Treatment of Obstructive Sleep Apnea. Prospects for Personalized Combined Modality Therapy

Combination Therapies with an Oral Appliance in the Management of Obstructive Sleep Apnea

Combination therapy (CT) with a mandibular advancement device (MAD) and positive airway pressure (PAP) has been advocated for patients for whom neither MAD nor PAP alone provides an efficacious and tolerated therapy. This article reviews the small and limited, but growing body of evidence in support of CT and highlights details in its implementation. In most studies, CT was found to be preferred by many, but not all PAP-intolerant patients. CT can be more efficacious than either MAD or PAP alone.

Factors associated with treatment adherence to mandibular advancement devices: a scoping review

PURPOSE

Obstructive sleep apnea (OSA) is frequently treated with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs). For various reasons, both treatment options are often affected by low adherence. While factors associated with low CPAP adherence are described in the literature extensively, less is known about adherence to MAD therapy. This scoping review aimed to synthesize the body of literature on the factors associated with adherence to MAD treatment.

METHODS

A systematic literature search was conducted using bibliographic databases PubMed, Embase.com , Web of Science, and the Cochrane Library (Wiley) to identify relevant studies that described factors associated with adherence to MAD in the treatment of OSA or snoring combined with OSA in adults.

RESULTS

The literature search yielded a total of 694 references. Forty studies were found eligible for inclusion. The literature showed that factors with a possible negative influence on the adherence to MAD treatment are personality aspects; failing effectiveness of MAD; side effects during MAD therapy; using a thermoplastic MAD; dental treatments during MAD therapy; and a poor first experience with the MAD with inadequate guidance by professionals. Factors that may have a positive effect on MAD adherence include effectiveness of therapy, custom-made MAD, good communication skills of the practitioner, early recognition of side effects, stepwise titration of the MAD, and positive first experience with MAD.

CONCLUSIONS

The knowledge of factors associated with MAD adherence can be used to provide further insight into individual adherence to OSA treatments.

Positive Airway Pressure Adherence and Health Care Resource Utilization in Patients With Obstructive Sleep Apnea and Heart Failure With Reduced Ejection Fraction

Background Obstructive sleep apnea (OSA) is a common comorbidity in patients with heart failure, although current evidence is equivocal regarding the potential benefits of treating OSA with positive airway pressure (PAP) therapy in patients with heart failure. This study assessed the impact of adherence to PAP therapy on health care resource utilization in patients with OSA and heart failure with reduced ejection fraction. Methods and Results Administrative insurance claims data linked with objective PAP therapy use data from patients with OSA and heart failure with reduced ejection fraction were used to determine associations between PAP adherence and a composite outcome of hospitalizations and emergency room visits. One-year PAP adherence was based on an adapted US Medicare definition. Propensity score methods were used to create groups with similar characteristics across PAP adherence levels. The study cohort included 3182 patients (69.9% male, mean age 59.7 years); 39% were considered adherent to PAP therapy (29% intermediate adherent, 31% nonadherent). One year after PAP initiation, adherent patients had fewer composite visits than matched nonadherent patients, driven by a 24% reduction in emergency room visits for adherent patients. Composite visit costs were lower in adherent versus nonadherent patients ($3500 versus $5879, P=0.031), although total health care costs were not statistically different ($13 028 versus $14 729, P=0.889). Conclusions PAP therapy adherence in patients with OSA with heart failure with reduced ejection fraction was associated with a reduction in health care resource utilization. This suggests that greater emphasis should be placed on diagnosing and effectively treating OSA with PAP in patients with heart failure with reduced ejection fraction.

Prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study

BACKGROUND

Obstructive sleep apnoea (OSA) is characterised by partial or complete obstruction of the upper airways during sleep and it has been associated with temporomandibular disorders (TMDs) on the basis of several pathophysiological hypotheses.

OBJECTIVES

To assess the prevalence of TMDs in a population of patients affected by OSA compared to a control group of subjects not affected by OSA.

METHODS

A cross-sectional controlled study was conducted on a group subjects studied by polygraphy (PG) at the snoring section of the ENT department, Sant'Orsola-Malpighi Hospital - University of Bologna. Patients who received a diagnosis of OSA were included in the study group and subjects with a negative PG diagnosis for Sleep Disordered Breathing and PG respiratory pattern that did not suggest the occurrence of sleep disorders were enrolled in the control group. Both the subjects included in the study group and the control group underwent an examination following the Diagnostic Criteria for Temporomandibular Disorders Axis I and II.

RESULTS

Forty-three OSA patients (29 M, 16 F, mean age 52.26 ± 11.40) and 43 healthy controls (25 M, 18 F, mean age 49.95 ± 7.59) were included in the study. No significant differences were found between groups in demographic data. TMD prevalence and Axis II results did not differ between groups.

CONCLUSIONS

This paper does not highlight a higher prevalence of TMDs in adults with OSA compared to healthy controls. Further high-quality studies are needed to confirm the results and to give possible pathophysiological explanations, providing reliable evidence.

Impact of Unintentional Air Leaks on Automatic Positive Airway Pressure Device Performance in Simulated Sleep Apnea Events

BACKGROUND

Positive airway pressure (PAP) is the accepted standard treatment for obstructive sleep apnea. In the last decades, automatic PAP (APAP) adjustment modes have been increasingly used. Pressure auto adjustment offers better comfort to the patient and represents a valuable help for the clinician to provide optimal treatment. However, device performance differs among manufacturers. Furthermore, the success of the therapy relies greatly on unintentional air leak level for many reasons, hence the importance to investigate the performance of the most common devices. The aim of this study was to compare the performance of 3 APAP devices from the most common manufacturers in specific conditions (ie, obstructive sleep apnea, central sleep apnea, hypopnea), with and without unintentional air leak.

METHODS

This was a bench test study. Performance tests were conducted on a breathing simulator using a Starling resistor, representing the upper airways, and an adjustable unintentional air leak valve. Three APAP devices (AirSense 10, DreamStation, and Prisma 20A) were tested in different scenarios.

RESULTS

Without unintentional air leak, performance of the 3 devices was similar to existing literature. However, performance was altered with the addition of unintentional air leak in some scenario. The AirSense 10 was not able to respond correctly to obstructive apnea (intraclass correlation coefficient [ICC] 0.021, P = .61) and hypopnea (ICC 0.059, P = .26). Prisma 20A lowest performance was seen during simulated obstructive apnea (ICC 0.708, P < .001). DreamStation lowest performance was seen during simulated hypopnea events (ICC 0.755, P < .001).

CONCLUSIONS

All 3 APAP devices reacted differently to the added unintentional air leak. Performance was altered with some devices, which could affect the therapy success in patients with sleep apnea syndrome. The variability of performance of some APAP devices with unintentional air leak should make clinicians evaluate their use in a home setting.

Patient-Centered Therapy for Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA) is one of the most common sleep problems defined by cessation or decreased airflow despite breathing efforts. It is known to be related to multiple adverse health consequences. Positive airway pressure (PAP) is considered an effective treatment that is widely used. Various modes of PAP and other emerging treatment options are now available. A multidisciplinary approach, understanding diverse phenotypes of OSA, and shared decision-making are necessary for successful OSA treatment. Patient-centered care is an essential modality to support patient care that can be utilized in patients with OSA to help improve outcomes, treatment adherence, and patient satisfaction.

Phenotyping OSAH patients during wakefulness

PURPOSE

Although currently there are simplified methods to measure the pathophysiological traits that stimulate the occurrence and maintenance of obstructive sleep apnea-hypopnea (OSAH), they remain difficult to implement in routine practice. This pilot study aimed to find a simpler daytime approach to obtain a meaningful, similar pathophysiological phenotypic profile in patients with OSAH.

METHODS

After obtaining diagnostic polygraphy from a group of consecutive patients with OSAH, we performed the dial-down CPAP technique during nocturnal polysomnography and used it as reference method. This allowed assessment of upper airway collapsibility, loop gain (LG), arousal threshold (AT), and upper airway muscle gain (UAG). We compared these results with a daytime protocol based on negative expiratory pressure (NEP) technique for evaluating upper airway collapsibility and UAG, on maximal voluntary apnea for LG, and on clinical predictors for AT.

RESULTS

Of 15 patients studied, 13 patients with OSAH accurately completed the two procedures. There were strong (all r² > 0.75) and significant (all p < 0.001) correlations for each phenotypic trait between the measurements obtained through the reference method and those achieved during wakefulness.

CONCLUSION

It is possible to phenotype patients with OSAH from a pathophysiological point of view while they are awake. Using this approach, cutoff values corresponding to those usually adopted using the reference method can be identified to detect abnormal traits, achieving profiles similar to those obtained through the dial-down CPAP technique.

European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

OSA-patients who refuse/don't adhere to CPAP can profit from established/emerging treatment options. High scientific evidence is lacking. Patients’ values/preference may weigh heavy in the decision for non-CPAP options, while health inequity is a concern.https://bit.ly/3o0tJeP

Reversible Verbal Memory Integration Deficits in Obstructive Sleep Apnoea

When presented with novel but semantically related elements after learning verbal material, healthy participants tend to endorse these items as previously learned. This reflects the normal integration and association of novel verbal information into long-term memory. How obstructive sleep apnoea (OSA) negatively impacts verbal memory performance, and whether deficits are reversible following positive airway pressure (PAP) treatment, remain elusive. We investigated immediate and delayed OSA- and PAP treatment-related effects on verbal memory integration, using a false memory paradigm. Twenty-three patients with OSA learned lists of words semantically related to target non-presented words (1) at baseline after a polysomnography diagnosis night, (2) after a consecutive polysomnography night under PAP titration, and (3) after three months of compliant PAP treatment. At each session, participants learned 10 different lists of words, each list comprising 15 semantically related items. They had then to recognize 15 minutes later (after an intermediate vigilance task) previously learned words within a list including studied words (learned), unstudied but semantically related items (lures), and non-related unstudied items (controls). Sleep quality and fatigue questionnaires, and psychomotor vigilance tests (PVT) were administered at each session. PAP treatment led to OSA remission and improvement in objective and subjective sleep quality. Crucially, recognition of learned and lure words increased after the first night under treatment and remained stable three months later, suggesting successful memory integration and restoration of semantic processes. No treatment-related outcome was found on PVT performance. OSA exerts a detrimental but PAP-reversible effect on verbal learning and semantic memory integration mechanisms underlying the acquisition of novel memory representations.

Positive Airway Pressure Therapy Adherence with Mask Resupply: A Propensity-Matched Analysis

There are currently few data on the impact of mask resupply on longer-term adherence to positive airway pressure (PAP) therapy. This retrospective analysis investigated the effects of mask/mask cushion resupply on the adherence to PAP versus no resupply. Deidentified patient billing data for PAP supply items were merged with telemonitoring data from Cloud-connected AirSense 10/AirCurve 10 devices via AirView^TM (ResMed). Eligible patients started PAP between 1 July 2014 and 17 June 2016, had ≥360 days of PAP device data, and achieved initial U.S. Medicare adherence criteria. Patients who received a resupply of mask systems/cushions (resupply group) were propensity-score-matched with those not receiving any mask/cushion resupply (control group). A total of 100,370 patients were included. From days 91 to 360, the mean device usage was 5.6 and 4.5 h/night in the resupply and control groups, respectively (p < 0.0001). The proportion of patients with a mean device usage ≥4 h/night was significantly higher in the resupply group versus the control group (77% vs. 59%; p < 0.0001). The therapy termination rate was significantly lower in the resupply group versus the control group (14.7% vs. 31.9%; p < 0.0001); there was a trend toward lower therapy termination rates as the number of resupplies increased. The replacement of mask interface components was associated with better longer-term adherence to PAP therapy versus no resupply.

Evaluation of efficacy and safety of intraoral negative air pressure device in adults with obstructive sleep apnea in Taiwan

OBJECTIVE

Through this study, we aimed to evaluate the efficacy and safety of the intraoral negative air pressure device (iNAP) in patients with moderate to severe obstructive sleep apnea (OSA) in Taiwan.

DESIGN

Crossover and evaluator-blind, self-control design.

SETTING

Academic medical center.

PATIENTS

A total of 35 patients provided their consent to participate in this study; however, only 34 patients (30 men [87.5%] and four women [12.50%]) were eligible and randomized to the Clinical Cohort and Safety Cohort. The mean age of the 32 evaluable patients (PE cohort) was 47.4 ± 11.2 years, and their mean BMI was 26.5 ± 3.2 kg/m².

MEASUREMENTS AND RESULTS

The clinical response rate was 75% (24/32 patients) comparing the treatment polysomnography values to the baseline values. The mean (±standard deviation) baseline apnea-hypopnea index was 32.0 ± 11.3 events/h, which decreased significantly to 8.7 ± 9.4 events/h. Mo medical device-related adverse event or serious adverse event occurred during the study period.

CONCLUSIONS

Compared with the previous oral pressure therapy device, the iNAP treated approximately three-fourths of the patients with OSA and had a superior comfort and safety profile. Thus, the iNAP device could be an alternative treatment solution for patients with moderate to severe OSA.

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.

Obstructive sleep apnoea and adherence to continuous positive airway therapy among Australian women

BACKGROUND

Clinical characteristics of women with different obstructive sleep apnoea (OSA) severity and adherence to Continuous Positive Airway Pressure (CPAP) therapy have not been previously explored. Therefore, in this retrospective study we assessed OSA prevalence. predictors, clinical and polysomnographic (PSG) characteristics and adherence to CPAP therapy among adult Australian women.

METHODS

All female patients who underwent a diagnostic PSG between 2014/2015 were included. CPAP adherence was assessed during the study period between 2018/2019 using multiple regression model.

RESULTS

Among a total of 591 females included in this study (Aboriginal n=86), OSA was diagnosed in 458/591 (78%) patients; mild, moderate and severe OSA was present in 44%, 27% and 29% respectively. Older age, higher BMI and hypertension predicted the presence and severity of OSA. The Epworth Sleepiness Scale (ESS) score was not significantly different with [10 (5, 13)] or without [8 (5, 12)] OSA. PSG showed rapid eye movement (REM) sleep associated apnoea hypopnea index (AHI) was higher with all severity of OSA. Adherence to CPAP therapy was noted in 171 (57%) patients; 47% mild, 57% moderate and 63% with severe OSA respectively. Three multiple regression models [clinical, PSG parameters, OSA severity, combined (clinical and PSG)] showed combined model had strongest predictive value and demonstrated that higher ESS and more severe oxygen desaturation were associated with CPAP adherence irrespective of OSA severity.

CONCLUSION

Older age, higher BMI and presence of hypertension predicted the presence of OSA. REM sleep related AHI was higher. Adherence to CPAP was associated with symptomatic OSA and severe oxygen desaturation. This article is protected by copyright. All rights reserved.

Dental sleep medicine: Time to incorporate sleep apnoea education in the dental curriculum

Dental sleep medicine is a discipline that includes conditions such as sleep breathing disorders (eg snoring and sleep apnoea), sleep bruxism, orofacial pain and sleep-related complaints, and to some extent gastro-oesophageal reflux disorder and/or insomnia. Obstructive sleep apnoea (OSA) is a life-threatening condition that dentists need to identify and manage when indicated in order to increase patient well-being and to be taken in consideration in the dental curriculum. The main objective of this paper is to highlight the relevance of dental sleep medicine in the context of dental education, and to discuss potential educational content for integration in the dental curriculum with a focus on OSA, a condition that is not yet integrated in many dental training curricula around the world.

Lacune is the stroke subtype linked to obstructive sleep apnea

BACKGROUND

Each stroke subtype is associated with specific risk factors, and stroke prevention depends solely on the control of the underlying risk factors for each stroke subtype. Obstructive sleep apnea has been established as a major risk factor for stroke and cardiovascular disease. However, information on the stroke subtype linked to obstructive sleep apnea is scarce.

METHODS

This was a single-center, observational case series study conducted on patients who were admitted with acute ischemic stroke to King Khalid University Hospital. The TOAST criteria were used to determine the stroke subtype in each of these patients. The Berlin questionnaire was utilized to assess the presence of obstructive sleep apnea. The proportion of each stroke subtype was then calculated and compared between the group with associated obstructive sleep apnea and the group without associated obstructive sleep apnea.

RESULTS

A total of 170 consecutive patients with acute ischemic stroke were admitted between January 2018 and September 2018. Eighty-seven (51%) patients were found to have obstructive sleep apnea. The proportion of small artery disease was significantly greater in the obstructive sleep apnea group (44% vs. 26%, P = 0.02). There was no difference in the distribution of the other stroke subtypes between the two groups. Univariate analysis revealed that small artery disease was associated with body mass index, hypertension, and obstructive sleep apnea. However, in a multivariate logistic analysis, only hypertension was found to be independently associated with small artery disease.

CONCLUSION

Small artery disease is the most common stroke subtype associated with obstructive sleep apnea. Clinicians must vigilantly assess the presence of obstructive sleep apnea in ischemic stroke patients, especially in patients whose stroke is attributed to small artery disease.

Electrical stimulation as a therapeutic approach in obstructive sleep apnea - a meta-analysis

PURPOSE

Electrical stimulation of the upper airway dilator muscles is an emerging treatment for obstructive sleep apnea (OSA). Invasive hypoglossal nerve stimulation (HNS) has been accepted as treatment alternative to continuous positive airway pressure (CPAP) for selected patients, while transcutaneous electrical stimulation (TES) of the upper airway is being investigated as non-invasive alternative.

METHODS

A meta-analysis (CRD42017074674) on the effects of both HNS and TES on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) in OSA was conducted including published evidence up to May 2018. Random-effects models were used. Heterogeneity and between-study variance were assessed by I² and τ², respectively.

RESULTS

Of 41 identified clinical trials, 20 interventional trials (n = 895) could be pooled in a meta-analysis (15 HNS [n = 808], 5 TES [n = 87]). Middle-aged (mean ± SD 56.9 ± 5.5 years) and overweight (body mass index 29.1 ± 1.5 kg/m²) patients with severe OSA (AHI 37.5 ± 7.0/h) were followed-up for 6.9 ± 4.0 months (HNS) and 0.2 ± 0.4 months (TES), respectively. The AHI improved by - 24.9 h^-1 [95%CI - 28.5, - 21.2] in HNS (χ² 79%, I² 82%) and by - 16.5 h^-1 [95%CI - 25.1, - 7.8] in TES (χ² 7%, I² 43%; both p < 0.001). The ESS was reduced by - 5.0 (95%CI - 5.9, - 4.1) (p < 0.001).

CONCLUSION

Both invasive and transcutaneous electrical stimulation reduce OSA severity by a clinically relevant margin. HNS results in a clinically relevant improvement of symptoms. While HNS represents an invasive treatment for selected patients with moderate to severe OSA, TES should be further investigated as potential non-invasive approach for OSA.

Obstructive Sleep Apnea, Hypertension, and Cardiovascular Risk: Epidemiology, Pathophysiology, and Management

PURPOSE OF REVIEW

Given the rising prevalence of obstructive sleep apnea (OSA), we aimed to review the epidemiologic and pathophysiologic relationship of OSA, hypertension, and cardiovascular disease, and to summarize recent advances in the treatment of OSA.

RECENT FINDINGS

OSA is associated with an elevated risk of hypertension and cardiovascular disease. Several pathophysiologic factors contribute to the relationship between OSA and vascular risk, including neurohormonal dysregulation, endothelial dysfunction, and inflammation. While CPAP reduces blood pressure, it has not been demonstrated to reduce cardiovascular risk. The combination of CPAP and weight loss has a synergistic effect on blood pressure and several metabolic parameters. Adherence to CPAP is poor across studies, potentially contributing to the attenuation of perceived cardiovascular benefit from CPAP therapy. A greater emphasis on adherence to CPAP and the combination of CPAP and weight loss are central to reducing cardiovascular risk among individuals with OSA.

Positional Sleep Apnea Among Regional and Remote Australian Population and Simulated Positional Treatment Effects

PURPOSE

To assess the prevalence of positional sleep apnea (POSA) and its predictors in patients diagnosed to have obstructive sleep apnea (OSA) in the regional and remote population of the Northern Territory of Australia over a two-year study period (2018 and 2019).

PATIENTS AND METHODS

Of the total 1463 adult patients who underwent a diagnostic polysomnography (PSG), 946 patients were eligible to be included in the study, of them, 810 consecutive patients with OSA (Apnea-Hypopnea Index (AHI) ≥ 5) who slept >4 h and had ≥30 min sleep in both supine and lateral positions were assessed. Patients were considered to have POSA if supine AHI to lateral AHI ratio ≥2. The likely comparative impact of use of continuous positive airway therapy (CPAP) or positional therapy (PT) on disease severity was evaluated using model simulation.

RESULTS

A total of 495/810 (61%) patients had POSA, the majority were males (68% vs 60%, p=0.013) and non-Indigenous Australians (93% vs 87%, p=0.004). POSA patients were younger (mean difference 2.23 years (95% CI 0.27, 4.19)), less obese (BMI mean difference 3.06 (95% CI 2.11, 4.01)), demonstrated less severe OSA (p < 0.001) and a greater proportion reported alcohol consumption (72% vs 62%, p=0.001) as compared to those with non-POSA. Using the simulation model, if patients with POSA use PT two-thirds (323/495, 65%) would obtain significant improvement of their OSA severity, with one in five (92/495, 19%) displaying complete resolution. Comparing this to simulated CPAP therapy, where the majority (444/495, 90%) will show significant improvement, and one-third (162/495, 33%) will display complete resolution.

CONCLUSION

POSA needs to be routinely recognised and positional therapy integrated in practice especially in the remote regions and in the developing world when effective methods are in place to monitor positional therapy.

Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.

The Effect of the Modified Jaw-Thrust Maneuver on the Depth of Sedation During Drug-Induced Sleep Endoscopy

STUDY OBJECTIVES

The modified jaw-thrust maneuver (MJTM) during drug-induced sleep endoscopy (DISE) is known to predict the treatment effect of mandibular advancement devices. However, its effect on the depth of sedation and potential to provoke arousal by awakening patients during the maneuver has not been studied so far. This study investigated the effect of the MJTM on the depth of sedation during DISE.

METHODS

Forty patients on whom the MJTM was performed during DISE were included. The effect of the maneuver was evaluated at the levels of the velum, lateral wall of the oropharynx, base of the tongue, and epiglottis. Obstruction was defined as the collapse of the upper airway exceeding 75%, and improvement with the MJTM was defined as the widening of the upper airway by more than 50% during the maneuver. A bolus injection of midazolam was used to induce sedation and control the depth of sedation (bispectral index value of 60 to 80).

RESULTS

Obstructions were present in the velum of all patients, lateral wall of the oropharynx of 13 patients, base of the tongue of 28 patients, and epiglottis of 6 patients. After the MJTM, improvement of the obstruction was observed in 57.5%, 61.5%, 82%, and 66.7% of patients with velum, lateral wall of the oropharynx, base of the tongue, and epiglottis obstructions, respectively. An increase in the bispectral index value of more than 20 was observed in 8 patients. Four patients awakened during the procedure.

CONCLUSIONS

The MJTM significantly relieved obstruction during DISE, especially at the base of the tongue. However, this might have been caused by an increase in the degree of awakening during the maneuver. Therefore, MJTM's effect on the depth of sedation may help in improving the degree of airway obstruction.

Drug-Induced Sleep Endoscopy: Clinical Application and Surgical Outcomes

The visualization of the level and pattern of apnea and hypopnea events is of pivotal importance in the diagnosis and therapeutic decision-making for sleep-disordered breathing (SDB). There are numerous techniques available to assess upper airway obstruction, which include imaging, acoustic analysis, pressure transducer recording, and endoscopic evaluation. Drug-induced sleep endoscopy (DISE) is a diagnostic tool that allows the dynamic, three-dimensional evaluation of the patterns of vibration and collapse of the upper airway of SDB patients. DISE may change the initial surgical planning in a high percentage of cases. A universally accepted and methodologically standardized DISE could provide significant insight into its role to improve surgical outcomes. However, up to now the ideal DISE protocol remains an open question.

Relationship Between Sleep Apnea and Coronary Artery Calcium in Patients With Ischemic Stroke

Study Objectives: Coronary artery disease is considered to be the major cause of death amongst patients with ischemic stroke. The coronary artery calcium (CAC) score is related not only to sleep-disordered breathing, but also with future risk of cardiovascular mortality. We investigated the association between the severity of sleep-disordered breathing and CAC score in patients with ischemic stroke.

Methods: We included 32 patients who underwent coronary multichannel computed tomography and polysomnography (within 2 years of the stroke event) amongst the patients admitted to our clinic due to acute ischemic stroke. We investigated vascular risk factors, polysomnography findings, and sleep questionnaire scores, and their relationships with the CAC score.

Results: All patients were found to have sleep apnea of any degree, and 23 (72%) had severe sleep apnea. Twenty-three (72%) patients had a positive CAC score. Higher CAC scores were associated with elevated respiratory disturbance index (RDI), apnea index, oxygen desaturation index, and STOP-BANG test scores. Multivariate analysis after adjusting for potential confounding factors revealed independent relationships between the CAC score and the RDI (ß [SE] = 5.3 [2.1], p = 0.01), oxygen desaturation index (ß [SE] = 6.8 [2.8], p = 0.02), and STOP-BANG test score (ß [SE] = 90.3 [37.7], p = 0.02).

Conclusion: Our findings indicate a relationship between coronary atherosclerotic burden measured by the CAC score and the severity of sleep apnea. Performing polysomnography could be useful for investigating the severity of hidden coronary artery disease among these patients.

Prediction of Obstructive Sleep Apnea Based on Respiratory Sounds Recorded Between Sleep Onset and Sleep Offset

OBJECTIVES

To develop a simple algorithm for prescreening of obstructive sleep apnea (OSA) on the basis of respiratory sounds recorded during polysomnography during all sleep stages between sleep onset and offset.

METHODS

Patients who underwent attended, in-laboratory, full-night polysomnography were included. For all patients, audio recordings were performed with an air-conduction microphone during polysomnography. Analyses included all sleep stages (i.e., N1, N2, N3, rapid eye movement, and waking). After noise reduction preprocessing, data were segmented into 5-s windows and sound features were extracted. Prediction models were established and validated with 10-fold cross-validation by using simple logistic regression. Binary classifications were separately conducted for three different threshold criteria at apnea hypopnea index (AHI) of 5, 15, or 30. Prediction model characteristics, including accuracy, sensitivity, specificity, positive predictive value (precision), negative predictive value, and area under the curve (AUC) of the receiver operating characteristic were computed.

RESULTS

A total of 116 subjects were included; their mean age, body mass index, and AHI were 50.4 years, 25.5 kg/m2 , and 23.0/hr, respectively. A total of 508 sound features were extracted from respiratory sounds recorded throughout sleep. Accuracies of binary classifiers at AHIs of 5, 15, and 30 were 82.7%, 84.4%, and 85.3%, respectively. Prediction performances for the classifiers at AHIs of 5, 15, and 30 were AUC, 0.83, 0.901, and 0.91; sensitivity, 87.5%, 81.6%, and 60%; and specificity, 67.8%, 87.5%, and 94.1%. Respective precision values of the classifiers were 89.5%, 87.5%, and 78.2% for AHIs of 5, 15, and 30.

CONCLUSION

This study showed that our binary classifier predicted patients with AHI of ≥15 with sensitivity and specificity of >80% by using respiratory sounds during sleep. Since our prediction model included all sleep stage data, algorithms based on respiratory sounds may have a high value for prescreening OSA with mobile devices.

The Impact of Altitude on Sleep-Disordered Breathing in Children Dwelling at High Altitude: A Crossover Study

Study Objectives

Sleep-disordered breathing (SDB) is prevalent among children and is associated with adverse health outcomes. Worldwide, approximately 250 million individuals reside at altitudes higher than 2000 meters above sea level (masl). The effect of chronic high-altitude exposure on children with SDB is unknown. This study aims to determine the impact of altitude on sleep study outcomes in children with SDB dwelling at high altitude.

Methods

A single-center crossover study was performed to compare results of high-altitude home polysomnography (H-PSG) with lower altitude laboratory polysomnography (L-PSG) in school-age children dwelling at high altitude with symptoms consistent with SDB. The primary outcome was apnea-hypopnea index (AHI), with secondary outcomes including obstructive AHI; central AHI; and measures of oxygenation, sleep quality, and pulse rate.

Results

Twelve participants were enrolled, with 10 included in the final analysis. Median altitude was 1644 masl on L-PSG and 2531 masl on H-PSG. Median AHI was 2.40 on L-PSG and 10.95 on H-PSG. Both obstructive and central respiratory events accounted for the difference in AHI. Oxygenation and sleep fragmentation were worse and pulse rate higher on H-PSG compared to L-PSG.

Conclusions

These findings reveal a clinically substantial impact of altitude on respiratory, sleep, and cardiovascular outcomes in children with SDB who dwell at high altitude. Within this population, L-PSG underestimates obstructive sleep apnea and central sleep apnea compared to H-PSG. Given the shortage of high-altitude pediatric sleep laboratories, these results suggest a role for home sleep apnea testing for children residing at high altitude.

Papageorgiou S. Oral Interventions for Obstructive Sleep Apnea

BACKGROUND

The effectiveness of intraoral appliances (IOA), maxillary expansion (ME), and maxillomandibular advancement (MMA) in the treatment of children and adults with obstructive sleep apnea (OSA) has not yet been adequately assessed.

METHODS

An umbrella review was performed based on established guidelines for evidence-based medicine. Data synthesis was performed only from randomized controlled trials with Paule-Mandel random-effects meta-analyses / meta-regressions using mean differences (MDs) and 95% confidence intervals (CIs) and was followed by the qualitative evaluation of the meta-evidence.

RESULTS

29 systematic reviews were included, 7 of which provided quantitative data. IOA were effective in improving apnea hypopnea index (AHI) compared to both, placebo appliances (12 trials; 525 patients; MD = -11.70; 95% CI: [-15.38; -8.01]; p<0.001) and no treatment (1 trial; 24 patients; MD = -14.30; [-21.59; -7.01]; p<0.001). Only the former comparison was supported by robust meta-evidence. Effectiveness of IOA as measured by the Epworth Sleepiness Scale, on the other hand, was not supported by robust meta-evidence. No randomized or prospective controlled trials were found on the effectiveness of ME (conventional or surgically assisted) and MMA.

CONCLUSION

Intraoral appliances are effective in reducing AHI and their use is substantiated by robust evidence. There is no evidence from high-quality research to support treatment with ME (conventional or surgically assisted) or MMA in patients with OSA.

Kinesthetic stimulation for obstructive sleep apnea syndrome: An "on-off" proof of concept trial

Obstructive sleep apnea (OSA) occurs when the upper airway narrows or collapses due to the loss of upper airway muscle activation at sleep onset. This study investigated the effectiveness of triggered kinesthetic stimulation in patients with OSA. This proof-of-concept, open-label, multicenter prospective study was conducted on 24 patients with severe OSA. During a one night evaluation, kinesthetic stimulation was intermittently delivered in 30 minute periods. The duration of apneas and hypopneas during Stim _on and Stim _off periods were compared. Five hospital-based university centers in France participated. Sleep studies were evaluated by a single scorer at a core laboratory (CHU Grenoble). Results show that during the Stim _on phases, statistically significant decreases in durations of apneas and hypopneas were observed in 56% and 46% of patients, respectively. Overall, 75% of patients showed an improvement in apneas or hypopneas durations. The mean reduction in durations for patients with a significant decrease was 4.86 seconds for apneas and 6.00 seconds for hypopneas. This proof of concept study is the first to identify kinesthetic stimulation as a potentially effective therapy for OSA. These data justify evaluation in a controlled study.

Patient Engagement Using New Technology to Improve Adherence to Positive Airway Pressure Therapy: A Retrospective Analysis

BACKGROUND

Sleep apnea has major neurocognitive and cardiovascular and metabolic risks. Treatment of sleep apnea is suboptimal because of variable adherence to existing therapies.

METHODS

This trial compared positive airway pressure adherence among patients who were provided active patient engagement (APE) technology vs those who received usual care monitoring (UCM). The primary outcome was expressed by using the US Medicare definition of adherence. Adherence data from two cloud-based databases (AirView and myAir) were analyzed for patients with sleep apnea. Data were included if a patient's activation date in the APE tool was within 7 days of the therapy start date in the UCM database during a defined time window. Data were propensity matched in a 1:2 ratio (APE:UCM) based on baseline patient characteristics.

RESULTS

A total of 128,037 patients were analyzed. Baseline characteristics were typical of a sleep clinic cohort. APE was associated with more patients achieving adherence criteria (87.3%) compared with UCM patients (70.4%; P < .0001 for the difference). Average therapy usage was 5.9 h per night in the APE group vs 4.9 h per night in the matched UCM patients (P < .0001). Patients with sleep apnea "struggling" with therapy adherence had a 17.6% absolute improvement in adherence using APE compared with UCM.

CONCLUSIONS

Robust therapy adherence rates can be achieved by adding modern technology to usual care. Adopting advances in technology in care management may allow clinicians to more effectively and efficiently treat patients who have sleep apnea. Rigorous randomized controlled trials may be required before making strong clinical recommendations.

Effectiveness of inspiratory muscle training on sleep and functional capacity to exercise in obstructive sleep apnea: a randomized controlled trial

PURPOSE

The aim of this study was to evaluate the effectiveness of inspiratory muscle training (IMT) on sleep and functional capacity to exercise in subjects with obstructive sleep apnea (OSA).

METHODS

This is a controlled, randomized, double-blind study conducted in 16 OSA patients divided into two groups: training (IMT: n = 8) and placebo-IMT (P-IMT: n = 8). IMT was conducted during 12 weeks with a moderate load (50-60% of maximal inspiratory pressure-MIP), while P-IMT used a load < 20% of MPI. Total daily IMT time for both groups was 30 min, 7 days per week, twice a day.

RESULTS

There was no difference comparing IMT to P-IMT group after training for lung function (p > 0.05) and respiratory muscle strength (p > 0.05). Maximal oxygen uptake (VO_2Max) was not significantly different between IMT and P-IMT group (mean difference - 1.76, confidence interval (CI) - 7.93 to 4.41, p = 0.71). The same was observed for the other ventilatory and cardiometabolic variables measured (p > 0.05). A significant improvement in sleep quality was found when Pittsburgh Sleep Quality Index (PSQI) values of IMT and P-IMT group after training were compared (mean difference: 3.7, confidence interval 95% (CI95%) 0.6 to 6.9, p = 0.02) but no significant changes were seen in daytime sleepiness between both groups after the intervention (mean difference: 3.4, CI 95%: - 3.3 to 10.0; p = 0.29).

CONCLUSION

According to these results, 12 weeks of moderate load IMT resulted in improved sleep quality, but there were no significant repercussions on functional capacity to exercise or excessive daytime sleepiness.

High-Flow, Heated, Humidified Air Via Nasal Cannula Treats CPAP-Intolerant Children With Obstructive Sleep Apnea

STUDY OBJECTIVES

Continuous positive airway pressure (CPAP) is effective but challenging for children with obstructive sleep apnea (OSA). High-flow air via open nasal cannula (HFNC) as treatment in children remains controversial. We report the efficacy of HFNC in children with OSA and CPAP intolerance, a titration protocol, and a discussion of potential mechanisms.

METHODS

Patients aged 1 to 18 years with OSA (defined by obstructive apnea-hypopnea index [OAHI] greater than 1 event/h) and CPAP intolerance were enrolled. Routine polysomnography data obtained during 1 night wearing HFNC was compared with diagnostic data by Wilcoxon rank-sum test.

RESULTS

Ten school-age subjects (representing all patients attempting HFNC at our institution to date) with varied medical conditions, moderate to severe OSA, and CPAP intolerance wore HFNC from 10 to 50 L/min of room air with oxygen supplementation if needed (room air alone for 6 of the 10). HFNC reduced median OAHI from 11.1 events/h (interquartile range 8.7-18.8 events/h) to 2.1 events/h (1.7-2.2 events/h; P = .002); increased oxyhemoglobin saturation (SpO₂) mean from 91.3% (89.6% to 93.5%) to 94.9% (92.4% to 96.0%; P < .002); increased SpO₂ nadir from 76.0% (67.3% to 82.3%) to 79.5% (77.2% to 86.0%; P = .032); decreased SpO₂ desaturation index from 19.2 events/h (12.7-25.8 events/h) to 6.4 events/h (4.7-10.7 events/h; P = .013); and reduced heart rate from 88 bpm (86-91 bpm) to 74 bpm (67-81 bpm; P = .004). Stratified analysis of the 6 subjects with only room air via HFNC, the OAHI, obstructive hypopnea index, and mean SpO₂ still demonstrated improvements (P = .031).

CONCLUSIONS

High-flow nasal cannula reduces respiratory events, improves oxygenation, reduces heart rate, and may be effective for CPAP intolerant children with moderate to severe OSA. Our data suggest HFNC warrants further study and consideration by payers as OSA therapy.

Obstructive sleep apnea: in search of precision

Introduction

Obstructive sleep apnea (OSA) is a highly prevalent condition that is viewed as a major global health concern, while affecting approximately 10% of the middle-aged population. OSA is a chronic disease that has been conclusively associated with poor quality of life, cognitive impairments and mood alterations, enhanced cardiovascular and metabolic morbidity, thereby leading to marked increments in healthcare costs.

Areas covered

The authors have reviewed the current evidence on the pathophysiology of OSA and its consequences, the heterogeneity of its phenotypic expression, the current therapeutic applications and their efficacy, and the implications for diagnosis, treatment and follow-up strategies in the context of the clinical management of OSA.

Expert commentary

Personalized medicine in OSA identifies different needs and approaches: i) phenotyping and defining the different and segregated clusters of OSA patients whose recognition may improve prognostic predictions and guide therapeutic strategies; ii) to further characterize and predict the impact of OSA and its treatment, particularly revolving around mortality and the processes closely related to ageing (cardiovascular diseases, cancer and neurocognitive diseases); iii) the introduction of new technologies including telemedicine that have shown promise in the implementation of personalized medicine approaches.

Patient-centered care in obstructive sleep apnea: A vision for the future

Obstructive sleep apnea is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, but patient engagement is typically required for treatment to be effective. Patients with sleep apnea are phenotypically diverse and have individual needs, preferences, and values that impact treatment decisions. There has been a shift in obstructive sleep apnea management from diagnosis to chronic care management. Making treatment decisions that incorporate an individual patient's values and preferences and are personalized for that patient's biology has the potential to improve patient outcomes. A patient-centered care approach in obstructive sleep apnea is reviewed including 1) determining patient-specific needs to guide treatment decisions, 2) understanding patient values, preferences, and other factors impacting treatment decisions and using shared decision-making, 3) enhancing patient education and support to improve treatment adherence, 4) promoting patient engagement, 5) optimizing care coordination, continuity of care, and access to care, and 6) determining and assessing patient-centered outcomes.

Decrease of respiratory events in patients with obstructive sleep apnea-hypopnea syndrome using a mandibular advancement device assessed with split night polysomnography

Introduction

Mandibular advancement device (MAD) may represent a feasible choice in the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS), in well selected patients.

Objective

The aim of this study is to assess the efficacy of MAD in patients with OSAHS, using split night polysomnography (SNP)

Method

We performed an auto controlled clinical trial to assess the efficacy of MAD in 30 patients with snoring and OSAHS. Clinical evaluation was made every 2 weeks to adjust treatment and observe changes in clinical symptoms. Three-months after placement of the MAD, a SNP was performed, using the MAD in the second half of the night, in order to compare the respiratory results.

Results

SNP show significant changes with use of MAD (p<0.05) such as: Decrease in Snore index (from 159.95 to 32.46/h) and in Apnea-hypopnea index (AHI, from 22.45 to 4.63/h), increase in oxygen saturation (SaO₂, from 89.98% to 91.39%) and somnolence improvement, using the Epworth Sleepiness Scale (from 14.4 to 4.6 points).

Conclusion

Our data supports that the use of MAD is an alternative in the management of OSAHS, in well selected patients, used in a multidisciplinary fashion, and evaluated using a SNP.

Treatments for Obstructive Sleep Apnea

OBJECTIVE

To review the efficacy of current treatment options for adults with obstructive sleep apnea (OSA).

METHODS

Review of the literature.

RESULTS

OSA, characterized by repetitive ≥ 10-second interruptions (apnea) or reductions (hypopnea) in airflow, is initiated by partial or complete collapse in the upper airway despite respiratory effort. When left untreated, OSA is associated with comorbid conditions, such as cardiovascular and metabolic diseases. The current "gold standard" treatment for OSA is continuous positive air pressure (CPAP), which pneumatically stabilizes the upper airways. CPAP has proven efficacy and potential cost savings via decreases in health comorbidities and/or motor-vehicle crashes. However, CPAP treatment is not well-tolerated due to various side effects, and adherence among OSA subjects can be as low as 50% in certain populations. Other treatment options for OSA include improving CPAP tolerability, increasing CPAP adherence through patient interventions, weight loss/exercise, positional therapy, nasal expiratory positive airway pressure, oral pressure therapy, oral appliances, surgery, hypoglossal nerve stimulation, drug treatment, and combining 2 or more of the aforementioned treatments. Despite the many options available to treat OSA, none of them are as efficacious as CPAP. However, many of these treatments are tolerable, and adherence rates are higher than those of the CPAP, making them a more viable treatment option for long-term use.

CONCLUSION

Patients need to weigh the benefits and risks of available treatments for OSA. More large randomized controlled studies on treatments or combination of treatments for OSA are needed that measure parameters such as treatment adherence, apnea-hypopnea index, oxygen desaturation, subjective sleepiness, quality of life, and adverse events.