Novel porous oral patches for patients with mild obstructive sleep apnea and mouth breathing: a pilot study

Nose vs. mouth breathing- acute effect of different breathing regimens on muscular endurance

BACKGROUND

It has been reported that the way we breathe (whether through the nose or mouth) can influence many aspects of our health and to some extent, sport performance. The purpose of this study was to evaluate the acute effects of different breathing regimens on muscular endurance and physiological variables.

METHODS

A randomized experiment to verify the acute effect of different breathing regimens (NN- inhaling and exhaling through the nose; NM- inhaling through the nose, exhaling through the mouth; MM- inhaling and exhaling through the mouth) on the muscular endurance performance was conducted. 107 physically active college students (68 males, 39 females) performed repeated bench press testing protocol (repetitions to failure (RTF) with 60% of body weight for males (BP60), respectively 40% of body weight for females (BP40)) with various breathing regimens (NN, NM, MM) in random order. Heart rate (HR), blood oxygen saturation (SpO2) and perceived exertion by Borg scale (RPE) were measured as well. A short questionnaire, given after the testing protocol and observation during familiarization, was used to detect each subject's normal breathing approach during resistance training.

RESULTS

In both genders, no significant differences in RTF, RPE and SpO2 were found. No individual case of deviation of arterial oxygen saturation outside the physiological norm was recorded. ​​In the male group, significantly lower HR values were found during the NN trials, compared to during the NM (p = 0.033) and MM (p = 0.047) trials with no significant differences in females. The HR differences in the males demonstrated a small effect size (NN < NM, d = 0.32; NN < MM, d = 0.30). Questionnaire results suggest that 80% of our participants use NM breathing, 15% use MM breathing and 5% use NN breathing during resistance training.

CONCLUSION

It seems, that various breathing regimens have none or only minor effect on muscular endurance performance and selected physiological parameters. NN seems to be as efficient as other two regimens, which are mostly used in practice (NM, MM).

Mouth puffing phenomena of patients with obstructive sleep apnea when mouth-taped: device's efficacy confirmed with physical video observation

PURPOSE

This study aimed to design a device to monitor mouth puffing phenomena of patients with obstructive sleep apnea when mouth-taped and to employ video recording and computing algorithms to double-check and verify the efficacy of the device.

METHODS

A mouth puffing detector (MPD) was developed, and a video camera was set to record the patients' mouth puffing phenomena in order to make ensure the data obtained from the device was appropriate and valid. Ten patients were recruited and had polysomnography. A program written in Python was used to investigate the efficacy of the program's algorithms and the relationship between variables in polysomnography (sleep stage, apnea-hypopnea index or AHI, oxygen-related variables) and mouth puffing signals (MPSs). The video recording was used to validate the program. Bland-Altman plot, correlations, independent sample t-test, and ANOVA were analyzed by SPSS 24.0.

RESULTS

Patients were found to mouth puff when they sleep with their mouths taped. An MPD was able to detect the signals of mouth puffing. Mouth puffing signals were noted and categorized into four types of MPSs by our algorithms. MPSs were found to be significantly related to relative OSA indices. When all participants' data were divided into minutes, intermittent mouth puffing (IMP) was found to be significantly different from non-mouth puffing in AHI, oxygen desaturation index (ODI), and time of oxygen saturation under 90% (T90) (AHI: 0.75 vs. 0.31; ODI: 0.75 vs. 0.30; T90: 5.52 vs. 1.25; p < 0.001). Participants with severe OSA showed a higher IMP percentage compared to participants with mild to moderate OSA and the control group (severe: 38%, mild-to-moderate: 65%, control: 95%; p < 0.001).

CONCLUSIONS

This study established a simple way to detect mouth puffing phenomena when patients were mouth-taped during sleep, and the signals were classified into four types of MPSs. We propose that MPSs obtained from patients wearing the MPD can be used as a complement for clinicians to evaluate OSA.

Mouth Puffing Phenomenon and Upper Airway Features May Be Used to Predict the Severity of Obstructive Sleep Apnea

Purpose

This study aimed to investigate (1) the role of mouth puffing phenomenon and upper airway features in obstructive sleep apnea (OSA) and (2) whether mouth-taping during sleep alleviated the severity of OSA.

Participants and Methods

Seventy-one participants underwent a two-night home sleep test (the first day sleeping normally; the second day sleeping with their mouths being taped); their oximetry desaturation index (ODI) and mouth puffing signals (non-mouth puffing, complete mouth puffing, intermittent mouth puffing (IMP), and side mouth puffing) were detected by a validated fingertip pulse oximeter and a mouth puffing detector. The participants were grouped into the ODI-improved group and the ODI-not-improved group according to their sleeping test results. The radiograph was taken by cone-beam computed tomography and cephalometries. Upper airway features including airways, soft tissues, and oral cavity variables were measured.

Results

Participants with severe OSA showed a higher IMP percentage compared with those with normal, mild, and moderate OSA (severe: 33.78%, moderate: 22.38%, mild: 14.55%, normal: 0.31%, p < 0.001). In all participants, the ODI and the percentage of SpO₂ under 90 (T90) were positively related to body mass index (BMI) (r = 0.310 and 0.333, respectively), while ODI and T90 were negatively correlated with the minimum width of the airway (r = -0.473 and -0.474, respectively); all mentioned relationships were significant (p < 0.05).

Conclusion

IMP proportions were found to be higher in the half of participants whose ODI did not improve after mouth-taping and in those with severe OSA. Moreover, OSA patients with higher ODI, higher T90, and higher proportions of IMP were more likely to have a narrower upper airway.

The Impact of Mouth-Taping in Mouth-Breathers with Mild Obstructive Sleep Apnea: A Preliminary Study

Background: Many patients with obstructive sleep apnea (OSA) are mouth-breathers. Mouth-breathing not only narrows the upper airway, consequently worsening the severity of OSA, but also it affects compliance with nasal continuous positive airway pressure (CPAP) treatment. This study aimed to investigate changes in OSA by the use of mouth tape in mouth-breathers with mild OSA. Method: Mouth-breathers with mild OSA who met inclusion criteria and tolerated the sealing of the mouth were enrolled in the study. We used 3M silicone hypoallergenic tape was used to seal the mouths of the participants during sleep. The home sleep test (HST) used in this study was ApneaLink^®. Subjects received both a baseline HST and an outcome HST to be used 1 week later while their mouths were taped. The changes between the baseline and the outcome HSTs were compared, and the factors that influenced the differences in the sleep-test parameters after the shift of the breathing route were analyzed. A “responder” was defined as a patient who experienced a reduction from the baseline snoring index of at least 50% under mouth-taping in the HST; otherwise, patients were considered as having a poor response. Results: A total of 20 patients with mild OSA were included. Following the taping of the mouth, a good response was found in 13 patients (65%). The median apnea/hypopnea index (AHI) decreased significantly, from 8.3 to 4.7 event/h (by 47%, p = 0.0002), especially in supine AHI (9.4 vs. 5.5 event/h, p = 0.0001). The median snoring index (SI) was also improved (by 47%, 303.8 vs. 121.1 event/h, p = 0.0002). Despite no significant difference in the mean saturation, improvements in the oxygen desaturation index (8.7 vs. 5.8, p = 0.0003) and the lowest saturation (82.5% vs. 87%, p = 0.049) were noted. The change in AHI was associated with baseline AHI (r = −0.52, p = 0.02), oxygen desaturation index (ODI) (r = −0.54, p = 0.01), and SI (r = −0.47, p = 0.04). The change in SI was strongly associated with baseline SI (r = −0.77, p = 0.001). Conclusions: Mouth-taping during sleep improved snoring and the severity of sleep apnea in mouth-breathers with mild OSA, with AHI and SI being reduced by about half. The higher the level of baseline AHI and SI, the greater the improvement was shown after mouth-taping. Mouth-taping could be an alternative treatment in patients with mild OSA before turning to CPAP therapy or surgical intervention.

The application of polyethylene glycol-coated collagen patches in nasal surgery

Nasal packing is a significant factor of postoperative morbidity that affects quality of recovery following nasal surgery. The polyethylene glycol-coated (PEG) collagen patch (Hemopatch^® ) is a synthetic hemostatic agent with a dual mechanism of action, but whether it can be applied in nasal surgery remains unexplored. The postoperative symptoms of thick nasal discharge, loss of smell, headache, postnasal discharge, ear fullness and lack of good night's sleep in patients with Hemopatch are minimal after surgery. The total nasal resistance at postoperative day 1 (0.224 Pa/cm3) is lower than the preoperative total nasal resistance (0.412 Pa/cm3), indicating that the nasal air flow increases after surgery in patients using Hemopatch at postoperative day 1. This is the first report to demonstrate that Hemopatch is an alternative nasal packing to reduce the postoperative morbidity after nasal surgery.

Mouth Closing to Improve the Efficacy of Mandibular Advancement Devices in Sleep Apnea

RATIONALE

Mouth breathing increases upper airway collapsibility, leading to decreased efficacy of obstructive sleep apnea (OSA) treatments. We hypothesized that the use of mandibular advancement devices (MAD) increases mouth breathing and, thus, using an adhesive mouthpiece (AMT), to prevent mouth breathing, in combination with MAD can improve the treatment efficacy.

OBJECTIVES

To evaluate the efficacy of MAD + AMT in comparison to MAD alone.

METHODS

A prospective crossover pilot study was designed to test this hypothesis. Briefly, adult participants with an apnea-hypopnea index (AHI) between 10-50 events/h at the screening visit were randomized to no treatment (baseline), MAD treatment, AMT treatment, and MAD+AMT treatment. As a primary analysis, absolute AHI was compared between MAD and MAD + AMT arms. Secondary analyses included quantifying the percent change in AHI, percentage of complete (AHI < 5 events/h) and incomplete (AHI 5 - 10 events/h) responders, and the efficacy of AMT alone in comparison with other treatment arms.

RESULTS

A total 21 of participants were included. (Baseline AHI= 24.3±9.9 event/h) The median AHI (Interquartile [IQR]) in the MAD and MAD+AMT arms were 10.5 [5.4-19.6] events/h and 5.6 [2.2-11.7] events/h (p-value= 0.02), respectively. A total of 76% of individuals achieved an AHI < 10 events/h in the MAD + AMT arm vs. 43% in the MAD arm (p-value<0.01). Finally, the observed effect was similar in moderate to severe OSA (AHI ≥15 events/h) in terms of absolute reduction and treatment responders, and AMT alone did not significantly reduce the AHI compared to baseline.

CONCLUSION

Combination of an adhesive mouthpiece and MAD is a more effective therapy than MAD alone. These findings may help improve clinical decision-making in sleep apnea.

Breathing Re-Education and Phenotypes of Sleep Apnea: A Review

Four phenotypes of obstructive sleep apnea hypopnea syndrome (OSAHS) have been identified. Only one of these is anatomical. As such, anatomically based treatments for OSAHS may not fully resolve the condition. Equally, compliance and uptake of gold-standard treatments is inadequate. This has led to interest in novel therapies that provide the basis for personalized treatment protocols. This review examines each of the four phenotypes of OSAHS and explores how these could be targeted using breathing re-education from three dimensions of functional breathing: biochemical, biomechanical and resonant frequency. Breathing re-education and myofunctional therapy may be helpful for patients across all four phenotypes of OSAHS. More research is urgently needed to investigate the therapeutic benefits of restoring nasal breathing and functional breathing patterns across all three dimensions in order to provide a treatment approach that is tailored to the individual patient.

Strategies for Addressing Mouth-Breathing Treatment with an “Adequate” Nose

Now that we have discussed and analyzed strategies to surgically achieve an adequately functioning and appearing nose, additional treatments are still required in many cases to achieve jaw closure due to limited musculoskeletal tone of the maxilla and mandible, as we described in Chaps. 4 and 5. From surgical jaw expansion, orthodontic treatments to jaw closure straps and appliances, these strategies are considered and evaluated in this chapter.

The Influence of Functional Endoscopic Sinus Surgery on Sleep Related Outcomes in Patients with Chronic Rhinosinusitis

Purpose

Chronic rhinosinusitis (CRS) patients often complain of nasal obstruction, which may cause sleep impairment for them. The goal of this study was to investigate the influence of functional endoscopic sinus surgery (FESS) on sleep related outcomes in CRS patients.

Materials and Methods

CRS patients who received FESS were included in this study. Prior to FESS and 3 months after surgery the patients were asked about the severity of nasal obstruction and completed the 20-item Sinonasal Outcome Test (SNOT-20), along with the Epworth Sleepiness Scale (ESS) questionnaire. Endoscopic examination, acoustic rhinometry, and polysomnography were performed in all patients. They were divided into four groups according to their preoperative apnea hypopnea index (AHI) scores: nonobstructive sleep apnea syndrome (non-OSAS), mild OSAS, moderate OSAS, and severe OSAS.

Results

A total of 96 subjects completed the study. The scores of the sleep domain of the SNOT-20 and ESS decreased in all of the AHI groups, with the exception of the severe OSAS group, after FESS. A reduction in the AHI of less than 5 was achieved in 9 patients (13.2%) after FESS.

Conclusions

Our results showed that FESS improved sleep quality in CRS patients, except those with severe OSAS, and a preoperative lower AHI was the only significant predictor of post-FESS OSAS outcome.

Gravitational forces, negative pressure and facial structure in the genesis of airway dysfunction during sleep: a review of the paradigm

The recent and distant literature has extensive discussion of how sleep apnea, adeno-tonsillar growth, and facial structural deformity are related. Conventionally, the order of cause and effect is as follows: (1) Inflammatory/infectious process→tonsillar/adenoid tissue growth→(2) airway obstruction and mouth breathing/Obstructive Sleep Apnea (OSA)→(3) altered facial structure (adenoid facies). Using this same reasoning, adenotonsillectomy is the first line of treatment in the prevention of structural abnormalities. However, through a lifetime of clinical research Christian Guilleminault and his colleagues have challenged this paradigm. Through multiple articles and studies, Guilleminault et al., teach that even slight (subclinical) facial structure/muscle tone variations may be the inciting event triggering mouth-breathing and the eventual adenotonsillar growth in most patients. Essentially, this is the reverse of the conventional paradigms. Initial treatments therefore shift from simplified removal of inflammatory tissue to limiting mouth-breathing via musculo-skeletal modification. The purpose of this paper is to synthesize and analyze the recent (and distant) relevant literature to provide support for, and provide a potential anatomic mechanism for Guilleminault et al.'s paradigm-questioning clinical observations.