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Tankéré P, Georges M, Abdulmalak C, Schenesse D, Beltramo G, Berrier A, Bonniaud P, Rabec C. Residual upper airway obstruction during nocturnal noninvasive ventilation despite high positive expiratory pressure. Impact of oronasal mask to nasal mask switch. Respir Med Res 2024; 85:101083. [PMID: 38232657 DOI: 10.1016/j.resmer.2023.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Nasal mask (NM) and oronasal masks (OM) can be used to provide noninvasive ventilation (NIV). Recent studies suggested that OM is the most used interface and that there is no difference in efficacy or in tolerance between OM and NM for chronic use. However, studies focusing on video laryngoscopy underlined the impact of OM in residual upper airway obstruction (UAO) under NIV. We sought to assess the real-life practice of switching from OM to NM when UAO events persist despite high EPAP levels. METHODS In an open-label single center prospective cohort study, data from files and full night polysomnography on NM and OM were collected for patients wearing OM and presenting an UAO index ≥15/h despite an EPAP level ≥ 10 cmH20. RESULTS Forty-four patients were included in the study. In 31 patients (74 %), switching to a NM reduced UAOi to ≥10/h. Interestingly, 92 % of these patients still had NM at 3 to 12 months of follow-up. Switching to a NM was also associated with a trend in paCO2 reduction and significant improvements in Epworth, sleep quality and NIV compliance. Successful interface switching was significantly associated with female gender, and a trend was observed in non-smokers. CONCLUSION As for CPAP, switching to a NM improved NIV efficacy in a selected group of patients presenting residual UAO events despite high EPAP levels. Additionally, this switch has an impact on compliance and subjective sleepiness. Thus, in patients with persisting UAO on OM, switching to a NM could be a first-line intervention before considering further investigation such as polygraphy or video laryngoscopy. We also derive an algorithm for mask allocation and adaptation in acute and chronic NIV use.
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Affiliation(s)
- Pierre Tankéré
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France
| | - Marjolaine Georges
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France; University of Bourgogne Franche-Comté, Dijon, France; Centre des Sciences du Goût et de l'Alimentation, INRA, UMR 6265 CNRS 1234, University of Bourgogne Franche-Comté, Dijon, France
| | - Caroline Abdulmalak
- Department of Intensive Care Medicine, William Morey General Hospital, Chalon-Sur-Saône, France
| | - Deborah Schenesse
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France
| | - Guillaume Beltramo
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France; University of Bourgogne Franche-Comté, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, Dijon, France
| | - Amaury Berrier
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France
| | - Philippe Bonniaud
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France; University of Bourgogne Franche-Comté, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, Dijon, France
| | - Claudio Rabec
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France.
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Deng B, Lai F, Zhang M, Xiong C, Chen F, Zhang H, Ma Y, Zhou D. Nasal pillow vs. standard nasal mask for treatment of OSA: a systematic review and meta-analysis. Sleep Breath 2023; 27:1217-1226. [PMID: 36214944 DOI: 10.1007/s11325-022-02721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/23/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The purpose of this study was to compare the effectiveness of nasal pillows with standard nasal masks in the treatment of patients with obstructive sleep apnea (OSA). METHODS A digitalized search was carried out in four different databases including PubMed, Scopus, EMBASE, and CENTRAL using relevant keywords along with a manual search in relevant journals. All comparative studies comparing outcomes of using a nasal pillow with the use of standard nasal masks for continuous positive airway pressure (CPAP) treatment in patients with OSA were included. The qualitative analysis was carried out by tabulating the demographic data. The quantitative data were subjected to meta-analysis. The quality of comparative studies (both retrospective and prospective cohorts) was evaluated using New-castle Ottawa scale (NOS). RESULTS A total of 14 studies (eight prospective and six retrospective) were included in the review. Of them, five studies were randomized and were of cross-over study design. No significant differences were observed in achieved CPAP and residual apnea-hypopnea index (AHI) levels between the nasal pillow and nasal mask with SMD - 0.05 95% CI [- 0.18, 0.09], p = 0.50 and SMD - 0.13 95% CI [- 0.28, 0.03], p = 0.12, respectively. However, nasal pillow usage was associated with better CPAP adherence with a difference of only + 0.29 min/night as compared to a standard nasal mask, with SMD 0.29 95% CI [0.07, 0.50], p = 0.009. CONCLUSION Nasal pillow and standard nasal mask were equally effective in terms of residual AHI level and achieved similar therapeutic CPAP pressures. However, the difference in CPAP adherence between groups, though statistically significant, is of questionable clinical significance.
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Affiliation(s)
- Bo Deng
- Department of Otolaryngology Head and Neck Surgery, Chengdu Longquanyi First People's Hospital, Chengdu, China
| | - Fei Lai
- Department of Otolaryngology Head and Neck Surgery, Chengdu Longquanyi First People's Hospital, Chengdu, China
| | - Manman Zhang
- Department of Otolaryngology Head and Neck Surgery, Chengdu Longquanyi First People's Hospital, Chengdu, China
| | - Chenyili Xiong
- Department of Otolaryngology Head and Neck Surgery, Chengdu Longquanyi First People's Hospital, Chengdu, China
| | - Feng Chen
- Department of Otolaryngology Head and Neck Surgery, Chengdu Longquanyi First People's Hospital, Chengdu, China
| | - Heng Zhang
- Department of Otolaryngology Head and Neck Surgery, Chengdu Longquanyi First People's Hospital, Chengdu, China.
| | - Yuanyuan Ma
- Department of Orthopedics, Chengdu Longquanyi First People's Hospital, Chengdu, China
| | - Daiying Zhou
- Department of Orthopedics, Chengdu Longquanyi First People's Hospital, Chengdu, China
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Outcome of Continuous Positive Airway Pressure Adherence Based on Nasal Endoscopy and the Measurement of Nasal Patency-A Prospective Study. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010219. [PMID: 36676168 PMCID: PMC9867109 DOI: 10.3390/life13010219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
The gold standard for treating obstructive sleep apnea in adults is continuous positive airway pressure (CPAP). However, it can be difficult to convince patients to adhere to this therapy. The aim of this study was to determine the relationship between nasal endoscopy findings/nose patency and CPAP adherence. Material and methods: A cohort of 450 consecutive patients suspected of having OSA were prospectively enrolled. For further analyses, 47 OSA patients undergoing CPAP treatment were selected (13 females and 34 males, average age, 65.3 years, BMI 34.1, apnea-hypopnea index. AHI 51.0). The patients were divided into two groups: patients with good CPAP adherence (n = 35) and patients who did not adhere to CPAP therapy (n = 12). The influence of nasal endoscopy and flow measurement on CPAP adherence was explored. Results: We found a statistical independence between adherence to CPAP and AHI (p = 0.124), T90 (p = 0.502), endoscopic findings (p = 0.588) and nasal patency measured by a flowmeter (p = 0.498). Conclusions: In our studied sample, endoscopic findings and nasal patency measured by a flowmeter were not predictors of CPAP non-adherence in the first year of the treatment. Our data show that while an endoscopic finding in the nasal cavity could indicate that a patient has a severe obstruction, compliance with CPAP therapy is not reduced in these patients and neither is it reduced with a decrease in nasal flow, according to our observation.
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Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Clinical and polysomnographic predictors of suboptimal auto-adjusting CPAP titration in adult OSA patients: a single-center study. Eur Arch Otorhinolaryngol 2023; 280:435-442. [PMID: 35994102 DOI: 10.1007/s00405-022-07605-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/09/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE To examine potential clinical, demographic, anthropometric, and polysomnographic predictors of successful auto-adjusting continuous positive airway pressure (CPAP) titration for treatment of obstructive sleep apnea (OSA). METHODS This cross-sectional study was conducted in adults diagnosed with moderate-to-severe OSA (baseline apnea-hypopnea index [AHI] ≥ 15.0/h), who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed®) in a sleep laboratory setting while wearing a nasal or pillow mask. Participants were then grouped into two groups: optimal CPAP titration (residual AHI < 5.0/h) or suboptimal CPAP titration (residual AHI ≥ 5.0/h). Multivariate logistic regression analysis was used to assess possible independent predictive factors for suboptimal CPAP titration. RESULTS A total of 1222 adults consisting of 874 subjects with optimal CPAP titration (71.5%) and 348 subjects with suboptimal CPAP titration (28.5%) were evaluated. Multivariate analysis resulted in a model with an adequate calibration (Hosmer-Lemeshow chi-square-test: 7.088; p = 0.527), with male sex, higher values of baseline AHI, therapeutic pressure (95th percentile), and mask leak (95th percentile) emerging as significant and independent predictors for suboptimal CPAP titration: adjusted odds ratio (OR): 1.456 (95% confidence interval [CI] 1.076-1.971; p = 0.015), OR: 1.009 (95% CI 1.002-1.016; p = 0.013), OR: 1.281 (95% CI 1.206-1.361; p < 0.001), and 1.035 (1.026-1.043; p < 0.001), respectively. CONCLUSIONS In a large cohort of adults undergoing auto-adjusting CPAP titration due to moderate-to-severe OSA, male sex, increased values of baseline AHI, pressure requirements, and mask leak were significant predictors for less than optimal CPAP titration.
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Affiliation(s)
- Ricardo L M Duarte
- SleepLab, Laboratório de Estudo dos Distúrbios do Sono, Centro Médico BarraShopping, Avenida das Américas 4666, sala 309, Barra da Tijuca, Rio de Janeiro, 22649-900, Brazil. .,Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Flavio J Magalhães-da-Silveira
- SleepLab, Laboratório de Estudo dos Distúrbios do Sono, Centro Médico BarraShopping, Avenida das Américas 4666, sala 309, Barra da Tijuca, Rio de Janeiro, 22649-900, Brazil
| | - David Gozal
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO, USA
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Chen L, Chen Y, Hu S, Lin M, Lee P, Chiang AA, Tu Y. In search of a better CPAP interface: A network meta-analysis comparing nasal masks, nasal pillows and oronasal masks. J Sleep Res 2022; 31:e13686. [PMID: 35821391 PMCID: PMC9787466 DOI: 10.1111/jsr.13686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/28/2022] [Accepted: 06/17/2022] [Indexed: 12/30/2022]
Abstract
Until now, no study has directly network meta-analysed the impact of nasal masks, nasal pillows and oronasal masks on continuous positive airway pressure therapy in patients with obstructive sleep apnea. This study aimed to meta-analyse the impact of three kinds of nasal interfaces with both network meta-analysis and pairwise comparison. PubMed, EMBASE, CENTRAL and ClinicalTrials.gov were systematically searched from inception to December 2020 for studies that compared the three types of nasal interfaces for treating obstructive sleep apnea with continuous positive airway pressure. The outcomes were residual apnea-hypopnea index, continuous positive airway pressure, and nightly average usage. The network meta-analysis was conducted using multivariate random-effects in a frequentist framework where three interfaces were ranked with the surface under the cumulative ranking probabilities. The pairwise comparison was conducted using random-effects meta-analysis. Twenty-nine articles comprising 6378 participants were included. The pairwise comparison showed both nasal masks and nasal pillows were associated with lower residual apnea-hypopnea index, lower continuous positive airway pressure, and higher continuous positive airway pressure adherence compared with oronasal masks. The surface under the cumulative ranking confirmed that nasal masks were associated with the lowest residual apnea-hypopnea index and highest adherence, while pillows were associated with the lowest continuous positive airway pressure. The meta-regression identified that lower pretreatment apnea-hypopnea index and continuous positive airway pressure determined during continuous positive airway pressure titration (versus determined during continuous positive airway pressure therapy) was associated with lower continuous positive airway pressure with nasal masks and nasal pillows. In conclusion, compared with oronasal masks, nasal masks and nasal pillows are better interfaces, especially in patients with lower pretreatment apnea-hypopnea index and those with the therapeutic pressure determined during continuous positive airway pressure titration.
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Affiliation(s)
- Li‐Yang Chen
- Department of Internal MedicineTainan Sin Lau HospitalTainanTaiwan
| | - Yung‐Hsuan Chen
- Center of Sleep DisorderNational Taiwan University HospitalTaipeiTaiwan,Department of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
| | | | - Ming‐Tzer Lin
- Center of Sleep DisorderNational Taiwan University HospitalTaipeiTaiwan,Department of Internal MedicineHsiao Chung‐Cheng HospitalNew TaipeiTaiwan
| | - Pei‐Lin Lee
- Center of Sleep DisorderNational Taiwan University HospitalTaipeiTaiwan,Department of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan,School of MedicineNational Taiwan UniversityTaipeiTaiwan,Center for Electronics Technology Integration, National Taiwan UniversityTaipeiTaiwan
| | - Ambrose A. Chiang
- Division of Sleep Medicine, Louis Stokes VA Medical Center; Department of MedicineCase Western Reserve UniversityClevelandOhioUSA
| | - Yu‐Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan UniversityTaipeiTaiwan
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6
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Weaver TE. Best Predictors of Continuous Positive Airway Pressure Adherence. Sleep Med Clin 2022; 17:587-595. [DOI: 10.1016/j.jsmc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kazemeini E, Van de Perck E, Dieltjens M, Willemen M, Verbraecken JA, Sands SA, Vanderveken OM, Op de Beeck S. Critical closing pressure (Pcrit) of the pharyngeal airway during routine drug-induced sleep endoscopy: feasibility and protocol. J Appl Physiol (1985) 2022; 132:925-937. [PMID: 35112928 PMCID: PMC8993534 DOI: 10.1152/japplphysiol.00624.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In obstructive sleep apnea (OSA), there are various pathophysiological factors affecting the upper airway during sleep. Two prominent factors contributing to OSA are site and pattern of upper airway collapse and degree of pharyngeal collapsibility. In a clinical setting, drug-induced sleep endoscopy (DISE) is used to visualize the structures of the upper airway. Critical closing pressure (Pcrit) is the gold standard measure of pharyngeal collapsibility. This prospective clinical study aimed to investigate the feasibility and protocol of Pcrit measurements during DISE. Thirteen patients with OSA were included. Pcrit was calculated using peak inspiratory airflow and inspiratory ventilation. The proposed protocol was successful in Pcrit measurement during DISE in all subjects [median[Q1;Q3] Pcrit for “peak inspiratory method” (n = 12): −0.84[−2.07;0.69] cmH2O, “ventilation method” (n = 13): −1.32[2.32;0.47] cmH2O], highlighting the feasibility of the approach. There was no significant difference (P = 0.67) between calculated Pcrit with either of the calculation methods, indicating high reliability. Correlation analysis showed Pcrit as an independent parameter of any of the anthropometric or polysomnographic parameters. The ventilation method proved to be more successful in assessment of Pcrit in subjects with epiglottic collapse (e.g., with high negative effort dependence). Subjects with palatal complete concentric collapse during DISE had a wide Pcrit range ([−2.86;2.51]cmH2O), suggesting no close correlation between Pcrit and this DISE pattern (P = 0.38). Incorporation of Pcrit measurements into DISE assessments is feasible and may yield valuable additional information for OSA management. Combining Pcrit and DISE provides information on both the site and degree of upper airway collapse and the degree of pharyngeal collapsibility. NEW & NOTEWORTHY The protocol of this study was successful in concomitant measurement of Pcrit during routine clinical endoscopy. Comparison of two calculation methods for Pcrit showed that the inspiratory ventilation method was more successful in assessment of Pcrit in subjects with epiglottic collapse who have high negative effort dependence. Subjects with palatal complete concentric collapse during DISE had a wide Pcrit range and did not have a greater Pcrit than patients in other site of collapse categories.
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Affiliation(s)
- Elahe Kazemeini
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Eli Van de Perck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan A Verbraecken
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Pulmonology, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Olivier M Vanderveken
- ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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Lepine J, Berthier F, Lorillou M, Maincent C, Perrin C. [Impact of AMARA VIEW™ interface on upper airway during nocturnal non invasive ventilation]. Rev Mal Respir 2021; 38:980-985. [PMID: 34763958 DOI: 10.1016/j.rmr.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Nasal masks can result in mouth leaks with implications on sleep quality. To reduce these leaks, oronasal masks are proposed. It has been shown that an oronasal mask can induce obstructive events in the upper airways (UA). Because of its fit around the nose, the Amara View™ facial mask may have less consequence on UA obstruction. METHODS This retrospective study assessed the impact of the Amara View™ mask on UA. The study was conducted on patients with chronic respiratory failure treated by home NIV with standard facial mask. Replacement of the standard facial mask by an Amara View™ mask was performed when the residual apnea hypopnea index recorded from the ventilator software exceeded 5/h. All patients underwent nocturnal respiratory polygraphy when on NIV with a standard facial mask and with an Amara View™ mask. Respiratory polygraphic traces were interpreted following the analysis methods published by the SomnoNIV Group. RESULTS Seven patients were studied. Although nocturnal oxygen saturation was similar between both masks, the index of UA obstruction without ventilatory blunting was significantly lower during NIV with the Amara View™ mask compared to the standard facial mask (P=0.01). CONCLUSIONS Nocturnal NIV using an Amara View™ facial interface may avoid UA obstruction without ventilatory command blunting.
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Affiliation(s)
- J Lepine
- Service de pneumologie, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98000 Monaco, Monaco
| | - F Berthier
- Département d'information médicale, Principauté de Monaco, centre hospitalier Princesse Grace, 1, avenue Pasteur, 98000 Monaco, Monaco
| | - M Lorillou
- Service de pneumologie, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98000 Monaco, Monaco
| | - C Maincent
- Service de pneumologie, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98000 Monaco, Monaco
| | - C Perrin
- Service de pneumologie, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98000 Monaco, Monaco.
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Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-lab titration? J Clin Sleep Med 2021; 17:1815-1820. [PMID: 33908344 DOI: 10.5664/jcsm.9282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The first-choice therapy for adults with moderate/severe obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP). However, studies evaluating whether the therapeutic CPAP level obtained from a titration is affected by sex are surprisingly scarce. Our main objective was to verify if sex influenced the optimal CPAP measurement obtained during a titration. METHODS This cross-sectional study was conducted in adults diagnosed with moderate/severe OSA (baseline apnea-hypopnea index [AHI] ≥ 15.0/h), who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed) in a sleep-lab setting. All participants used a nasal mask during the titration. The optimal pressure, leak, and residual AHI values were registered. Multiple linear regression was used to evaluate if clinical and polysomnographic data influenced the therapeutic CPAP level setting (95th percentile pressure). RESULTS A total of 1,006 adults were enrolled: 354 women and 652 men. There were no statistically significant sex-related differences in the CPAP requirements and leak values as delineated during the titration; all p-values > 0.005. However, the median residual AHI was significantly higher in males versus females: 2.7/h versus 2.2/h (p = 0.008). Body mass index [BMI] (β: 0.292, p < 0.001), baseline AHI (β: 0.167, p < 0.001), and age (β: 0.065, p = 0.035) were independent predictors of the therapeutic CPAP level settings. CONCLUSIONS Sex does not significantly influence the therapeutic CPAP settings. However, age, BMI, and baseline AHI emerge as independent predictors of the 95th percentile CPAP requirement during an auto-adjusting CPAP titration.
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Affiliation(s)
- Ricardo L M Duarte
- SleepLab - Laboratório de Estudo dos Distúrbios do Sono, Rio de Janeiro, Brazil.,Instituto de Doenças do Tórax - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - David Gozal
- Department of Child Health, University of Missouri School of Medicine, Columbia, MO
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10
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Yui MS, Tominaga Q, Lopes BCP, Eckeli AL, de Almeida LA, Rabelo FAW, Küpper DS, Valera FCP. Can drug-induced sleep endoscopy (DISE) predict compliance with positive airway pressure therapy? A pilot study. Sleep Breath 2021; 26:109-116. [PMID: 33829370 DOI: 10.1007/s11325-021-02360-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/07/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Drug-induced sleep endoscopy (DISE) has been poorly explored as an examination to assess positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA). The present study aimed to identify by DISE possible characteristics related to low compliance with PAP therapy due to respiratory complaints. METHODS Patients using PAP for OSA underwent DISE in two conditions: (1) baseline (without PAP) and (2) PAP (with the same mask and airway pressure used at home). We compared patients reporting low compliance to PAP due to respiratory complaints to those well-adapted to therapy. VOTE classification (assessment of velopharynx, oropharynx, tongue base, and epiglottis) and TOTAL VOTE score (the sum of VOTE scores at each anatomical site) were assessed. ROC curve analyzed the accuracy of TOTAL VOTE to predict low compliance due to persistent pharyngeal obstruction in both conditions. RESULTS Of 19 patients enrolled, all presented multilevel pharyngeal obstruction at baseline condition, with no difference between groups at this study point. When PAP was added, the median VOTE value was higher in the epiglottis (P value=0.02) and tended to be higher at the velum and tongue base in the poorly adapted group; TOTAL VOTE score was also significantly increased in patients with low compliance (P value<0.001). ROC curve demonstrated that patients with TOTAL VOTE scored 2.5 or more during DISE with PAP presented a 4.6-fold higher risk for low compliance with PAP therapy due to pharyngeal obstruction (AUC: 0.88±0.07; P value<0.01; sensitivity: 77%; specificity: 83%). CONCLUSIONS Adding PAP during a DISE examination may help to predict persistent pharyngeal obstruction during PAP therapy.
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Affiliation(s)
- Mariane S Yui
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil
| | - Quedayr Tominaga
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil
| | - Bruno C P Lopes
- Anesthesiology Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Alan L Eckeli
- Neurosciences Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Leila A de Almeida
- Neurosciences Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Daniel S Küpper
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil
| | - Fabiana C P Valera
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil.
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11
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Duarte RLM, Mendes BA, Oliveira-E-Sá TS, Magalhães-da-Silveira FJ, Gozal D. Nasal versus oronasal mask in patients under auto-adjusting continuous positive airway pressure titration: a real-life study. Eur Arch Otorhinolaryngol 2020; 277:3507-3512. [PMID: 32725272 DOI: 10.1007/s00405-020-06242-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/22/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE Mask type (nasal versus oronasal) can affect the optimal pressure required to correct the apnea/hypopnea index (AHI) in obstructive sleep apnea (OSA) subjects treated with CPAP. Our objective was to evaluate if mask type influenced CPAP titration outcomes in OSA patients. METHODS A retrospective study of individuals with a baseline AHI ≥ 15.0/h, who received an auto-adjusting CPAP titrating device (S9 AutoSet ResMed®) in a sleep-lab setting. The mask type oronasal (OM) or nasal (NM) was always selected by the patients. Optimal pressure requirements, leak, and residual AHI were compared based on mask type. RESULTS Overall, 436 patients were included: 283 with NM (64.9%) and 153 with OM (35.1%). At baseline, NM and OM cohorts had similar AHI (p = 0.160). Patients allocated to the OM cohort had a higher 95th percentile pressure, a higher 95th percentile leak, and a higher residual AHI than those with a NM: pressure requirement: 12.9 cm H2O (IQR: 10.6-15.0) versus 10.7 cm H2O (IQR: 9.2-12.3); leak: 21.6 L/min (IQR: 9.6-37.2) versus 9.6 L/min (IQR: 3.6-19.2); and residual AHI: 4.9/h (IQR: 2.4-10.2) versus 2.2/h (IQR: 1.0-4.4), respectively (p < 0.001 for all). CONCLUSIONS CPAP mask type based on individual preferences exerts profound effects on optimal CPAP pressures and efficacy. Patients titrated with OM showed higher pressure requirements, had higher a leak, and higher residual AHI when compared to NM, which may adversely impact treatment adherence and other health outcomes.
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Affiliation(s)
- Ricardo L M Duarte
- SleepLab, Laboratório de Estudo dos Distúrbios do Sono, Centro Médico BarraShopping, Avenida das Américas 4666, sala 309, Barra da Tijuca, Rio de Janeiro, 22649-900, Brazil. .,Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Bruno A Mendes
- Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Tiago S Oliveira-E-Sá
- Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Flavio J Magalhães-da-Silveira
- SleepLab, Laboratório de Estudo dos Distúrbios do Sono, Centro Médico BarraShopping, Avenida das Américas 4666, sala 309, Barra da Tijuca, Rio de Janeiro, 22649-900, Brazil
| | - David Gozal
- Department of Child Health, University of Missouri School of Medicine, Columbia, USA
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Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial. Eur J Anaesthesiol 2020; 36:633-640. [PMID: 31313720 DOI: 10.1097/eja.0000000000001052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Continuous positive airways pressure (CPAP) with a CPAP machine and mask has been shown to be more effective at minimising hypoxaemia than other devices under deep sedation. However, the efficacy of a new and simple CPAP device for spontaneously breathing obese patients during colonoscopy is unknown. OBJECTIVE We hypothesised that oxygenation and ventilation in obese patients under deep sedation during colonoscopy using CPAP via a new nasal mask (SuperNO2VA) would be better than routine care with oxygen supplementation via a nasal cannula. DESIGN Randomised study. SETTING Single-centre, June 2017 to October 2017. PATIENTS A total of 174 patients were enrolled and randomly assigned to Mask group or Control group. Thirty-eight patients were excluded and data from 136 patients underwent final analysis. INTERVENTION Patients in the Mask group were provided with nasal CPAP (10 cmH2O) at an oxygen flow rate of 15 l min. In the Control group, patients were given oxygen via a nasal cannula at a flow rate of 5 l min. MAIN OUTCOME MEASURES The primary outcome was elapsed time from anaesthesia induction to the first airway intervention. RESULTS The elapsed time from anaesthesia induction to the first airway intervention was 19 ± 10 min in the Mask group (n=63) vs. 10 ± 12 min in the Control group (n=73, P < 0.001). In all, 87.5% (56/64) of patients achieved the target CPAP value. More patients in the Control group (63%) received airway intervention than in the Mask group (22%) (P < 0.001). Hypoxaemia (pulse oximeter oxygen saturation, SpO2 < 90%) occurred more frequently in the Control group (22%) than in the Mask group (5%) (P = 0.004). Minute ventilationPostinduction/minute ventilationBaseline and minute ventilationProcedure-end/minute ventilationBaseline was lower in the Control group than in the Mask group (P = 0.007 and 0.001, respectively). CONCLUSION Application of a nasal mask at a target CPAP of 10 cmH2O improves ventilation and decreases the frequency and severity of hypoxaemia. TRIAL REGISTRATION NCT03139448, registered at ClinicalTrials.gov.
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13
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How to manage continuous positive airway pressure (CPAP) failure -hybrid surgery and integrated treatment. Auris Nasus Larynx 2020; 47:335-342. [PMID: 32386825 DOI: 10.1016/j.anl.2020.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 12/12/2022]
Abstract
Obstructive sleep apnea (OSA) is a prevalent disease, which influences social relations and quality of life with major health impact. The etiology of OSA is multi-factorial involving both anatomical obstruction and physiological collapse of the upper airway during sleep with different proportion in individual patients. Continuous positive airway pressure (CPAP) is the gold standard and first-line treatment for OSA patients. The mechanism of CPAP is acting as air splint to avoid principal pharyngeal collapse during sleep. Consequently, extrapharyngeal collapse and significant pharyngeal obstructions can lower its compliance and lead to its failure. Adequate mask and pressure with thorough survey to eliminate side effects of CPAP from nasal, mask and flow-related problems are the prerequisite to improve CPAP compliance. For CPAP failure patients, multi-dimensional surgery is an alternative and salvage treatment that involves soft tissue surgery, skeletal surgery, and bariatric surgery. OSA patients with craniofacial anomaly are suggested to skeletal surgery. By contrast, OSA patients with pathological obesity are referred to bariatric surgery. Soft tissue surgery targets at the nose, soft palate, lateral pharyngeal wall, tongue and epiglottis that can be implemented by multi-level surgery with hybrid technique (mucosa-preservation, fat-ablation, muscle-suspension, tonsil-excision, cartilage-reconstruction) to maximize surgical outcomes and minimize complications. Some evolution in surgical concept and technique are noteworthy that include mini-invasive septoturbinoplasty, palatal suspension instead of excision, whole tongue treatment, and two-dimensional supraglottoplasty. Postoperative integrated treatment including myofunctional, positional therapy and body weight control reduces relapse of OSA and improves long-term treatment outcomes.
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Conde B, Martins N, Brandão M, Pimenta AC, Winck JC. Upper Airway Video Endoscopy: Assessment of the response to positive pressure ventilation and mechanical in-exsufflation. Pulmonology 2019; 25:299-304. [PMID: 31000441 DOI: 10.1016/j.pulmoe.2019.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/25/2019] [Accepted: 02/26/2019] [Indexed: 12/13/2022] Open
Abstract
Upper airways (UA) include the nasal cavities, pharynx, and larynx, and its main function is to warm and filter the inspired air. UA dysfunction is in the pathogenesis of various disorders, such as obstructive sleep apnea syndrome (OSAS) and vocal cord dysfunction. In addition, in some neurodegenerative diseases (e.g. Amyotrophic Lateral Sclerosis - ALS), UA dysfunction may also compromise the effective use of ventilatory support (VS). In this context, the endoscopic evaluation of UA may be useful in understanding the OSAS mechanisms, in determining the causes for treatment-induced airway obstruction and even in helping to titrate noninvasive ventilation (NIV) in ALS patients with bulbar or pseudo-bulbar (spastic) dysfunction. Specifically, in OSAS patients, when residual obstructive events persist, although an optimal ventilatory mode has been apparently achieved, along with interface and equipment, the endoscopic evaluation of UA seems to be a valuable tool in understanding its mechanisms, even assisting adjustments to NIV parameters. In addition, it has also been described as being useful in laryngeal response to mechanical in-exsufflation (MI-E) and Exercise-Induced Laryngeal Obstruction (EILO). However, no protocol has yet been published or validated for this. For this reason, a literature review was conducted on UA function and its response to positive pressure and MI-E. Special emphasis has also been given to the current indication for video endoscopy in chronically ventilated patients.
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Affiliation(s)
- B Conde
- Centro Hospitalar Trás-os-Montes e Alto Douro, EPE, Vila Real, Portugal.
| | - N Martins
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Institute for Research and Innovation in Health (i3S), Porto, Portugal
| | - M Brandão
- Centro Hospitalar Trás-os-Montes e Alto Douro, EPE, Vila Real, Portugal
| | - A C Pimenta
- Centro Hospitalar Trás-os-Montes e Alto Douro, EPE, Vila Real, Portugal
| | - J C Winck
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Cheng H, Shelgikar AV. Pressure Requirements With a Nasal Versus Oronasal Mask During a PAP Titration Study. J Clin Sleep Med 2019; 15:673-674. [PMID: 30952220 DOI: 10.5664/jcsm.7742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/15/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Hao Cheng
- Miami VA Healthcare System, Miami, Florida
| | - Anita Valanju Shelgikar
- Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, Michigan
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Athayde RABD, Oliveira Filho JRBD, Lorenzi Filho G, Genta PR. Obesity hypoventilation syndrome: a current review. ACTA ACUST UNITED AC 2019; 44:510-518. [PMID: 30726328 PMCID: PMC6459748 DOI: 10.1590/s1806-37562017000000332] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 02/11/2018] [Indexed: 02/06/2023]
Abstract
Obesity hypoventilation syndrome (OHS) is defined as the presence of obesity (body mass index ≥ 30 kg/m²) and daytime arterial hypercapnia (PaCO2 ≥ 45 mmHg) in the absence of other causes of hypoventilation. OHS is often overlooked and confused with other conditions associated with hypoventilation, particularly COPD. The recognition of OHS is important because of its high prevalence and the fact that, if left untreated, it is associated with high morbidity and mortality. In the present review, we address recent advances in the pathophysiology and management of OHS, the usefulness of determination of venous bicarbonate in screening for OHS, and diagnostic criteria for OHS that eliminate the need for polysomnography. In addition, we review advances in the treatment of OHS, including behavioral measures, and recent studies comparing the efficacy of continuous positive airway pressure with that of noninvasive ventilation.
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Affiliation(s)
- Rodolfo Augusto Bacelar de Athayde
- . Serviço de Pneumologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.,. Laboratório do Sono, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Geraldo Lorenzi Filho
- . Laboratório do Sono, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Pedro Rodrigues Genta
- . Laboratório do Sono, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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17
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Goh KJ, Soh RY, Leow LC, Toh ST, Song PR, Hao Y, Lee KCH, Tan GL, Ong TH. Choosing the right mask for your Asian patient with sleep apnoea: A randomized, crossover trial of CPAP interfaces. Respirology 2018; 24:278-285. [PMID: 30189465 DOI: 10.1111/resp.13396] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/06/2018] [Accepted: 08/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVE A major challenge with the treatment of obstructive sleep apnoea (OSA) is adherence to continuous positive airway pressure (CPAP) therapy. Mask tolerability is an important determinant of adherence, however evidence to guide selection of mask interfaces is lacking. METHODS We conducted a randomized crossover trial of mask interfaces in CPAP therapy for moderate-to-severe OSA to assess adherence and efficacy of CPAP therapy with nasal mask, nasal pillow and oronasal masks. Demographic data, Nasal Obstruction Symptom Evaluation (NOSE) scores and craniofacial measurements were also analysed for associations with adherence with oronasal masks. RESULTS Eighty-five patients were included in the study (mean ± SD age: 46 ± 12 years; body mass index: 29.9 ± 5.6 kg/m2 ; apnoea-hypopnoea index (AHI): 53.6 ± 24.0 events/h). Patients had better adherence with nasal masks (average night use: 3.96 ± 2.26 h/night) compared to oronasal masks (3.26 ± 2.18 h/night, P < 0.001) and nasal pillows (3.48 ± 2.20 h/night, P = 0.007). Residual AHI was higher with oronasal masks (7.2 ± 5.2) compared to nasal masks (4.0 ± 4.2, P < 0.001) and nasal pillows (4.1 ± 3.3, P < 0.001). Twenty-two (25.9%) patients had the best adherence with oronasal masks (4.22 ± 2.14 vs 2.93 ± 2.12 h/night, P = 0.016). These patients had lower NOSE scores (15 (0-35) vs 40 (10-55), P = 0.024) and larger menton-labrale inferioris/biocular width ratios (31 ± 3% vs 28 ± 4%, P = 0.019). CONCLUSION Nasal masks are the preferred interface during CPAP initiation. Patients with less nasal obstruction and a proportionally increased chin-lower lip distance to mid-face width may have better CPAP adherence with an oronasal mask interface.
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Affiliation(s)
- Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Rui Ya Soh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.,Sleep Disorder Unit, Singapore General Hospital, Singapore
| | - Leong Chai Leow
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.,Sleep Disorder Unit, Singapore General Hospital, Singapore
| | - Song Tar Toh
- Sleep Disorder Unit, Singapore General Hospital, Singapore.,Department of Otolaryngology, Singapore General Hospital, Singapore
| | - Pei Rong Song
- Sleep Disorder Unit, Singapore General Hospital, Singapore
| | - Ying Hao
- Health Services Research Unit (HSRU), Division of Medicine, Singapore General Hospital, Singapore
| | - Ken Cheah Hooi Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Gan Liang Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.,Sleep Disorder Unit, Singapore General Hospital, Singapore
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18
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Oronasal mask may compromise the efficacy of continuous positive airway pressure on OSA treatment: is there evidence for avoiding the oronasal route? Curr Opin Pulm Med 2018; 22:555-62. [PMID: 27607153 DOI: 10.1097/mcp.0000000000000318] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Continuous positive airway pressure (CPAP) delivered by nasal mask is the gold standard treatment for obstructive sleep apnea (OSA). However, oral and oronasal masks are also available. We considered experimental evidence and reviewed clinical trials that evaluated the impact of oral and oronasal mask on OSA treatment. RECENT FINDINGS One recent study in 18 OSA patients that slept with a customized oronasal mask with two sealed compartments showed that the change of CPAP flow from nasal to oronasal and oral caused upper airway obstruction because of posterior displacement of the tongue demonstrated by nasoendoscopy. Oral masks use a mouthpiece that may stabilize the jaw and the tongue and have shown to be effective. However, oral masks are not widely used in clinical practice. Four out of five observational studies and all five reviewed randomized studies showed a worse performance of oronasal when compared with nasal masks. Oronasal masks were associated with higher residual apnea-hypopnea index, lower adherence, more leaks, and less satisfaction than nasal mask in the majority of the studies. SUMMARY Nasal CPAP must be the first choice to treat OSA. Patients on oronasal mask should be carefully followed. VIDEO ABSTRACT.
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20
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Schell AE, Soose RJ. Positive airway pressure adherence and mask interface in the setting of sinonasal symptoms. Laryngoscope 2017; 127:2418-2422. [PMID: 28434204 DOI: 10.1002/lary.26486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 11/10/2016] [Accepted: 12/05/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Despite reports of lower positive pressure adherence rates with oronasal masks, patients with sinonasal problems are often prescribed this interface over a nasal interface. The aim of this study was to characterize the relationship between mask type and therapy adherence in the setting of sinonasal symptoms. STUDY DESIGN Retrospective case series with chart review. METHODS We reviewed 328 patients who underwent positive pressure titration between January 2012 and May 2015. Follow-up adherence data were available for 218 patients (66.5%). Multivariate analysis examined whether patients with sinonasal symptoms have improved adherence with oronasal masks compared to nasal or nasal pillow interfaces. RESULTS At a median follow-up of 95 days, positive pressure adherence in patients with sinonasal symptoms was highest with the nasal pillow interface. When compared with oronasal interfaces, the odds of adequate therapy adherence were >5 times greater with nasal pillow interfaces (odds ratio [OR] = 5.20, 95% confidence interval [CI] = 1.61-16.80, P = .006) and >3 times greater with nasal interfaces (OR = 3.67, 95% CI = 1.20-11.26, P = .02) in these symptomatic patients. CONCLUSIONS The presence of nasal problems does not predict the need for an oronasal mask. Positive pressure adherence rates are higher with nasal and nasal pillow interfaces compared to oronasal masks, even in patients with sinonasal complaints. LEVEL OF EVIDENCE 4. Laryngoscope, 127:2418-2422, 2017.
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Affiliation(s)
- Amy E Schell
- UPMC Department of Otolaryngology, Pittsburgh, Pennsylvania, U.S.A
| | - Ryan J Soose
- UPMC Department of Otolaryngology, Pittsburgh, Pennsylvania, U.S.A
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21
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Choosing the right interface for positive airway pressure therapy in patients with obstructive sleep apnea. Sleep Breath 2017; 21:569-575. [DOI: 10.1007/s11325-017-1490-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/08/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
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Influence of interface and position on upper airway collapsibility assessed by negative expiratory pressure. Sleep Breath 2017; 21:631-638. [PMID: 28064430 DOI: 10.1007/s11325-016-1445-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/22/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Negative expiratory pressure (NEP) is a simple technique for the evaluation of upper airway collapsibility in patients with obstructive sleep apnea (OSA). Most studies evaluated NEP using a mouthpiece that may exclude the cephalic portion of the upper airway. We hypothesize that NEP determination is influenced by interface and position. METHODS We evaluated patients with suspected OSA using polysomnography, NEP (-5 cmH2O in sitting and supine position with mouthpiece and nasal mask). A subgroup also underwent computed tomography (CT) of the upper airway. RESULTS We studied a total of 86 subjects (72 male, age 46 ± 12 yrs, body mass index 30.0 ± 4.4 kg/m2, neck circumference 40.0 ± 3.5 cm, AHI 32.9 ± 26.4, range 0.5 to 122.5 events/hour). NEP was influenced by interface and position (p = 0.007), and upper airway was more collapsible with mouthpiece than with nasal mask in sitting position (p = 0.001). Position influenced NEP and was worse in supine only when evaluated by nasal mask. Expiratory resistance (R 0.2) at 0.2 s during NEP was significantly higher and independent of position with mouthpiece than with nasal mask (20.7 versus 8.6 cmH2O/L s-1, respectively, p = 0.018). NEP evaluated with nasal mask in supine position and with mouthpiece in sitting position, but not when evaluated with mouthpiece in supine position, were correlated with upper airway anatomical measurements including tongue dimensions and pharyngeal length. CONCLUSIONS Interface and position influence NEP. NEP evaluated with nasal mask in supine position may convey more relevant information for patients under investigation for OSA than when evaluated with mouthpiece.
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Kiraz K, Çörtük M, Zitouni B, Çetinkaya EA, Benli AR. Uyku Apne Sendromu Hastalarında Pozitif Hava Yolu Basıncı Tedavisinin Yaşam Kalitesi Üzerine Etkisi. ANKARA MEDICAL JOURNAL 2016. [DOI: 10.17098/amj.26198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Ng JR, Aiyappan V, Mercer J, Catcheside PG, Chai-Coetzer CL, McEvoy RD, Antic N. Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series. J Clin Sleep Med 2016; 12:1227-32. [PMID: 27306398 DOI: 10.5664/jcsm.6118] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 05/20/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The choice of mask interface used with continuous positive airway pressure (CPAP) therapy can affect the control of upper airway obstruction (UAO) in obstructive sleep apnea (OSA). We describe a case series of four patients with paradoxical worsening of UAO with an oronasal mask and the effect of changing to a nasal mask. METHODS We retrospectively reviewed the case histories of 4 patients and recorded patient demographics, in-laboratory and ambulatory CPAP titration data, CPAP therapy data, type of mask interface used and potential confounding factors. RESULTS The 4 cases (mean ± SD: age = 59 ± 16 y; BMI = 30.5 ± 4.5 kg/m(2)) had a high residual apnoea-hypopnea index (AHI) (43 ± 14.2 events/h) and high CPAP pressure requirements (14.9 ± 6.6 cmH2O) with an oronasal mask. Changing to a nasal mask allowed adequate control of UAO with a significant reduction in the average residual AHI (3.1 ± 1.5 events/h). In two of the four cases, it was demonstrated that control of UAO was obtained at a much lower CPAP pressure compared to the oronasal mask (Case one = 17.5 cmH2O vs 12cmH2O; Case two = 17.9 cmH2O vs 7.8 cmH2O). Other potential confounding factors were unchanged. There are various physiological observations that may explain these findings but it is uncertain which individuals are susceptible to these mechanisms. CONCLUSIONS If patients have OSA incompletely controlled by CPAP with evidence of residual UAO and/or are requiring surprisingly high CPAP pressure to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask. COMMENTARY A commentary on this article appears in this issue on page 1209.
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Affiliation(s)
- Justin R Ng
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
| | - Vinod Aiyappan
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
| | - Jeremy Mercer
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
| | - Peter G Catcheside
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
| | - Nick Antic
- Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia
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Efficiency of bimaxillary advancement surgery in increasing the volume of the upper airways: a systematic review of observational studies and meta-analysis. Eur Arch Otorhinolaryngol 2016; 274:35-44. [DOI: 10.1007/s00405-016-4015-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 03/23/2016] [Indexed: 11/26/2022]
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McMillan A, Bratton DJ, Faria R, Laskawiec-Szkonter M, Griffin S, Davies RJ, Nunn AJ, Stradling JR, Riha RL, Morrell MJ. A multicentre randomised controlled trial and economic evaluation of continuous positive airway pressure for the treatment of obstructive sleep apnoea syndrome in older people: PREDICT. Health Technol Assess 2016; 19:1-188. [PMID: 26063688 DOI: 10.3310/hta19400] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The therapeutic and economic benefits of continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnoea syndrome (OSAS) have been established in middle-aged people. In older people there is a lack of evidence. OBJECTIVE To determine the clinical efficacy of CPAP in older people with OSAS and to establish its cost-effectiveness. DESIGN A randomised, parallel, investigator-blinded multicentre trial with within-trial and model-based cost-effectiveness analysis. METHODS Two hundred and seventy-eight patients, aged ≥ 65 years with newly diagnosed OSAS [defined as oxygen desaturation index at ≥ 4% desaturation threshold level for > 7.5 events/hour and Epworth Sleepiness Scale (ESS) score of ≥ 9] recruited from 14 hospital-based sleep services across the UK. INTERVENTIONS CPAP with best supportive care (BSC) or BSC alone. Autotitrating CPAP was initiated using standard clinical practice. BSC was structured advice on minimising sleepiness. COPRIMARY OUTCOMES Subjective sleepiness at 3 months, as measured by the ESS (ESS mean score: months 3 and 4) and cost-effectiveness over 12 months, as measured in quality-adjusted life-years (QALYs) calculated using the European Quality of Life-5 Dimensions (EQ-5D) and health-care resource use, information on which was collected monthly from patient diaries. SECONDARY OUTCOMES Subjective sleepiness at 12 months (ESS mean score: months 10, 11 and 12) and objective sleepiness, disease-specific and generic quality of life, mood, functionality, nocturia, mobility, accidents, cognitive function, cardiovascular risk factors and events at 3 and 12 months. RESULTS Two hundred and seventy-eight patients were randomised to CPAP (n = 140) or BSC (n = 138) over 27 months and 231 (83%) patients completed the trial. Baseline ESS score was similar in both groups [mean (standard deviation; SD) CPAP 11.5 (3.3), BSC 11.4 (4.2)]; groups were well balanced for other characteristics. The mean (SD) in ESS score at 3 months was -3.8 (0.4) in the CPAP group and -1.6 (0.3) in the BSC group. The adjusted treatment effect of CPAP compared with BSC was -2.1 points [95% confidence interval (CI) -3.0 to -1.3 points; p < 0.001]. At 12 months the effect was -2.0 points (95% CI -2.8 to -1.2 points; p < 0.001). The effect was greater in patients with increased CPAP use or higher baseline ESS score. The number of QALYs calculated using the EQ-5D was marginally (0.005) higher with CPAP than with BSC (95% CI -0.034 to 0.044). The average cost per patient was £1363 (95% CI £1121 to £1606) for those allocated to CPAP and £1389 (95% CI £1116 to £1662) for those allocated to BSC. On average, costs were lower in the CPAP group (mean -£35; 95% CI -£390 to £321). The probability that CPAP was cost-effective at thresholds conventionally used by the NHS (£20,000 per QALY gained) was 0.61. QALYs calculated using the Short Form questionnaire-6 Dimensions were 0.018 higher in the CPAP group (95% CI 0.003 to 0.034 QALYs) and the probability that CPAP was cost-effective was 0.96. CPAP decreased objective sleepiness (p = 0.02), increased mobility (p = 0.03) and reduced total and low-density lipoprotein cholesterol (p = 0.05, p = 0.04, respectively) at 3 months but not at 12 months. In the BSC group, there was a fall in systolic blood pressure of 3.7 mmHg at 12 months, which was not seen in the CPAP group (p = 0.04). Mood, functionality, nocturia, accidents, cognitive function and cardiovascular events were unchanged. There were no medically significant harms attributable to CPAP. CONCLUSION In older people with OSAS, CPAP reduces sleepiness and is marginally more cost-effective than BSC over 12 months. Further work is required in the identification of potential biomarkers of sleepiness and those patients at increased risk of cognitive impairment. Early detection of which could be used to inform the clinician when in the disease cycle treatment is needed to avert central nervous system sequelae and to assist patients decision-making regarding treatment and compliance. Treatment adherence is also a challenge in clinical trials generally, and adherence to CPAP therapy in particular is a recognised concern in both research studies and clinical practice. Suggested research priorities would include a focus on optimisation of CPAP delivery or support and embracing the technological advances currently available. Finally, the improvements in quality of life in trials do not appear to reflect the dramatic changes noted in clinical practice. There should be a greater focus on patient centred outcomes which would better capture the symptomatic improvement with CPAP treatment and translate these improvements into outcomes which could be used in health economic analysis. TRIAL REGISTRATION Current Controlled Trials ISRCTN90464927. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 40. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alison McMillan
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel J Bratton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Rita Faria
- Centre for Health Economics, University of York, York, UK
| | | | - Susan Griffin
- Oxford University and Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Robert J Davies
- Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - John R Stradling
- Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK
| | - Renata L Riha
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Mary J Morrell
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
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Neuzeret PC, Morin L. Impact of different nasal masks on CPAP therapy for obstructive sleep apnea: a randomized comparative trial. CLINICAL RESPIRATORY JOURNAL 2016; 11:990-998. [PMID: 26780403 DOI: 10.1111/crj.12452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 12/11/2015] [Accepted: 01/04/2016] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Patient interface is important for the success of continuous positive airway pressure (CPAP), but few trials have examined the influence of mask choice on CPAP adherence. OBJECTIVES To compare the impact of different nasal masks on CPAP in patients with newly-diagnosed obstructive sleep apnea (OSA). METHODS OSA patients were randomized in a 2:3 ratio to receive CPAP via different first-line nasal masks: ResMed Mirage FX® (MFX) or control mask (Fisher & Paykel Zest® , HC407® or Philips EasyLife® ). Mask acceptance, CPAP compliance and Home Care Provider (HCP) interventions were compared between groups after 3 months of CPAP therapy using modified intent-to-treat (mITT; after exclusion of patients with mouth leaks during CPAP initiation) and on-treatment (OT; CPAP adherent) analyses. RESULTS Of 285 randomized patients, 90 requiring a full-face mask were excluded, leaving 195 and 151 in the mITT and OT analyses, respectively. Mask acceptance rate was higher in the MFX versus control group (mITT: 79% vs 68%, P = 0.067; OT: 90% vs 76%, P = 0.022). CPAP compliance was higher (5.9 ± 1.8 vs 5.1 ± 1.6 h/night, P = 0.011) and nasal mask issue-related HCP visits lower (3% vs 17%, P = 0.006) in the MFX group. Nasal mask failures due to mask discomfort (5% vs 1%) or unintentional leakage (5% vs 0%) were higher in control vs MFX group. Mask acceptance was significantly associated with fewer mask leaks (P = 0.002) and higher pressure therapy (P = 0.042). CONCLUSIONS This study highlights differences between nasal masks for CPAP delivery and shows that initial mask selection can influence adherence and healthcare utilization during CPAP.
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