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Carpenter JW. Effect of Obstructive Sleep Disorder Treatment on Posttraumatic Stress Disorder Symptoms: A Literature Review. J Psychosoc Nurs Ment Health Serv 2024:1-8. [PMID: 39373725 DOI: 10.3928/02793695-20241001-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2024]
Abstract
PURPOSE To explore whether continuous positive airway pressure (CPAP) adherence among adult patients with obstructive sleep apnea (OSA) and posttraumatic stress disorder (PTSD) affects the PTSD Checklist (PCL), a validated tool that measures severity of PTSD symptoms. METHOD Studies focusing on PTSD and OSA were searched in PubMed and CINAHL databases. Inclusion and exclusion criteria were applied, decreasing the article yield to nine. All articles chosen focused on the adult population and were conducted in North America. RESULTS The literature review yielded eight observational cohort studies and one descriptive study. Seven studies were conducted with Veterans and all studies used the PCL tool. Three themes were identified: (a) Trauma and OSA, (b) OSA and PTSD Symptoms, and (c) CPAP Therapy and PTSD Symptoms. An area of further study is assessing how CPAP adherence might affect improvement in PTSD symptoms and how adherence can be improved. CONCLUSION OSA is correlated with more severe PTSD symptoms, but CPAP use is associated with improvement in PTSD symptoms. The literature reviewed found PCL scores improved up to 10 points within 3 months of CPAP use. These findings highlight the importance of collaboration between mental health and sleep medicine professionals and opportunity for further study in this area. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].
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Titone MK, Hunt C, Bismark A, Nokes B, Lee E, Ramanathan D, Park J, Colvonen P. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med 2023; 19:2043-2051. [PMID: 37539643 PMCID: PMC10692930 DOI: 10.5664/jcsm.10746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVES Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression. METHODS Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories. RESULTS We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis. CONCLUSIONS Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD. CITATION Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.
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Affiliation(s)
- Madison K. Titone
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | | | | | - Brandon Nokes
- VA San Diego Healthcare System, San Diego, California
| | - Ellen Lee
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Dhakshin Ramanathan
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Jane Park
- VA San Diego Healthcare System, San Diego, California
| | - Peter Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
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3
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Fagundes NCF, Minervini G, Furio Alonso B, Nucci L, Grassia V, d'Apuzzo F, Puigdollers A, Perillo L, Flores-Mir C. PATIENT-REPORTED OUTCOMES WHILE MANAGING OBSTRUCTIVE SLEEP APNEA WITH ORAL APPLIANCES: A SCOPING REVIEW. J Evid Based Dent Pract 2023; 23:101786. [PMID: 36707161 DOI: 10.1016/j.jebdp.2022.101786] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/21/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This scoping review aims to describe dental treatment-related patient-reported outcomes (dPROs) while using oral appliances (OAs) to manage obstructive sleep apnea (OSA) in children and adults. METHODS Available literature that assessed dPROs in children and adults with OSA managed through OAs. Any clinical studies were included without restrictions of year or country. The results were analyzed and reported using narrative text and tables accompanying a descriptive summary. RESULTS The searches identified 1718 citations, and of these, forty-five studies were finally included. A total of 3498 adults were included in all 42 primary studies included in this review, in which all the studies presented adults as participants. The dPROs assessed were quality of life (QoL), reported side effects after OA usage, patient satisfaction, and experience with treatment, and subjective perception of occlusal changes after treatment. CONCLUSION This scoping review suggests that dPROs are mostly investigated as a secondary outcome from major studies exploring the effects of OAs on OSA severity, and often, dPROs are not well discussed or displayed on their report. As no risk of bias or certainty level assessment was completed, findings need to be carefully considered. Although in general terms management with OAs among adults with OSA does not seem to be uncomfortable or causing major problems to their lives, some mild discomfort and endured occlusal disturbances was reported in some studies. QoL seems to improve but consistent agreement was elusive. Data does not include experiences among those that dropped OA use. No data seems to exist about dPROs in children.
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Affiliation(s)
| | - Giuseppe Minervini
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Berta Furio Alonso
- Department of Orthodontics and Craniofacial Orthopedics, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ludovica Nucci
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vincenzo Grassia
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Fabrizia d'Apuzzo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Andreu Puigdollers
- Department of Orthodontics and Craniofacial Orthopedics, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Letizia Perillo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Orthodontic Program, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlos Flores-Mir
- School of Dentistry, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada.
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4
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Kang JH, Lee JK. Associations between obstructive sleep apnea and painful temporomandibular disorder: a systematic review. J Korean Assoc Oral Maxillofac Surg 2022; 48:259-266. [PMID: 36316183 PMCID: PMC9639245 DOI: 10.5125/jkaoms.2022.48.5.259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/29/2022] Open
Abstract
The relationship between obstructive sleep apnea (OSA) and diverse types of pain conditions have been proposed. However, no consensus on the relationship between OSA and painful temporomandibular disorders (TMDs) has been established. Therefore, this systematic review has been conducted to review the existing literatures and provide comprehensive synthesis of such literatures about OSA and painful TMDs using the evidence-based methodology. A literature search was conducted using two electronic databases, Scopus, and PubMed. Risk of bias was assessed using the risk-ofbias assessment tool for non-randomized study version 2.0. A total of 158 articles were screened from the initial search and eventually, 5 articles were included in this systematic review. One study adopted both the longitudinal prospective cohort and case-control designs and other 4 articles adopted the cross-sectional design. Two studies employed polysomnography (PSG) for the diagnosis of OSA and mentioned the results from the PSG. All crosssectional studies demonstrated higher OSA prevalence among patients with TMD, and one cohort study suggested OSA as a risk factor for TMD. OSA appears to have potential influences on the development of TMD; however, the role of TMD in the development of OSA remains to be unknown owing to the lack of high-quality evidences.
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Affiliation(s)
- Jeong-Hyun Kang
- Clinic of Oral Medicine and Orofacial Pain, Institute of Oral Health Science, Ajou University School of Medicine, Suwon, Korea
| | - Jeong Keun Lee
- Department of Oral and Maxillofacial Surgery, Institute of Oral Health Science, Ajou University School of Medicine, Suwon, Korea,Jeong Keun Lee, Department of Oral and Maxillofacial Surgery, Institute of Oral Health Science, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtong-gu, Suwon 16499, Korea, TEL: +82-31-219-5333, E-mail: , ORCID: https://orcid.org/0000-0002-5561-6297
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5
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Vimal J, Dutt P, Singh N, Singh BP, Chand P, Jurel S. To compare different non-surgical treatment modalities on treatment of obstructive sleep apnea: A systematic review and meta-analysis. J Indian Prosthodont Soc 2022; 22:314-327. [PMID: 36511065 PMCID: PMC9709867 DOI: 10.4103/jips.jips_261_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/07/2022] Open
Abstract
The study aimed to assess the effect of mandibular advancement device (MAD) in patients with obstructive sleep apnea for reduction in 24-h mean blood pressure, sleep quality, Apnea Hypopnea Index (AHI), and patient compliance, compared to continuous positive airway pressure (CPAP), other interventions, or no treatment. Three different databases such as PubMed, EMBASE, and CENTRAL were searched using different search terms till July 2021 as per the inclusion and exclusion criteria. After inclusion of studies, data extraction including risk of bias assessment was done. For each study, we used odds ratio, mean difference, and 95% confidence interval to assess and synthesize the outcomes. The quality of evidence was evaluated as per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Twenty-one randomized controlled trials were included: 497 patients in the MAD group, 239 patients in the CPAP group, and 274 patients in the sham group. In MAD-CPAP comparison, the results favored CPAP in the reduction of AHI of 3.48 (1.76-5.19). However, unclear results were found for sleep quality measured as Epworth Sleepiness Scale (ESS), patient compliance, and 24-h mean blood pressure. In MAD-sham comparison, the results favored MAD in the reduction of AHI of - 8.39 (-10.90--5.88] and ESS of - 0.91 (-1.70--0.12) and favored sham in terms of patient compliance while, unclear results for 24-h mean blood pressure. The GRADE score indicated that the quality of evidence is very low, low, and moderate for different outcomes. CPAP in comparison to MAD and MAD in comparison to sham showed a significant AHI reduction. However, patient compliance and 24-h mean blood pressure were not significantly different in MAD-CPAP or MAD-sham. Quality of evidence is very low and low when MAD was compared with CPAP and sham, respectively, for AHI.
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Affiliation(s)
- Jyotsna Vimal
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pranjali Dutt
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Nishi Singh
- Department of Conservative Dentistry and Endodontics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Balendra P. Singh
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pooran Chand
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sunit Jurel
- Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
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Kim HY, Jo JH, Chung JW, Park JW. The multisystemic effects of oral appliance therapy for obstructive sleep apnea: A narrative review. Medicine (Baltimore) 2022; 101:e29400. [PMID: 35866792 PMCID: PMC9302291 DOI: 10.1097/md.0000000000029400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a chronic condition accompanied by repeated obstruction of the upper airway during sleep despite respiratory efforts, resulting in intermittent hypoxemia, altered sleep structure, and sympathetic activation. Previous studies have shown a significant association between OSA and general health issues such as cardiovascular diseases, endocrine disorders, neurocognitive function decline, and poor quality of life. Continuous positive airway pressure (CPAP) has been considered as the first line treatment for OSA. However, accumulating evidence supports the role of oral appliance (OA) therapy, including mandibular advancement devices, as an alternative option for snoring and OSA patients who do not comply with or refuse CPAP usage. Despite a generally favorable outcome of OA therapy for OSA related respiratory indices, studies focusing on the impact of systemic effects of OA therapy in OSA patients are relatively scarce compared with the extensive literature focusing on the systemic effects of CPAP. Therefore, this article aimed to provide an overview of the current evidence regarding the multisystemic effects of OA therapy for OSA.
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Affiliation(s)
- Hee Young Kim
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Jung Hwan Jo
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Jin Woo Chung
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
- Dental Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Ji Woon Park
- Department of Oral Medicine, Seoul National University Dental Hospital, Seoul, Republic of Korea
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University, Seoul, Republic of Korea
- Dental Research Institute, Seoul National University, Seoul, Republic of Korea
- *Correspondence: Ji Woon Park, Orofacial Pain Clinic, Department of Oral Medicine and Oral Diagnosis, School of Dentistry and Dental Research Institute, Seoul National University, 101 Yunkeun-Dong, Chongro-Ku, Seoul 03080, Republic of Korea (e-mail: )
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7
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McCall CA, Watson NF. A Narrative Review of the Association between Post-Traumatic Stress Disorder and Obstructive Sleep Apnea. J Clin Med 2022; 11:415. [PMID: 35054110 PMCID: PMC8780754 DOI: 10.3390/jcm11020415] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 12/10/2022] Open
Abstract
Obstructive sleep apnea (OSA) and post-traumatic stress disorder (PTSD) are often co-morbid with implications for disease severity and treatment outcomes. OSA prevalence is higher in PTSD sufferers than in the general population, with a likely bidirectional effect of the two illnesses. There is substantial evidence to support the role that disturbed sleep may play in the pathophysiology of PTSD. Sleep disturbance associated with OSA may interfere with normal rapid eye movement (REM) functioning and thus worsen nightmares and sleep-related movements. Conversely, hyperarousal and hypervigilance symptoms of PTSD may lower the arousal threshold and thus increase the frequency of sleep fragmentation related to obstructive events. Treating OSA not only improves OSA symptoms, but also nightmares and daytime symptoms of PTSD. Evidence suggests that positive airway pressure (PAP) therapy reduces PTSD symptoms in a dose-dependent fashion, but also presents challenges to tolerance in the PTSD population. Alternative OSA treatments may be better tolerated and effective for improving both OSA and PTSD. Further research avenues will be introduced as we seek a better understanding of this complex relationship.
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Affiliation(s)
- Catherine A. McCall
- Department of Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Nathaniel F. Watson
- Department of Neurology, University of Washington School of Medicine, Seattle, WA 98195, USA;
- University of Washington Medicine Sleep Center, Seattle, WA 98104, USA
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8
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Randerath W, Verbraecken J, de Raaff CAL, Hedner J, Herkenrath S, Hohenhorst W, Jakob T, Marrone O, Marklund M, McNicholas WT, Morgan RL, Pepin JL, Schiza S, Skoetz N, Smyth D, Steier J, Tonia T, Trzepizur W, van Mechelen PH, Wijkstra P. European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea. Eur Respir Rev 2021; 30:30/162/210200. [PMID: 34853097 PMCID: PMC9489103 DOI: 10.1183/16000617.0200-2021] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 12/12/2022] Open
Abstract
Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes. OSA-patients who refuse/don't adhere to CPAP can profit from established/emerging treatment options. High scientific evidence is lacking. Patients’ values/preference may weigh heavy in the decision for non-CPAP options, while health inequity is a concern.https://bit.ly/3o0tJeP
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Affiliation(s)
- Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany .,Co-shared first authorship
| | - Johan Verbraecken
- Antwerp University Hospital and University of Antwerp, Edegem (Antwerp), Belgium.,Co-shared first authorship
| | | | - Jan Hedner
- Dept of Sleep Medicine, Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Simon Herkenrath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany
| | | | - Tina Jakob
- Evidence-based Oncology, Dept I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Oreste Marrone
- National Research Council of Italy, Institute for Biomedical Research and Innovation, Palermo, Italy
| | - Marie Marklund
- Dept of Odontology, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Walter T McNicholas
- School of Medicine, University College Dublin, Dublin, Ireland.,Dept of Respiratory and Sleep Medicine, St Vincent's Hospital Group, Dublin, Ireland
| | - Rebecca L Morgan
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Sofia Schiza
- Sleep Disorders Unit, Dept of Respiratory Medicine, Medical School, University of Crete, Greece
| | - Nicole Skoetz
- Evidence-based Oncology, Dept I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dan Smyth
- European Lung Foundation, Sheffield, UK.,Sleep Disorder Support Foundation, Dublin, Ireland
| | - Jörg Steier
- Lane Fox Unit and Sleep Disorders Centre at Guy's & St Thomas' NHS Foundation Trust, Centre for Human & Applied Physiological Sciences, King's College London, London, UK
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Wojciech Trzepizur
- Dept of Respiratory and Sleep Medicine, Angers University hospital, Angers, France
| | | | - Peter Wijkstra
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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9
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Bortolotti F, Corazza G, Bartolucci ML, Incerti Parenti S, Paganelli C, Alessandri-Bonetti G. Dropout and adherence of obstructive sleep apnoea patients to mandibular advancement device therapy: A systematic review of randomised controlled trials with meta-analysis and meta-regression. J Oral Rehabil 2021; 49:553-572. [PMID: 34865235 DOI: 10.1111/joor.13290] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 11/19/2021] [Accepted: 11/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mandibular advancement devices (MADs) are used as an alternative to continuous positive airways pressure to treat obstructive sleep apnoea (OSA) patients, but to date, specific data on the adherence to MAD therapy are lacking. OBJECTIVES The aim of the present systematic review was to investigate the dropout rate and adherence of OSA patients to different custom-made (CM) and non-custom-made (NCM) MAD therapies. SEARCH METHODS An electronic search was performed in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, LILACS and Web of Science. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the compliance to customised and not customised MADs in the treatment of adult OSA patients were included. DATA COLLECTION AND ANALYSIS The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in RCT. The dropout rate of each study was computed and the adherence to MAD therapy in terms of hours per night and nights per week was extracted from each study. RESULTS Thirty-two RCTs were included. The risk of bias resulted low in most of the studies. The GRADE scores indicated that the quality of evidence was from very low to moderate. The meta-analyses showed that the mean dropout rate did not significantly differ between CM and NCM MADs: The overall mean dropout rate was 0.171 [0.128-0.213] with a mean follow-up of 4.1 months. The hours per night adherence was significantly higher for CM MADs (6.418 [6.033-6.803]) compared to NCM MADs (5.107 [4.324-5.890]. The meta-regression showed that the dropout rate increases significantly during time (p < .05). CONCLUSIONS There is a very low to moderate quality of evidence that the dropout rate of MAD therapy is similar among CM and NCM MADs, that the dropout rate increases significantly during time and that CM MADs have higher hours per night adherence compared with NCM MAD. REGISTRATION The study protocol was registered on PROSPERO (n. CRD42020199866).
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Affiliation(s)
- Francesco Bortolotti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Giulia Corazza
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
| | - Maria Lavinia Bartolucci
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Serena Incerti Parenti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Corrado Paganelli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
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10
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Maher AR, Apaydin EA, Hilton L, Chen C, Troxel W, Hall O, Azhar G, Larkin J, Motala A, Hempel S. Sleep management in posttraumatic stress disorder: a systematic review and meta-analysis. Sleep Med 2021; 87:203-219. [PMID: 34634573 DOI: 10.1016/j.sleep.2021.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Post-traumatic stress disorder (PTSD) can lead to many negative secondary outcomes for patients, including sleep disturbances. The objective of this meta-analysis is (1) to evaluate the effect of interventions for adults with PTSD on sleep outcomes, PTSD outcomes, and adverse events, and (2) to evaluate the differential effectiveness of interventions aiming to improve sleep compared to those that do not. METHODS Nine databases were searched for relevant randomized controlled trials (RCTs) in PTSD from January 1980 to October 2019. Two independent reviewers screened 7176 records, assessed 2139 full-text articles, and included 89 studies in 155 publications for this review. Sleep, PTSD, and adverse event outcomes were abstracted and meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method for random effects. RESULTS Interventions improved sleep outcomes (standardized mean difference [SMD] -0.56; confidence interval [CI] -0.75 to -0.37; 49 RCTs) and PTSD symptoms (SMD -0.48; CI -0.67 to -0.29; 44 RCTs) across studies. Adverse events were not related to interventions overall (RR 1.17; CI 0.91 to 1.49; 15 RCTs). Interventions targeting sleep improved sleep outcomes more than interventions that did not target sleep (p = 0.03). Improvement in PTSD symptoms did not differ between intervention types. CONCLUSIONS Interventions for patients with PTSD significantly improve sleep outcomes, especially interventions that specifically target sleep. Treatments for adults with PTSD directed towards sleep improvement may benefit patients who suffer from both ailments.
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Affiliation(s)
- Alicia Ruelaz Maher
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Eric A Apaydin
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Lara Hilton
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Center for Work & Family Life, University of Southern California, Los Angeles, CA, USA
| | - Christine Chen
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Wendy Troxel
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Pittsburgh, PA, USA; Department of Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Owen Hall
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Gulrez Azhar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jody Larkin
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Pittsburgh, PA, USA
| | - Aneesa Motala
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Susanne Hempel
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, CA, USA; Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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11
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Trzepizur W, Cistulli PA, Glos M, Vielle B, Sutherland K, Wijkstra PJ, Hoekema A, Gagnadoux F. Health outcomes of continuous positive airway pressure versus mandibular advancement device for the treatment of severe obstructive sleep apnea: an individual participant data meta-analysis. Sleep 2021; 44:6119670. [PMID: 33493338 DOI: 10.1093/sleep/zsab015] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2021] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES The impact of therapy with continuous positive airway pressure (CPAP) and mandibular advancement device (MAD) has not been directly compared in patients with severe obstructive sleep apnea (OSA). The purpose of this individual participant data meta-analysis was to compare the treatment effects of CPAP and titratable MAD on sleepiness, quality of life, sleep-disordered breathing severity, and sleep structure in patients with severe OSA. METHODS Randomized controlled trials (RCTs) that included severe OSA patients were identified in order to compare the impact of the two treatments. Individual data from severe OSA patients were extracted from the databases and pooled for analysis. RESULTS Of the seven studies identified, three crossover RCT and one parallel-group RCT corresponding to 151 patients and 249 observations (125 in the CPAP treatment arm and 124 in the MAD treatment arm) were included in the analysis. Titratable MAD had a similar impact to CPAP on major patient-centered outcomes (sleepiness and quality of life). CPAP was more effective in reducing AHI and ODI. However, the two treatments had a similar impact on sleep structure with an increase of N3 and REM sleep. Finally, treatment adherence and preference were largely in favor of MAD. CONCLUSION This meta-analysis suggests that MAD represents an effective alternative treatment in severe OSA patients intolerant to CPAP or who prefer alternate therapy.
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Affiliation(s)
- Wojciech Trzepizur
- Department of Respiratory and Sleep Medicine, Angers University hospital, INSERM U1063, SOPAM, Angers University, Angers, France
| | - Peter A Cistulli
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Centre for Sleep Health and Research, Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
| | - Martin Glos
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bruno Vielle
- Centre de Recherche Clinique, CHU d'Angers, Angers, France
| | - Kate Sutherland
- Sleep Research Group, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Centre for Sleep Health and Research, Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia
| | - Peter J Wijkstra
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Aarnoud Hoekema
- Department of Orofacial pain and dysfunction, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands.,Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | - Frédéric Gagnadoux
- Department of Respiratory and Sleep Medicine, Angers University hospital, INSERM U1063, SOPAM, Angers University, Angers, France
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12
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Dhanda Patil R, Sarber KM, Epperson MV, Tabangin M, Altaye M, Mesa F, Ishman SL. Hypoglossal Nerve Stimulation: Outcomes in Veterans with Obstructive Sleep Apnea and Common Comorbid Post-traumatic Stress Disorder. Laryngoscope 2020; 131 Suppl 3:S1-S11. [PMID: 33295673 DOI: 10.1002/lary.29292] [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] [Received: 07/01/2020] [Revised: 11/14/2020] [Accepted: 11/20/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Veterans have an increasing prevalence of obstructive sleep apnea (OSA) and high levels of intolerance to positive airway pressure (PAP). The hypoglossal nerve stimulator (HNS) is a promising alternative surgical treatment for OSA in these patients, many of whom suffer from mental health conditions such as post-traumatic stress disorder (PTSD) that may negatively affect their ability to use PAP. Our aims were: 1) to assess postoperative changes in OSA severity and sleepiness in a veteran only population after HNS; 2) to compare postoperative changes in OSA severity, sleepiness and HNS adherence between veterans with and without PTSD; and 3) to compare HNS adherence in our population to HNS adherence in the current literature as well as published PAP adherence data. STUDY DESIGN Retrospective and prospective case series. METHODS Clinical data on consecutive patients undergoing HNS in a Veterans Affairs hospital were examined for demographic data as well as medical, sleep, and mental health comorbidities. The overall cohort as well as subsets of patients with and without PTSD were examined for postoperative changes in OSA severity (apnea hypopnea index [AHI], lowest oxygen saturation (LSAT]), and sleepiness (Epworth sleepiness scale [ESS]), as well as for device adherence. PTSD and depression symptomatology were measured using the PTSD Checklist 5 (PCL-5) and Patient Health Questionnaire 9 (PHQ-9). RESULTS Forty-six veterans were included. Forty-four patients were male (95.6%), 45 were white (97.8%), and the mean age was 61.3 years. Twenty-six patients met PCL-5 criteria for PTSD and 17 did not. OSA severity and sleepiness improved significantly in the overall cohort after HNS; median (IQR) AHI decreased from 39.2 (24.0, 63.0) to 7.4 (1.2, 20.8) events/hour (P < .0001), mean LSAT increased from 81% to 88% (P < .0001) and mean ESS decreased from 10.9 to 6.7 (P < .0001). These improvements were similar between patients with and without PTSD (P = .434-.918). Overall device adherence was 6.1 hours/night for the overall cohort and was not significantly different between patients with and without PTSD (P = .992). CONCLUSIONS HNS is an efficacious therapy in a veteran population, providing patients with significant improvements in OSA severity and sleepiness. Veterans with and without PTSD benefited similarly from HNS when comparing improvements in sleep apnea severity and sleepiness as well as device usage. Adherence was similar to previously published HNS adherence data and better than PAP adherence reported in the literature. LEVEL OF EVIDENCE 4 Laryngoscope, 131:S1-S11, 2021.
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Affiliation(s)
- Reena Dhanda Patil
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, U.S.A.,Department of Surgical Services, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, U.S.A
| | - Kathleen M Sarber
- Department of Otolaryngology, 96th Medical Group, Eglin Air Force Base, Florida, U.S.A
| | - Madison V Epperson
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - Meredith Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Franklin Mesa
- Department of Surgical Services, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, U.S.A
| | - Stacey L Ishman
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, U.S.A.,Division of Pediatric Otolaryngology and Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
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13
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Bartolucci ML, Bortolotti F, Corazza G, Incerti Parenti S, Paganelli C, Alessandri Bonetti G. Effectiveness of different mandibular advancement device designs in obstructive sleep apnoea therapy: A systematic review of randomised controlled trials with meta-analysis. J Oral Rehabil 2020; 48:469-486. [PMID: 32805753 DOI: 10.1111/joor.13077] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 11/28/2022]
Abstract
Mandibular advancement devices (MADs) are used to treat patients with obstructive sleep apnoea (OSA). To date, there are no data that identify the most effective MAD design for apnoea-hypopnea index (AHI) reduction. The purpose of this systematic review is to investigate the effectiveness of different MAD designs in AHI reduction and oxygen saturation improvement in OSA patients. An electronic search was performed in MEDLINE, Cochrane Database, Scopus, Web of Knowledge and LILACS. Randomised controlled trials (RCTs) investigating the reduction of AHI on adult patients wearing MAD for OSA were included. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in randomised controlled trial. The success rate of each study was computed: [(mean baseline AHI - mean AHI after treatment)/mean baseline AHI]. Fifty RCTs were included. The risk of bias resulted with some concerns in most of the studies. The GRADE scores indicated that the quality of evidence was very low. The meta-analysis showed a success rate with mono-bloc and duo-bloc MADs respectively of 0.821 [0.722-0.887] and 0.547 [0.443-0.637]. The mono-bloc compared with duo-bloc better improved the minimum oxygen saturation (10.048 [7.733-12.363] and 3.357 [2.290-4.423], respectively). There is a very low quality body of evidence that mono-bloc MADs are more effective in reducing AHI and improving minimum oxygen saturation compared with duo-bloc MADs. The study protocol was registered on PROSPERO (n. CRD42019118084).
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Affiliation(s)
- Maria Lavinia Bartolucci
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Bortolotti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Giulia Corazza
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
| | - Serena Incerti Parenti
- Section of Orthodontics, Department of Biomedical Sciences, University of Bologna, Bologna, Italy
| | - Corrado Paganelli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Dental School, University of Brescia, Brescia, Italy
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14
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Chhatre S, Chang YHA, Gooneratne NS, Kuna S, Strollo P, Jayadevappa R. Association between adherence to continuous positive airway pressure treatment and cost among medicare enrollees. Sleep 2020; 43:5548694. [PMID: 31403696 DOI: 10.1093/sleep/zsz188] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 05/19/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To analyze the cost associated with sleep apnea and effects of continuous positive airway pressure (CPAP) treatment on costs among fee-for-service Medicare beneficiaries. METHODS Retrospective cohort design using 5% Medicare claims between 2006 and 2010. Medicare beneficiaries with and without sleep apnea diagnosis between 2007 and 2008 were identified and followed retrospectively for 2 years pre-index-date and 2 years post-index-date. We defined CPAP fill as at least one durable medical equipment claim for CPAP in 6-month period. At least three CPAP fills was defined as "full adherence," and one or two CPAP fills was "partial adherence." We used interrupted time series and generalized linear log-link models to study the association between sleep apnea, CPAP treatment, and costs. To minimize bias, we used propensity score and instrumental variables approach. RESULTS Sleep apnea was associated with higher costs (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.58, 1.63) compared to those without sleep apnea. Almost half of those with sleep apnea received CPAP treatment. Interrupted time series analysis indicated post level increase in mean monthly cost for full CPAP adherence group, partial CPAP adherence group and no-CPAP group. However, the increase was smallest for the full CPAP adherence group. Full CPAP adherence was associated with lower change in cost (OR = 0.92; 95% CI = 0.88, 0.97) compared to the no-CPAP group. CONCLUSIONS Medicare beneficiaries with sleep apnea experience increased cost. Full adherence to CPAP treatment for sleep apnea was associated with lower increase in cost. These findings emphasize the need to effectively identify and treat sleep apnea in Medicare patients.
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Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Yoon Hee A Chang
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nalaka S Gooneratne
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Division of Geriatric Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Sam Kuna
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA
| | - Patrick Strollo
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ravishankar Jayadevappa
- Division of Geriatric Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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15
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Askland K, Wright L, Wozniak DR, Emmanuel T, Caston J, Smith I. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database Syst Rev 2020; 4:CD007736. [PMID: 32255210 PMCID: PMC7137251 DOI: 10.1002/14651858.cd007736.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP. OBJECTIVES To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices. SEARCH METHODS Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices. DATA COLLECTION AND ANALYSIS We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro. MAIN RESULTS Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies. AUTHORS' CONCLUSIONS In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.
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Affiliation(s)
- Kathleen Askland
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Lauren Wright
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
- AstraZeneca Canada Inc.MississaugaOntarioCanada
| | - Dariusz R Wozniak
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
| | - Talia Emmanuel
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Jessica Caston
- Waypoint Centre for Mental Health CareWaypoint Research InstitutePenetanguisheneCanada
| | - Ian Smith
- Royal Papworth HospitalRespiratory Support and Sleep CentrePapworth EverardCambridgeUKCB23 3RE
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16
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Sleep Apnea Treatment Considerations in Patients with Comorbidities. Otolaryngol Clin North Am 2020; 53:339-349. [PMID: 32199633 DOI: 10.1016/j.otc.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A wide range of sleep, psychiatric, and medical comorbidities can present with obstructive sleep apnea (OSA), complicating treatment because of intolerance or low adherence to traditional modalities of therapy. Providers must have heightened awareness of how these comorbidities can affect their patients' OSA and work together as a team to optimize health and well-being in this complex population.
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17
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Mysliwiec V, Martin JL, Ulmer CS, Chowdhuri S, Brock MS, Spevak C, Sall J. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med 2020; 172:325-336. [PMID: 32066145 DOI: 10.7326/m19-3575] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. METHODS In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.
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Affiliation(s)
- Vincent Mysliwiec
- University of Texas Health Science Center at San Antonio, San Antonio, Texas (V.M.)
| | - Jennifer L Martin
- David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, California (J.L.M.)
| | - Christi S Ulmer
- Durham VA Healthcare System and Duke University School of Medicine, Durham, North Carolina (C.S.U.)
| | - Susmita Chowdhuri
- John D. Dingell VA Sleep Wake Disorders Center and Wayne State University, Detroit, Michigan (S.C.)
| | - Matthew S Brock
- U.S. Army SAMHS Sleep Medicine Service, San Antonio, Texas, and Wilford Hall Ambulatory Surgical Center, Lackland Air Force Base, Texas (M.S.B.)
| | - Christopher Spevak
- Walter Reed National Military Medical Center/Defense Health Agency, Bethesda, Maryland (C.S.)
| | - James Sall
- Department of Veterans Affairs, Washington, DC (J.S.)
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18
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A randomized, placebo-controlled trial using a novel PAP delivery platform to treat patients with OSA and comorbid PTSD. Sleep Breath 2019; 24:1001-1009. [PMID: 31691105 DOI: 10.1007/s11325-019-01936-x] [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] [Received: 04/26/2019] [Revised: 08/16/2019] [Accepted: 09/07/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Positive airway pressure (PAP) adherence is poor in comorbid OSA/PTSD. SensAwake™ (SA) is a wake-sensing PAP algorithm that lowers pressure when wake is detected. We compared auto-PAP (aPAP) with and without SA for comorbid OSA/PTSD. METHODS Prospective, randomized crossover study comparing aPAP to aPAP + SA. We enrolled patients with OSA/PTSD who were PAP naïve. Four weeks after randomization, the patients were crossed over to the alternate treatment group, with final follow-up at eight weeks. Sleep questionnaires (ESS, ISI, FSS, and FOSQ-10) were assessed at baseline and follow-up. RESULTS We enrolled 85 patients with OSA/PTSD. aPAP reduced AHI to < 5/h in both groups. Our primary endpoint, average hours of aPAP adherence (total) after 4 weeks, was significantly increased in the SA group in our intention-to-treat (ITT) analysis (ß = 1.13 (95% CI 0.16-2.1); p = 0.02), after adjustment for ESS differences at baseline. After adjustment for ESS, SA (ITT analysis) also showed significant improvement in percentage of nights used for ≥ 4 h (ß = 14.9 (95% CI 1.02-28.9); p = 0.04). There were trends toward an increase in percentage nights used total (ß = 17.4 (95% CI - 0.1 to 34.9); p = 0.05), average hours of aPAP adherence (nights used) (ß = 1.04 (95% CI - 0.07 to 2.1); p = 0.07), and regular use (OR = 7.5 (95% CI 0.9-64.7); p = 0.07) after adjustment for ESS at baseline. After adjustment for ESS and days to cross over, SA by actual assignment did not show any effect on adherence variables. The ESS, ISI, FSS, and FOSQ-10 all showed significant improvements with PAP, but there were no differences in the magnitude of improvement in any score between groups. CONCLUSIONS Adherence to aPAP may be improved with the addition of SA and deserves further study. SA is as effective as standard aPAP for normalizing the AHI and improving sleep-related symptoms. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02549508 https://clinicaltrials.gov/ct2/show/NCT02549508?term=NCT02549508&rank=1 "Comparison Study Using APAP With and Without SensAwake in Patients With OSA and PTSD".
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19
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Donovan LM, Shah A, Chai-Coetzer CL, Barbé F, Ayas NT, Kapur VK. Redesigning Care for OSA. Chest 2019; 157:966-976. [PMID: 31639334 DOI: 10.1016/j.chest.2019.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023] Open
Abstract
Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.
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Affiliation(s)
- Lucas M Donovan
- HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA; University of Washington School of Medicine, Seattle, WA
| | - Aditi Shah
- Leon Judah Blackmore Sleep Disorders Program, University of British Columbia, Vancouver, BC, Canada
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia; Respiratory and Sleep Service, Southern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Ferran Barbé
- Institut de Recerca Biomèdica of Lleida and CIBERES, Lleida, Catalonia, Spain
| | - Najib T Ayas
- Leon Judah Blackmore Sleep Disorders Program, University of British Columbia, Vancouver, BC, Canada
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20
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The effect of treating obstructive sleep apnea with continuous positive airway pressure on posttraumatic stress disorder: A systematic review and meta-analysis with hypothetical model. Neurosci Biobehav Rev 2019; 102:172-183. [DOI: 10.1016/j.neubiorev.2019.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 02/24/2019] [Accepted: 03/24/2019] [Indexed: 12/14/2022]
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21
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Krakow BJ, McIver ND, Obando JJ, Ulibarri VA. Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study. Mil Med Res 2019; 6:15. [PMID: 31072385 PMCID: PMC6507057 DOI: 10.1186/s40779-019-0204-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors. METHODS OSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates. RESULTS The C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group (P = 0.019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0.001; SC-RU, P = 0.027; NC-MU, P = 0.007). Hours of weekly PAP use and insomnia severity were inversely correlated (P = 0.001, r = - 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents. CONCLUSIONS In a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.
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Affiliation(s)
- Barry J Krakow
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA. .,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA. .,Los Alamos Medical Center, 3917 W Rd, Los Alamos, NM, 87544, USA.
| | - Natalia D McIver
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA
| | - Jessica J Obando
- Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Institution: Mozaik Solutions, Solana Beach, CA, 92075, USA
| | - Victor A Ulibarri
- Sleep & Human Health Institute, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA.,Maimonides Sleep Arts & Sciences, 6739 Academy Rd NE Ste380, Albuquerque, NM, 87109, USA
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Yamamoto U, Nishizaka M, Tsuda H, Tsutsui H, Ando SI. Crossover comparison between CPAP and mandibular advancement device with adherence monitor about the effects on endothelial function, blood pressure and symptoms in patients with obstructive sleep apnea. Heart Vessels 2019; 34:1692-1702. [PMID: 30927057 DOI: 10.1007/s00380-019-01392-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/22/2019] [Indexed: 01/22/2023]
Abstract
Mandibular advancement device (MAD) is an alternative therapeutic option for CPAP to treat obstructive sleep apnea (OSA). While MAD showed the better adherence, patients with over moderate OSA have been treated more frequently with CPAP despite increasing positive evidence on the cardiovascular outcome with MAD, even in severe patients. Thus, more information is needed regarding the cardiovascular and symptomatic outcome of MAD treatment objectively compared to CPAP. Forty-five supine-dependent OSA patients (apnea-hypopnea index 20-40/h) were randomized to either CPAP or MAD and treated for 8 weeks and switched to another for 8 weeks. The primary endpoint was improvement in the endothelial function, indexed by the flow-mediated dilatation (FMD), and the secondary endpoint was the sleep-time blood pressure (BP). The duration of MAD use was evaluated objectively by an implanted adherence monitor. Treatment efficacy was also evaluated by home sleep monitor and a questionnaire about the symptoms. The adherence was not significantly different (CPAP vs. MAD: 274.5 ± 108.9 min/night vs. 314.8 ± 127.0 min/night, p = 0.095). FMD and sleep-time mean BP were not markedly changed from the baseline with either approach (CPAP vs. MAD: FMD, + 0.47% ± 3.1% vs. + 0.85% ± 2.6%, p = 0.64; BP, - 1.5 ± 5.7 mmHg vs. - 1.2 ± 7.5 mmHg, p = 0.48), although sleepiness, nocturia, and sleep-related parameters were similarly improved and more patients preferred MAD. As MAD and CPAP showed similar effects on cardiovascular outcome and symptomatic relief even with a comparable length of usage, we might expect MAD as an alternative treatment option for CPAP in this range of OSA group.
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Affiliation(s)
- Umpei Yamamoto
- Sleep Apnea Center, Kyushu University Hospital, 3-1-1 Maidashi Higashiku, Fukuoka, Japan
- Cardiology, General Internal Medicine, Onga Hospital, Fukuoka, Japan
| | - Mari Nishizaka
- Kirameki Projects Career Support Center, Kyushu University Hospital, Fukuoka, Japan
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hiroko Tsuda
- Sleep Apnea Center, Kyushu University Hospital, 3-1-1 Maidashi Higashiku, Fukuoka, Japan
- General Dentistry, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shin-Ichi Ando
- Sleep Apnea Center, Kyushu University Hospital, 3-1-1 Maidashi Higashiku, Fukuoka, Japan.
- Saiseikai Futsukaichi Hospital, Futsukaichi, Japan.
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Sleep Disorders in Patients With Posttraumatic Stress Disorder. Chest 2018; 154:427-439. [PMID: 29684315 DOI: 10.1016/j.chest.2018.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 02/05/2023] Open
Abstract
A growing body of evidence supports a bidirectional relationship between posttraumatic stress disorder (PTSD) and sleep disturbances. Fragmented sleep induced by sleep-related breathing disorders, insomnia, and nightmares impacts recovery and treatment outcomes and worsens PTSD symptoms. Despite recent attention, management of these disorders has been unrewarding in the setting of PTSD. This review summarizes the evidence for empirically supported treatments of these sleep ailments, including psychotherapeutic and pharmacologic interventions, as it relates to PTSD. Recent advances in positive airway pressure technology have made treatment of OSA more acceptable; however, adherence to CPAP therapy presents a substantial challenge. Concomitant insomnia, which engenders psychiatric and medical conditions, including depression, suicide, and alcohol and substance abuse, can be managed with cognitive behavioral therapy. Hypnotic agents are considered an alternative therapy, but concerns about adverse events and lack of high-level evidence supporting their efficacy in PTSD treatment have limited their use to resistant cases or as adjuncts to behavioral therapy when the response is less than desirable. Intrusion of nightmares can complicate PTSD treatment and exert serious strain on social, occupational, and marital relations. Imagery rehearsal therapy has shown significant reduction in nightmare intensity and frequency. The success of noradrenergic blocking agents has not been consistent among studies, with one-half reporting treatment failure. An integrated stepped care approach that includes components of both behavioral and pharmacologic interventions customized to patients' sleep-maladaptive behaviors may offer a solution to delivering accessible, effective, and efficient services for individuals with PTSD.
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