When continuous positive airway pressure (CPAP) fails

Comprehensive Analysis of Adverse Events Associated With Hypoglossal Nerve Stimulators: Insights From the MAUDE Database

OBJECTIVE

This study aims to examine the adverse events associated with hypoglossal nerve stimulator (HNS) implantation for treating obstructive sleep apnea (OSA), drawing data from the Manufacturer and User Facility Device Experience (MAUDE) database. We aim to provide a comprehensive and updated account of these adverse events.

STUDY DESIGN

Retrospective analysis.

SETTING

MAUDE Database review.

METHODS

A retrospective analysis was performed on the MAUDE database to collect all HNS-related reports from May 2014 to December 2023. Variables collected included date of event, event description, nature of event, iatrogenic injuries, required interventions, and, if available, root causes. Each event description was analyzed to classify the adverse event, the postevent intervention, and device model number.

RESULTS

Out of 1178 reports fulfilling the inclusion criteria, 1312 adverse events were identified. Common adverse events included infection (24.0%), pain (19.7%), and hematoma/seroma (10.2%). Approximately 83.1% of these adverse events necessitated medical and/or surgical intervention. The most frequent procedures included explantation (29.4%) and device repositioning (15.8%). Pneumothorax was reported in 50 cases, with 41 (82.0%) requiring a chest tube to be inserted. Three adverse events described overstimulation in the setting of magnetic resonance imaging (MRI) despite the implantation of MRI-compatible second-generation internal pulse generators.

CONCLUSION

While HNS implantation has been established as a reliable intervention for OSA in cases of continuous positive airway pressure failure or intolerance, this study highlights several perioperative and postoperative difficulties and complications. Understanding these challenges is essential for refining surgical practices and enhancing patient consent processes, ultimately aiming to improve therapeutic outcomes.

Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder

STUDY OBJECTIVES

To examine differences in sample characteristics and longitudinal sleep outcomes according to weighted blanket (WB) adherence.

METHODS

Children with attention-deficit/hyperactivity disorder (n = 94), mean age 9.0 (standard deviation 2.2, range 6-14) participated in a 16-week sleep intervention with WBs. Children were classified as WB adherent (use of WB ≥ 4 nights/wk) or nonadherent (use of WB ≤ 3 nights/wk). Changes in objectively measured sleep by actigraphy, parent-reported sleep problems (Children's Sleep Habits Questionnaire) and child-reported Insomnia Severity Index were evaluated according to adherence with mixed effect models. Sex, age, and attention-deficit/hyperactivity disorder subtype were examined as potential moderators.

RESULTS

Children adherent to WBs (48/94) showed an early response in sleep outcomes and an acceptance of the WB after 4 weeks of use as well as a decrease in parent-reported (Children's Sleep Habits Questionnaire) (-5.73, P = .000) and child-reported (Insomnia Severity Index) (-4.29, P = .005) sleep problems after 16 weeks. The improvement in sleep was larger among WB adherent vs nonadherent (between-group difference: Children's Sleep Habits Questionnaire: -2.09, P = .038; Insomnia Severity Index: -2.58, P = .007). Total sleep time was stable for children adherent to WB but decreased for nonadherent (between-group difference: +16.90, P = .019).

CONCLUSIONS

An early response in sleep and acceptance of the WB predicted later adherence to WBs. Improvements in sleep were more likely among WB adherents vs nonadherents. Children with attention-deficit/hyperactivity disorder may thus benefit from using WBs to handle their sleep problems.

CITATION

Lönn M, Svedberg P, Nygren J, Jarbin H, Aili K, Larsson I. Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder. J Clin Sleep Med. 2024;20(9):1455-1466.

Prevalence of continuous positive airway pressure-related aerophagia in obstructive sleep apnea: an observational study of 753 cases undergoing CPAP/BiPAP treatment in a sleep clinic - part one of a two-part series

PURPOSE

Aerophagia occurring during continuous positive airway pressure (C-aerophagia in CPAP) in patients with obstructive sleep apnea (OSA) disturbs CPAP therapy. However, the diagnostic criteria and exact prevalence of C-aerophagia are not well documented; therefore, this study aimed to evaluate them.

METHODS

Newly developed criteria (flatulence, eructation, and abdominal bloating, with quantitative evaluation of these symptoms and a clear timing of onset) were used to diagnose C-aerophagia. The study included 753 adults with OSA who underwent follow-up visits for positive airway pressure treatment (including CPAP and bilevel positive airway pressure). The observation period ranged from 6 months to 3 years past the survey date (between May 1 and July 31, 2023). Medical records of patients were retrospectively analyzed. Discomfort associated with C-aerophagia was examined using a visual analog scale (VAS); a score ≥ 7 was associated with definite discomfort. Association of patient demographics and CPAP parameters with occurrence of C-aerophagia was analyzed using multivariate analysis.

RESULTS

The prevalence of C-aerophagia was 7.2%. Although more than half of these patients reported discomfort associated with aerophagia, only 44.4% reported to their physician. The multivariate analysis showed that increased CPAP pressure level (odds ratio [OR] = 1.24) and comorbid gastroesophageal reflux disease (GERD; OR = 2.52) promote C-aerophagia, while increased age (OR = 0.76) and body mass index (BMI; OR = 0.88) inhibit it.

CONCLUSION

The prevalence of C-aerophagia was 7.2%. Most patients with C-aerophagia experience discomfort, but may not report these symptoms. High CPAP pressure and GERD promoted C-aerophagia, while aging and increased BMI prevented it.

The impact of obstructive sleep apnea treatment on microvascular complications in patients with type 2 diabetes: a feasibility randomized controlled trial

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is associated with an increased risk of diabetes-related complications. Hence, it is plausible that continuous positive airway pressure (CPAP) could have a favorable impact on these complications. We assessed the feasibility of conducting a randomized control trial in patients with type 2 diabetes and OSA over 2 years.

METHODS

We conducted an open-label multicenter feasibility randomized control trial of CPAP vs no CPAP in patients with type 2 diabetes and OSA. Patients with resting oxygen saturation < 90%, central apnea index > 15 events/h, or Epworth Sleepiness Scale ≥ 11 were excluded. OSA was diagnosed using a multichannel portable device (ApneaLink Air, ResMed). The primary outcome measures were related to feasibility and the secondary outcomes were changes in various clinical and biochemical parameters related to diabetes outcomes.

RESULTS

Eighty-three (40 CPAP vs 43 no CPAP) patients were randomly assigned, with a median (interquartile range) follow-up of 645 (545, 861) days. CPAP compliance was inadequate, with a median usage of approximately 3.5 hours/night. Early CPAP use predicted longer-term compliance. The adjusted analysis showed a possible favorable association between being randomly assigned to CPAP and several diabetes-related end points (chronic kidney disease, neuropathy, and quality of life).

CONCLUSIONS

It was feasible to recruit, randomly assign, and achieve a high follow-up rate over 2 years in patients with OSA and type 2 diabetes. CPAP compliance might improve by a run-in period before randomization. A full randomized control trial is necessary to assess the observed favorable association between CPAP and chronic kidney disease , neuropathy, and quality of life in patients with type 2 diabetes.

CLINICAL TRIAL REGISTRATION

Registry: ISRCTN; Name: The impact of sleep disorders in patients with type 2 diabetes; URL: https://www.isrctn.com/ISRCTN12361838; Identifier: ISRCTN12361838.

CITATION

Makhdom EA, Maher A, Ottridge R, et al. The impact of obstructive sleep apnea treatment on microvascular complications in patients with type 2 diabetes: a feasibility randomized controlled trial. J Clin Sleep Med. 2024;20(6):947-957.

The Prevalence of Sentinel Central Events (SCent) During Drug-Induced Sleep Endoscopy

OBJECTIVE

With the recent addition of airflow and respiratory effort channels, our group has observed central and mixed apnea events during drug-induced sleep endoscopy (DISE). We measured the frequency and timing of sentinel central and/or mixed events (SCents), as well as assessed for differences in velum, oropharynx, tongue, and epiglottis (VOTE) classification compared to obstructive events.

STUDY DESIGN

Prospective single-cohort study.

SETTING

Tertiary Care Academic Medical Center.

METHODS

Patients underwent DISE between June 2020 and November 2022. Nasal airflow, thoracoabdominal effort belt signals, and videoendoscopy were simultaneously captured. Demographics, sleep study, and DISE data were compared among patients with and without SCents using Student's T tests or χ2 tests.

RESULTS

On average, the cohort (n = 103) was middle-aged (53.5 ± 12.1 years), overweight (body mass index of 29.7 ± 5.3 kg/m2), and had severe obstructive sleep apnea (apnea-hypopnea index of 30.7 ± 18.7 events/h). Forty-seven patients (46%) were found to have at least 1 SCent. Among those with SCent, 45 (95.7%) transitioned to obstructive pathology after an average of 7.91 ± 2.74 minutes, with at least 95% of patients expected to do so within 12.57 minutes. Twenty-nine out of 47 patients (61.2% [95% confidence interval: 46.4.9%, 75.5%]) with SCent had meaningful differences between central/mixed and obstructive VOTE scores.

CONCLUSION

Central events were present in almost half of our cohort. At least 95% of patients were expected to transition to obstructive events within 12 to 13 minutes of propofol initiation. In addition, over half of patients demonstrate significantly different VOTE scores between central and obstructive events. These factors should raise awareness of central events and scoring passive apneas during DISE and consider delaying VOTE scoring.

Effects of combined exercise training with sleep education in older adults with obstructive sleep apnea: protocol for a randomized clinical trial

Background

Obstructive sleep apnea (OSA) is a common disorder that affects approximately 1 billion people worldwide. Advanced age is a significant risk factor. Various treatment options have been explored to reduce the severity of OSA symptoms and physical exercise has emerged as a potential alternative therapy. Therefore, this study aims to investigate the effects of a combined exercise program with sleep education on sleep quality and on the severity of OSA in older adults.

Methods

This is a randomized clinical trial with two parallel groups that will involve individuals of both genders aged between 60 and 79 years who have an apnea-hypopnea index (AHI) of more than 15 events per hour and who have not received or are currently undergoing treatment for OSA. Older adults who have engaged in regular exercise in the last six months and individuals with contraindications to exercise will be excluded. The study will assess outcomes related to OSA, including AHI, oxygen desaturation index, minimum and mean oxyhemoglobin saturation, sleep efficiency, sleep latency, and the type of respiratory events. Additionally, sleep quality-related outcomes, daytime sleepiness, physical activity, physical fitness, aerobic capacity, cognitive status, anthropometric measures, and health-related quality of life will be analyzed. Participants will be randomized to two groups: a combined exercise group (involving both resistance and aerobic training) with sleep education, and a control group that will receive only educational recommendations for managing OSA. The intervention will last 12 weeks and will consist of three sessions per week, totaling 36 exercise sessions. Sample size calculation indicates a minimum number of 36 participants.

Discussion

If the hypothesis is confirmed, this clinical trial will indicate an effective non-pharmacological intervention for treating OSA in older adults. This intervention could be used as an adjunct to existing approaches designed to improve OSA management.

Clinical trail registration

Brazil Clinical Trials Registry (ReBEC), identifier RBR-9hk6pgz.

A Critical Analysis of Pharyngeal Patterns of Collapse in Obstructive Sleep Apnea: Beyond the Endoscopic Classification Systems

(1) Background: Drug-Induced Sleep Endoscopy (DISE) enables the three-dimensional and dynamic visualization of the upper airway (UA) during sleep, which is useful in selecting the best treatment option for obstructive sleep apnea (OSA) patients, particularly for surgical procedures. Despite international consensus statements or position papers, a universally accepted DISE methodology and classification system remain a controversial open question. (2) Methods: A review of the English scientific literature on DISE related to endoscopic classification systems and surgical outcome predictors (3) Results: Of the 105 articles, 47 were included in the analysis based on their content's relevance to the searched keywords. (4) Conclusions: A final report and scoring classification system is not universally accepted; the most internationally applied endoscopic classification system during DISE does not cover all patterns of events that occur simultaneously during the endoscopic examination, highlighting that several configurations of collapse and obstruction at different UA levels could be observed during DISE, which should be described in detail if DISE has to be considered in the decision-making process for the UA surgical treatment in OSA patients and if DISE has to have a role as a predictive factor for surgical outcomes analysis.

A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults

STUDY OBJECTIVES

The treatment of obstructive sleep apnea is often impeded by intolerance of positive airway pressure therapy, which is frequently attributed to the inability to breathe through the nose. Providers caring for patients with sleep apnea need a working knowledge of nasal passage disease and available treatments to better manage this common comorbidity.

METHODS

This review examines the literature connecting rhinosinusitis to adverse sleep and sleep apnea outcomes. It explores the different types of nasal and sinus diseases a sleep apnea provider might encounter, focusing on the medications used to treat them and indications for referral to otolaryngology.

RESULTS

Chronic rhinosinusitis can be either allergic or nonallergic. Both types can interfere with sleep and sleep apnea therapy. The successful management of chronic rhinosinusitis can improve positive airway pressure tolerance and adherence. A wide range of over-the-counter and prescription pharmacotherapy is available, with data supporting intranasal over oral treatment. Surgical treatment for chronic rhinosinusitis in obstructive sleep apnea addresses nasal obstruction, often with inferior turbinate reduction and septoplasty.

CONCLUSIONS

Sleep specialists should have a working knowledge of the available options to treat chronic rhinosinusitis. These options are often safe, effective, and readily accessible. Otolaryngologists and allergists/immunologists provide additional treatment options for more complicated patients. Providing treatment for chronic rhinosinusitis should be included as part of comprehensive sleep apnea care.

CITATION

Ali MM, Ellison M, Iweala OI, Spector AR. A sleep clinician's guide to runny noses: evaluation and management of chronic rhinosinusitis to improve sleep apnea care in adults. J Clin Sleep Med. 2023;19(8):1545-1552.

Management of hypertension in obstructive sleep apnea

Obstructive sleep apnea (OSA) plays an important role in the development of hypertension. Thus, this review summarizes pharmacological and non-pharmacological approaches to blood pressure (BP) control in patients with OSA. Current treatments for OSA, such as continuous positive airway pressure, are effective at lowering BP. However, they only provide a modest BP reduction, and pharmacological treatment remains important for achieving optimal BP control. Furthermore, current guidelines for the treatment of hypertension do not make specific recommendations on pharmacological treatment protocols for controlling BP in patients with OSA. Moreover, the BP-lowering effects of various classes of antihypertensives may be different in hypertensive patients with OSA than in those without OSA due to the underlying mechanisms that promote hypertension in OSA. The acute and chronic increase in sympathetic nerve activity in patients with OSA explain the effectiveness of beta blockers in controlling BP in these patients. As activation of the renin-angiotensin-aldosterone system may also promote hypertension in OSA, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers have generally been found effective for lowering BP in hypertensive patients with OSA. The aldosterone antagonist spironolactone also produces a good antihypertensive response in patients with OSA and resistant hypertension. However, there are limited data available that compare the effects of various classes of antihypertensive medication on BP control in those with OSA, and most data have been obtained from small-scale studies. This demonstrates the need for large-scale randomized controlled trials to evaluate a range of BP-lowering regimens in patients with OSA and hypertension.

Comparison of CPAP and Expansion Sphincter Pharyngoplasty using the Mean Disease Alleviation Concept

OBJECTIVE

Continuous Positive Airway Pressure (CPAP) is the typical first treatment for Obstructive Sleep Apnea (OSA); however, patient adherence is often suboptimal. Expansion Sphincter Pharyngoplasty (ESP) is an alternative treatment option for patients with OSA who demonstrate signs of palatal and lateral pharyngeal collapse. The aim of this study is to compare therapeutic outcomes, using the mean disease alleviation concept, for patients who underwent ESP to patients undergoing CPAP therapy.

DATA SOURCES

Single-institution retrospective cohort study.

METHODS

All patients who underwent ESP from 2018 to 2021 or were prescribed CPAP from December to June 2021 at our institution were assessed for inclusion. ESP patients who had pre- and post-operative sleep studies available and CPAP patients who followed up at our institution's sleep clinic were included for analysis. Charts were reviewed for demographic information and sleep study results, and treatment outcomes were measured by calculating mean disease alleviation.

RESULTS

There were 77 patients in the ESP group and 107 patients in the CPAP group. AHI reduction was greater in the CPAP group (p = 0.016); however, mean disease alleviation was similar between groups (p = 0.076). One-way ANCOVA demonstrated similar MDA between groups when controlling for patient age, BMI, gender, and pre-operative AHI (F [1,177] = 2,931.6, p = 0.104).

CONCLUSION

CPAP therapy provided superior reduction in AHI compared to ESP; however, overall treatment efficacy as measured by mean disease alleviation was similar for both groups.

LEVEL OF EVIDENCE

3 Laryngoscope, 2023.

High-flow nasal cannula improves hypoxemia in dogs failing conventional oxygen therapy

OBJECTIVE

A prospective clinical trial was performed to evaluate the efficacy and tolerance of high-flow nasal cannula (HFNC) in dogs with hypoxemia.

ANIMALS

20 client-owned dogs failing conventional oxygen therapy (COT).

PROCEDURES

Patients admitted to the ICU for treatment of hypoxemic respiratory failure were enrolled in the study. PaO2, SPO2, respiratory rate (RR), and acute patient physiologic and laboratory evaluation scores were obtained at the time of COT failure and after initiation of HFNC. Complications and patient tolerance while receiving HFNC were also recorded.

RESULTS

Compared to COT, the median PaO2 and SO2 were significantly higher when dogs were receiving HFNC (60.8 vs 135.6 mm Hg and 90.7% vs 99.25%, respectively). Dogs receiving HFNC had a significant reduction in median RR as compared to dogs undergoing COT (52 vs 36 breaths per minute). After the initiation of HFNC, all dogs showed clinical improvement as measured by PaO2, SO2, and RR. Of 20 dogs, 6 ultimately failed HFNC and mechanical ventilation was recommended. Nine dogs undergoing HFNC survived to discharge, and acute patient physiologic and laboratory evaluation scores had a significant positive severity correlation with death. Complications included pneumothorax in 1 dog.

CLINICAL RELEVANCE

COT has limited flow rates due to airway irritation caused by room temperature, nonhumidified oxygen. HFNC uses vapor humidification and heated oxygen, allowing for higher flow rates. In people, HFNC is used as escalation of oxygen therapy when COT fails. Dogs treated with HFNC had significant improvements in PaO2, SO2, and RR as compared to COT. HFNC is well tolerated and effective in treating hypoxemia in dogs.

A telemonitoring system to support CPAP therapy in patients with obstructive sleep apnea: a participatory approach in analysis, design, and evaluation

Background

Continues positive airway pressure (CPAP) therapy is a gold standard treatment for moderate to severe cases of OSA (obstructive sleep apnea). The present research aimed to describe the analysis, design, and evaluation of a telemonitoring system to improve CPAP adherence in patients afflicted with OSA.

Methods

The telemonitoring system was developed in five phases. In the exploratory phase, the body of related literature was reviewed. Then a need analysis was conducted through a focus group discussion with sleep medicine specialists and sales company representatives and an interview with patients. The third phase involved data integration. Then the content and system development were done based on the previous phases. Finally, usability and functionality tests were used to evaluate the system.

Results

The exploratory phase and the needs analysis were conducted by four sleep medicine specialists, two medical informatics specialists, six key figures of the sales companies, two system developers, and 46 patients in different phases. Based on the results obtained from the data integration phase, the telemonitoring system involved three main parts: a patient’s application, a doctor’s portal, a selling companies’ portal (operator’s portal) along with facilitating software for patients to send the CPAP data. Usability and functionality tests were given to 7 and 10 patients, respectively. The total number of usability issues reported by users in the evaluation process was 18, with an average of 2.5 issues per user. The installation problems, disrupted links and improper playing of videos were the main functionalities problems that were solved.

Conclusion

The telemonitoring system, as a means of communication between patients, doctors, and selling companies, can be used to support patients clinically and technically. It has the potential to improve CPAP adherence in patients with OSA.

Pulmonary rehabilitation: A novel adjunct in management of obstructive sleep apnea

Pulmonary rehabilitation (PR) is being used in the routine management of patients of obstructive sleep apnea (OSA) at some centers. However, the studies documenting benefits of PR in OSA lack standardization in terms of outcome measures. A study was hence planned to determine the efficacy of PR on exercise capacity, health related quality of life (HRQOL), day time sleepiness and sleep-quality of life (QOL) in patients of OSA. As a part of comprehensive therapy, patients diagnosed with OSA are managed with continuous positive airway pressure (CPAP), 8 weeks thrice weekly outpatient hospital-based PR and medical treatment at the Pulmonary Medicine Department, Government Medical College and Hospital, Chandigarh. However, some patients refuse for PR because of time constraints and travel issues. Patients with newly diagnosed OSA without co-existing respiratory disease, who agreed for the CPAP, PR and medical management were enrolled in group A. The patients who refused for PR but were ready for CPAP and medical management were enrolled in Group B; 30 patients were taken in each group. Exercise capacity, HRQOL, day time sleepiness and sleep-QOL were determined at baseline and at 8-weeks follow-up by 6-minute walk distance (6MWD), St. George's Respiratory Questionnaire (SGRQ), Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) and compared amongst the two groups. Four patients from group A were excluded as they did not complete PR; 26 patients from group A and 30 patients from group B were finally analyzed. At baseline, both groups were matched with respect to age, gender, apnea-hypopnea index (AHI), body mass index (BMI), FEV1%predicted, 6MWD, SGRQ, ESS and FOSQ. At follow up at 8 weeks, BMI, 6MWD, SGRQ, ESS and FOSQ improved significantly from baseline in group A (p<0.001). FEV1%predicted also improved but non significantly. In group B, FEV1%predicted, BMI, 6MWD, SGRQ, ESS and FOSQ score did not improve significantly from baseline. Mean improvement from baseline in BMI, 6MWD, SGRQ, ESS and FOSQ was significantly more in group A than group B (p<0.001, p<0.001, p=0.041, p<0.001 and p<0.001, respectively). PR, being beneficial, should be incorporated in standard management of OSA.

Nasal Symptoms in Patients with Obstructive Sleep Apnoea and Their Association with Continuous Positive Airway Pressure Usage

The role of nasal symptoms in continuous positive airway pressure (CPAP) tolerance is not completely clear. This study aimed to investigate the association between CPAP usage and nasal symptoms, either prior to, or developing during, CPAP use in patients with obstructive sleep apnoea (OSA). Two hundred thirty patients were studied and divided into high-, low-, and non-CPAP users. Nasal symptoms and related quality of life parameters were evaluated prior to CPAP initiation and after three months. We also investigated predictive factors for CPAP usage. Non-CPAP users had significantly worse baseline scores for runny nose compared with high and low users (1.34 vs. 0.68 and 0.75, respectively, p = 0.006). There were no other significant differences between the groups. Runny nose was an independent predictive factor for lower CPAP usage (p = 0.036). An evaluation after three months showed worsening in runny nose score in high-CPAP users (p = 0.025) but not in low- and non-users. There were no significant changes in other nasal symptoms. Our study demonstrates that nasal symptoms were very common in this population but rhinorrhoea was the only symptom associated with poorer CPAP adherence. Moreover, rhinorrhoea worsened after a three-month trial of high-CPAP usage.

Dose response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study

STUDY OBJECTIVES

Clinical benefits of PAP therapy for OSA are assumed to require adherent PAP usage, as defined by CMS as ≥ 4 hours of use ≥ 70% of nights. However, this is based on early data and does not necessarily capture improvements at subthreshold adherence. We explored dose-response relationships between PAP adherence measures and EDS from the HomePAP RCT.

METHODS

Participants ≥18 years with apnea hypopnea index ≥ 15 and baseline sleepiness (Epworth Sleepiness Scale (ESS) ≥ 12) received PAP therapy. Data were collected at baseline, 1-month, and 3-months follow-up. Regression models and receiver operating characteristic curves evaluated PAP measures as predictors of ESS change and normalization (ESS < 10).

RESULTS

In 119 participants (age 49.4 ± 12.6 years, 66.4% male, 72.3% white), > 50% were PAP non-adherent per CMS criteria at 3 months. Percent of nights with PAP use ≥ 4 hours predicted ESS change (p = 0.023), but not when controlling for AHI. Percent of nights with ≥ 4 hours and average PAP use provided the best discrimination for predicting ESS normalization; each 10% increase in PAP use ≥ 4 hours increased the odds of ESS normalization by 22% (p = 0.007); those using PAP ≥ 4 hours had nearly 3-fold greater odds of ESS normalization (p = 0.025). At least 4 hours and 70% of nights provided the best balance between specificity (0.50) and sensitivity (0.73).

CONCLUSIONS

Although sub-adherent PAP usage may still confer some benefit for OSA patients, adherence to current criteria confers the highest likelihood for ESS change and normalization.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP); Identifier: NCT00642486; URL: http://clinicaltrials.gov/show/NCT00642486.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Sleep Disruption Worsens Seizures: Neuroinflammation as a Potential Mechanistic Link

Sleep disturbances, such as insomnia, obstructive sleep apnea, and daytime sleepiness, are common in people diagnosed with epilepsy. These disturbances can be attributed to nocturnal seizures, psychosocial factors, and/or the use of anti-epileptic drugs with sleep-modifying side effects. Epilepsy patients with poor sleep quality have intensified seizure frequency and disease progression compared to their well-rested counterparts. A better understanding of the complex relationship between sleep and epilepsy is needed, since approximately 20% of seizures and more than 90% of sudden unexpected deaths in epilepsy occur during sleep. Emerging studies suggest that neuroinflammation, (e.g., the CNS immune response characterized by the change in expression of inflammatory mediators and glial activation) may be a potential link between sleep deprivation and seizures. Here, we review the mechanisms by which sleep deprivation induces neuroinflammation and propose that neuroinflammation synergizes with seizure activity to worsen neurodegeneration in the epileptic brain. Additionally, we highlight the relevance of sleep interventions, often overlooked by physicians, to manage seizures, prevent epilepsy-related mortality, and improve quality of life.

Continuous Positive Airway Pressure Titration During Pediatric Drug Induced Sleep Endoscopy

OBJECTIVE

To observe the degree of airway collapse at varying levels of continuous positive airway pressure (CPAP) during drug pediatric induced sleep endoscopy.

METHODS

Using our institutional anesthesia protocol for pediatric DISE procedures, patients were anesthetized followed by evaluation of the nasal airway, nasopharynx, velum, hypopharynx, arytenoids, tongue base, and epiglottis. CPAP titration was performed under vision to evaluate the degree of airway collapse at the level of the velum. Comparison was made with pre-operative polysomnography findings.

RESULTS

Twelve pediatric patients underwent DISE with intraoperative CPAP titration. In 7/12 patients, DISE observed CPAP titration was beneficial in elucidating areas of obstruction that were observed at pressures beyond those recommended during preoperative sleep study titrations. In 3 patients, DISE observations provided a basis for evaluation in children not compliant with sleep study CPAP titration testing. With regard to regions effected, airway collapse was observed at the velum and oropharynx to a greater degree when compared with the tongue base and epiglottis.

CONCLUSION

DISE evaluation of the pediatric patient with obstructive sleep apnea may present a source for further patient evaluation with respect to CPAP optimization and severity of OSA assessment, particularly in syndromic patients.

The Rise of IGFBP4 in People with Obstructive Sleep Apnea and Multilevel Sleep Surgery Recovers Its Basal Levels

IGFBP4 is the smallest member of the insulin-like growth factor binding protein family (IGFBP). It is a hepatic protein that plays a role in modulating the activity and bioavailability of IGF-I. The expression of IGFBP4 was found to increase under conditions of hypoxia. Obstructive sleep apnea (OSA) is a common disorder, characterized by cyclic episodes of intermittent hypoxia and fragmented sleep. Our aim was to quantify levels of circulating IGFBP1, IGFBP2, IGFBP3, IGFBP4, and IGFBP7 in fasting plasma samples of 69 Kuwaiti participants and explore its correlation with indices of OSA. The quantification was performed using multiplexing assay. The study involved 28 controls and 41 patients with OSA. Levels of circulating IGFBP4 were significantly higher in people with OSA (289.74 ± 23.30 ng/ml) compared to the control group (217.60 ± 21.74 ng/ml, p = 0.028). The increase in IGFBP4 correlated significantly and positively with AHI (r = .574, p = .01) and AI (r = .794, p = .001) in people with moderate and severe OSA. There was a significant decline in circulating IGFBP4 after 3 months of surgery (225.89 ± 18.16 ng/ml, p = 0.012). This was accompanied by a prominent improvement in OSA (AHI 8.97 ± 2.37 events/h, p = 0.001). In this study, our data showed a significant increase in circulating IGFBP4 in people with OSA. We also report a significant positive correlation between IGFBP4 and indices of OSA at baseline, which suggests IGFBP4 as a potential diagnostic biomarker for OSA. There was a significant improvement in OSA after 3 months of surgical intervention, which concurred with a significant decline in IGFBP4 levels. Altogether, the detected change suggests a potential link between IGFBP4 and OSA or an OSA-related factor, whereby OSA might play a role in triggering the induction of IGFBP4 expression.

Sleep and White Matter in Adults with Down Syndrome

Adults with Down syndrome are at a high risk for disordered sleep. These sleep problems could have marked effects on aging and Alzheimer's disease, potentially altering white matter integrity. This study examined the associations between disordered sleep assessed via an actigraph accelerometer worn on 7 consecutive nights, presence of diagnosis of obstructive sleep apnea, and diffusion tensor imaging indices of white matter integrity in 29 non-demented adults with Down Syndrome (48% female, aged 33-54 years). Average total sleep time was associated with lower mean diffusivity in the left superior longitudinal fasciculus (r = -0.398, p = 0.040). Average sleep efficiency, length of awakenings, and movement index were related to fractional anisotropy in the right inferior longitudinal fasciculus (r = -0.614 to 0.387, p ≤ 0.050). Diagnosis of obstructive sleep apnea was associated with fractional anisotropy in the right inferior longitudinal fasciculus (r = -0.373, p = 0.050). Findings suggest that more disrupted sleep is associated with lower white matter integrity in the major association tracts in middle-aged adults with Down syndrome. Longitudinal work is needed to confirm the directionally of associations. Sleep interventions could be an important component for promoting optimal brain aging in the Down syndrome population.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline

Introduction

This guideline establishes clinical practice recommendations for referring adults with obstructive sleep apnea (OSA) for surgical consultation.

Methods

The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine, otolaryngology, and bariatric surgery to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force evaluated the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations.

Recommendations

The following recommendations are intended as a guide for clinicians who treat adults with OSA. Each recommendations statement is assigned a strength ("Strong" or "Conditional"). A "Strong" recommendation (i.e., "We recommend…") is one that clinicians should follow under most circumstances. A "Conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and strongly consider the patient's values and preferences to determine the best course of action. 1. We recommend that clinicians discuss referral to a sleep surgeon with adults with OSA and BMI<40 who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 2. We recommend that clinicians discuss referral to a bariatric surgeon with adults with OSA and obesity (class II/III, BMI ≥35) who are intolerant or unaccepting of PAP as part of a patient-oriented discussion of alternative treatment options. (STRONG) 3. We suggest that clinicians discuss referral to a sleep surgeon with adults with OSA, BMI<40, and persistent inadequate PAP adherence due to pressure-related side effects as part of a patient-oriented discussion of adjunctive or alternative treatment options. (CONDITIONAL) 4. We suggest clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery. (CONDITIONAL).

Virtual otolaryngologic management of sleep apnea patients: Lessons learned from COVID-19 pandemic

OBJECTIVE

To discuss the virtual management options and strategies learned during the COVID-19 pandemic for treatment of patients with sleep complaints and sleep disordered breathing presenting to the otolaryngologist.

METHODS/RESULTS

The addition of a virtual evaluation can be beneficial in assessing the patient presenting to the otolaryngologist with sleep complaints. With the implementation of telemedicine, validated subjective assessment tools, and a limited physical exam, patients can be triaged for the need for treatment implementation, further evaluation or testing, and counseled regarding various management options.In this article, we discuss the lessons learned from the authors' collective experience on how to effectively use telemedicine as a tool in the management repertoire for patients with sleep disorders.

CONCLUSION

The otolaryngologist will commonly see patients with sleep complaints, particularly patients diagnosed with obstructive sleep apnea not able to tolerate conservative therapies. These patients are well suited for virtual evaluation utilizing telemedicine. The technology and workflows which have been developed during the COVID-19 pandemic can be carried forward for select patients to improve access and efficiency of care.Level of evidence: 5.

The Considerations and Controversies in Using High-Flow Nasal Oxygen with Self-Prone Positioning in SARS-CoV-2 COVID-19 Disease

Evidence exists for the use of high-flow nasal oxygen (HFNO) in the general critical care population for acute hypoxemic respiratory failure. There is discord between guidelines for hypoxemia management in COVID-19. Both noninvasive management and intubation present risk to patients and staff and potentially overwhelm hospital mechanical ventilator capacity. The use of HFNO has been particularly controversial in the UK, with oxygen infrastructure failure. We discuss our experience of managing COVID-19 with HFNO and awake self-prone positioning. We focus upon the less-usual case of an eighteen-year-old female to illustrate the type of patient where HFNO may be used when perhaps earlier intubation once was. It is important to consider the wider implications of intubation. We have used HFNO as a bridge to intubation or as definitive management. As we await clinical trial evidence, HFNO with self-prone positioning has a role in COVID-19 for certain patients. Response parameters must be set and reviewed, oxygen infrastructure considered, and potential staff droplet exposure minimised.

Determinants of usage and non-adherence to noninvasive ventilation in children and adults with Duchenne muscular dystrophy

STUDY OBJECTIVES

Duchenne muscular dystrophy (DMD) is a neuromuscular disorder that leads to chronic respiratory insufficiency and failure. Use of home noninvasive ventilation (NIV) has been linked to improved outcomes including reduced mortality. Despite the importance of NIV, factors promoting optimal NIV usage and determinants of non-adherence have not been rigorously examined. Moreover, given that respiratory issues in DMD span between childhood and adulthood, examination across a broad age group is needed. The objectives of this study were to (1) evaluate NIV usage across a broad spectrum of DMD patients including both children and adults; and (2) identify biological and socioeconomic determinants of NIV usage and NIV non-adherence.

METHODS

We performed a retrospective review of all DMD patients from Feb 2016 to Feb 2020 who underwent evaluation at associated pediatric and adult neuromuscular disease clinics. NIV use was determined objectively from device downloads. A priori, we defined non-adherence as <4 hours use per night, quantified as the percentage of nights below this threshold across a 30-day period within 6 months of a clinic visit. We also assessed the average hours of NIV usage over this time period. Predictors examined included demographics, social determinants, and pulmonary function.

RESULTS

33 patients with DMD were identified, 29 (87%) of whom were using NIV (13 age < 21 years). Mean age was 22.9±6.6 years (range 13-39 years), BMI was 23.4±10.4 kg/m², and seated forced vital capacity (FVC) was 23%±18% predicted. Mean nightly NIV usage was 7.4±3.8 hours and mean percentage of non-adherent nights was 13%±30%. In univariable analysis, age did not predict use. Those with lower FVC had higher NIV usage hours (p=0.01) and a trend toward less non-adherence (p=0.06). Higher estimated household income demonstrated a trend towards increased usage hours and less non-adherence (both p=0.08). Multivariable analysis found increased usage hours were predicted best by higher income, higher IPAP, and higher bicarbonate. Non-adherence was higher in those with lower income or higher FVC.

CONCLUSIONS

In this cohort of adult and pediatric DMD patients, most individuals were using NIV. While usage hours were higher with lower lung function, substantial variability remains unexplained by examined factors. Non-adherence was observed in some individuals, including those with advanced disease. Further investigations should focus on evaluating patient-oriented outcomes in order to define optimal NIV usage across the spectrum of disease, and determine strategies to counteract issues with non-adherence.

Clinical Implications of Geometric and Dosimetric Uncertainties of Inter- and Intra-Fractional Movement during Volumetric Modulated Arc Therapy for Breast Cancer Patients

Simple Summary

Radiotherapy is an essential treatment modality for breast cancer. Compared to conventional radiotherapy techniques, modern radiotherapy with fewer fractions and smaller target volumes requires higher accuracy. Image-guidance using cone-beam computed tomography (CBCT) is one of the most common methods used for positional verification before treatment. This study reports geometric and dosimetric outcomes evaluated by analyzing CBCT images acquired before and during treatments. The positional change and internal movement of the patient were less than 1 cm in most cases without significant deviation in the dosimetric parameters of interest. However, there were cases involving extreme variation, which resulted in insufficient radiation delivered to the target areas and increased radiation exposure to adjacent normal organs. The results of the current study suggest that unexpected intra-fractional motion may occur, prompting for marginal adaptation in selected patients who are deemed to suffer from this kind of event.

Abstract

With the introduction of modern sophisticated radiotherapy (RT) techniques, the significance of accuracy has increased considerably. This study evaluated the necessity of pre-treatment and intra-fractional cone-beam computed tomography (CBCT) by analyzing inter- and intra-fractional CBCT images of breast cancer patients receiving RT. From 57 patients, 1206 pre-treatment CBCT and 1067 intra-fractional CBCT images were collected. Geometric movements of patients were measured quantitively in both inter- and intra-fractional CBCT, and changes in dosimetric parameters were evaluated in selected patients with extreme intra-fractional movement. For right-sided breast cancer patients, left-sided breast cancer patients treated using deep-inspiration breath hold (DIBH), and left-sided breast cancer patients treated using continuous positive airway pressure (CPAP), median inter-fractional deviations were 0.53 (range 0.06–2.98) cm, 0.66 (range 0.08–4.41) cm, and 0.69 (range 0.04–3.80) cm, and median intra-fractional deviations were 0.14 (range 0.00–0.62) cm, 0.23 (range 0.02–0.96) cm, and 0.24 (0.00–1.15) cm, respectively. Modified plans reflecting large changes in intra-fractional position in 10 selected cases revealed insufficient target coverage in seven cases and more than 20-fold increase in the volume of heart receiving at least 25 Gy in two cases. Intra-fractional verification, as well as pre-treatment verification, might be considered in patients using DIBH or CPAP.

A novel intraoral neuromuscular stimulation device for treating sleep-disordered breathing

Purpose

To ascertain the usefulness of a novel intraoral neuromuscular stimulation device in treating patients with primary snoring and mild obstructive sleep apnoea (OSA). This device uses daytime awake neuromuscular electrical stimulation (NMES) as an application to induce toning of the tongue muscles.

Methods

A prospective cohort study of 70 patients with sleep-disordered breathing was conducted. Objective snoring and respiratory parameters were recorded with 2 consecutive night WatchPat sleep studies before and after treatment. The device was used for 20 min once daily for a 6-week period. Secondary outcome measures using visual analogue scale reporting of snoring by patient and Epworth Sleepiness Score (ESS) were recorded. Quality of life parameters were also noted.

Results

Objective reduction of snoring was noted on the sleep studies in 95% of participants, with an average snoring time reduction of 48%. Subjectively, the visual analogue scale reported by partners’ similarly demonstrated reduction in 95% of the patients with an average reduction of 40%. In a subset of 38 patients with mild OSA, AHI reduced from 9.8 to 4.7/h (52% reduction), ODI 7.8 to 4.3/h (45% reduction), and ESS from 9.0 to 5.1. Adverse effects encountered were minimal.

Conclusion

This prospective cohort study demonstrates a notable improvement in both objective and subjective parameters of snoring and mild OSA in both simple snorers and patients with mild OSA. This device offers a safe and novel approach to reduce snoring and mild OSA by utilising intraoral neuromuscular electrical stimulation. This could be a preferred option for patients as it alleviates the need of using an oral device during sleep.

Trial registration

clinicaltrials.gov identifier NCT03829956

Minimally Invasive Combined Nd:YAG and Er:YAG Laser-Assisted Uvulopalatoplasty for Treatment of Obstructive Sleep Apnea

Objective: In this article, efficacy of minimally invasive outpatient laser-assisted uvulopalatoplasty (LAUP) procedure (NightLase^® LAUP) to reduce apnea-hypopnea index (AHI) in patients with obstructive sleep apnea (OSA) is evaluated. Background: OSA is a serious condition, but its treatment is often not effective or is poorly accepted by patients. Newer modes of therapy that are more effective and also more accepted by patients need to be developed. The latest treatment approaches involve a minimally invasive LAUP procedure. This procedure involves thermal processing of the relaxed soft palate and surrounding tissues using neodimium-doped yttrium aluminum garnet (Nd:YAG) and erbium-doped yttrium aluminum garnet (Er:YAG) lasers, resulting in favorable collagen shrinkage and development of new collagen fibers. Procedure has previously been reported to safely and effectively reduce snoring, as well as increase the volume of the oropharyngeal airway, and is well accepted by patients. Materials and methods: The efficacy of the minimally invasive LAUP procedure, combining Nd:YAG laser (λ = 1064 nm) and Er:YAG laser (λ = 2940 nm) applied to the soft palate for treatment of OSA on 27 patients with different severities of OSA was evaluated based on AHI measurements before and after only three 20-min sessions in an outpatient setting over a period of 45-60 days. Results: A decrease in AHI for all the patients with different severities of OSA tested in this study was achieved, with 66.3% average improvement (32-100%). Fifty percent or more improvement was achieved in 78% (21) of all patients. Conclusions: Based on our observations, the NightLase^® LAUP treatment of OSA represents an effective and safe therapeutic method. Further research and longer term prospective trials are needed to improve the evidence base for the potential integration of this treatment method into the current guidelines for treatment of OSA.

Redox-Oligomeric State of Peroxiredoxin-2 and Glyceraldehyde-3-Phosphate Dehydrogenase in Obstructive Sleep Apnea Red Blood Cells under Positive Airway Pressure Therapy

In this study, we examined the effect of six months of positive airway pressure (PAP) therapy on Obstructive Sleep Apnea (OSA) red blood cell (RBC) proteome by two dimensional difference gel electrophoresis (2D-DIGE) - based proteomics followed by Western blotting (WB) validation. The discovered dysregulated proteins/proteoforms are associated with cell death, H2O2 catabolic/metabolic process, stress response, and protein oligomerization. Validation by nonreducing WB was performed for peroxiredoxin-2 (PRDX2) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) by using antibodies against the sulfinylated/sulfonylated cysteine of these proteins to better evaluate their redox-oligomeric states under OSA and/or in response to PAP therapy. The results indicated that the redox-oligomeric state of GAPDH and PRDX2 involving overoxidation by sulfinic/sulfonic acids were differentially modulated in OSA RBC, which might be compromising RBC homeostasis. PAP therapy by restoring this modulation induced a higher oligomerization of overoxidized GAPDH and PRDX2 in some patients that could be associated with eryptosis and the chaperone "gain" of function, respectively. This varied response following PAP may result from the complex interplay between OSA and OSA metabolic comorbidity. Hence, information on the redox status of PRDX2 and GAPDH in RBC will help to better recognize OSA subtypes and predict the therapeutic response in these patients. GAPDH monomer combined with body mass index (BMI) and PRDX2 S-S dimer combined with homeostatic model assessment for insulin resistance (HOMA-IR) showed to be very promising biomarkers to predict OSA and OSA severity, respectively.

The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea

Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.

Adverse Events in Hypoglossal Nerve Stimulator Implantation: 5-Year Analysis of the FDA MAUDE Database

OBJECTIVE

Use of hypoglossal nerve stimulator implantation has dramatically improved the surgical treatment of multilevel airway collapse during obstructive sleep apnea (OSA). Understanding causes of adverse events and their impact on patients undergoing stimulator implantation will help improve patient preparation and surgical practices to avoid future complications.

STUDY DESIGN

This study is a retrospective review of the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database, a publicly available voluntary reporting system.

SETTING

National patient event database.

METHODS

The MAUDE database was searched for reports associated with the terms "hypoglossal nerve stimulator" and "Inspire," being the only currently FDA-approved system for upper airway stimulation for OSA. All records were searched with the events limited in dates between May 2014 and September 2019.

RESULTS

A total of 132 patient reports were identified over the 5-year inclusion period, containing 134 adverse events. The reported adverse events resulted in 32 device revision procedures as well as 17 explantations. Device migration and infection were 2 of the most commonly reported adverse events. Complications not witnessed in previous large-scale clinical trials included pneumothorax, pleural effusion, and lead migration into the pleural space.

CONCLUSION

Previous data have demonstrated hypoglossal nerve stimulator implantation results in reliable OSA improvement. However, a number of technical difficulties and complications still exist during the perioperative period, which should be communicated to patients during the surgical consent process.

[Are There Recommended Alternatives to Positive Airway Pressure Therapy in the Treatment of Sleep Apnea?]

Are There Recommended Alternatives to Positive Airway Pressure Therapy in the Treatment of Sleep Apnea? Abstract. For decades, positive airway pressure (PAP) ventilation has been considered the gold standard in the therapy of obstructive sleep apnea (OSA). Although this is a very successful procedure with regard to the elimination of apnea, the long-term adherence of patients to PAP is only 60-80 % for various reasons. In the meantime, there are numerous options such as intraoral devices, spine sleep position avoidance or newer surgical procedures which are advertised as an alternative to PAP in the therapy of OSA. This raises questions about the significance and effectiveness. This article is intended to provide an up-to-date overview of the significance and possibilities of the therapy alternatives.

The Converging Pathologies of Obstructive Sleep Apnea and Atrial Arrhythmias

Obstructive sleep apnea (OSA) is highly prevalent in the United States (US). Along with epidemic rates of obesity, the rate of OSA cases is also on the rise. OSA is associated with multiple chronic health conditions, including hypertension, diabetes, stroke, myocardial ischemia, and heart rhythm disturbances. OSA is commonly treated with continuous positive airway pressure (CPAP) therapy. Several reports indicate that effective treatment of OSA can reduce the risk of cardiovascular diseases, including cardiac arrhythmias, especially atrial fibrillation (AF). CPAP therapy helps to maintain sinus rhythm after interventions such as electrical cardioversion and catheter ablation in patients with AF. However, more data is required to establish a relationship between OSA and other atrial arrhythmias as well to evaluate the effect of CPAP. This review will compile the latest evidence on the pathophysiology, management, and treatment of atrial arrhythmias associated with OSA.

How to manage continuous positive airway pressure (CPAP) failure -hybrid surgery and integrated treatment

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.

Upper airway surgery to rescue the "untitratable" patient with OSA and obesity

None

This is a case report of an 41-year-old male with obesity (body mass index 90 kg/m²), severe obstructive sleep apnea (OSA), and an apnea-hypopnea index of 90 events/h despite high bilevel positive airway pressure (BPAP). He presented to the PAP Alternatives Clinic and underwent tonsillectomy, expansion sphincter pharyngoplasty, and partial uvulectomy to improve positive airway pressure effectiveness. Postoperative BPAP retitration resolved the patient's OSA. The patient is currently using BPAP therapy at home with improvement in both objective and self-reported OSA outcomes.

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.

Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease which impacts quality of life, mood, cardiovascular morbidity, and mortality. Continuous positive airway pressure (CPAP) is the first-line treatment for patients with moderate to severe OSA. CPAP ameliorates respiratory disturbances, leading to improvements in daytime sleepiness, quality of life, blood pressure, and cognition. However, despite the high efficacy of this device, CPAP adherence is often sub-optimal. Factors including: socio-demographic/economic characteristics, disease severity, psychological factors, and side-effects are thought to affect CPAP adherence in OSA patients. Intervention studies have suggested that augmented support/education, behavioral therapy, telemedicine and technological interventions may improve CPAP adherence. In this paper, we will extensively review the most common factors including age, gender, race/ethnicity, socioeconomic status, smoking status, severity of OSA, severity of OSA symptoms, psychological variables, social support, marital status/bed partner involvement, dry nose and mouth, mask leak, and nasal congestion that may predict CPAP adherence. We will also extensively review interventions that may increase adherence to CPAP.

Transoral robotic surgery of the tongue base for obstructive sleep apnea: Preliminary results

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a major public health issue. Robotic tongue-base reduction surgery is being developed, but needs assessment. The present study reports clinical and polygraphic results at 6 months' follow-up.

METHOD

Single-center prospective study of 8 patients undergoing transoral robotic surgery (TORS) for severe OSAS.

RESULTS

Mean age was 47 years. M/F sex ratio was 5:3. Initial body-mass index ranged from 18 to 35kg/m². Mean Epworth score was 12. Mean preoperative apnea-hypopnea index (AHI) was 47 (range, 36-60). At 6 months, only 1 patient did not meet usual success criteria (AHI<20 with>50% decrease); 2 patients had residual AHI between 10 and 20; the other 5 had non-significant event rates.

CONCLUSION

TORS tongue-base reduction showed promising results, which need confirmation on long-term multicenter studies.

Tailoring surgical interventions to treat obstructive sleep apnoea: one size does not fit all

While continuous positive airway pressure (CPAP) remains the gold standard treatment of choice in patients with moderate or severe obstructive sleep apnoea (OSA), surgery has been established as a means to improve compliance and facilitate the use of CPAP, both of which are potential pitfalls in the efficacy of this treatment modality. In a minority of cases, with obvious oropharyngeal anatomical obstruction, corrective surgery may completely alleviate the need for CPAP treatment. In this review, we summarise clinical assessment, surgical options, discuss potential new treatments, and outline the importance of investigating and addressing the multiple anatomical levels that can contribute to OSA. Research into effectiveness of these procedures is rapidly accumulating, and surgery can be an effective treatment. However, given the myriad of options available and multiple levels of anatomical pathology that can present, it is imperative that correctly selected patients are matched with the most appropriate treatment for the best outcomes.

KEY POINTS

OSA is an increasingly prevalent disorder which has significant systemic effects if left untreated.Anatomical abnormalities can be corrected surgically to good effect with a growing and robust evidence base.Drug-induced sleep endoscopy is a key tool in the otolaryngologist's armamentarium to tailor specific surgery to address specific anatomical concerns, and to facilitate appropriate patient selection.Multilevel surgical approaches are often indicated instead of a "one size fits all" model.

EDUCATIONAL AIMS

To discuss how to assess patients presenting with OSA in clinic, from an otorhinolaryngology perspective.To discuss the indications for intervention.To provide an overview of nonsurgical interventions for treating OSA, with evidence.To discuss the different surgical modalities available for treatment of OSA, with evidence.

First Successful Mechanical Splint for Obstructive Sleep Apnea With an Orally Administrable Pharyngeal Stenting Device

We report the case of obstructive sleep apnea in a 19-year-old, otherwise healthy male presenting with persistent daytime sleepiness and nonrestorative sleep after velo- and uvuloplasty. An individually tailored prototype of an orally inserted pharyngeal stenting device was proposed in the framework of a first clinical feasibility trial. The noninvasive, easily self-administered device is mounted on a simple inferior dental guard. Baseline total apnea-hypopnea index (AHI) was 15.5 and 24.4 per hour of rapid eye movement (REM) sleep. With the device, total AHI dropped to 6.7 per hour (56.8% reduction) and 1.4 per hour of REM (94.3% reduction). Recorded sleep efficiency during treatment was excellent at 96.5%. Laryngoscope, 129:1945-1948, 2019.

Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for obstructive sleep apnea syndrome (OSAS). However, poor adherence is a limiting factor, and a significant proportion of patients are unable to tolerate CPAP. The aim of this study was to determine predictors of long-term non-compliance with CPAP.

METHODS

CPAP treatment was prescribed to all consecutive patients with moderate or severe OSAS (AHI ≥15 events/h) (n = 295) who underwent a full-night CPAP titration study at home between February 1, 2002 and December 1, 2016. Adherence was defined as CPAP use for at least 4 h per night and five days per week. Subjects had periodical follow-up visits including clinical and biochemical evaluation and assessment of adherence to CPAP.

RESULTS

Median follow-up observation was 74.8 (24.2/110.9) months. The percentage of OSAS patients adhering to CPAP was 41.4% (42.3% in males and 37.0% in females), and prevalence was significantly higher in severe OSAS than in moderate (51.8% vs. 22.1%; p < 0.001; respectively). At multivariate analysis, lower severity of OSAS (HR = 0.66; CI 95 0.46-0.94) p < 0.023), cigarette smoking (HR = 1.72; CI 95 1.13-2.61); p = 0.011), and previous cardiovascular events (HR = 1.95; CI 95 1.03-3.70; p = 0.04) were the only independent predictors of long-term non-adherence to CPAP after controlling for age, gender, and metabolic syndrome.

CONCLUSIONS

In our cohort of patients with moderate/severe OSAS who were prescribed CPAP therapy, long-term compliance to treatment was present in less than half of the patients. Adherence was positively associated with OSAS severity and negatively associated with cigarette smoking and previous cardiovascular events at baseline.

Drug induced sleep endoscopy: its role in evaluation of the upper airway obstruction and patient selection for surgical and non-surgical treatment

Sleep related breathing disorders cause obstruction of the upper airway which can be alleviated by continuous positive airway pressure (CPAP) therapy, oral devices or surgical intervention. Non-surgical treatment modalities are not always accepted by patients and in order to attain successful surgical outcomes, evaluation of the upper airway is necessary to carefully select the patients who would benefit from surgery. There are numerous techniques available to assess the upper airway obstruction and these include imaging, acoustic analysis, pressure transducer recording and endoscopic evaluation. It is essential to note that the nocturnal obstructive upper airway has limited muscle control compared to the tone of the upper airway lumen during wakefulness. Thus, if one were to attempt to identify the anatomical segments contributing to upper airway obstruction in sleep related breathing disorders; it must be borne in mind that evaluation of the airway must be performed if possible when the patient is awake and asleep albeit during drug induced sleep. This fact as such limits the use of imaging techniques for the purpose. Drug induced sleep endoscopy (DISE) was pioneered at Royal National Throat, Nose and Ear Hospital, London in 1990 and initially introduced as sleep nasendoscopy. The nomenclature and the technique has been modified by various Institutions but the core value of this evaluation technique remains similar and extremely useful for identifying the anatomical segment responsible for obstructing the upper airway during sleep in patients with sleep related breathing disorders. There have been numerous controversies that have surrounded this technique but over the last two decades most of these have been addressed and it now remains in the forefront of methods of evaluating the upper airway obstruction. A variety of sedative agents and different grading systems have been described and efforts to unify various aspects of the technique have been made. This article will look at its usefulness and advantages and will discuss some important contributions made to the field of evaluation of the upper airway using DISE.

Non-surgical treatment of obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS), a pervasive disease, is closely associated with complications such as cardiovascular diseases, neurocognitive diseases, and metabolic syndromes. Continuous positive airway pressure (CPAP) is the standard treatment for OSAS, with low compliance due to multifarious factors. The two other modes of ventilation, bi-level positive airway pressure (BPAP) and autotitrating positive airway pressure (APAP), which were developed from CPAP, are slightly different from CPAP in specific groups, as well as the corresponding treatment effect and compliance. The compliance of traditional positional therapy is not high, but with the emergence of the neck-based position treatment device, its compliance and indications have changed. Although CPAP is superior to mandibular advancement device (MAD) in improving AHI, MAD seems to be comparable to CPAP in improving other indicators. Corticosteroids and leukotriene receptor antagonists are effective treatments for mild OSAS children. Whether corticosteroids can be used in other OSAS groups and their adjunctive functions to CPAP remains unclear. The combination of these two kinds of drugs appears to be more effective than single drug. Researches on transcutaneous electrical stimulation are still not enough. Its effectiveness and stimulation settings still need further study. This review summarized the various OSAS non-surgical treatments from indications, treatment outcomes, compliance, adverse reactions, and recent progress.

Narrative review of contemporary treatment options in the care of patients with obstructive sleep apnoea

Snoring and obstructive sleep apnoea (OSA) are increasingly common conditions, and confer a significant health and socioeconomic burden. Furthermore, untreated OSA represents a significant mortality risk. Patients require careful assessment, including detailed clinical history and examination, sleep study and drug-induced sleep endoscopy (DISE). Although nasal continuous positive airway pressure (nCPAP) is the gold standard treatment for moderate and severe OSA, multidisciplinary team assessment is often required to develop the best treatment plan for an individual, especially when nasal CPAP is poorly tolerated. There is a wide range of medical and surgical treatment options, and following appropriate patient selection and assessment, a focused site-specific, often multilevel, intervention is indicated. There is an increasing body of evidence in the literature supporting these multilevel interventions and with agreement on standardized outcome measures more trials are likely to improve the robustness of these data further.

Anaesthetic Preparation of Obese Patients: Current Status on Optimal Work-up

PURPOSE OF REVIEW

With the prevalence of obesity rapidly growing, bariatric anaesthesia becomes everyday anaesthesia rather than a subspecialty. In this review, we are aiming to draw attention to this complex group of patients and their comorbidities, relevant to everyday practice for contemporary anaesthetists.

RECENT FINDINGS

We wanted to focus greatly on sleep-related breathing disorders, because preoperative screening, diagnosis and treatment of the aforementioned make a huge impact in the improvement of preoperative morbidity and mortality, including positive effects on the cardiovascular system. The overview is touching on main obesity-related comorbidities and guides the anaesthetist and associated health professionals on how to approach and manage them. A multidisciplinary approach widely used in bariatric care may be adopted in the care of obese patients in order to reduce preoperative morbidity and mortality. We advocate the early involvement of the anaesthetic team in the preoperative assessment of obese patients in order to achieve appropriate risk stratification and optimise the care.