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Law M, Villar S, Oscroft N, Stoneman V, Fox-Rushby J, Chiu YD, Steele J, Devine T, Francis C, Claydon T, Hill G, Lim KK, Rayner J, Williams M, Spires E, Quinnell T. Continuous Positive Airway Pressure plus Mandibular Advancement Therapy (PAPMAT): study protocol for an adaptive randomised crossover trial comparing the benefits and costs of combining two established treatments for obstructive sleep apnoea. Trials 2023; 24:474. [PMID: 37488626 PMCID: PMC10367275 DOI: 10.1186/s13063-023-07484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) involves repeated breathing pauses during sleep due to upper airway obstruction. It causes excessive daytime sleepiness and has other health impacts. Continuous positive airway pressure (CPAP) therapy is effective first line treatment for moderate to severe OSA. Unfortunately, many patients have difficulty tolerating CPAP and pressure intolerance is probably an important contributing factor. Mandibular advancement devices (MAD) are an alternative to CPAP. They are worn in the mouth during sleep to reduce airway obstruction. There is some evidence that, when used in combination with CPAP, MADs improve airway anatomy enough to reduce the CPAP pressure required to treat OSA and that this combination therapy could improve CPAP adherence. METHODS Consecutive patients starting on CPAP for moderate to severe OSA will be recruited at a regional NHS sleep service. Patients with high CPAP pressure requirements after initial titration, who satisfy all entry criteria and consent to participate, will undertake a 2-arm randomised crossover trial. The arms will be (i) standalone CPAP and (ii) CPAP + MAD therapy. Each arm will last 12 weeks, including 2 weeks acclimatisation. CPAP machines will be auto-titrating and with facility for data download, so the impact of MAD on CPAP pressure requirements and CPAP adherence can be easily measured. The primary outcome will be CPAP adherence. Secondary outcomes will include measures of OSA severity, patient-reported outcome measures including subjective daytime sleepiness, quality of life, and treatment preference at the trial exit and health service use. Cost-effectiveness analyses will be undertaken. DISCUSSION If the intervention is shown to be effective and cost-effective in improving adherence in this standard CPAP-eligible OSA patient population it would be relatively straightforward to introduce into existing OSA treatment pathways, within the wider NHS and more widely. Both MAD and CPAP are already used by sleep services so their combination would require only minor adjustments to existing clinical pathways. It would be straightforward to disseminate the results of the study through regional, national, and international respiratory meetings. The health economics analysis would provide cost-effectiveness data to inform service planning and clinical guidelines through policy briefing papers, including those by NICE and SIGN. TRIAL REGISTRATION PAPMAT was registered with ISRCTN prior to recruitment beginning (ISRCTN Registry 2021): https://www.isrctn.com/ISRCTN33966032 . Registered on 17th November 2021.
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Affiliation(s)
- Martin Law
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
| | - Sofia Villar
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
| | - Nicholas Oscroft
- Respiratory Support and Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | - Victoria Stoneman
- Papworth Trials Unit Collaboration, Royal Papworth Hospital, Cambridge, UK
| | - Julia Fox-Rushby
- Department of Population Health Sciences, King’s College London, London, UK
| | - Yi-Da Chiu
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
| | - Jo Steele
- Papworth Trials Unit Collaboration, Royal Papworth Hospital, Cambridge, UK
| | - Thomas Devine
- Papworth Trials Unit Collaboration, Royal Papworth Hospital, Cambridge, UK
| | - Claire Francis
- Respiratory Support and Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | | | | | - Ka Keat Lim
- Department of Population Health Sciences, King’s College London, London, UK
| | - Joanna Rayner
- Respiratory Support and Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | - Mandy Williams
- Respiratory Support and Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | - Emma Spires
- Respiratory Support and Sleep Centre, Royal Papworth Hospital, Cambridge, UK
| | - Timothy Quinnell
- Respiratory Support and Sleep Centre, Royal Papworth Hospital, Cambridge, UK
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2
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Sosero YL, Yu E, Estiar MA, Krohn L, Mufti K, Rudakou U, Ruskey JA, Asayesh F, Laurent SB, Spiegelman D, Trempe JF, Quinnell TG, Oscroft N, Arnulf I, Montplaisir JY, Gagnon JF, Desautels A, Dauvilliers Y, Gigli GL, Valente M, Janes F, Bernardini A, Sonka K, Kemlink D, Oertel W, Janzen A, Plazzi G, Antelmi E, Biscarini F, Figorilli M, Puligheddu M, Mollenhauer B, Trenkwalder C, Sixel-Döring F, Cochen De Cock V, Monaca CC, Heidbreder A, Ferini-Strambi L, Dijkstra F, Viaene M, Abril B, Boeve BF, Postuma RB, Rouleau GA, Ibrahim A, Stefani A, Högl B, Hu MTM, Gan-Or Z. Rare PSAP Variants and Possible Interaction with GBA in REM Sleep Behavior Disorder. J Parkinsons Dis 2022; 12:333-340. [PMID: 34690151 DOI: 10.3233/jpd-212867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND PSAP encodes saposin C, the co-activator of glucocerebrosidase, encoded by GBA. GBA mutations are associated with idiopathic/isolated REM sleep behavior disorder (iRBD), a prodromal stage of synucleinopathy. OBJECTIVE To examine the role of PSAP mutations in iRBD. METHODS We fully sequenced PSAP and performed Optimized Sequence Kernel Association Test in 1,113 iRBD patients and 2,324 controls. We identified loss-of-function (LoF) mutations, which are very rare in PSAP, in three iRBD patients and none in controls (uncorrected p = 0.018). RESULTS Two variants were stop mutations, p.Gln260Ter and p.Glu166Ter, and one was an in-frame deletion, p.332_333del. All three mutations have a deleterious effect on saposin C, based on in silico analysis. In addition, the two carriers of p.Glu166Ter and p.332_333del mutations also carried a GBA variant, p.Arg349Ter and p.Glu326Lys, respectively. The co-occurrence of these extremely rare PSAP LoF mutations in two (0.2%) GBA variant carriers in the iRBD cohort, is unlikely to occur by chance (estimated co-occurrence in the general population based on gnomAD data is 0.00035%). Although none of the three iRBD patients with PSAP LoF mutations have phenoconverted to an overt synucleinopathy at their last follow-up, all manifested initial signs suggestive of motor dysfunction, two were diagnosed with mild cognitive impairment and all showed prodromal clinical markers other than RBD. Their probability of prodromal PD, according to the Movement Disorder Society research criteria, was 98% or more. CONCLUSION These results suggest a possible role of PSAP variants in iRBD and potential genetic interaction with GBA, which requires additional studies.
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Affiliation(s)
- Yuri L Sosero
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Eric Yu
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Mehrdad A Estiar
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Lynne Krohn
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Kheireddin Mufti
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Uladzislau Rudakou
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Jennifer A Ruskey
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Farnaz Asayesh
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Sandra B Laurent
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Dan Spiegelman
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Jean-François Trempe
- Department of Pharmacology & Therapeutics and Centre de Recherche en Biologie Structurale, McGill University, Montréal, Québec, Canada
| | | | | | - Isabelle Arnulf
- Sleep Disorders Unit, Sorbonne University, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Jacques Y Montplaisir
- Centre d'Études Avancées en Médecine du Sommeil, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Psychiatry, Université de Montréal, Montréal, QC, Canada
| | - Jean-François Gagnon
- Centre d'Études Avancées en Médecine du Sommeil, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Psychology, Université du Québec à Montréal, Montréal, QC, Canada
| | - Alex Desautels
- Centre d'Études Avancées en Médecine du Sommeil, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Neurosciences, Université de Montréal, Montréal, QC, Canada
| | - Yves Dauvilliers
- National Reference Centre for Orphan Diseases, Narcolepsy- Rare hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, Institute for Neurosciences of Montpellier INM, Univ Montpellier, INSERM, Montpellier, France
| | - Gian Luigi Gigli
- Department of Neurosciences, Clinical Neurology Unit, University Hospital of Udine, Udine, Italy.,Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Department of Neurosciences, Clinical Neurology Unit, University Hospital of Udine, Udine, Italy.,Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Francesco Janes
- Department of Neurosciences, Clinical Neurology Unit, University Hospital of Udine, Udine, Italy
| | - Andrea Bernardini
- Department of Neurosciences, Clinical Neurology Unit, University Hospital of Udine, Udine, Italy
| | - Karel Sonka
- Department of Neurology and Centre of Clinical Neuroscience, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - David Kemlink
- Department of Neurology and Centre of Clinical Neuroscience, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Wolfgang Oertel
- Department of Neurology, Philipps University, Marburg, Germany
| | - Annette Janzen
- Department of Neurology, Philipps University, Marburg, Germany
| | - Giuseppe Plazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Elena Antelmi
- IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Neurosciences, Neurology Unit, Movement Disorders Division, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesco Biscarini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Michela Figorilli
- Department of Medical Sciences and Public Health, Sleep Disorder Research Center, University of Cagliari, Cagliari, Italy
| | - Monica Puligheddu
- Department of Medical Sciences and Public Health, Sleep Disorder Research Center, University of Cagliari, Cagliari, Italy
| | - Brit Mollenhauer
- Paracelsus-Elena-Klinik, Kassel, Germany.,Department of Neurology, University Medical Centre Göttingen, Göttingen, Germany
| | - Claudia Trenkwalder
- Paracelsus-Elena-Klinik, Kassel, Germany.,Department of Neurology, University Medical Centre Göttingen, Göttingen, Germany
| | - Friederike Sixel-Döring
- Department of Neurology, Philipps University, Marburg, Germany.,Paracelsus-Elena-Klinik, Kassel, Germany
| | - Valérie Cochen De Cock
- Sleep and Neurology Unit, Beau Soleil Clinic, Montpellier, France.,EuroMov, University of Montpellier, Montpellier, France
| | - Christelle Charley Monaca
- Department of Clinical Neurophysiology and Sleep Center, University Lille North of France, CHU Lille, Lille, France
| | - Anna Heidbreder
- Department of Sleep Medicine and Neuromuscular Disorders, University of Münster, Münster, Germany
| | - Luigi Ferini-Strambi
- Department of Neurological Sciences, Università Vita-Salute San Raffaele, Milan, Italy
| | - Femke Dijkstra
- Laboratory for Sleep Disorders, St. Dimpna Regional Hospital, Geel, Belgium.,Department of Neurology, St. Dimpna Regional Hospital, Geel, Belgium.,Department of Neurology, University Hospital Antwerp, Edegem, Antwerp, Belgium
| | - Mineke Viaene
- Laboratory for Sleep Disorders, St. Dimpna Regional Hospital, Geel, Belgium.,Department of Neurology, St. Dimpna Regional Hospital, Geel, Belgium
| | - Beatriz Abril
- Sleep disorder Unit, Carémeau Hospital, University Hospital of Nîmes, France
| | | | - Ronald B Postuma
- Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.,Centre d'Études Avancées en Médecine du Sommeil, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada
| | - Guy A Rouleau
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
| | - Abubaker Ibrahim
- Department of Neurology, Sleep Disorders Clinic, Medical University of Innsbruck, Innsbruck, Austria
| | - Ambra Stefani
- Department of Neurology, Sleep Disorders Clinic, Medical University of Innsbruck, Innsbruck, Austria
| | - Birgit Högl
- Department of Neurology, Sleep Disorders Clinic, Medical University of Innsbruck, Innsbruck, Austria
| | - Michele T M Hu
- Department of Sleep Medicine and Neuromuscular Disorders, University of Münster, Münster, Germany.,Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Ziv Gan-Or
- Department of Human Genetics, McGill University, Montréal, QC, Canada.,Montreal Neurological Institute, McGill University, Montréal, QC, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
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4
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Murphy PB, Rehal S, Arbane G, Bourke S, Calverley PMA, Crook AM, Dowson L, Duffy N, Gibson GJ, Hughes PD, Hurst JR, Lewis KE, Mukherjee R, Nickol A, Oscroft N, Patout M, Pepperell J, Smith I, Stradling JR, Wedzicha JA, Polkey MI, Elliott MW, Hart N. Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation: A Randomized Clinical Trial. JAMA 2017; 317:2177-2186. [PMID: 28528348 PMCID: PMC5710342 DOI: 10.1001/jama.2017.4451] [Citation(s) in RCA: 353] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Outcomes after exacerbations of chronic obstructive pulmonary disease (COPD) requiring acute noninvasive ventilation (NIV) are poor and there are few treatments to prevent hospital readmission and death. OBJECTIVE To investigate the effect of home NIV plus oxygen on time to readmission or death in patients with persistent hypercapnia after an acute COPD exacerbation. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial of patients with persistent hypercapnia (Paco2 >53 mm Hg) 2 weeks to 4 weeks after resolution of respiratory acidemia, who were recruited from 13 UK centers between 2010 and 2015. Exclusion criteria included obesity (body mass index [BMI] >35), obstructive sleep apnea syndrome, or other causes of respiratory failure. Of 2021 patients screened, 124 were eligible. INTERVENTIONS There were 59 patients randomized to home oxygen alone (median oxygen flow rate, 1.0 L/min [interquartile range {IQR}, 0.5-2.0 L/min]) and 57 patients to home oxygen plus home NIV (median oxygen flow rate, 1.0 L/min [IQR, 0.5-1.5 L/min]). The median home ventilator settings were an inspiratory positive airway pressure of 24 (IQR, 22-26) cm H2O, an expiratory positive airway pressure of 4 (IQR, 4-5) cm H2O, and a backup rate of 14 (IQR, 14-16) breaths/minute. MAIN OUTCOMES AND MEASURES Time to readmission or death within 12 months adjusted for the number of previous COPD admissions, previous use of long-term oxygen, age, and BMI. RESULTS A total of 116 patients (mean [SD] age of 67 [10] years, 53% female, mean BMI of 21.6 [IQR, 18.2-26.1], mean [SD] forced expiratory volume in the first second of expiration of 0.6 L [0.2 L], and mean [SD] Paco2 while breathing room air of 59 [7] mm Hg) were randomized. Sixty-four patients (28 in home oxygen alone and 36 in home oxygen plus home NIV) completed the 12-month study period. The median time to readmission or death was 4.3 months (IQR, 1.3-13.8 months) in the home oxygen plus home NIV group vs 1.4 months (IQR, 0.5-3.9 months) in the home oxygen alone group, adjusted hazard ratio of 0.49 (95% CI, 0.31-0.77; P = .002). The 12-month risk of readmission or death was 63.4% in the home oxygen plus home NIV group vs 80.4% in the home oxygen alone group, absolute risk reduction of 17.0% (95% CI, 0.1%-34.0%). At 12 months, 16 patients had died in the home oxygen plus home NIV group vs 19 in the home oxygen alone group. CONCLUSIONS AND RELEVANCE Among patients with persistent hypercapnia following an acute exacerbation of COPD, adding home noninvasive ventilation to home oxygen therapy prolonged the time to readmission or death within 12 months. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00990132.
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Affiliation(s)
- Patrick B. Murphy
- Lane Fox Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, England
- Asthma, Allergy, and Lung Biology, King’s College London, London, England
| | - Sunita Rehal
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, England
| | - Gill Arbane
- Lane Fox Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, England
| | - Stephen Bourke
- Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, Newcastle, England
- Institute of Cellular Medicine, Newcastle University, Newcastle, England
| | | | - Angela M. Crook
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, England
| | - Lee Dowson
- Respiratory Medicine, Royal Wolverhampton NHS Trust, Wolverhampton, England
| | - Nicholas Duffy
- Respiratory Medicine, Aintree University Hospital, Liverpool, England
| | - G. John Gibson
- Respiratory Medicine, Newcastle University, Newcastle, England
| | - Philip D. Hughes
- Respiratory Medicine, Plymouth Hospital NHS Trust, Plymouth, England
| | - John R. Hurst
- Respiratory Medicine, University College London, Royal Free Campus, London, England
| | - Keir E. Lewis
- Respiratory Medicine, Swansea University, Swansea, England
| | - Rahul Mukherjee
- Respiratory Medicine, Heart of England NHS Trust, Birmingham, England
| | - Annabel Nickol
- Oxford NIHR Biomedical Research Centre, Oxford University and NHS Foundation Trust, Oxford, England
| | - Nicholas Oscroft
- Respiratory Support and Centre, Papworth Hospital, Cambridge, England
| | - Maxime Patout
- Lane Fox Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, England
| | - Justin Pepperell
- Respiratory Medicine, Taunton and Somerset NHS Trust, Taunton, England
| | - Ian Smith
- Respiratory Support and Centre, Papworth Hospital, Cambridge, England
| | - John R. Stradling
- Oxford NIHR Biomedical Research Centre, Oxford University and NHS Foundation Trust, Oxford, England
| | - Jadwiga A. Wedzicha
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, England
| | - Michael I. Polkey
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, England
| | - Mark W. Elliott
- Department of Respiratory Medicine, Leeds University Hospital, Leeds, England
| | - Nicholas Hart
- Lane Fox Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, England
- Asthma, Allergy, and Lung Biology, King’s College London, London, England
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9
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Quinnell TG, Bennett M, Jordan J, Clutterbuck-James AL, Davies MG, Smith IE, Oscroft N, Pittman MA, Cameron M, Chadwick R, Morrell MJ, Glover MJ, Fox-Rushby JA, Sharples LD. A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO). Thorax 2014; 69:938-45. [PMID: 25035126 DOI: 10.1136/thoraxjnl-2014-205464] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
RATIONALE Mandibular advancement devices (MADs) are used to treat obstructive sleep apnoea-hypopnoea syndrome (OSAHS) but evidence is lacking regarding their clinical and cost-effectiveness in less severe disease. OBJECTIVES To compare clinical- and cost-effectiveness of a range of MADs against no treatment in mild to moderate OSAHS. MEASUREMENTS AND METHODS This open-label, randomised, controlled, crossover trial was undertaken at a UK sleep centre. Adults with Apnoea-Hypopnoea Index (AHI) 5-<30/h and Epworth Sleepiness Scale (ESS) score ≥9 underwent 6 weeks of treatment with three non-adjustable MADs: self-moulded (SleepPro 1; SP1); semi-bespoke (SleepPro 2; SP2); fully-bespoke MAD (bMAD); and 4 weeks no treatment. Primary outcome was AHI scored by a polysomnographer blinded to treatment. Secondary outcomes included ESS, quality of life, resource use and cost. MAIN RESULTS 90 patients were randomised and 83 were analysed. All devices reduced AHI compared with no treatment by 26% (95% CI 11% to 38%, p=0.001) for SP1, 33% (95% CI 24% to 41%) for SP2 and 36% (95% CI 24% to 45%, p<0.001) for bMAD. ESS was 1.51 (95% CI 0.73 to 2.29, p<0.001, SP1) to 2.37 (95% CI 1.53 to 3.22, p<0.001, bMAD) lower than no treatment (p<0.001 for all). Compliance was lower for SP1, which was the least preferred treatment at trial exit. All devices were cost-effective compared with no treatment at a £20,000/quality-adjusted life year (QALY) threshold. SP2 was the most cost-effective up to £39,800/QALY. CONCLUSIONS Non-adjustable MADs achieve clinically important improvements in mild to moderate OSAHS and are cost-effective. Of those trialled, the semi-bespoke MAD is an appropriate first choice. TRIAL REGISTRATION NUMBER ISRCTN02309506.
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Affiliation(s)
- Timothy G Quinnell
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Maxine Bennett
- Medical Research Council Biostatistics Unit, Institute of Public Health, University Forvie Site, Cambridge, UK
| | - Jake Jordan
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK
| | | | - Michael G Davies
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Ian E Smith
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nicholas Oscroft
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Marcus A Pittman
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Malcolm Cameron
- Department of Oral and Maxillofacial Surgery, Addenbrooke's NHS Foundation Trust, Cambridge, UK
| | - Rebecca Chadwick
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Mary J Morrell
- National Heart & Lung Institute, Royal Brompton Campus, Imperial College, London, UK
| | - Matthew J Glover
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK
| | - Julia A Fox-Rushby
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK
| | - Linda D Sharples
- Respiratory Support and Sleep Centre, Papworth Hospital NHS Foundation Trust, Cambridge, UK Medical Research Council Biostatistics Unit, Institute of Public Health, University Forvie Site, Cambridge, UK Clinical Trials Research Unit, University of Leeds, Leeds, UK
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