Dynamic Upper Airway Imaging during Wakefulness in Obese Subjects with and without Sleep Apnea

Analysis of Possible Predictors of Moderate and Severe Obstructive Sleep Apnea in Obese Patients

Objectives: To determine if there are clinical or anatomical differences between patients with grade II-IV obesity without obstructive sleep apnea (OSA) or mild OSA and patients with moderate or severe OSA and to assess whether any of these factors are predictive of moderate/severe OSA. Methods: Observational case-control study with consecutive sampling including patients between 18 and 65 years of age with grade II-IV obesity who were candidates for bariatric surgery. An anamnesis regarding OSA symptoms, a physical examination of the upper airway and a cardiorespiratory polygraphy were performed. Results: A total of 124 patients were included in the study, of whom 61.3% did not have OSA or had mild OSA and 38.7% had moderate or severe OSA. Age over 48 years was the only independent factor associated with moderate or severe OSA. Other factors showed a relation with moderate/severe OSA after multivariate analysis: male sex, STOP-BANG questionnaire ≥ 3, weight ≥ 105 kg, thick neck, neck circumference ≥ 41.25 cm, flaccid palate, Mallampati III-IV index, Friedman tongue position III-IV and retropalatal narrowing. Conclusions: The only independent predictive factor related to moderate or severe OSA in patients with morbid obesity was age over 48 years, therefore a sleep study remains essential for its diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04908-0.

Study of the upper airway anatomy using magnetic resonance imaging in Indian obese patients with obstructive sleep apnea - A pilot study

BACKGROUND

Obstructive sleep apnea (OSA) is very common in obese patients. However, why some obese patients have severe OSA while others do not is unclear. Research is limited regarding which structures contribute to upper airway narrowing, especially in Asian patients where bony restrictions is thought to be important.

METHODS

Nineteen consecutive patients with BMI ≥35 kg/m2, and newly diagnosed with OSA based on overnight polysomnography were studied using non-contrast magnetic resonance imaging (MRI) of the upper airway during wakefulness.

RESULTS

Patients were divided into two groups, one with severe OSA comprising 11 patients and one without severe OSA having 8 patients. The retro-palatal airway was narrowest in both groups. Patients with severe OSA had a significantly narrower retroglossal airway (0.99 ± 0.48 cm2 vs 2.61 ± 2.02 cm2, p = 0.02), primarily due to a narrower anteroposterior diameter at this level (p = 0.03). The tongue volume (p = 0.91), lateral pharyngeal wall volume (p = 0.26), tongue length (p = 0.93), soft palate length (p = 0.13), and dynamic change of upper airway with inspiration (p = 0.31) were not significantly different between the two groups.

CONCLUSIONS

While the retro-palatal airway is equally narrow in both groups of patients, patients with severe OSA also have a significantly narrower retro-glossal airway. This finding could represent either a generalized reduction in airway area in whole of the oropharynx or multiple-level obstruction; probably aggravating upper airway collapse during sleep, predisposing some Asian obese patients to develop severe OSA.

State-Dependent Biomechanical Behavior of Oropharyngeal Structures in Apneic and Control Subjects: A Proof-of-Concept Study

Rationale: Apneic individuals have reduced airway caliber during sleep. The biomechanical changes in upper airway anatomy contributing to this airway narrowing are largely unknown. Objectives: We sought to investigate the state-dependent (wake vs. sleep) biomechanical behavior of the upper airway soft-tissue and craniofacial structures. Methods: Upper airway magnetic resonance imaging was performed in 15 sleep-deprived control subjects (apnea-hypopnea index, <5; 0.3 ± 0.5 events per hour) and 12 sleep-deprived apneic subjects (apnea-hypopnea index, ⩾5; 35.2 ± 18.1 events per hour) during wake and sleep and analyzed for airway measures and soft-tissue/mandibular movement. Results: In the retropalatal region, control subjects showed sleep-dependent reductions (P ⩽ 0.037) in average cross-sectional airway area (CSA), minimum CSA, and anteroposterior and lateral dimensions. Apneic subjects showed sleep-dependent reductions (P ⩽ 0.002) in average CSA, minimum CSA, and anteroposterior and lateral dimensions. In the retroglossal region, control subjects had no sleep-dependent airway reductions. However, apneic subjects had sleep-dependent reductions in minimal CSA (P = 0.001) and lateral dimensions (P = 0.014). Control subjects only showed sleep-dependent posterior movement of the anterior-inferior tongue octant (P = 0.039), whereas apneic subjects showed posterior movement of the soft palate (P = 0.006) and all tongue octants (P ⩽ 0.012). Sleep-dependent medial movement of the lateral walls was seen at the retropalatal minimum level (P = 0.013) in control subjects and at the retropalatal and retroglossal minimum levels (P ⩽ 0.017) in apneic subjects. There was posterior movement of the mandible in apneic subjects (P ⩽ 0.017). Conclusions: During sleep, control and apneic subjects showed reductions in retropalatal airway caliber, but only the apneic subjects showed retroglossal airway narrowing. Reductions in anteroposterior and lateral airway dimensions were primarily due to posterior soft palate, tongue and mandibular movement and to medial lateral wall movement. These data provide important initial insights into obstructive sleep apnea pathogenesis.

Characteristics and Mechanism of Upper Airway Collapse Revealed by Dynamic MRI During Natural Sleep in Patients with Severe Obstructive Sleep Apnea

Purpose

Upper airway collapse during sleep in patients with obstructive sleep apnea (OSA) is a complex and dynamic phenomenon. By observing and analyzing the dynamic changes in the upper airway and its surrounding tissues during airway obstruction, we aim to reveal dynamic characteristics in different obstruction patterns, and the relationship between anatomical features during normal breathing and dynamic characteristics of airway obstruction.

Patients and Methods

Dynamic MRI was performed in 23 male patients (age range 26-63) with severe OSA diagnosed by overnight polysomnography, and obstruction events were identified from their images. Dynamic changes in parameters of the upper airway and surrounding tissues were measured to assess the key characteristics in different obstruction patterns.

Results

We categorized airway obstruction into four types based on the obstruction location and motion characteristics of tissues during collapse, and detailed the alterations in the airway and surrounding tissues under each obstruction pattern. In all 112 obstruction events extracted from the dynamic images of 23 patients, type A (retropalatal obstruction caused by the soft palate separated from the tongue), BI, BII (both retropalatal obstructions caused by the soft palate attached to the tongue, and C (retropalatal and retroglossal obstruction caused by the soft palate and the tongue), accounted for 28.6%, 44.6%, 12.5%, and 14.3% respectively. In severe OSA patients with tongue and palatal obstruction related to type B or C, the more posterior hyoid position, shorter distance between tongue and uvula, and wider retropalatal space, the larger the tongue displacement and deformation during collapse, and the greater the reduction in airway space.

Conclusion

There are multiple airway obstruction patterns, each with its own anatomical characteristics and behaviors during collapse. Hyoid position, tongue and uvula distance, and retropalatal space play an important role in airway collapse and should be paid more attention in the treatment of OSA.

The relationship of tongue fat content and efficacy of uvulopalatopharyngoplasty in Chinese patients with obstructive sleep apnea

BACKGROUND

To investigate the relationship between tongue fat content and severity of obstructive sleep apnea (OSA) and its effects on the efficacy of uvulopalatopharyngoplasty (UPPP) in the Chinese group.

METHOD

Fifty-two participants concluded to this study were diagnosed as OSA by performing polysomnography (PSG) then they were divided into moderate group and severe group according to apnea hypopnea index (AHI). All of them were also collected a series of data including age, BMI, height, weight, neck circumference, abdominal circumference, magnetic resonance imaging (MRI) of upper airway and the score of Epworth Sleepiness Scale (ESS) on the morning after they completed PSG. The relationship between tongue fat content and severity of OSA as well as the association between tongue fat content in pre-operation and surgical efficacy were analyzed.Participants underwent UPPP and followed up at 3rd month after surgery, and they were divided into two groups according to the surgical efficacy.

RESULTS

There were 7 patients in the moderate OSA group and 45 patients in the severe OSA group. The tongue volume was significantly larger in the severe OSA group than that in the moderate OSA group. There was no difference in tongue fat volume and tongue fat rate between the two groups. There was no association among tongue fat content, AHI, obstructive apnea hypopnea index, obstructive apnea index and Epworth sleepiness scale (all P > 0.05), but tongue fat content was related to the lowest oxygen saturation (r=-0.335, P < 0.05). There was no significantly difference in pre-operative tongue fat content in two different surgical efficacy groups.

CONCLUSIONS

This study didn't show an association between tongue fat content and the severity of OSA in the Chinese group, but it suggested a negative correlation between tongue fat content and the lowest oxygen saturation (LSaO2). Tongue fat content didn't influence surgical efficacy of UPPP in Chinese OSA patients.

TRIAL REGISTRATION

This study didn't report on a clinical trial, it was retrospectively registered.

Pharyngeal Inflammation on Positron Emission Tomography/Magnetic Resonance Imaging Before and After Obstructive Sleep Apnea Treatment

Rationale: There is upper airway inflammation in patients with obstructive sleep apnea (OSA), which reduces with continuous positive airway pressure (CPAP) therapy. Objectives: Validate the use of positron emission tomography (PET)/magnetic resonance imaging (MRI) to quantify metabolic activity within the pharyngeal mucosa of patients with OSA against nasal lavage proteomics and assess the impact of CPAP therapy. Methods: Adults with OSA underwent [18F]-Fluoro-2-deoxy-D-glucose PET/MRI of the neck before and 3 months after initiating CPAP. Nasal lavage samples were collected. Inflammatory protein expression from samples was analyzed using the Olink platform. Upper airway imaging segmentation was performed. Target-to-background ratio (TBRmax) was calculated from target pharyngeal maximum standard uptake values (SUV) and personalized background mean SUV. Most-diseased segment TBRmax was identified per participant at locations with the highest PET avidity. Correlation analysis was performed between baseline TBRmax and nasal lavage proteomics. TBRmax was compared before and after CPAP using linear mixed-effect models. Results: Among 38 participants, the baseline mean age was 46.3 years (standard deviation [SD], 12.5), 21% were female, the mean body mass index was 30.9 kg/m2 (SD, 4.6), and the mean respiratory disturbance index measured by peripheral arterial tonometry was 31 events/h (SD, 16.4). There was a significant positive correlation between pharyngeal mucosa most-diseased segment TBRmax and nasal lavage proteomic inflammation (r = 0.41 [P < 0.001, false discovery rate = 0.002]). Primary analysis revealed a reduction in the most-diseased segment TBRmax after a median of 2.91 months of CPAP therapy (-0.86 [standard error (SE) ± 0.30; P = 0.007]). Stratified analysis by smoking status revealed a significantly decreased most-diseased segment TBRmax after CPAP therapy among never-smokers but not among ever-smokers (-1.01 [SE ± 0.39; P = 0.015] vs. -0.64 [SE ± 0.49; P = 0.201]). Conclusions: CPAP therapy reduces metabolic activity measured by PET/MRI within the upper airway of adults with OSA. Furthermore, PET/MRI measures of upper airway metabolic activity correlate with a noninvasive marker of inflammation (i.e., nasal lavage inflammatory protein expression).

Ultrasound measurements for evaluation of changes in upper airway during anaesthesia induction and prediction difficult laryngoscopy: a prospective observational study

Upper airway collapsibility after anaesthesia induction may be associated with unpredictable difficult airway. However, most works on airway anatomy are tended to morphological description before anaesthesia. This study aimed to evaluate the changes of upper airway after anaesthesia induction and using pre-anesthetic ultrasound measurements to predict Difficult Laryngoscopy (DL). We included 104 eligible subjects with complete data, who were performed tracheal intubations under general anaesthesia in the study. The upper airway changes before and after anaesthesia induction were determined by seven neck ultrasound measurements, included as follow: (1) Distance from skin to under surface of Tongue (DT), (2) Thickness of the thickest part of Tongue body (TT), (3) Hyoid Mental Distance (HMD), (4) Depth of Hyoid (DH), (5) Width of Hyoid (WH), (6) Distance from Skin to Epiglottis (DSE), (7) Depth of the anterior combination of the Vocal Cords (DVC). DL was evaluated with Cormack-Lehane (CL). Data regarding HMD [from 45.3 (42.4-48.5) to 41.1 (38.5-44.9) mm], DH [from 8.7 (6.6-10.9) to 7.0 (5.3-9.1) mm], DSE [from 20.1 (16.6-22.5) to 19.5 (16.5-21.6) mm] and the DVC [from 7.1 (5.7-8.3) to 6.8 (5.7-7.9) mm] were decreased (P < 0.05), while the DT [from 15.9 (13.1-18.4) to 17.4 (14.5-19.8) mm] was increased (P > 0.05) after anaesthesia induction. Additionally, when cut-off value of DSE was 21.25 mm before anaesthesia, it may be better predicted to DL [sensitivity 80.0% (95% CI: 60.7-91.6%) and specificity 83.8% (95% CI: 73.0-91.0%)]. The upper airway after induction showed the propensity of collapsibility by ultrasound measurements. Compared with other indicators, the DSE assessed by ultrasound might be considered to a valuable predictor of DL.Trial registration: The study was registered in ClinicalTrials.gov on 23th Jan 2019, ChiCTR1900021123.

Inherent regional brain activity changes in male obstructive sleep apnea with mild cognitive impairment: A resting-state magnetic resonance study

Obstructive sleep apnea (OSA) is the most common sleep disorder worldwide. Previous studies have shown that OSA patients are often accompanied by cognitive function loss, and the underlying neurophysiological mechanism is still unclear. This study aimed to determine whether there are differences in regional homogeneity (Reho) and functional connectivity (FC) across the brain between OSA patients with MCI (OSA-MCI) and those without MCI (OSA-nMCI) and whether such differences can be used to distinguish the two groups. Resting state magnetic resonance data were collected from 48 OSA-MCI patients and 47 OSA-nMCI patients. The brain regions with significant differences in Reho and FC between the two groups were identified, and the Reho and FC features were combined with machine learning methods for classification. Compared with OSA-nMCI patients, OSA-MCI patients showed significantly lower Reho in bilateral lingual gyrus and left superior temporal gyrus. OSA-MCI patients also showed significantly lower FC between the bilateral lingual gyrus and bilateral cuneus, left superior temporal gyrus and left middle temporal gyrus, middle frontal gyrus, and bilateral posterior cingulate/calcarine/cerebellar anterior lobe. Based on Reho and FC features, logistic regression classification accuracy was 0.87; sensitivity, 0.70; specificity, 0.89; and area under the curve, 0.85. Correlation analysis showed that MoCA scale score in OSA patients was significant positive correlation sleep efficiency and negatively correlation with neck circumference. In conclusion, our results showed that the OSA-MCI group showed decreased Reho and FC in specific brain regions compared with the OSA-nMCI group, which may help to understand the underlying neuroimaging mechanism of OSA leading to cognitive dysfunction and may serve as a potential biomarker to distinguish whether OSA is accompanied by cognitive impairment.

The Impact of Obstructive Sleep Apnea on Clinical, Perioperative, and Cost Outcomes in Patients Who Underwent Posterior Cervical Decompression and Fusion: A Single-Center Retrospective Analysis From 2008 to 2016

BACKGROUND

Obstructive sleep apnea (OSA) is a pervasive problem that can result in diminished neurocognitive performance, increased risk of all-cause mortality, and significant cardiovascular disease. While previous studies have examined risk factors that influence outcomes following cervical fusion procedures, to our knowledge, no study has examined the cost or outcome profiles for posterior cervical decompression and fusion (PCDF) procedures in patients with OSA.

METHODS

All cases at a single institution between 2008 and 2016 involving a PCDF were included. The primary outcome was prolonged extubation, defined as an extubation that took place outside of the operating room. Secondary outcomes included admission to the intensive care unit (ICU), complications, extended hospitalization, nonhome discharge, readmission within 30 and 90 days, emergency room visit within 30 and 90 days, and higher total costs.

RESULTS

We reviewed 1191 PCDF cases, of which 93 patients (7.81%) had a history of OSA. At the univariate level, patients with OSA had higher rates of ICU admissions (33.3% vs 16.8%, P < 0.0001), total complications (29.0% vs 19.0%, P = 0.0202), and respiratory complications (12.9% vs 6.6%, P = 0.0217). Multivariate regression analyses revealed no difference in the odds of a prolonged extubation (P = 0.4773) and showed that history of OSA was not predictive of higher costs. However, a significant difference was observed in the odds of having an ICU admission (P = 0.0046).

CONCLUSION

While patients with sleep apnea may be more likely to be admitted to the ICU postoperatively, OSA status a lone is not a risk factor for poor primary and secondary clinical outcomes following posterior cervical fusion procedures.

CLINICAL RELEVANCE

Various deformities of the cervical spine can exert extraluminal forces that partially collapse or obstruct the airway, thereby predisposing patients to OSA; however, no study has examined the cost or outcome profiles for PCDF procedures in patients with OSA. Therefore, this investigation highlights the ways in which OSA influences the risks, outcomes, and costs following PCDF using medical data from an institutional registry.

LEVEL OF EVIDENCE: 3

Dynamic sleep MRI in obstructive sleep apnea: a systematic review and meta-analysis

PURPOSE

The objective of this study is to systematically review the international literature for dynamic sleep magnetic resonance imaging (MRI) as a diagnostic tool in obstructive sleep apnea (OSA), to perform meta-analysis on the quantitative data from the review, and to discuss its implications in future research and potential clinical applications.

STUDY DESIGN

A comprehensive review of the literature was performed, followed by a detailed analysis of the relevant data that has been published on the topic.

METHODS

Clinical key, Uptodate, Ovid, Ebscohost, Pubmed/MEDLINE, Scopus, Dynamed, Web of Science and The Cochrane Library were systematically searched. Once the search was completed, dynamic sleep MRI data were analyzed.

RESULTS

Nineteen articles reported on 410 OSA patients and 79 controls that underwent dynamic sleep MRI and were included in this review. For meta-analysis of dynamic sleep MRI data, eight articles presented relevant data on 160 OSA patients. Obstruction was reported as follows: retropalatal (RP) 98%, retroglossal (RG) 41% and hypopharyngeal (HP) in 5%. Lateral pharyngeal wall (LPW) collapse was found in 35/73 (48%) patients. The combinations of RP + RG were observed in 24% and RP + RG + LPW in 16%. If sedation was used, 98% of study participants fell asleep compared to 66% of unsedated participants.

CONCLUSIONS

Dynamic sleep MRI has demonstrated that nearly all patients have retropalatal obstruction, retroglossal obstruction is common and hypopharyngeal obstruction is rare. Nearly all patients (98%) who are sedated are able to fall asleep during the MRI. There is significant heterogeneity in the literature and standardization is needed.

Neck fat and obstructive sleep apnea in obese adolescents

STUDY OBJECTIVES

Increased neck circumference, a surrogate for the neck fat that can narrow the upper airway in obese individuals, is a risk factor for obstructive sleep apnea syndrome (OSAS) in adults, but the association between neck fat and OSAS in adolescent males and females is unknown. We hypothesized that obese adolescents with OSAS have more neck fat than controls, females more neck fat than males, and that neck fat correlates with obesity and OSAS severity.

METHODS

Obese adolescents with OSAS and obese and normal-weight controls underwent upper airway magnetic resonance imaging, polysomnography, and anthropometrics, including neck circumference measurement. Intra-neck and subcutaneous neck fat measurements were manually segmented and compared among the three groups using ANOVA and between males and females using t-tests. The relationship between polysomnographic parameters and neck fat measurements was assessed in adolescents with OSAS using Pearson correlations.

RESULTS

One-hundred nineteen adolescents (38 females) were studied: 39 obese with OSAS, 34 obese controls, and 46 normal-weight controls. Neck fat was not greater in adolescents with OSAS compared to obese controls (p=0.35), and neck fat volume was not related to OSAS severity (p = 0.36). However, obese adolescents had more neck fat than normal-weight controls (p < 0.001), and neck fat volume correlated with neck circumference (r = 0.53, p < 0.001). Females had significantly greater cross-sectional neck fat than males (p < 0.001).

CONCLUSIONS

While neck fat is associated with obesity and neck circumference in adolescents and is greater in females versus males, it does not appear to correlate with presence and severity of OSAS.

Obstructive Sleep Apnea: A Surgeon's Perspective

Obstructive sleep apnea (OSA) is a complex medical disorder with significant impact on mortality, quality of life, and long-term cardiovascular outcomes. The apnea-hypopnea index does not correlate well with either quality-of-life measures or health outcomes, so other outcome measures must be evaluated in treatment of OSA. OSA can be successfully treated through behavioral, nonsurgical, and surgical methods with improvements in quality of life, morbidity, and mortality. Surgical intervention should be considered in patients who are noncompliant with or fail positive airway pressure use. As is true with PAP therapy, surgery for OSA improves mortality and symptoms of OSA even when the polysomnogram does not fully normalize.

Novel non-invasive assessment of upper airway inflammation in obstructive sleep apnea using positron emission tomography/magnetic resonance imaging

PURPOSE

To develop a novel non-invasive technique to quantify upper airway inflammation using positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with obstructive sleep apnea (OSA).

METHODS

Patients with treatment naïve moderate-to-severe OSA underwent [18F]-fluoro-2-deoxy-D-glucose (FDG) PET/MRI. Three readers independently performed tracings of the pharyngeal soft tissue on MRI. Standardized uptake values (SUV) were generated from region of interest (ROI) tracings on corresponding PET images. Background SUV was measured from the sternocleidomastoid muscle. SUV and target-to-background (TBR) were compared across readers using intraclass correlation coefficient (ICC) analyses. SUV from individual image slices were compared between each reader using Bland-Altman plots and Pearson correlation coefficients. All tracings were repeated by one reader for assessment of intra-reader reliability.

RESULTS

Five participants completed our imaging protocol and analysis. Median age, body mass index, and apnea-hypopnea index were 41 years (IQR 40.5-68.5), 32.7 kg/m² (IQR 28.1-38.1), and 30.7 event per hour (IQR 19.5-48.1), respectively. The highest metabolic activity regions were consistently localized to palatine or lingual tonsil adjacent mucosa. Twenty-five ICC met criteria for excellent agreement. The remaining three were TBR measurements which met criteria for good agreement. Head-to-head comparisons revealed strong correlation between each reader.

CONCLUSIONS

Our novel imaging technique demonstrated reliable quantification of upper airway FDG avidity. This technology has implications for future work exploring local airway inflammation in individuals with OSA and exposure to pollutants. It may also serve as an assessment tool for response to OSA therapies.

Effect of sleep on upper airway dynamics in obese adolescents with obstructive sleep apnea syndrome

STUDY OBJECTIVES

The biomechanical basis of obstructive sleep apnea syndrome (OSAS) may influence upper airway dynamics. In this study, we investigate dynamic changes during respiration in wakefulness and sleep in obese adolescents with and without OSAS.

METHODS

Respiratory-gated dynamic magnetic resonance imaging (MRI) at the retropalatal and retroglossal regions was performed with simultaneous measurement of SpO2 and nasal-oral mask airflow and pressure. Airway cross-sectional area (CSA) was determined using AMIRA. Percent change in CSA was calculated from five continuous tidal breaths in states of wakefulness and sleep. Mixed effects models were used to evaluate interactions between group (OSAS/control), site (retropalatal/retroglossal), and stage (wake/sleep).

RESULTS

We studied 24 children with OSAS (mean age 15.49 ± 2.00 years, mean apnea-hypopnea index [AHI] 16.53 ± 8.72 events/h) and 19 controls (mean age 14.86 ± 1.75 years, mean AHI 2.12 ± 1.69 events/h). Groups were similar in age, sex, height, weight, and BMI Z-score. Participants with OSAS had a 48.17% greater increase in percent change of airway CSA during sleep than controls (p < 0.0001), while there was no difference between groups during wakefulness (p = 0.6589). Additionally, participants with OSAS had a 48.80% increase in percent change of airway CSA during sleep as compared with wakefulness (p < 0.0001), whereas no such relationship was observed in controls (p = 0.5513).

CONCLUSIONS

This study demonstrates significant effects of sleep on upper airway dynamics in obese children with OSAS. Dynamic MRI with physiological data can potentially provide further insight into the biomechanical basis of OSAS and assist in more effective management.

Obstructive sleep apnoea in adult patients post-tonsillectomy

BACKGROUND

The impact of removing the upper airway lymphoid tissue and in particular, tonsillectomy, in adults with OSA has not been demonstrated in large populations.

AIMS

To compare the severity of OSA and the prevalence of cardiovascular, metabolic and respiratory co-morbidities between patients with OSA who had undergone previous tonsillectomy and those who had not.

METHODS

The 19,711 participants in this study came from the European sleep apnea database (ESADA) which comprises data from unselected adult patients aged 18-80 years with a history of symptoms suggestive of OSA referred to sleep centers throughout Europe.

RESULTS

There were no differences between the two groups in terms of sex ratio and age (146 patients with previous tonsillectomy vs. 19565 patients without). Patients who had undergone tonsillectomy had a lower body mass index (29.3 ± 5.2 kg/m² vs 32.2 ± 6.6 kg/m², p < 0.001), lower subjective sleep latency (17.1 ± 17.8 min vs 25.5 ± 30.4 min, p = 0.001), lower ODI (15.7 ± 18.3 events/hour vs 30.7 ± 26.1 events/hour, p < 0.001), and SpO₂<90% time during sleep (21.8 ± 47.5 min vs 52.6 ± 80.8 min, p < 0.001). OSA patients with tonsillectomy had a lower prevalence of Type II diabetes mellitus (p = 0.001), hypertension (p < 0.001) and a higher prevalence of hyperlipidemia (p < 0.001) and were less likely to be commenced on CPAP (p < 0.001).

CONCLUSION

In a large population of almost 20,000 OSA patients from across Europe, patients who had undergone tonsillectomy presented with less severe OSA at time of diagnosis, and had a lower prevalence of Type II diabetes mellitus and cardiovascular co-morbidities.

Ultrasonographic Measurement of Pharyngeal-Airway Dimension and Its Relationship with Obesity and Sleep-Disordered Breathing

Previous studies based on magnetic resonance imaging (MRI) or computed tomography (CT) have shown that pharyngeal airway diameter during wakefulness is different between healthy controls and patients with a high risk of sleep-disordered breathing (SDB). However, MRI and CT are expensive and not easily accessible. Conversely, ultrasonography is more accessible and is getting more attention as a point-of-care technology to assess physiologic systems, such as the pharynx. Thus, we aimed to evaluate the feasibility of ultrasonography in estimating the pharyngeal airway dimension. To evaluate the pharyngeal airway with ultrasonography, we measured the parasagittal anterior-posterior (PAP) diameter and transverse diameter. For PAP diameter measurements, the transducer probe was placed in a submandibular lateral oblique position, with its superior margin abutting the angle of the left mandible. For the transverse measurement, the ultrasound probe was positioned in a submandibular location, in a near-coronal plane, just above the hyoid bone so that the tongue could be seen in cross-section. The diameter measurements were performed manually by two technicians. The reliability of these measurements was assessed by the intra-class correlation coefficient (ICC). To validate our measurements, we compared the measured PAP diameter with the average pharyngeal airway cross-sectional area from vellum to glottis measured by acoustic pharyngometry. Furthermore, we compared the influence of obesity and SDB in the measured pharyngeal diameters. Eighteen controls and 13 individuals with a high risk of SDB participated in this study. Reliability analysis of the PAP measurements yielded an ICC of 0.97 (95% confidence interval: 0.94-0.98). Furthermore, measured PAP diameters were significantly correlated with the pharyngeal airway cross-sectional area (r = 0.76, p < 0.01). Moreover, obesity and SDB were associated with decreases in PAP diameter. Our study shows that ultrasonography measurement of the PAP diameter may provide a quantitative assessment of the pharyngeal airway and may be useful for screening of SDB.

Ultrasound assessment of upper airway dilator muscle contraction during transcutaneous electrical stimulation in patients with obstructive sleep apnoea

Background

Electrical current can be used to stimulate upper airway dilator muscles to treat obstructive sleep apnoea (OSA). Ultrasound devices are widely available and may be used to detect contraction of the upper airway dilator muscles assessing the functionality of electrical stimulation (ES) used for this treatment.

Methods

In a physiological sub-study of a randomised controlled trial, patients with OSA underwent ultrasound examination to assess contraction of the upper airway dilator muscles in response to transcutaneous ES. Ultrasound scans were scored according to the picture quality (poor = '0', acceptable = '1' and good = '2'). Tongue base thickness was assessed in mid-sagittal and coronal planes with (D2, A2) and without ES (D1, A1), while awake and seated. The primary outcome was to determine the increase in tongue thickness during ES in both views (D2 - D1 = ΔD), as well as any increase in the cross-sectional area (CSA) in the coronal view (A2 - A1 = ΔA). Data were presented as mean and standard deviation (SD).

Results

Fourteen patients [eight male, age 57.5 (9.8) years, body mass index (BMI) 29.5 (2.8) kg/m²] with OSA [Apnea-Hypopnea Index (AHI) 19.5 (10.6) × hour^-1] were studied. Quality of the ultrasound scans was acceptable or good with 1.5 (0.5) points. In the mid-sagittal plane, ΔD was +0.17 (0.07) cm in midline and +0.21 (0.09) cm in the widest diameter, a percentual change of 12.2% (4%) and 12.8% (5.2%) (P<0.001, respectively). In the coronal plane, ΔD was +0.17 (0.04) cm, an increase of 12.3% (4.6%) (P<0.001, respectively), ΔA in the CSA increased by +18.9% (3.0%) with stimulation (P<0.001). There was a negative correlation between age and ΔA (r= -0.6, P=0.03), but no significant associations were found with gender, BMI, neck circumference, Epworth Sleepiness Scale (ESS), AHI, skin and subcutaneous tissue in the submental area.

Conclusions

Ultrasound can visualise upper airway dilator muscle contraction during transcutaneous ES in awake patients with OSA. Contraction is best detected in the CSA of the tongue base in the coronal plane.

Duration of safe apnea in patients with morbid obesity during passive oxygenation using high-flow nasal insufflation versus regular flow nasal insufflation, a randomized trial

BACKGROUND

Obese patients are at risk for rapid oxygen desaturation during anesthesia induction. Apneic oxygenation with regular flow oxygen insufflation has successfully been used to prolong the duration of safe apnea without desaturation (DAWD) in morbidly obese patients. Using high-flown nasal insufflation of oxygen (HFNI) for apneic oxygenation might further increase the DAWD.

OBJECTIVES

To compare the duration of safe apnea using high-flown nasal insufflation of oxygen or standard flow oxygen insufflation for apneic oxygenation in a simulated difficult intubation scenario in patients with morbid obesity.

SETTING

Operating room, University Hospital, Austria.

METHODS

In a prospective, randomized, clinical trial, patients received standardized preoxygenation and anesthesia induction. Apneic oxygenation was performed using standard nasal prongs (10 L/min) or HFNI (120 L/min) during laryngoscopy. A Cormack-Lehane 3° view was maintained until the oxygen saturation on pulse oximetry (SpO₂) dropped ≤95% or for a maximum of 15 minutes. The primary outcome of this study was to compare the duration of safe apnea using HFNI or standard flow oxygen insufflation for apneic oxygenation. In addition, arterial blood gas results, and airway pressures were investigated.

RESULTS

In 40 patients with morbid obesity (body mass index [BMI] >40 kg/m²) and the American Society of Anesthesiologists physical classification ≤3 who underwent bariatric surgery, the median duration of safe apnea was 601 (268-900) seconds in the standard group and 537 (399-808) seconds in the HFNI group (P = .698). No differences in arterial blood gas results were observed between the groups. The median airway pressure was 0 (0-0) cm H₂O in the standard group and 1 (0-2) cm H₂O in the HFNI group (P = .005).

CONCLUSION

Compared with standard nasal apneic oxygenation, HFNI did not increase the duration of safe apnea in patients with morbid obesity. A significant but clinically negligible higher airway pressure was observed when using HFNI.

Effect of Weight Loss on Upper Airway Anatomy and the Apnea-Hypopnea Index. The Importance of Tongue Fat

Rationale: Obesity is the primary risk factor for obstructive sleep apnea (OSA). Tongue fat is increased in obese persons with OSA, and may explain the relationship between obesity and OSA. Weight loss improves OSA, but the mechanism is unknown.Objectives: To determine the effect of weight loss on upper airway anatomy in subjects with obesity and OSA. We hypothesized that weight loss would decrease soft tissue volumes and tongue fat, and that these changes would correlate with reductions in apnea-hypopnea index (AHI).Methods: A total of 67 individuals with obesity and OSA (AHI ≥ 10 events/h) underwent a sleep study and upper airway and abdominal magnetic resonance imaging before and after a weight loss intervention (intensive lifestyle modification or bariatric surgery). Airway sizes and soft tissue, tongue fat, and abdominal fat volumes were quantified. Associations between weight loss and changes in these structures, and relationships to AHI changes, were examined.Measurements and Main Results: Weight loss was significantly associated with reductions in tongue fat and pterygoid and total lateral wall volumes. Reductions in tongue fat were strongly correlated with reductions in AHI (Pearson's rho = 0.62, P < 0.0001); results remained after controlling for weight loss (Pearson's rho = 0.36, P = 0.014). Reduction in tongue fat volume was the primary upper airway mediator of the relationship between weight loss and AHI improvement.Conclusions: Weight loss reduced volumes of several upper airway soft tissues in subjects with obesity and OSA. Improved AHI with weight loss was mediated by reductions in tongue fat. New treatments that reduce tongue fat should be considered for patients with OSA.

Effects of clear aligner therapy for Class II malocclusion on upper airway morphology and daytime sleepiness in adults: A case series

INTRODUCTION

To evaluate the effects of clear aligner therapy (CAT) on the upper airway dimensions and on daytime sleepiness in adults with dentoskeletal Class II malocclusion.

METHODS

This study was conducted from August 2017 to February 2019. Inclusion criteria were healthy adults≥18years old, Angle Class II division 1 malocclusion, first-molar relationship of end-to-end or greater, overjet<10mm, and presenting for multi-arch comprehensive orthodontic treatment with aligners. Treatment mechanics included mandibular dentoalveolar advancement with Class II elastics without maxillary sequential distalization programmed into aligners. Post-treatment changes in dentoskeletal and upper airway dimensions were assessed using CBCT images. The treatment effect on daytime sleepiness was evaluated using an Epworth Sleepiness Scale (ESS).

RESULTS

Eight subjects were included in this pilot study (mean age at treatment initiation=44.6years [SD=15.3]). The mean treatment duration was 12.2months (SD=3.4). No statistically significant treatment changes were observed in upper airway dimensions or dentoskeletal cephalometric analyses. Subjects with excessive daytime sleepiness at pre-treatment reported an improvement post-treatment, but no significant difference in the mean ESS score was found.

CONCLUSION

Treatment of Class II division 1 malocclusion in adults by mandibular dentoalveolar advancement using CAT has no statistically significant effects on the airway and dentoskeletal measurements, or daytime sleepiness.

Threshold of the upper airway cross-section for hypopnea onset during sleep and its identification under waking condition

Background

There is currently no method that can predict whether or under what condition hypopnea, even obstructive sleep apnea (OSA), will occur during sleep for individuals based on credible parameters measured under waking condition. We propose a threshold concept based on the narrowest cross-sectional area of the upper airway (CSA-UA) and aim to prove our hypothesis on the threshold of the area for hypopnea onset (TAHO), which can be used as an indicator of hypopnea onset during sleep and measured while awake.

Methods

We performed magnetic resonance imaging for 20 OSA patients to observe CSA-UA changes during fluid accumulation in the neck caused by elevating their legs, and identified TAHO by capturing the sudden enlargement in CSA-UA. Correlation analyses between TAHO and the body mass index (BMI), and between the reduction in CSA-UA and the increase in the neck circumference (NC) with fluid accumulation were performed. Logistic regression analysis was performed for identifying OSA patients based on the behaviors of their CSA-UA changes during leg raising. Shape changes of airway cross-section were also investigated.

Results

Four CSA-UA change patterns after fluid redistribution were identified. Six patients had similar CSA-UA variation behaviors observed in healthy subjects. From the other three change patterns involving 14 patients, a threshold value of CSA-UA 0.63 ± 0.21 cm² was identified for normal breathing. Data showed a positive correlation between TAHO and BMI (r = 0.681, p = 0.0007), and a negative correlation between the reduction in CSA-UA and the increase in NC (r = − 0.513, p = 0.051) with fluid accumulation. A sigmoid function for the probability of being a OSA patient p = 1/[1 + exp. (4.836 + 3.850 t-8.4 h)] was obtained to effectively separate OSA patients from normal subjects. The upper airway narrowing occurred in anteroposterior, lateral, or both directions, suggesting different tendencies of upper airway collapse in patients. Three types of shape changes in the cross-section of the upper airway, which had different effects on airway resistance, were measured.

Conclusions

Our findings prove TAHO hypothesis. The threshold measured while awake for normal breathing can be used clinically as the indicator of hypopnea onset during sleep, and therefore to identify OSA patients under waking condition and design effective personalized treatments for OSA patients. Both shape and size changes in the cross-section of the upper airway affect airway resistance significantly. Shape change in the cross-section of the upper airway can provide key clinical information on the collapse patterns of the upper airway for individuals.

Changes in the upper airway following induction of anaesthesia: a prospective observational study protocol to determine the use of ultrasound in the assessment of a difficult airway in China

INTRODUCTION

Difficult airway management is closely related to the safety and quality of medical care. However, the low incidence of correct prediction of difficult airway in clinical screening tests presents physicians with a dilemma. Depressed airway neuromuscular tension during sleep and anaesthesia tends to cause collapse of fragile parts of the upper airway. Although previous studies have confirmed that anterior cervical tissue thickness is associated with difficult airways, there is no evidence to support a correlation between a difficult airway and specific patterns or findings of anaesthesia-induced airway collapse. Thus, this study aims to examine changes in airway dimensions before and after induction of general anaesthesia to explore whether it could provide useful information regarding the specific anatomic changes occurring which may cause difficult airways.

METHODS AND ANALYSIS

This will be a single-centre prospective observational single-blinded study, conducted in a tertiary teaching hospital in Guangzhou, China. Subjects will be recruited from patients (aged 18-65 years) scheduled for elective surgery under general anaesthesia. Sonographic measurement will be performed to detect changes in the thickness of the anterior cervical soft tissue before and after anaesthetic induction. Based on the resulting data distribution, analyses will initially compare these changes using a paired t-test or the Wilcoxon signed-rank test. The correlation of sonographic changes and Cormack-Lehane grade will be evaluated by using receiver-operating characteristic curves to detect the sensitivity and specificity of a measurement for detecting difficulties. Linear stepwise regression analysis will be used to assess the correlation between airway changes and demographic variables as well as clinical tests.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine (ZYYECK (2018) 041). The results will be disseminated through conference presentations, professional journals and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR1900021123; Pre-results.