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Renslo B, Virgen CG, Sawaf T, Arambula A, Sykes KJ, Larsen C, Rouse DT. Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter? J Clin Sleep Med 2023; 19:1061-1071. [PMID: 36740926 PMCID: PMC10235707 DOI: 10.5664/jcsm.10496] [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: 09/11/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVES Upper airway stimulation is a surgical option for patients with obstructive sleep apnea who fail other forms of noninvasive treatment. Current guidelines recommend a baseline body mass index (BMI) below 32 kg/m2 for eligibility. In this study, we identify trends in BMI before and after upper airway stimulation to characterize the influence of BMI on treatment success. METHODS Patients underwent upper airway stimulation implantation between 2016 and 2021. Sleep study data were collected from preoperative and most recent postoperative sleep study. BMI data were collected and compared across the following time points: preoperative sleep study (BMI-1), initial surgeon consultation (BMI-2), surgery (BMI-3), titration polysomnogram (BMI-4), and second postoperative sleep study (BMI-5). Patients were categorized into groups (BMI ≥32 [BMI32], 25 ≤ BMI <32 [BMI25], BMI <25 [BMI18]) based BMI-1, and clinical outcomes were compared. RESULTS 253 patients were included. The BMI32 group showed a significant decrease in BMI between BMI-1 and BMI-3 (33.9 vs 32.2; P < .001) and a significant increase in BMI between BMI-3 and BMI-5 (32.2 vs 33.0; P = .047). Apnea-hypopnea index improvement and treatment success rate were not significantly different between groups. On univariate and multivariable logistic regression, a lower BMI-5 was significantly predictive of treatment success (odds ratio: 0.88; 95% confidence interval: 0.79-0.97; P = .016). BMI-5 was also significantly associated with improvement in apnea-hypopnea index (P = .002). Other BMI time points were not associated with measures of treatment success. CONCLUSIONS Reduced BMI after upper airway stimulation implantation, as opposed to baseline BMI, predicted treatment success. These findings may guide patient counseling, with implications for long-term adherence and therapy success. CITATION Renslo B, Virgen CG, Sawaf T, et al. Long-term trends in body mass index throughout upper airway stimulation treatment: does body mass index matter? J Clin Sleep Med. 2023;19(6):1061-1071.
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Affiliation(s)
- Bryan Renslo
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Celina G. Virgen
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Tuleen Sawaf
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Alexandra Arambula
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Kevin J. Sykes
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher Larsen
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - David T. Rouse
- Department of Otolaryngology—Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
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Pépin JL, Eastwood P, Eckert DJ. Novel avenues to approach non-CPAP therapy and implement comprehensive OSA care. Eur Respir J 2021; 59:13993003.01788-2021. [PMID: 34824053 DOI: 10.1183/13993003.01788-2021] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/16/2021] [Indexed: 11/05/2022]
Abstract
Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, "one size fits all", trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.
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Affiliation(s)
- Jean-Louis Pépin
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France .,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Peter Eastwood
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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3
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MacKay SG, Lewis R, McEvoy D, Joosten S, Holt NR. Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association . Respirology 2020; 25:1292-1308. [PMID: 33190389 PMCID: PMC7839593 DOI: 10.1111/resp.13967] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 12/11/2022]
Abstract
Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.
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Affiliation(s)
- Stuart G MacKay
- University of Wollongong, Wollongong, NSW, Australia.,Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia.,Department of Otolaryngology Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW, Australia
| | - Richard Lewis
- Hollywood Medical Centre, Perth, WA, Australia.,Department of Otolaryngology Head and Neck Surgery, Royal Perth Hospital, Perth, WA, Australia
| | - Doug McEvoy
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Respiratory and Sleep Service, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Simon Joosten
- Monash Lung and Sleep, Monash Health, Monash Medical Centre, Melbourne, VIC, Australia.,School of Clinical Sciences, Melbourne, VIC, Australia
| | - Nicolette R Holt
- The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Yu MS, Ibrahim B, Riley RW, Liu SYC. Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 13:225-233. [PMID: 32683836 PMCID: PMC7435433 DOI: 10.21053/ceo.2020.00360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022] Open
Abstract
There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.
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Affiliation(s)
- Myeong Sang Yu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Badr Ibrahim
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Robert Wayne Riley
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
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Upper airway stimulation for obstructive sleep apnea-Can radiological position monitoring predict tongue motion one year after implantation? HNO 2020; 68:11-16. [PMID: 31598770 DOI: 10.1007/s00106-019-0717-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tongue motion patterns (TMP) can influence the outcome of upper airway stimulation (UAS) in the treatment of obstructive sleep apnea (OSA). As a postoperative control, the cuff position of the stimulation lead is monitored via X‑ray imaging. A multidimensional X‑ray assessment system was established and the association between these positional assessments and TMP was investigated 1 year after implantation. MATERIAL AND METHODS The study on TMP and the X‑ray assessments were carried out at a German ear nose and throat clinic as an implantation center. The TMPs were assessed under bipolar electrode configuration and were categorized according to the currently available literature as right-sided protrusion (RP), left-sided protrusion (LP), bilateral protrusion (BP) and mixed activation (MA). The X‑ray assessment was carried out in five dimensions: the position relative to the mandible and hyoid, cuff steepness in the lateral view of the neck, the cuff position based on the single electrode, and the lead connection to the cuff in the anterior-posterior view. The analyses were performed by three raters with different medical backgrounds and knowledge regarding TMP. RESULTS In approximately 60% of patients, the apnea-hypopnea index was reduced to below 15/h 1 year after implantation. The most common TMPs were RP and BP (82.9%). The interrater variability of the X‑ray assessment was good except for one category. Furthermore, no relevant associations were found apart from the correlation between a favorable TMP and the cuff position with respect to the lateral position of the stimulation cable. CONCLUSION Despite good interrater variability and convenient usage of the suggested X‑ray assessment system, this approach did not enable the identification of any associations by which a TM and, therefore, a possible straightforward or complicated treatment pathway could be predicted. Attention should possibly be paid to a rotation of the cuff during implantation with a lateral position of the stimulation lead.
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Baptista PM, Costantino A, Moffa A, Rinaldi V, Casale M. Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: Patient Selection and New Perspectives. Nat Sci Sleep 2020; 12:151-159. [PMID: 32104122 PMCID: PMC7026121 DOI: 10.2147/nss.s221542] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Hypoglossal nerve stimulation (HNS) is an increasingly widespread OSA treatment. It is a non-anatomical modifying surgery able to achieve an adequate objective and subjective result with a reasonable complication rate. HNS exploits the neurostimulation to reduce upper airway collapsibility providing a multilevel upper airway improvement within a single procedure. Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome. All patient candidates for HNS undergo a standard comprehensive sleep medicine assessment and upper airway surgical examination. Several features should be assessed preoperatively in order to predict patients' response to HNS treatment. In particular, the assessment of OSA severity, BMI > 32 Kg/m2, collapse pattern during drug-induced sleep endoscopy (DISE), and many other parameters, is central for a good patient selection and customization of OSA treatment. HNS is indeed one of the most promising tools in the widespread context of personalized sleep medicine. HNS is an adjustable medical device that could be titrated in order to improve HNS effectiveness, maintaining patient comfort. Moreover, HNS provides the opportunity for patients to play an active role in their own care, with a potential improvement in therapy adherence and efficacy. This review summarizes the current evidence in patient selection for HNS, highlighting the reasons behind the optimistic future of this OSA treatment in the context of personalized medicine.
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Affiliation(s)
- Peter M Baptista
- Department of ORL, Clínica Universidad de Navarra, Pamplona, Spain
| | - Andrea Costantino
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Antonio Moffa
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy.,Department of Otolaryngology, University of Foggia, Foggia, Italy
| | - Vittorio Rinaldi
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
| | - Manuele Casale
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
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Steffen A, Wozny AS, König IR, Goltz JP, Wollenberg B, Hasselbacher K. [Upper Airway Stimulation for obstructive sleep apnea-Can radiological position monitoring predict tongue motion one year after implantation? German version]. HNO 2019; 67:690-697. [PMID: 31414154 DOI: 10.1007/s00106-019-0715-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tongue motion patterns (TMP) can influence the outcome of upper airway stimulation (UAS) in the treatment of obstructive sleep apnea (OSA). As a postoperative control the cuff position of the stimulation lead is monitored via X‑ray imaging. A multidimensional X‑ray assessment system was established and the association between these positional assessments and TMP was investigated 1 year after implantation. MATERIAL AND METHODS The study on TMP and the X‑ray assessments were carried out at a German ear nose and throat clinic as an implantation center. The TMPs were assessed under bipolar electrode configuration and were categorized according to the currently available literature as right-sided protrusion (RP), left-sided protrusion (LP), bilateral protrusion (BP) and mixed activation (MA). The X‑ray assessment was carried out in five dimensions: the position relative to the mandible and hyoid, cuff steepness in the lateral view of the neck, the cuff position based on the single electrode and the lead connection to the cuff in the anterior-posterior view. The analyses were performed by three raters with different medical backgrounds and knowledge regarding TMP. RESULTS In approximately 60% of the patients the apnea-hypopnea index was reduced to below 15/h, 1 year after implantation. The most common TMPs were RP and BP (82.9%). The interrater variability of the X‑ray assessment was good except for one category. Furthermore, no relevant associations were found apart from the correlation between a favorable TMP and the cuff position with respect to the lateral position of the stimulation cable. CONCLUSION Despite good interrater variability and convenient usage of the suggested X‑ray assessment system, this approach did not enable the identification of any associations, by which a TM and therefore a possible straightforward or complicated treatment pathway could be predicted. Attention should possibly be paid to a rotation of the cuff during implantation with a lateral position of the stimulation lead.
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Affiliation(s)
- A Steffen
- Klinik für Hals-Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - A S Wozny
- Klinik für Hals-Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - I R König
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Lübeck, Deutschland
| | - J-P Goltz
- Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Lübeck, Deutschland
| | - B Wollenberg
- Klinik für Hals-Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - K Hasselbacher
- Klinik für Hals-Nasen- und Ohrenheilkunde, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
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Die HNO-spezifische operative Therapie bei schlafbezogenen Atmungsstörungen. SOMNOLOGIE 2019. [DOI: 10.1007/s11818-019-00218-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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