Innovative treatments for adults with obstructive sleep apnea

Evolution of adherence and self-reported symptoms over 36 months with mandibular advancement device therapy for obstructive sleep apnea: a retrospective study

STUDY OBJECTIVES

Mandibular advancement devices (MAD) constitute a feasible option for management of mild-to-moderate obstructive sleep apnea (OSA) and in severe cases, when indicated. As a chronic condition, the management of OSA with MAD requires long-term patient adherence to treatment. The aim of the study was to investigate adherence to MAD therapy during a 36-month observation period in relation to changes in self-reported symptoms and objective response to therapy.

METHODS

Retrospective chart review of patients referred to the Orofacial Pain Clinic (University of Kentucky) between 2016 and 2021 for management of OSA with MAD was performed. Based on a posttreatment sleep study with MAD in situ, participants were subdivided into optimal response (> 50% reduction of baseline apnea-hypopnea index) and suboptimal response (< 50% reduction of baseline apnea-hypopnea index) groups. Outcomes included self-reported adherence to MAD use, self-reported OSA symptoms including snoring, apneic episodes, tiredness upon awakening, fatigue, and sleep quality (on a 100-mm numerical rating scale), and daytime sleepiness (0-24 on the Epworth Sleepiness Scale). Intragroup and intergroup differences at different time points over a 36-month observation period were assessed with one-way and repeated-measures analysis of variance.

RESULTS

Of 54 participants included (46.3% female, age 64.4 ± 10.71 years), 30 (55.6%) achieved optimal response and 24 (44.4%) achieved suboptimal response. At baseline, participants with optimal response differed from those with suboptimal response in apnea-hypopnea index (P = .007), snoring (P = .026), and sleep quality (P = .042). Although fluctuating in both groups, no difference was found over time in adherence (7 nights/wk, 7 h/night) and in OSA symptoms (all P > .05).

CONCLUSIONS

Adherence to MAD was maintained over 36 months regardless of fluctuation in self-reported OSA symptoms and effectiveness of MAD therapy.

CITATION

Sangalli L, Yanez-Regonesi F, Moreno-Hay I. Evolution of adherence and self-reported symptoms over 36 months with mandibular advancement device therapy for obstructive sleep apnea: a retrospective study. J Clin Sleep Med. 2024;20(4):487-496.

Pharmacological interventions for the treatment of obstructive sleep apnea syndrome

Obstructive Sleep Apnea Syndrome (OSAS) affects 13-33% of males and 6-9% of females globally and poses significant treatment challenges, including poor adherence to Continuous Positive Airway Pressure (CPAP) and residual excessive sleepiness (RES). This review aims to elucidate the emerging interest in pharmacological treatments for OSAS, focusing on recent advancements in this area. A thorough analysis of extensive clinical trials involving various drugs, including selective dopamine reuptake inhibitors, selective norepinephrine inhibitors, combined antimuscarinic agents, and orexin agonists, was conducted. These trials focused on ameliorating respiratory metrics and enhancing sleep quality in individuals affected by OSAS. The studied pharmacological agents showed potential in improving primary outcomes, notably the apnea-hypopnea index (AHI) and the Epworth sleepiness scale (ESS). These improvements suggest enhanced sleep quality and symptom management in OSAS patients. With a deeper understanding of OSAS, pharmacological interventions are emerging as a promising direction for its effective management. This review provides a comprehensive overview of the current state of drug research in OSAS, highlighting the potential of these treatments in addressing the disorder's complex challenges.

Self-reported improvement in obstructive sleep apnea symptoms compared to treatment response with mandibular advancement device therapy: a retrospective study

PURPOSE

Mandibular advancement device (MAD) is recognized as the treatment option for management of obstructive sleep apnea (OSA) in mild-moderate cases or those unable to tolerate positive airway pressure therapy. Post-treatment sleep study is recommended to establish MAD efficacy when maximal therapeutic benefit is achieved based on OSA symptom improvement or maximum anatomical protrusion. The aim of this study was to investigate the difference between responders and non-responders in OSA symptom improvement and predictors of treatment success.

METHODS

Medical charts of patients referred to the Orofacial Pain Clinic between 2016 and 2021 for management of OSA with MAD were retrospectively evaluated. Participants with post-treatment sleep study with MAD in situ were included. Participants were categorized as responders according to different criteria: 50% reduction in apnea-hypopnea index (AHI) compared to baseline; post-treatment AHI ≤ 10 with ≥ 50% reduction from baseline; AHI ≤ 5 with ≥ 50% reduction. OSA symptoms included snoring, apneas, sleep quality, tiredness upon awakening, daytime sleepiness, and subjective improvement. Differences in pre- and post-treatment variables within/between groups and predictors were analyzed with t test and logistic regression.

RESULTS

Among 53 participants (30 females), mean age was 64.2 ± 10.7 and pre-treatment was AHI 23.3 ± 17.2. Depending upon the criteria, responders ranged between 26 and 57%. At first follow-up after MAD delivery, non-responders reported less tiredness upon awakening (p = 0.003), better sleep quality (p = 0.005), and greater subjective improvement (p = 0.012) than responders. Among significant OSA symptoms, tiredness upon awakening, poorer sleep quality, and less subjective improvement were consistently found as predictors of treatment response.

CONCLUSION

Subjective improvement, sleep quality, and tiredness upon awakening significantly improved in non-responders at first follow-up compared to responders, according to the strictest definition of treatment response. Therefore, a post-treatment sleep study is crucial to confirm proper management of OSA with MAD.

Sleep-disordered breathing, sleep apnea, and other obesity-related sleep disorders: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of sleep-disordered breathing, (e.g., sleep-related hypopnea, apnea), and other obesity-related sleep disorders.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Obesity contributes to sleep-disordered breathing, with the most prevalent manifestation being obstructive sleep apnea. Obesity is also associated with other sleep disorders such as insomnia, primary snoring, and restless legs syndrome. This CPS outlines the evaluation, diagnosis, and treatment of sleep apnea and other sleep disorders, as well as the clinical implications of altered circadian system.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on "Sleep-Disordered Breathing, Sleep Apnea, and Other Obesity-Related Sleep Disorders" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.

Obesity definition, diagnosis, bias, standard operating procedures (SOPs), and telehealth: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

The Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding definition, diagnosis, bias, standard operating procedures (SOPs) and telehealth is intended to provide clinicians an overview of obesity medicine and provide basic organizational tools towards establishing, directing, managing, and maintaining an obesity medical practice.

Methods

This CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by Obesity Medicine Association leadership.

Results

OMA has defined obesity as: "A chronic, progressive, relapsing, and treatable multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences." While body mass index may be sufficiently diagnostic for populations and many patients, accurate diagnosis of adiposity in an individual may require anthropometric assessments beyond body weight alone (e.g., waist circumference, percent body fat, and android/visceral fat). Obesity complications can be categorized as "sick fat disease" (adiposopathy) and/or "fat mass disease." Obesity complications predominantly of fat mass origins include sleep apnea and orthopedic conditions. Obesity complications due to adiposopathic endocrinopathies and/or immunopathies include cardiovascular disease, cancer, elevated blood sugar, elevated blood pressure, dyslipidemia, fatty liver, and alterations in sex hormones in both males (i.e., hypogonadism) and females (i.e., polycystic ovary syndrome). Obesity treatment begins with proactive steps to avoid weight bias, including patient-appropriate language, office equipment, and supplies. To help manage obesity and its complications, this CPS provides a practical template for an obesity medicine practice, creation of standard operating procedures, and incorporation of the OMA "ADAPT" method in telehealth (Assessment, Diagnosis, Advice, Prognosis, and Treatment).

Conclusions

The OMA CPS regarding "Obesity Definition, Diagnosis, Bias, Standard Operating Procedures (SOPs), and Telehealth" is one in a series of OMA CPSs designed to assist clinicians care for patients with the disease of obesity.

Identifying Patient Characteristics That Predict Drug-Induced Sleep Endoscopy Anatomy

OBJECTIVE

To examine if age, sex, body mass index (BMI), neck circumference, or apnea-hypopnea index can predict whether a patient will demonstrate velopharyngeal complete circumferential (CC) collapse on drug-induced sleep endoscopy (DISE).

STUDY DESIGN

Single-center retrospective review at The Ohio State Wexner Medical Center of 289 patients between March 2014 and June 2020.

SETTING

Quaternary care hospital.

METHODS

Patient characteristic and DISE information was extracted from charts and summarized with mean and standard deviation for continuous variables and count and percentage for categorical. CC collapse and patient characteristic associations were explored: 2-sample t test for continuous and chi-square test for categorical. Classification and regression tree (CART) analysis with 3-fold cross-validation was employed to search for the best CC collapse predictors.

RESULTS

Male and female BMI and female neck circumference were correlated to velopharyngeal CC collapse, with BMI more strongly correlated. CART analysis for males showed that a BMI ≤34.8 kg/m² is associated with an 89.4% chance of not demonstrating velopharyngeal CC collapse vs 48% for BMI >34.8 (area under the curve [AUC] = 0.705; AUC >0.7 is acceptable). For females, the CART analysis showed that a BMI ≤36.4 is associated with a 98.4% of not demonstrating velopharyngeal CC collapse vs 30.8% for BMI >36.4 (AUC = 0.73). For females, a neck circumference ≤38.05 cm is associated with a 100% chance of not demonstrating velopharyngeal CC collapse vs 18.4% for >38.05 cm (AUC = 0.72).

CONCLUSION

The BMI values for males and females and the female neck circumference values established by the CART model may accurately predict DISE anatomy and possible candidacy for hypoglossal nerve stimulation.

Effectiveness of Continuous Positive Airway Pressure Versus Mandibular Advancement Device in Severe Obstructive Sleep Apnea Patients With Mandibular Retrognathia: A Prospective Clinical Trial

AIM

Some obstructive sleep apnea (OSA) patients may have mandibular retrognathia (ANB > 4.7° and SNB < 76.2°). Currently, there are no studies that have compared the effectiveness of continuous positive airway pressure (CPAP) versus mandibular advancement device (MAD) in severe OSA patients with mandibular retrognathia. We explored the efficacy of CPAP versus MAD for the treatment of severe OSA patients with mandibular retrognathia.

METHODS

A total of 105 patients were enrolled. Outcomes were assessed by using polysomnography, Epworth Sleepiness Scale (ESS), Snore Scale (SS), Self-rating Anxiety Scale (SAS), and compliance, before treatment and after 6 and 12 months of treatment.

RESULTS

Continuous positive airway pressure was superior to MAD in improving polysomnographic outcomes and SS score, but reported compliance was higher on MAD. There is no significant difference between the 2 treatments in terms of ESS score and SAS score. Obstructive sleep apnea patients with mandibular retrognathia showed greater improvement than those without mandibular retrognathia in terms of apnea-hypopnea index and oxygen desaturation index after MAD.

CONCLUSION

Continuous positive airway pressure and MAD are both effective in treating severe OSA patients with mandibular retrognathia. Mandibular advancement device is a good alternative to CPAP in severe OSA patients with mandibular retrognathia. Mandibular advancement device is more effective in treating OSA patients with mandibular retrognathia than those without. Trial registration: ChiCTR2000032541.

Update on Research and Practices in Major Sleep Disorders: Part I. Obstructive Sleep Apnea Syndrome

PURPOSE

The purpose of this first of two review articles providing an update on sleep disorders was to examine the pathophysiology, epidemiology, and treatment of obstructive sleep apnea (OSA). OSA is a common sleep disorder whose prevalence is similar to asthma. As with other sleep disorders, OSA has a broad impact on individuals, affecting their daily behaviors, cognitive abilities, and performance, and putting them at increased risk for accidents, mood disorders, cancer, cardiovascular disease, and hypertension. Thus, early recognition and management, much of which can be implemented by nurses, can reduce health and accident risks and improve daily functioning.

METHODS

This narrative review utilized medical databases such as PubMed to identify relevant English language original and systematic review articles predominantly from peer-reviewed journals from 2012 to 2018. However, as background, findings from classic articles prior to 2012 were also included.

CLINICAL RELEVANCE

OSA is a common condition with considerable impact on daily functioning and potential for accidents and serious comorbidities such as hypertension, cardiovascular disease, diabetes, and depressed mood. The impairments and comorbidities associated with OSA can be reduced through early detection, encouraging treatment, providing education about sleep and OSA, and, importantly, promoting adherence to the predominant therapy, positive airway pressure.

Evaluation of telemonitoring of continuous positive airway pressure therapy in obstructive sleep apnoea syndrome: TELEPAP pilot study

INTRODUCTION

Continuous positive airway pressure is an effective treatment for obstructive sleep apnoea syndrome. However, positive airway pressure compliance rates are disappointingly low, so effective interventions are needed to improve compliance in sleep apnoea. Telemonitoring has been used to improve compliance, but results have been inconsistent. This study aimed to determine outcomes of telemonitoring positive airway pressure compliance and efficacy data compared to usual care and phone-call care.

METHODS

Randomized controlled study in which 51 patients (82.4% male; between 25 and 78 years), diagnosed with moderate to severe obstructive sleep apnoea were consecutively randomized to usual care, weekly phone-call care or telemonitored care with the use of Restraxx™. All patients were submitted to a comprehensive educational programme during positive airway pressure adaptation. Patients were followed for the first four weeks of treatment with automatic positive airway pressure (AutoSet Spirit S8®; ResMed), and compliance and efficacy data were analyzed.

RESULTS

Telemonitored care group used automatic positive airway pressure an average of 5.0 ± 1.8 hours/night, usual care patients 5.1 ± 2.5 hours and phone-call care patients 3.9 ± 2.6 hours. The residual Apnoea--Hypopnoea Index was 5.3 ± 3.0 in telemonitored care, 5.0 ± 2.5 in usual care and 5.6 ± 3.8 in phone-call care. No statistically significant differences were found between groups regarding positive airway pressure compliance or efficacy (p = 0.296 and p = 0.825, respectively).

DISCUSSION

In the presence of a comprehensive educational programme during positive airway pressure adaptation, telemonitoring patients did not show benefits concerning compliance and efficacy. A larger follow-up period is needed to evaluate the long-term results of a telemonitoring programme.

Detection on pharyngeal wall floppiness in patients with nonstructural factor-induced obstructive sleep apnea-hypopnea syndrome: Difference in position detection

OBJECTIVES/HYPOTHESIS

To evaluate changes in pharyngeal wall floppiness (PWF) between patients with obstructive sleep apnea-hypopnea syndrome induced by non-upper-airway structural factors and normal subjects, as well as the clinical significance using acoustic pharyngealmetry technology.

STUDY DESIGN

Cohort study.

METHODS

The obstructive sleep apnea (OSA) group (n = 102) and the normal control group (n = 50) were identified using the Eccovision Acoustic Pharyngometer measuring instrument. The volume of the pharyngeal cavity in the sitting and supine positions during expiration and inspiration was recorded, respectively, and the PWF index in the sitting and supine positions was calculated for further statistical analysis.

RESULTS

PWF in the sitting (P < .001) and supine positions (P < .001) in the OSA group was notably higher than that in the control group. PWF in the supine position in both the OSA group and control group was remarkably higher than that in the sitting position (P < .001, P = .025, respectively). The difference in PWF between the supine and sitting positions (ΔPWF) (PWF_supine-PWF_sit) was distinctly higher than in control group (P < .01). PWF was positively correlated with age (P < .001) but not with body mass index (P > .05).

CONCLUSIONS

PWF, quantified as elevated PWF, is an important nonstructural factor for the pathogenesis of OSA patients. PWF in the supine position can more accurately reflect airway collapsibility in OSA patients. Our pilot study of a novel observation may help us in the choice of proper surgical candidates for OSA procedures.

LEVEL OF EVIDENCE

3b Laryngoscope, 128:2200-2205, 2018.

Can positional therapy be simple, effective and well tolerated all together? A prospective study on treatment response and compliance in positional sleep apnea with a positioning pillow

PURPOSE

Until now, there is no clear consensus on optimal care for mild sleep-related breathing disorders (SRBD) in general or for positional obstructive sleep apnea (POSA) in particular. Most proposed treatment options are either invasive and/or expensive. Positional therapy (PT) may therefore present as a valuable first-line intervention in POSA.

METHODS

Twenty-eight patients presenting with POSA were enrolled in a prospective cohort study. The protocol consisted of three nights of polysomnography (PSG) in an academic sleep lab. Inclusion was based on the first PSG. During a consecutive PSG, PT was provided by means of a sleep-positioning pillow (Posiform®). The third PSG was performed after 1 month of PT. Sleepiness, fatigue, and sleep quality were assessed with the Epworth Sleepiness Scale (ESS), the fatigue severity scale (FSS), the Pittsburgh Sleep Quality Index (PSQI), and the Function Outcomes of Sleep Questionnaire (FOSQ) at baseline, and after 1 and at 6 months of PT alongside satisfaction and compliance ratings.

RESULTS

Significant immediate treatment effects after one night and sustained after 1 month were observed by significant reductions of sleep in supine position (p < .001), sleep fragmentation (p < .05), apnea-hypopnea (p < .001), respiratory disturbance (p < .001), and oxygen desaturation (p < .001) indices. PSQI (p < .001), ESS (p < .005), and FOSQ (p < .001) also showed significant and persistent improvements.

CONCLUSIONS

Combined effects on sleep-related respiration and clinical symptoms were observed after PT initiation as well as after 1 month using the sleep-positioning pillow. Furthermore, reported compliance and overall satisfaction appeared to be highly concordant both at 1 month and 6 months follow-up.

Cannabis, Cannabinoids, and Sleep: a Review of the Literature

PURPOSE OF REVIEW

The current review aims to summarize the state of research on cannabis and sleep up to 2014 and to review in detail the literature on cannabis and specific sleep disorders from 2014 to the time of publication.

RECENT FINDINGS

Preliminary research into cannabis and insomnia suggests that cannabidiol (CBD) may have therapeutic potential for the treatment of insomnia. Delta-9 tetrahydrocannabinol (THC) may decrease sleep latency but could impair sleep quality long-term. Novel studies investigating cannabinoids and obstructive sleep apnea suggest that synthetic cannabinoids such as nabilone and dronabinol may have short-term benefit for sleep apnea due to their modulatory effects on serotonin-mediated apneas. CBD may hold promise for REM sleep behavior disorder and excessive daytime sleepiness, while nabilone may reduce nightmares associated with PTSD and may improve sleep among patients with chronic pain. Research on cannabis and sleep is in its infancy and has yielded mixed results. Additional controlled and longitudinal research is critical to advance our understanding of research and clinical implications.

Cervical computed tomography in patients with obstructive sleep apnea: influence of head elevation on the assessment of upper airway volume

OBJECTIVE

Obstructive sleep apnea syndrome (OSAS) has a high prevalence and carries significant cardiovascular risks. It is important to study new therapeutic approaches to this disease. Positional therapy might be beneficial in reducing the apnea-hypopnea index (AHI). Imaging methods have been employed in order to facilitate the evaluation of the airways of OSAS patients and can be used in order to determine the effectiveness of certain treatments. This study was aimed at determining the influence that upper airway volume, as measured by cervical CT, has in patients diagnosed with OSAS.

METHODS

This was a quantitative, observational, cross-sectional study. We evaluated 10 patients who had been diagnosed with OSAS by polysomnography and on the basis of the clinical evaluation. All of the patients underwent conventional cervical CT in the supine position. Scans were obtained with the head of the patient in two positions (neutral and at a 44° upward inclination), and the upper airway volume was compared between the two.

RESULTS

The mean age, BMI, and neck circumference were 48.9 ± 14.4 years, 30.5 ± 3.5 kg/m2, and 40.3 ± 3.4 cm, respectively. The mean AHI was 13.7 ± 10.6 events/h (range, 6.0-41.6 events/h). The OSAS was classified as mild, moderate, and severe in 70%, 20%, and 10% of the patients, respectively. The mean upper airway volume was 7.9 cm3 greater when the head was at a 44° upward inclination than when it was in the neutral position, and that difference (17.5 ± 11.0%) was statistically significant (p = 0.002).

CONCLUSIONS

Elevating the head appears to result in a significant increase in the caliber of the upper airways in OSAS patients.

Surgical Management of Obstructive Sleep Apnea

Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons' experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.

Intracerebroventricular injections of dronabinol, a cannabinoid receptor agonist, does not attenuate serotonin-induced apnea in Sprague-Dawley rats

Background

Evidence suggests that vagal nerve activity may play a role in sleep apnea induction. In anesthetized rats, dronabinol, a cannabinoid (CB) receptor agonist, injected into the nodose ganglia attenuates reflex apnea and increases genioglossus activity, and reflex apnea attenuation is blocked by systemic pre-treatment with cannabinoid type 1 and/or type 2 receptor antagonists. However, it is unclear whether dronabinol has similar effects in the central nervous system; CB receptors are widely distributed in the brain, especially on neuronal circuitry important for respiration and upper airway activation. Here, we examine the effects of intracerebroventricular (ICV) injection of dronabinol on serotonin (5-HT)-induced apnea.

Methods

Adult male Sprague-Dawley rats were anesthetized and instrumented with bilateral electrodes to monitor genioglossi EMG and with a piezoelectric strain gauge to monitor respiratory pattern. Serotonin was intravenously infused into a femoral vein to induce reflex apnea. After baseline recordings, rats were placed in a stereotaxic apparatus. A unilateral osteotomy was made to allow access for injection to the right lateral ventricle, and the dura were carefully removed. Dronabinol (100, 10, 1, or 0.1 μg/3 μl DMSO) or control (3 μl DMSO) was injected into the right lateral ventricle and 5-HT infusion was repeated. Data (mean ± SEM) were analyzed using a mixed model analysis with a repeated/fixed measure.

Results

There was no main effect in 5-HT-induced apnea or breath duration, or in breath instability, between ICV dronabinol injected and ICV vehicle control injected groups. Moreover, there was no main effect in phasic or tonic genioglossus activity between ICV dronabinol injected and ICV vehicle control injected groups.

Conclusion

Our data show that ICV injection of dronabinol did not decrease 5-HT-induced apneas, and did not increase genioglossus activity. This in contrast to published results of dronabinol’s effect on apnea via the vagus nerve. Our results suggest that the effects of dronabinol on reflex apneas are peripherally mediated via suppression of vagal nerve activity.

Treatments for Obstructive Sleep Apnea

OBJECTIVE

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

METHODS

Review of the literature.

RESULTS

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

CONCLUSION

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

[Implantable nerve stimulation for obstructive sleep apnea hypopnea syndrome]

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common disorder that has been identified as a contributor to cardiovascular disease making it a major public health problem. Continuous positive airway pressure is the standard treatment but compliance is suboptimal. Mandibular advancement devices and surgery have limited indications, inconstant efficiency and potential irreversible side effects. Stimulation of the hypoglossal nerve, that innervates the genioglossus, a protrusor muscle of the tongue, is now a new treatment option for moderate and severe cases of OSAHS. Two types of stimulation are currently available: stimulation synchronous with inspiration and continuous stimulation. The indication of each type of stimulation and long-term effects still need to be assessed but the implantable nerve stimulation is a promising treatment for patients without a therapy solution so far.

Emerging drugs for common conditions of sleepiness: obstructive sleep apnea and narcolepsy

INTRODUCTION

Obstructive sleep apnea (OSA) and narcolepsy are sleep disorders associated with high prevalence and high symptomatic burden including prominent sleepiness, daytime dysfunction and poor nocturnal sleep. Both have elevated risk of poor health outcomes. Current therapies are often underutilized, cumbersome, costly or associated with residual symptoms.

AREAS COVERED

This review covers current available therapies for OSA and narcolepsy as well as discusses areas for potential drug development, and agents in the therapeutic pipeline, including the cannabinoid dronabinol (OSA), the histamine inverse agonist/ antagonist pitolisant (narcolepsy), and stimulants with uncertain and/or multiple activities such as JZP-110 and JZP-386 (narcolepsy, possibly OSA). Finally it addresses new approaches and uses for therapies currently on the market such as the carbonic anhydrase inhibitor acetazolamide (OSA).

EXPERT OPINION

Both OSA and narcolepsy are conditions of sleepiness for which lifelong treatments are likely to be required. In OSA, while continuous positive airway pressure will likely remain the gold standard therapy for the foreseeable future, there is plenty of room for integrating phenotypes and variants of OSA into therapeutic strategies to lead to better, more personalized disease modification. In narcolepsy, unlike OSA, drug therapy is the current mainstay of treatment. Advances using novel mechanisms to treat targeted symptoms such as sleepiness and/or novel agents that can treat more than one symptom of narcolepsy, hold promise. However, cost, convenience and side effects remain challenges.

Office management of obstructive sleep apnoea: appliances

PURPOSE OF REVIEW

Oral appliances are becoming increasingly common in the treatment of obstructive sleep apnoea (OSA). They work by advancing the mandible and opening the pharynx. There are several types of devices available for use. Many patients intolerant to continuous positive airway pressure (CPAP) are using oral appliances for OSA.

RECENT FINDINGS

Oral appliances have been shown to improve polysomnography, quality of life and health measures associated with OSA. There is current work to better identify patients who are ideal candidates. Development of titratable devices and monitoring are optimizing usage. They have been compared with CPAP, with both showing improvement in OSA; however, CPAP remains superior overall.

SUMMARY

Oral appliances are becoming first-line therapy for mild and moderate OSA. They provide a meaningful alternative in severe OSA for patients unable to use CPAP. Device titration and usage monitoring are beginning to hone oral appliances as a therapeutic option.

Positive airway pressure and electrical stimulation methods for obstructive sleep apnea treatment: a patent review (2005 - 2014)

INTRODUCTION

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a major health problem with significant negative effects on the health and quality of life. Continuous positive airway pressure (CPAP) is currently the primary treatment option and it is considered the most effective therapy for OSAHS. Nevertheless, comfort issues due to improper fit to patient's changing needs and breathing gas leakage limit the patient's adherence to treatment.

AREAS COVERED

The present patent review describes recent innovations in the treatment of OSAHS related to optimization of the positive pressure delivered to the patient, methods and systems for continuous self-adjusting pressure during inspiration and expiration phases, and techniques for electrical stimulation of nerves and muscles responsible for the airway patency.

EXPERT OPINION

In the last few years, CPAP-related inventions have mainly focused on obtaining an optimal self-adjusting pressure according to patient's needs. Despite intensive research carried out, treatment compliance is still a major issue. Hypoglossal electrical nerve stimulation could be an effective secondary treatment option when CPAP primary therapy fails. Several patents have been granted focused on selective stimulation techniques and parameter optimization of the stimulating pulse waveform. Nevertheless, there remain important issues to address, like effectiveness and adverse events due to improper stimulation.