and lifestyle factors, OSA symptoms, and 1-month change in daytime sleepiness, as well as CPAP side effects and adherence (during sham screening, titration week, and in the first month), were entered in univariate linear regression analyses to identify predictors of CPAP adherence at 24 months. Variables with p <0.2 were assessed for inclusion in a multivariate linear mixed model with country, age, and sex included a priori and site as a random effect.ResultsSignificant univariate predictors of adherence at 24 months in 1,121 participants included: early adherence measures, improvement in daytime sleepiness at 1 month, fixed CPAP pressure, some measures of OSA severity, cardiovascular disease history, breathing pauses, and very loud snoring. While observed adherence varied between countries, adherence during sham screening, initial titration, and the first month of treatment retained independent predictive value in the multivariate model along with fixed CPAP pressure and very loud snoring.ConclusionsEarly CPAP adherence had the greatest predictive value for identifying those at highest risk of non-adherence to long-term CPAP therapy.Clinical Trial RegistrationSAVE is registered with clinicaltrials.gov (NCT00738179).
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Affiliation(s)
- Emer Van Ryswyk
- Adelaide Institute for Sleep Health: A Flinders Centre for Research Excellence, Flinders University, Adelaide, Australia
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Nicholas A Antic
- Adelaide Institute for Sleep Health: A Flinders Centre for Research Excellence, Flinders University, Adelaide, Australia
| | - Ferran Barbe
- Respiratory Department, Hospital Universitari Arnau de Vilanova-Santa María, Lleida, Spain
- CIBERES, Madrid, Spain
| | - Lia Bittencourt
- Instituto do Sono, AFIP, Sao Paulo, Brazil
- Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Ruth Freed
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Emma Heeley
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Zhihong Liu
- Department of Cardiology, Fuwai Hospital, Beijing, China
| | - Kelly A Loffler
- Adelaide Institute for Sleep Health: A Flinders Centre for Research Excellence, Flinders University, Adelaide, Australia
| | | | - Yuanming Luo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Maria J Masdeu Margalef
- Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health: A Flinders Centre for Research Excellence, Flinders University, Adelaide, Australia
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Olga Mediano
- University Hospital of Guadalajara, Guadalajara, Spain
| | - Sutapa Mukherjee
- Adelaide Institute for Sleep Health: A Flinders Centre for Research Excellence, Flinders University, Adelaide, Australia
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Qiong Ou
- Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, Australia
| | - Xilong Zhang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health: A Flinders Centre for Research Excellence, Flinders University, Adelaide, Australia
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
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Noda A, Hayano J, Ito N, Miyata S, Yasuma F, Yasuda Y. Very low frequency component of heart rate variability as a marker for therapeutic efficacy in patients with obstructive sleep apnea: Preliminary study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2019; 24:84. [PMID: 31620183 PMCID: PMC6788180 DOI: 10.4103/jrms.jrms_62_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 11/14/2018] [Accepted: 07/01/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although positive airway pressure (PAP) therapy is effective for treating obstructive sleep apnea (OSA), some patients with severe OSA are intolerable to this treatment, which may lead to an increase in the mortality and morbidity of cardiovascular diseases. We investigated the relationship between heart rate variability (HRV) and sleep parameters during natural sleep and treatment of patients with OSA. MATERIALS AND METHODS This was the cross-sectional observation study. Patients were 17 males with severe OSA who were unable to accept continuous PAP. Standard polysomnography was performed for two consecutive nights, i.e., during natural sleep and following night with bilevel PAP (BiPAP) treatment. Time-dependent responses of the amplitudes of low frequency (LF), very low frequency (VLF), and high frequency components of HRV were assessed with the technique of complex demodulation. RESULTS Apnea-hypopnea index, oxygen desaturation time, and percentage of stage 1 sleep were significantly reduced, whereas the percentages of rapid eye movement and stages 3 + 4 sleep were increased, by BiPAP treatment. Therapy also reduced the amplitudes of VLF and LF components of HRV. Difference in amplitudes of VLF during natural sleep and treatment with BiPAP was significantly correlated with difference in percentages of stage 1 and stages 3 + 4 sleep. CONCLUSION Therapy-induced amelioration of OSA and sleep quality was accompanied by decrease in the amplitudes of VLF components of HRV. The VLF component may thus reflect physiological changes in both autonomic activity and sleep structure and serve as an objective marker for therapeutic efficacy in patients with severe OSA.
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Affiliation(s)
- Akiko Noda
- Department of Biomedical Sciences, Chubu University Graduate School of Life and Health Sciences, Kasugai, Japan
- Innovative Research Center for Preventive Medical Engineering, Nagoya University, Nagoya, Japan
| | - Junichiro Hayano
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nami Ito
- Department of Medical Technology, Nagoya University School of Health Sciences, Nagoya, Japan
| | - Seiko Miyata
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumihiko Yasuma
- Department of Internal Medicine, National Hospital Organization Suzuka Hospital, Suzuka, Japan
| | - Yoshinari Yasuda
- Department of CKD Intitatives, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Streatfeild J, Hillman D, Adams R, Mitchell S, Pezzullo L. Cost-effectiveness of continuous positive airway pressure therapy for obstructive sleep apnea: health care system and societal perspectives. Sleep 2019; 42:5546946. [DOI: 10.1093/sleep/zsz181] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/12/2019] [Indexed: 12/20/2022] Open
Abstract
AbstractStudy ObjectivesTo determine cost-effectiveness of continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA) in Australia for 2017–2018 to facilitate public health decision-making.MethodsAnalysis was undertaken of direct per-person costs of CPAP therapy (according to 5-year care pathways), health system and other costs of OSA and its comorbidities averted by CPAP treatment (5-year adherence rate 56.7%) and incremental benefit of therapy (in terms of disability-adjusted life years [DALYs] averted) to determine cost-effectiveness of CPAP. This was expressed as the incremental cost-effectiveness ratio (= dollars per DALY averted). Direct costs of CPAP were estimated from government reimbursements for services and advertised equipment costs. Costs averted were calculated from both the health care system perspective (health system costs only) and societal perspective (health system plus other financial costs including informal care, productivity losses, nonmedical accident costs, deadweight taxation and welfare losses). These estimates of costs (expressed in US dollars) and DALYs averted were based on our recent analyses of costs of untreated OSA.ResultsFrom the health care system perspective, estimated cost of CPAP therapy to treat OSA was $12 495 per DALY averted while from a societal perspective the effect was dominant (−$10 688 per DALY averted) meaning it costs more not to treat the problem than to treat it.ConclusionsThese estimates suggest substantial community investment in measures to more systematically identify and treat OSA is justified. Apart from potential health and well-being benefits, it is financially prudent to do so.
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Affiliation(s)
- Jared Streatfeild
- Health Economics and Social Policy, Deloitte Access Economics, Canberra, Australia
| | - David Hillman
- Centre for Sleep Science, University of Western Australia, Perth, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Robert Adams
- The Health Observatory, University of Adelaide, Adelaide, Australia
| | - Scott Mitchell
- Health Economics and Social Policy, Deloitte Access Economics, Canberra, Australia
| | - Lynne Pezzullo
- Health Economics and Social Policy, Deloitte Access Economics, Canberra, Australia
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22
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Predictors of positive airway pressure therapy termination in the first year: analysis of big data from a German homecare provider. BMC Pulm Med 2018; 18:186. [PMID: 30518372 PMCID: PMC6280473 DOI: 10.1186/s12890-018-0748-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 11/20/2018] [Indexed: 11/28/2022] Open
Abstract
Background There is a lack of robust data about factors predicting continuation (or termination) of positive airway pressure therapy (PAP) for sleep apnea. This analysis of big data from a German homecare provider describes patients treated with PAP, analyzes the therapy termination rate over the first year, and investigates predictive factors for therapy termination. Methods Data from a German homecare service provider were analyzed retrospectively. Patients who had started their first PAP therapy between September 2009 and April 2014 were eligible. Patient demographics, therapy start date, and the date of and reason for therapy termination were obtained. At 1 year, patients were classified as having compliance-related therapy termination or remaining on therapy. These groups were compared, and significant predictors of therapy termination determined. Results Of 98,329 patients included in the analysis, 11,702 (12%) terminated PAP therapy within the first year (after mean 171 ± 91 days). There was a U-shaped relationship between therapy termination and age; therapy termination was higher in the youngest (< 30 years, 15.5%) and oldest (≥ 80 years, 19.8%) patients, and lower in those aged 50–59 years (9.9%). Therapy termination was significantly more likely in females versus males (hazard ratio 1.48, 95% confidence interval 1.42–1.54), in those with public versus private insurance (1.75, 1.64–1.86) and in patients whose first device was automatically adjusting or fixed-level continuous positive airway pressure versus bilevel or adaptive servo-ventilation (1.28, 1.2–1.38). Conclusions This analysis of the largest dataset investigating PAP therapy termination identified a number of predictive factors. These can help health care providers chose the most appropriate PAP modality, identify specific patient phenotypes at higher risk of stopping PAP and target interventions to support ongoing therapy to these groups, as well as allow them to develop a risk stratification tool.
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Gordon A, Wu SJ, Munns N, DeVries A, Power T. Untreated Sleep Apnea: An Analysis of Administrative Data to Identify Risk Factors for Early Nonadherence. J Clin Sleep Med 2018; 14:1303-1313. [PMID: 30092889 DOI: 10.5664/jcsm.7260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/29/2018] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVES Discontinuation of positive airway pressure (PAP) treatment for obstructive sleep apnea (OSA) is widely reported, but research has not adequately addressed nonadherence with diagnostic testing for sleep disorders and initiation of PAP. This study sought to identify drivers of nonadherence with diagnostic sleep testing and PAP treatment initiation among patients preauthorized for these services. METHODS This observational cohort study used preauthorization records from a sleep management program and administrative medical claims from a large commercial health insurer. Participants included adults preauthorized for sleep testing and a subset in whom OSA was diagnosed and who were preauthorized for PAP treatment. Outcome measures were nonadherence with diagnostic sleep testing and PAP treatment initiation, identified as lack of a claim for a preauthorized service within 3 months of preauthorization of that service. Risk factors for nonadherence included patient demographics, prescribing factors, signs and symptoms of OSA, comorbidities, and prior health service utilization. RESULTS Of 51,749 patients preauthorized for diagnostic testing, 23.5% did not undergo testing. Among 19,968 patients preauthorized for PAP treatment, 11.1% did not initiate treatment. Testing and treatment ordered by primary care providers, residence outside the Midwest region, and two or fewer office visits within 6 months before preauthorization were strong predictors of nonadherence. Apnea-hypopnea index score < 30 events/h was also a strong predictor of nonadherence with treatment initiation. CONCLUSIONS This study adds to existing knowledge about risk factors for nonadherence with sleep testing and treatment initiation following preauthorization. Health plans and providers should develop strategies to better engage patients with higher risk of nonadherence.
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Abstract
Importance Obstructive sleep apnea syndrome (OSAS) is a common medical condition in the United States and affects gynecologic surgical outcomes. Objective The aim of this review was to improve perioperative diagnosis and management of OSAS in patients presenting for gynecologic surgery and ultimately improve perioperative outcomes. The role of preoperative evaluation and screening is also addressed. Evidence Acquisition Medical databases were queried for publications pertaining to OSAS complications, risk factors, screening, and perioperative management. Pertinent articles were reviewed by the study authors. Results Obstructive sleep apnea syndrome is underdiagnosed in the preoperative surgical population. Obesity and other risk factors for OSAS are prevalent in patients with gynecologic issues but are not fully assessed with screening prior to surgery. Effective treatment modalities, such as continuous positive airway pressure, and perioperative management strategies are available to improve patient outcomes. Conclusions and Relevance Increased diagnosis and treatment for OSAS in the perioperative period can improve perioperative outcomes, surgical outcomes, and long-term patient outcomes. Strategies to increase effective management in patients presenting for gynecologic surgery are needed.
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25
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May AM, Gharibeh T, Wang L, Hurley A, Walia H, Strohl KP, Mehra R. CPAP Adherence Predictors in a Randomized Trial of Moderate-to-Severe OSA Enriched With Women and Minorities. Chest 2018; 154:567-578. [PMID: 29684316 DOI: 10.1016/j.chest.2018.04.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/12/2018] [Accepted: 04/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Suboptimal CPAP adherence in OSA clinical trials involving predominantly white men limits interpretability and generalizability. We examined predictors of CPAP adherence in a clinical trial enriched with minorities. METHODS The Sleep Apnea Stress Study-a randomized, double-blind, sham-controlled trial of patients with moderate-to-severe OSA-included participants with complete 8-week adherence data (n = 138). Overnight 14-channel polysomnography, anthropometry, socioeconomic status, mood questionnaires, and week 1 CPAP adherence were analyzed via adjusted linear models relative to CPAP adherence (average minutes per night usage). RESULTS Overall, age was 51 ± 12 years, 55% of the patients were male, 55% were white, BMI was 36.7 ± 7.7 kg/m2, and median apnea-hypopnea index was 20 (interquartile range, 13-37). In univariate analyses adherence increased with randomization to active CPAP (81 min; 95% CI, 30-132), increasing age (35 min/decade; 95% CI, 13-57), white race (78 min, 95% CI, 26-129), and per hour of week 1 adherence (41 min, 95% CI, 32-51). Active CPAP (48 min, 95% CI, 6-91), increasing age (27 min/decade, 95% CI, 10-44), and higher 1-week adherence (36 min/h, 95% CI, 27-46) were significantly associated with improved adherence in multivariable analyses. Subgroup analyses showed stronger associations of adherence with treatment arm in whites and increasing age in minorities. Increasing age and white race were more strongly associated with adherence in women. CONCLUSIONS In this trial with near-even sex distribution and high ethnic minority representation, we identified CPAP assignment, increasing age, and early adherence to be associated with improved adherence in addition to sex-specific and race-specific adherence differences. These results can inform targeted clinical trial adherence optimization strategies. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00607893; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Anna M May
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Case Medical Center, Cleveland, Case Western Reserve University, Cleveland, OH; Division of Pulmonary, Critical Care, and Sleep Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH.
| | - Tarek Gharibeh
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Ahuja Medical Center, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Amanda Hurley
- Indiana Wesleyan University School of Nursing, Marion, IN
| | - Harneet Walia
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Case Medical Center, Cleveland, Case Western Reserve University, Cleveland, OH; Division of Pulmonary, Critical Care, and Sleep Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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26
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Nasal vs Oronasal CPAP for OSA Treatment. Chest 2018; 153:665-674. [DOI: 10.1016/j.chest.2017.10.044] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/17/2017] [Accepted: 10/20/2017] [Indexed: 01/11/2023] Open
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Woehrle H, Cowie MR, Eulenburg C, Suling A, Angermann C, d'Ortho MP, Erdmann E, Levy P, Simonds AK, Somers VK, Zannad F, Teschler H, Wegscheider K. Adaptive servo ventilation for central sleep apnoea in heart failure: SERVE-HF on-treatment analysis. Eur Respir J 2017; 50:50/2/1601692. [PMID: 28860264 PMCID: PMC5593355 DOI: 10.1183/13993003.01692-2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 05/28/2017] [Indexed: 12/24/2022]
Abstract
This on-treatment analysis was conducted to facilitate understanding of mechanisms underlying the increased risk of all-cause and cardiovascular mortality in heart failure patients with reduced ejection fraction and predominant central sleep apnoea randomised to adaptive servo ventilation versus the control group in the SERVE-HF trial.Time-dependent on-treatment analyses were conducted (unadjusted and adjusted for predictive covariates). A comprehensive, time-dependent model was developed to correct for asymmetric selection effects (to minimise bias).The comprehensive model showed increased cardiovascular death hazard ratios during adaptive servo ventilation usage periods, slightly lower than those in the SERVE-HF intention-to-treat analysis. Self-selection bias was evident. Patients randomised to adaptive servo ventilation who crossed over to the control group were at higher risk of cardiovascular death than controls, while control patients with crossover to adaptive servo ventilation showed a trend towards lower risk of cardiovascular death than patients randomised to adaptive servo ventilation. Cardiovascular risk did not increase as nightly adaptive servo ventilation usage increased.On-treatment analysis showed similar results to the SERVE-HF intention-to-treat analysis, with an increased risk of cardiovascular death in heart failure with reduced ejection fraction patients with predominant central sleep apnoea treated with adaptive servo ventilation. Bias is inevitable and needs to be taken into account in any kind of on-treatment analysis in positive airway pressure studies.
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Affiliation(s)
- Holger Woehrle
- ResMed Science Center, ResMed Germany Inc., Martinsried, Germany .,Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | | | - Christine Eulenburg
- Department of Epidemiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Anna Suling
- Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg, Germany
| | - Christiane Angermann
- Department of Medicine I and Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany
| | - Marie-Pia d'Ortho
- University Paris Diderot, Sorbonne Paris Cité, Hôpital Bichat, Explorations Fonctionnelles, DHU FIRE, AP-HP, Paris, France
| | | | | | | | | | - Faiez Zannad
- INSERM, Université de Lorraine, CHU Nancy, France
| | - Helmut Teschler
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg, Germany
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Eysteinsdottir B, Gislason T, Pack AI, Benediktsdottir B, Arnardottir ES, Kuna ST, Björnsdottir E. Insomnia complaints in lean patients with obstructive sleep apnea negatively affect positive airway pressure treatment adherence. J Sleep Res 2016; 26:159-165. [PMID: 27976438 DOI: 10.1111/jsr.12482] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/26/2016] [Indexed: 01/28/2023]
Abstract
The objective of this study was to evaluate the determinants of long-term adherence to positive airway pressure treatment among patients with obstructive sleep apnea, with special emphasis on patients who stop positive airway pressure treatment within 1 year. This is a prospective long-term follow-up of subjects in the Icelandic Sleep Apnea Cohort who were diagnosed with obstructive sleep apnea between 2005 and 2009, and started on positive airway pressure treatment. In October 2014, positive airway pressure adherence was obtained by systematically evaluating available clinical files (n = 796; 644 males, 152 females) with moderate to severe obstructive sleep apnea (apnea-hypopnea index ≥15 events per h). The mean follow-up time was 6.7 ± 1.2 years. In total, 123 subjects (15.5%) returned their positive airway pressure device within the first year, 170 (21.4%) returned it later and 503 (63.2%) were still using positive airway pressure. The quitters within the first year had lower body mass index, milder obstructive sleep apnea, less sleepiness, and more often had symptoms of initial and late insomnia compared with long-term positive airway pressure users at baseline. Both initial and late insomnia were after adjustment still significantly associated with being an early quitter among subjects with body mass index <30 kg m-2 , but not among those with body mass index ≥30 kg m-2 . The prevalence of early quitters decreased significantly during the study period (2005-2009). Almost two-thirds of patients with moderate to severe obstructive sleep apnea are positive airway pressure users after 7 years. Obesity level, obstructive sleep apnea severity and daytime sleepiness are important determinants of long-term adherence. Symptoms of initial and late insomnia are associated with early quitting on positive airway pressure among non-obese subjects.
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Affiliation(s)
- Bjorg Eysteinsdottir
- Department of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Thorarinn Gislason
- Department of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Allan I Pack
- Center for Sleep and Circadian Neurobiology and Division of Sleep Medicine/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bryndís Benediktsdottir
- Department of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Erna S Arnardottir
- Department of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Samuel T Kuna
- Center for Sleep and Circadian Neurobiology and Division of Sleep Medicine/Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Erla Björnsdottir
- Department of Respiratory Medicine and Sleep, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
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Jerrentrup L, Canisius S, Wilhelm S, Kesper K, Ploch T, Vogelmeier C, Greulich T, Becker HF. Work of Breathing in Fixed and Pressure Relief Continuous Positive Airway Pressure (C-Flex™): A post hoc Analysis. Respiration 2016; 93:23-31. [PMID: 27871083 DOI: 10.1159/000452423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 10/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Expiratory pressure relief continuous positive airway pressure (pressure relief CPAP; C-Flex™) causes increases in inspiratory duty cycle and shortening of expiratory time. It has been suggested that these changes are caused by an increase in work of breathing. OBJECTIVES We studied the effects of C-Flex on work of breathing and intrinsic positive end-expiratory pressure as compared to fixed CPAP. METHODS Work of breathing was analyzed in 24 patients with obstructive sleep apnea during treatment with fixed CPAP and C-Flex with 3 different pressure relief settings in a randomized order during rapid-eye-movement (REM) and non-REM sleep. Work of breathing was assessed on a breath-by-breath basis using a piezoelectric esophageal pressure catheter and a pneumotachograph for measuring airflow. RESULTS We found there was no increase in inspiratory work of breathing observed using C-Flex compared to fixed CPAP. Instead, we found a linear decrease in inspiratory work of breathing with increasing pressure relief, with a mean difference of 1.22 J/min between CPAP and maximum pressure release (C-Flex 3; 90% of the value with nasal CPAP); however, the decrease was not statistically significant. The decrease in inspiratory work of breathing associated with C-Flex has a significant inverse correlation with BMI. CONCLUSIONS The C-Flex technology does not change work of breathing but shows a tendency towards a reduction of inspiratory work of breathing in patients with a lower BMI using higher C-Flex. The effect is probably caused by diminishing airway resistance generated by the positive end-expiratory pressure. Our findings may lead to additional fields of application of the C-Flex technology, such as chronic obstructive pulmonary disease or muscular dystrophy.
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Affiliation(s)
- Lukas Jerrentrup
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Marburg, Germany
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Impact of a New Nasal Pillows Mask on Patients' Acceptance, Compliance, and Willingness to Remain on CPAP Therapy. SLEEP DISORDERS 2016; 2016:6713236. [PMID: 27648308 PMCID: PMC5014980 DOI: 10.1155/2016/6713236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/09/2016] [Indexed: 12/03/2022]
Abstract
Aim. Continuous positive airway pressure (CPAP) masks are a key factor in patient compliance. This program assessed the performance of a new nasal pillows mask (NPM) on a variety of new and established obstructive sleep apnea (OSA) patients using CPAP therapy. Methods. Five programs were developed to assess the new NPM [AirFit P10, ResMed] on naïve patients; patients established on another NPM; patients using a nasal mask; patients with low CPAP compliance; and patients who wished to stop using CPAP therapy. Results. A total of 212 patients were included. In naïve patients, CPAP usage after 3 months was 5.9 ± 1.7 hours/night, compared with the control group at 4.6 ± 2.4 hours/night (p < 0.05). In patients established on another NPM, usage improved to 7.4 ± 1.1 hours/night versus 6.7 ± 1.4 (p = 0.001). 78% of nasal mask users wished to continue using the new NPM. Low compliance patients improved with an average of 0.87 hours/night (p = 0.001) when using the new NPM. In patients at the point of quitting CPAP, 60% continued with therapy using the new NPM. Conclusion. The new NPM mask performed well in a variety of clinical groups of OSA patients receiving CPAP therapy and shows that technical advances in CPAP masks can improve patient compliance.
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Teschler H, Werther S, Bassenge-Sauer Z, Weinreich G, Stuck BA. Elektrische Atemwegsstimulation zur Therapie der obstruktiven Schlafapnoe. PNEUMOLOGE 2016. [DOI: 10.1007/s10405-016-0062-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Maeder MT, Schoch OD, Rickli H. A clinical approach to obstructive sleep apnea as a risk factor for cardiovascular disease. Vasc Health Risk Manag 2016; 12:85-103. [PMID: 27051291 PMCID: PMC4807890 DOI: 10.2147/vhrm.s74703] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Obstructive sleep apnea (OSA) is associated with cardiovascular risk factors, cardiovascular diseases, and increased mortality. Epidemiological studies have established these associations, and there are now numerous experimental and clinical studies which have provided information on the possible underlying mechanisms. Mechanistic proof-of-concept studies with surrogate endpoints have been performed to demonstrate that treatment of OSA by continuous positive airway pressure (CPAP) has the potential to reverse or at least to attenuate not only OSA but also the adverse cardiovascular effects associated with OSA. However, no randomized studies have been performed to demonstrate that treatment of OSA by CPAP improves clinical outcomes in patients with cardiovascular risk factors and/or established cardiovascular disease and concomitant OSA. In the present review, we summarize the current knowledge on the role of OSA as a potential cardiovascular risk factor, the impact of OSA on cardiac function, the role of OSA as a modifier of the course of cardiovascular diseases such as coronary artery disease, atrial fibrillation, and heart failure, and the insights from studies evaluating the impact of CPAP therapy on the cardiovascular features associated with OSA.
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Affiliation(s)
- Micha T Maeder
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Otto D Schoch
- Department of Respiratory Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
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