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Schuitenmaker JM, Kuipers T, Schijven MP, Smout AJPM, Fockens P, Bredenoord AJ. The effect of sleep positional therapy on nocturnal gastroesophageal reflux measured by esophageal pH-impedance monitoring. Neurogastroenterol Motil 2023; 35:e14614. [PMID: 37246930 DOI: 10.1111/nmo.14614] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/12/2023] [Accepted: 05/14/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND & AIMS The aim of the study was to evaluate the effect of an electronic positional therapy wearable device on nocturnal gastroesophageal reflux measured by pH-impedance reflux monitoring. METHODS We performed a single-center, prospective, interventional study in 30 patients with nocturnal reflux symptoms and a nocturnal esophageal acid exposure time (AET) ≥1.5% measured off acid-suppressive medication by ambulatory pH-impedance reflux monitoring. Patients were treated with an electronic positional therapy wearable device for 2 weeks. The device vibrates in the right lateral decubitus position so it conditions patients to avoid that sleep position. After 2 weeks treatment, the pH-impedance study was repeated. Primary outcome was the change in nocturnal AET. Secondary outcomes include change in number of reflux episodes and reflux symptoms. RESULTS Complete data were available for 27 patients (13 females, mean age 49.8 years). The median nocturnal AET decreased from 6.0% (IQR, 2.3-15.3) to 3.1% (0.1-10.8) after 2 weeks of treatment (p = 0.079). The number of reflux episodes was significantly reduced after 2 weeks of treatment (baseline: 8.0 (3.0-12.3) vs. end: 3.0 (1.0-8.0); p = 0.041). Treatment led to a statistically significant decrease in time spent in right lateral decubitus position (baseline: mean 36.9% ± 15.2% vs. end: 2.7% ± 8.2%; p = <0.001) and an increase in the left lateral decubitus position (baseline 29.2% ± 14.8% vs. end: 63.3% ± 21.9%; p = <0.001). Symptom improvement was reported by 70.4% of the patients. CONCLUSIONS Sleep positional therapy using an electronic wearable device promotes sleeping in the left lateral decubitus position and improves reflux parameters measured by pH-impedance reflux monitoring.
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Affiliation(s)
- Jeroen M Schuitenmaker
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - Thijs Kuipers
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - Marlies P Schijven
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - André J P M Smout
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, The Netherlands
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Grote L, Anderberg CP, Friberg D, Grundström G, Hinz K, Isaksson G, Murto T, Nilsson Z, Spaak J, Stillberg G, Söderberg K, Tegelberg Å, Theorell-Haglöw J, Ulander M, Hedner J. National Knowledge-Driven Management of Obstructive Sleep Apnea-The Swedish Approach. Diagnostics (Basel) 2023; 13:diagnostics13061179. [PMID: 36980487 PMCID: PMC10047173 DOI: 10.3390/diagnostics13061179] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION This paper describes the development of "Swedish Guidelines for OSA treatment" and the underlying managed care process. The Apnea Hypopnea Index (AHI) is traditionally used as a single parameter for obstructive sleep apnea (OSA) severity classification, although poorly associated with symptomatology and outcome. We instead implement a novel matrix for shared treatment decisions based on available evidence. METHODS A national expert group including medical and dental specialists, nurses, and patient representatives developed the knowledge-driven management model. A Delphi round was performed amongst experts from all Swedish regions (N = 24). Evidence reflecting treatment effects was extracted from systematic reviews, meta-analyses, and randomized clinical trials. RESULTS The treatment decision in the process includes a matrix with five categories from a "very weak"" to "very strong" indication to treat, and it includes factors with potential influence on outcome, including (A) OSA-related symptoms, (B) cardiometabolic comorbidities, (C) frequency of respiratory events, and (D) age. OSA-related symptoms indicate a strong incitement to treat, whereas the absence of symptoms, age above 65 years, and no or well-controlled comorbidities indicate a weak treatment indication, irrespective of AHI. CONCLUSIONS The novel treatment matrix is based on the effects of treatments rather than the actual frequency of respiratory events during sleep. A nationwide implementation of this matrix is ongoing, and the outcome is monitored in a prospective evaluation by means of the Swedish Sleep Apnea Registry (SESAR).
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Affiliation(s)
- Ludger Grote
- Center for Sleep and Wake Disorders, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, 405 30 Gothenburg, Sweden
- Pulmonary Medicine, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | | | - Danielle Friberg
- Department of Otorhinolaryngology, Surgical Sciences, Uppsala University, 752 36 Uppsala, Sweden
| | - Gert Grundström
- Sleep Apnea Patient Organisation (Apne Sverige), 13332 Saltsjoebaden, Sweden
| | - Kerstin Hinz
- Department for Health Care Development, Region of Västra Götaland, 40544 Gothenburg, Sweden
| | | | - Tarmo Murto
- Sleep Apnea Unit, Respiratory Medicine, Umeå University Hospital, 90185 Umeå, Sweden
| | - Zarita Nilsson
- Sleep Apnea Unit, ENT Department, Ystad Hospital, 271 82 Ystad, Sweden
| | - Jonas Spaak
- Department of Cardiology and Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, 18288 Danderyd, Sweden
| | | | - Karin Söderberg
- Sleep Apnea Patient Organisation (Apne Sverige), 13332 Saltsjoebaden, Sweden
| | - Åke Tegelberg
- Sleep Apnea Patient Association (Apnefoereningen Syd), 14630 Tullinge, Sweden
| | | | - Martin Ulander
- Department for Clinical Neurophysiology, 58185 Linköping, Sweden
| | - Jan Hedner
- Center for Sleep and Wake Disorders, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, 405 30 Gothenburg, Sweden
- Pulmonary Medicine, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Ben Sason Y, Oksenberg A, Sobel JA, Behar JA. Characteristics of patients with positional OSA according to ethnicity and the identification of a novel phenotype-lateral positional patients: a Multi-Ethnic Study of Atherosclerosis (MESA) study. J Clin Sleep Med 2023; 19:529-538. [PMID: 36533408 PMCID: PMC9978421 DOI: 10.5664/jcsm.10382] [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: 04/27/2022] [Revised: 10/30/2022] [Accepted: 11/01/2022] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVES We investigated the characteristics of obstructive sleep apnea (OSA) positional patients' (PP) phenotypes among different ethnic groups in the Multi-Ethnic Study of Atherosclerosis (MESA) dataset. Moreover, we hypothesized the existence of a new OSA PP phenotype we coined "Lateral PP," for whom the lateral apnea-hypopnea index is at least double the supine apnea-hypopnea index. METHODS From 2,273 adults with sleep information, we analyzed data of 1,323 participants who slept more than 4 hours and had at least 30 minutes of sleep in both the supine and the nonsupine positions. Demographics and clinical information were compared for the different PP and ethnic groups. RESULTS 861 (65.1%) patients had OSA, and 35 (4.1%) were Lateral PP. Lateral PP patients were mainly females (62.9%), obese (median body mass index: 31.4 kg/m2), had mild-moderate OSA (94.3%), and mostly were non-Chinese American (97.1%). Among all patients with OSA, 550 (63.9%) were Supine PP and 17.7% were supine-isolated OSA. Supine PP and Lateral PP were present in 73.1% and 1.0% of Chinese Americans, 61.0% and 3.4% of Hispanics, 68.3% and 4.7% of White/Caucasian, and 56.2% and 5.2% of Black/African-American patients with OSA. CONCLUSIONS Chinese Americans have the highest prevalence of Supine PP, whereas Black/African-American patients lean toward less Supine PP and higher Lateral PP. Lateral PP appears to be a novel OSA phenotype. However, Lateral PP was observed in a small group of patients with OSA and thus its existence should be further validated. CITATION Ben Sason Y, Oksenberg A, Sobel JA, Behar JA. Characteristics of patients with positional OSA according to ethnicity and the identification of a novel phenotype-lateral positional patients: a Multi-Ethnic Study of Atherosclerosis (MESA) study. J Clin Sleep Med. 2023;19(3):529-538.
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Affiliation(s)
- Yuval Ben Sason
- Faculty of Biomedical Engineering, Technion Institute of Technology, Haifa, Israel
| | - Arie Oksenberg
- Former Director of the Sleep Disorders Unit (retired), Loewenstein Hospital Rehabilitation Center, Raanana, Israel
| | - Jonathan A. Sobel
- Faculty of Biomedical Engineering, Technion Institute of Technology, Haifa, Israel
| | - Joachim A. Behar
- Faculty of Biomedical Engineering, Technion Institute of Technology, Haifa, Israel
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Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med 2023; 19:403-408. [PMID: 36117433 PMCID: PMC9892739 DOI: 10.5664/jcsm.10296] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
Treatment of moderate to severe obstructive sleep apnea poses clinical challenges in persons with intolerance or inadequate response to traditional treatment modalities, including positive airway pressure and mandibular advancement devices. Hypoglossal nerve stimulation is a new treatment option, but few management guidelines exist when it is intolerable or ineffective. Combining several treatment modalities has been an effective strategy for improving symptoms, tolerance, and efficacy. We describe a patient intolerant to positive airway pressure therapy who had continued sleepiness, morning headaches, and snoring with a mandibular advancement device. He underwent hypoglossal nerve stimulation implantation but was intolerant of the voltages required to adequately control his obstructive sleep apnea. Multimodal management with hypoglossal nerve stimulation, mandibular advancement device, and positional therapy was successfully implemented to improve sleepiness, nocturnal symptoms, and the apnea-hypopnea index. This case highlights the personalization and adaptability of combination therapy to suit patient needs while effectively controlling obstructive sleep apnea. CITATION Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med. 2023;19(2):403-408.
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Affiliation(s)
- Megan M. Lowery
- Pulmonary, Critical Care and Sleep, University of Florida, Gainesville, Florida
| | - Jessica Vensel Rundo
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Harneet K. Walia
- Sleep Medicine, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Vaishal Shah
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Wasef S, Mir S, Ryan C, Waseem R, Bellingham G, Kashgari A, Wong J, Chung F. Treatment for patients with sleep apnea on opioids for chronic pain: results of the OpSafe trial. J Clin Sleep Med 2021; 17:819-824. [PMID: 33382032 DOI: 10.5664/jcsm.9064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 01/06/2023]
Abstract
STUDY OBJECTIVES Approximately 20% of North Americans are afflicted with chronic pain with 3% being opioid users. The objective was to determine whether patients on opioids for chronic pain with newly diagnosed sleep apnea attended sleep clinic review and followed treatment recommendations. METHODS The study was a post hoc analysis from a multicenter perspective cohort study. Inclusion criteria included adults taking opioid medications for chronic pain for >3 months. Demographic data and daily opioid dose were collected. Sleep apnea was diagnosed via level 1 polysomnography. Patients who attended sleep clinic review were grouped based on the types of treatment they received. RESULTS A total of 204 patients completed polysomnography and 58.8% were diagnosed to have sleep apnea (apnea-hypopnea index ≥5 events/h). Of those with sleep apnea, 58% were recommended to have an evaluation by a sleep physician. Body mass index and age were 29.5 ± 6 kg/m² and 56 ± 12 years, respectively. Of those with newly diagnosed sleep apnea, 25% received treatment, with the majority being treated with positive airway pressure therapy, whereas the rest received positional therapy and opioids/sedative reduction. The adherence rate of positive airway pressure therapy was 55% at 1 year. Over 50% of participants on opioids for chronic pain with newly diagnosed sleep apnea declined attendance for sleep clinic review or treatment. CONCLUSIONS There was a high refusal rate to attend clinic for treatment. Adherence to positive airway pressure therapy was low at 55%. This sheds light on the high rate of treatment nonadherence and the need for further research. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Opioid Safety Program in Pain Clinics (Op-Safe); URL: https://www.clinicaltrials.gov/ct2/show/NCT02513836; Identifier: NCT02513836.
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Affiliation(s)
- Sara Wasef
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Soodaba Mir
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh Ryan
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Health and Research, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rida Waseem
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Geoff Bellingham
- St Joseph's Chronic Pain Clinic, St Joseph's Hospital, London, Ontario, Canada
| | - Alia Kashgari
- Department of Medicine, Respirology Division, Western University, London, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
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De Corso E, Mastrapasqua RF, Fiorita A, Settimi S, Mele DA, Picciotti PM, Loperfido A, Marrone S, Rizzotto G, Paludetti G, Scarano E. Efficacy and long-term follow-up of positional therapy by vibrotactile neck-based device in the management of positional OSA. J Clin Sleep Med 2021; 16:1711-1719. [PMID: 32621579 DOI: 10.5664/jcsm.8664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/17/2022]
Abstract
STUDY OBJECTIVES Different therapeutic strategies have been investigated for the treatment of positional obstructive sleep apnea, but more evidence is needed about efficacy and compliance. The objective of this study was to describe the efficacy of vibrotactile neck-based treatment in patients with positional obstructive sleep apnea with different degrees of obstructive sleep apnea severity who were followed for 6 months. METHODS This is a retrospective study including 162 patients with positional obstructive sleep apnea undergoing vibrotactile neck-based positional therapy. We compared polysomnographic data obtained at baseline and during positional therapy after 1 month. We performed a subgroup analysis based on obstructive sleep apnea severity. Furthermore, we analyzed follow-up data in 84/162 (51.8%) patients with particular focus on discontinuation and complications related to the device. RESULTS We observed a significant difference between mean baseline obstructive apnea-hypopnea index (OAHI; 21.9 ± 9.9 events/h) and during positional therapy (12 ± 9.2 events/h; P < .01). Moreover, 87/162 (54.9%) patients showed a reduced baseline OAHI of at least 50% and 38/162 (23.4%) achieved complete disease control (OAHI < 5 events/h). At subgroup analysis, at least 50% reduction from baseline OAHI was observed in 56.8% of patients with mild, 55% with moderate, and 47.4% with severe OAHI, whereas complete control of disease was achieved in 50% of patients with mild, 22.5% with moderate, and 7.9% with severe OAHI. At a 6-month follow-up, only 35/84 patients (41.6%) were regularly using the device, with a mean of 5.9 ± 1.2 days per week. CONCLUSIONS Our results on the efficacy and long-term adherence to vibrotactile neck-based positional therapy showed that positional therapy can be an efficient first-line treatment option for mild positional obstructive sleep apnea and in selected cases of moderate disease. Long-term compliance is limited because of complications and low satisfaction in some patients.
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Affiliation(s)
- Eugenio De Corso
- Unit of Otorhinolaryngology and Head and Neck Surgery. Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy.,Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Antonella Fiorita
- Unit of Otorhinolaryngology and Head and Neck Surgery. Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy.,Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Stefano Settimi
- Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Dario Antonio Mele
- Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Pasqualina Maria Picciotti
- Unit of Otorhinolaryngology and Head and Neck Surgery. Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy.,Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Loperfido
- Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Sabino Marrone
- Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Grazia Rizzotto
- Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy.,Unit of Neurophysiopathology. Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Unit of Otorhinolaryngology and Head and Neck Surgery. Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy.,Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Emanuele Scarano
- Unit of Otorhinolaryngology and Head and Neck Surgery. Fondazione Policlinico Universitario "A. Gemelli" - IRCCS, Rome, Italy.,Head and Neck Department, Catholic University of the Sacred Heart, Rome, Italy
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Kulkas A, Duce B, Töyräs J, Seppä J, Leppänen T. Comparison of the effect of weight change, simulated computational continuous positive airway pressure treatment and positional therapy on severity of sleep apnea. J Sleep Res 2020; 30:e13070. [PMID: 32557941 DOI: 10.1111/jsr.13070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 11/28/2022]
Abstract
Weight loss, continuous positive airway pressure (CPAP) and positional therapy (PT) are important treatments in obstructive sleep apnea (OSA). Although all of these reduce the apnea-hypopnea index (AHI) effectively, the benefits of these treatments have not been thoroughly investigated in a patient-specific manner. Therefore, clinicians do not have objective means to choose an optimal treatment for each patient. We aim to provide clinicians the possibility for treatment optimization in a patient-specific manner by introducing a computational simulation approach. The effect of actual weight change, computationally simulated CPAP treatment and PT and their combinations on the AHI were compared in 54 OSA patients divided into three equally sized groups (weight loss > 7%, weight loss 0%-7%, and weight gain) after a 5-year follow-up with lifestyle intervention. Weight loss reduced the AHI by 43.5% (p < .05) and 18%, simulated CPAP treatment with 3.3-hr adherence by 42.4% (p < .05) and 35.5% (p < .05), and simulated PT by 13.5% (p < .05) and 30.7% (p < .05) in > 7% and 0%-7% weight loss groups, respectively. Simulated CPAP treatment and PT were able to compensate for the increase in the AHI caused by weight gain. A developed simulation approach could help clinicians to estimate treatment success in advance in order to prescribe the most optimal patient-specific treatment to reduce OSA-related health risks.
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Affiliation(s)
- Antti Kulkas
- Department of Clinical Neurophysiology, Seinäjoki Central Hospital, Seinäjoki, Finland.,Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Brett Duce
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Juha Töyräs
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.,Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland.,School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Qld, Australia
| | - Juha Seppä
- Department of Otorhinolaryngology, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Timo Leppänen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.,Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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Garg H, Er XY, Howarth T, Heraganahally SS. Positional Sleep Apnea Among Regional and Remote Australian Population and Simulated Positional Treatment Effects. Nat Sci Sleep 2020; 12:1123-1135. [PMID: 33304112 PMCID: PMC7723233 DOI: 10.2147/nss.s286403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/19/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To assess the prevalence of positional sleep apnea (POSA) and its predictors in patients diagnosed to have obstructive sleep apnea (OSA) in the regional and remote population of the Northern Territory of Australia over a two-year study period (2018 and 2019). PATIENTS AND METHODS Of the total 1463 adult patients who underwent a diagnostic polysomnography (PSG), 946 patients were eligible to be included in the study, of them, 810 consecutive patients with OSA (Apnea-Hypopnea Index (AHI) ≥ 5) who slept >4 h and had ≥30 min sleep in both supine and lateral positions were assessed. Patients were considered to have POSA if supine AHI to lateral AHI ratio ≥2. The likely comparative impact of use of continuous positive airway therapy (CPAP) or positional therapy (PT) on disease severity was evaluated using model simulation. RESULTS A total of 495/810 (61%) patients had POSA, the majority were males (68% vs 60%, p=0.013) and non-Indigenous Australians (93% vs 87%, p=0.004). POSA patients were younger (mean difference 2.23 years (95% CI 0.27, 4.19)), less obese (BMI mean difference 3.06 (95% CI 2.11, 4.01)), demonstrated less severe OSA (p < 0.001) and a greater proportion reported alcohol consumption (72% vs 62%, p=0.001) as compared to those with non-POSA. Using the simulation model, if patients with POSA use PT two-thirds (323/495, 65%) would obtain significant improvement of their OSA severity, with one in five (92/495, 19%) displaying complete resolution. Comparing this to simulated CPAP therapy, where the majority (444/495, 90%) will show significant improvement, and one-third (162/495, 33%) will display complete resolution. CONCLUSION POSA needs to be routinely recognised and positional therapy integrated in practice especially in the remote regions and in the developing world when effective methods are in place to monitor positional therapy.
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Affiliation(s)
- Himanshu Garg
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Xin Yi Er
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Timothy Howarth
- College of Health and Human Sciences, Charles Darwin University, Darwin, Northern Territory, Australia.,Darwin Respiratory and Sleep Health, Darwin Private Hospital, Tiwi, Darwin, Northern Territory, Australia
| | - Subash S Heraganahally
- Department of Respiratory and Sleep Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Darwin Respiratory and Sleep Health, Darwin Private Hospital, Tiwi, Darwin, Northern Territory, Australia.,Flinders University - College of Medicine and Public Health, Adelaide, South Australia
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Oksenberg A, Goizman V, Eitan E, Nasser K, Gadoth N, Leppänen T. Obstructive Sleep Apnea: Do Positional Patients Become Nonpositional Patients With Time? Laryngoscope 2019; 130:2263-2268. [PMID: 31721222 DOI: 10.1002/lary.28387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 09/08/2019] [Accepted: 10/15/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) patients with breathing abnormalities only or mainly in the supine posture are designated positional patients (PPs), whereas nonpositional patients (NPPs) have many breathing abnormalities in both lateral and supine postures. Positional therapy (PT), the avoidance of the supine posture during sleep, is the obvious treatment for PPs. The stability over time of being PP and leading factors that are involved in converting a PP to an NPP are addressed. METHODS We analyzed polysomnographic (PSG) recordings of 81 consecutive adult patients with OSA who were judged to be PPs at the first PSG evaluation, and their follow-up PSGs were obtained after an average period of 6.6 years. RESULTS The follow-up PSGs indicated that 57 PPs (70.4%) remained PPs, whereas 24 (29.6 %) converted to NPPs. Among PPs and NPPs, body mass index (P ≤ 0.05), overall Apnea-Hypopnea Index (AHI, P ≤ 0.087), and lateral AHI (P ≤ 0.046) increased and minimum SpO2 during rapid eye movement (REM) sleep (P ≤ 0.028) decreased significantly during the follow-up. However, among patients who became NPPs, the changes in these parameters were significantly (P ≤ 0.05) more pronounced compared to the patients who remained PPs. CONCLUSION After an average of 6.6 years, 70.4% of PPs remained PPs. Therefore, if adherence for PT is good, they could continue to benefit from this therapy. For those who turned to NPPs, PT will not be the optimal treatment anymore; thus, these patients should be frequently monitored. Furthermore, an early treatment of PPs with PT would be highly beneficial to prevent worsening of their OSA. LEVEL OF EVIDENCE 2b Laryngoscope, 130:2263-2268, 2020.
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Affiliation(s)
- Arie Oksenberg
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Vlada Goizman
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Edith Eitan
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Kitham Nasser
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Natan Gadoth
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Timo Leppänen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.,Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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Coleman J, Okere M, Seffah J, Kember A, O'Brien LM, Borazjani A, Butler M, Wells J, MacRitchie S, Isaac A, Chu K, Scott H. The Ghana PrenaBelt trial: a double-blind, sham-controlled, randomised clinical trial to evaluate the effect of maternal positional therapy during third-trimester sleep on birth weight. BMJ Open 2019; 9:e022981. [PMID: 31048420 PMCID: PMC6502032 DOI: 10.1136/bmjopen-2018-022981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the effect, on birth weight and birth weight centile, of use of the PrenaBelt, a maternal positional therapy device, during sleep in the home setting throughout the third trimester of pregnancy. DESIGN A double-blind, sham-controlled, randomised clinical trial. SETTING Conducted from September 2015 to May 2016, at a single, tertiary-level centre in Accra, Ghana. PARTICIPANTS Two-hundred participants entered the study. One-hundred-eighty-one participants completed the study. Participants were women, 18 to 35 years of age, with low-risk, singleton, pregnancies in their third-trimester, with body mass index <35 kg/m2 at the first antenatal appointment for the index pregnancy and without known foetal abnormalities, pregnancy complications or medical conditions complicating sleep. INTERVENTIONS Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either the PrenaBelt or sham-PrenaBelt. Participants were instructed to wear their assigned device to sleep every night for the remainder of their pregnancy (approximately 12 weeks in total) and were provided a sleep diary to track their use. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants and the outcomes assessor were blinded to allocation. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were birth weight and birth weight centile. Secondary outcomes included adherence to using the assigned device nightly, sleeping position, pregnancy outcomes and feedback from participants and maternity personnel. RESULTS One-hundred-sixty-seven participants were included in the primary analysis. The adherence to using the assigned device nightly was 56%. The mean ±SD birth weight in the PrenaBelt group (n=83) was 3191g±483 and in the sham-PrenaBelt group (n=84) was 3081g±484 (difference 110 g, 95% CI -38 to 258, p=0.14). The median (IQR) customised birth weight centile in the PrenaBelt group was 43% (18 to 67) and in the sham-PrenaBelt group was 31% (14 to 58) (difference 7%, 95% CI -2 to 17, p=0.11). CONCLUSIONS The PrenaBelt did not have a statistically significant effect on birth weight or birth weight centile in comparison to the sham-PrenaBelt. TRIAL REGISTRATION NUMBER NCT02379728.
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Affiliation(s)
- Jerry Coleman
- Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
- University of Ghana School of Medicine and Dentistry, Accra, Greater Accra, Ghana
| | - Maxfield Okere
- Biostatistics, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
| | - Joseph Seffah
- Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
- University of Ghana School of Medicine and Dentistry, Accra, Greater Accra, Ghana
| | - Allan Kember
- Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada
- Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Louise M O'Brien
- University of Michigan Department of Obstetrics and Gynaecology, Ann Arbor, Michigan, USA
| | - Ali Borazjani
- Global Innovations for Reproductive Health & Life, Cleveland, Ohio, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Michael Butler
- Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Jesse Wells
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Andre Isaac
- Innovative Canadians for Change, Edmonton, Alberta, Canada
| | - Kaishin Chu
- Method Squared Designhaus, Surrey, British Columbia, Canada
| | - Heather Scott
- Obstetrics & Gynaecology, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
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Warland J, Dorrian J, Kember AJ, Phillips C, Borazjani A, Morrison JL, O'Brien LM. Modifying Maternal Sleep Position in Late Pregnancy Through Positional Therapy: A Feasibility Study. J Clin Sleep Med 2018; 14:1387-1397. [PMID: 30092890 PMCID: PMC6086963 DOI: 10.5664/jcsm.7280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 05/06/2018] [Accepted: 05/14/2018] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVES To test whether a customized positional therapy device, PrenaBelt, would reduce time spent sleeping supine and evaluate any change in maternal or fetal parameters, in a group of healthy pregnant women in the third trimester of pregnancy. METHODS Participants underwent an in-home, overnight sleep study during late pregnancy (32-38 weeks). Participants were observed over 2 nights: 1 night when the PrenaBelt was not worn (nonintervention or control) and 1 night when it was (intervention). The intervention night was randomly allocated, and the study nights were consecutive. On the control night, participants were filmed using a night-capable (infrared) video camera, maternal sleep was measured by the Watch-PAT200, and the fetus was continuously monitored using the Monica AN24. On the intervention night, video, maternal, and fetal monitoring were repeated with the addition of the mother wearing the PrenaBelt. RESULTS A total of 25 healthy pregnant women were studied. Four had missing data for the Watch-PAT or Monica, and eight had missing or disrupted video data. Video-determined time in bed was not significantly different during intervention and control nights (P = .196, r = -.23). Median time spent supine during the intervention night was reduced from 48.3 minutes, to 28.5 minutes during the control night (P = .064, r = -.33). The difference in the proportion of time spent supine was significant (P = .039). There was no significant difference in objectively estimated sleep time (P = .651, r = -.07). Improvement was observed in both maternal and fetal parameters during the intervention night with an increase in median minimum maternal oxygen saturations (control = 91.6%, intervention = 92.4%, P = .006, r = -.42), fewer maternal oxygen desaturations (control = 7.1, intervention = 5.9, P = .095, r = -.26), and fewer fetal heart rate decelerations (control = 14.0, intervention = 10.4, P = .045, r = -.31) compared to the control night. CONCLUSIONS Results provide preliminary evidence that an intervention to reduce supine sleep in late pregnancy may provide maternal and fetal health benefits, with minimal effect on maternal perception of sleep quality and objectively estimated sleep time. Further research to explore relationships between objectively determined maternal sleep position, maternal respiratory indices, and fetal well-being is warranted.
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Affiliation(s)
- Jane Warland
- Mother's Babies and Families Research Group, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
| | - Jillian Dorrian
- Behaviour-Brain-Body Research Centre, Sleep and Chronobiology Laboratory, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
| | - Allan J. Kember
- Dalhousie Medical School, Dalhousie University, Halifax, Nova Scotia, Canada
- Global Innovations for Reproductive Health and Life (GIRHL) Cleveland, Ohio
| | - Craig Phillips
- School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia; Global Innovations for Reproductive Health and Life (GIRHL) Cleveland, Ohio
| | - Ali Borazjani
- Global Innovations for Reproductive Health and Life (GIRHL) Cleveland, Ohio
| | - Janna L. Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Louise M. O'Brien
- Sleep Disorders Center and Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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12
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Beyers J, Dieltjens M, Kastoer C, Opdebeeck L, Boudewyns AN, De Volder I, Van Gastel A, Verbraecken JA, De Backer WA, Braem MJ, Van de Heyning PH, Vanderveken OM. Evaluation of a Trial Period With a Sleep Position Trainer in Patients With Positional Sleep Apnea. J Clin Sleep Med 2018; 14:575-583. [PMID: 29609712 DOI: 10.5664/jcsm.7048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 12/27/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To assess the overall clinical effectiveness of a sleep position trainer (SPT) in patients with positional obstructive sleep apnea (POSA) and to evaluate how many patients were willing to continue treatment after a 1-month trial period. METHODS Patients in whom POSA was diagnosed underwent a 1-month trial period with the SPT. Home sleep apnea tests were used to measure baseline data and data following the trial period with the SPT. RESULTS The 79 patients who completed the study protocol were 81% male, had a mean age of 52 ± 12 years, and a median baseline respiratory event index (REI) of 11 (8, 16) events/h. A significant reduction in overall REI to 5 (3, 10) events/h was observed with the SPT as compared to baseline (P < .001). The median percentage of sleep time in the supine position decreased significantly from 27 (20, 48) to 7 (2, 20) with the SPT (P < .001). Adherence was found to be 95 ± 8%. Of the 44 patients who decided to continue treatment, 27 were categorized as responders (having a decrease in REI of at least 50%) and 17 were non-responders. The most important reasons for not purchasing the SPT were poor objective results, intolerance to the vibrations, cost of the device, persistent daytime sleepiness, or patient preference for other treatment options. CONCLUSIONS Treatment with the SPT came with high adherence rates and was effective in reducing REI and supine sleep position. The trial period is in the patients' best interest, as it may prevent those who will not benefit from positional training from purchasing an SPT.
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Affiliation(s)
- Jolien Beyers
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Marijke Dieltjens
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Special Care Dentistry, Antwerp University Hospital, Edegem, Belgium
| | - Chloé Kastoer
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Lynn Opdebeeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - An N Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Ilse De Volder
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Psychiatry, Antwerp University Hospital, Edegem, Belgium
| | - Ann Van Gastel
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Psychiatry, Antwerp University Hospital, Edegem, Belgium
| | - Johan A Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonary Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Wilfried A De Backer
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonary Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Special Care Dentistry, Antwerp University Hospital, Edegem, Belgium
| | - Paul H Van de Heyning
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Olivier M Vanderveken
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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13
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Ravesloot MJL, White D, Heinzer R, Oksenberg A, Pépin JL. Efficacy of the New Generation of Devices for Positional Therapy for Patients With Positional Obstructive Sleep Apnea: A Systematic Review of the Literature and Meta-Analysis. J Clin Sleep Med 2017; 13:813-824. [PMID: 28212691 DOI: 10.5664/jcsm.6622] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/18/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES In approximately 56% to 75% of patients with obstructive sleep apnea (OSA), the frequency and duration of apneas are influenced by body position. This is referred to as position-dependent OSA or POSA. Patients with POSA can be treated with a small device attached to either the neck or chest. These devices-a new generation of devices for positional therapy (PT)-provide a subtle vibrating stimulus that prevents patients adopting the supine position. The objectives of this study were to determine whether PT is effective in improving sleep study variables and sleepiness, and to assess compliance. METHODS A systematic review and meta-analysis. RESULTS Three prospective cohort studies and four randomized controlled trials were included in this review. Combined data for studies reporting on the effect of PT show that there was a mean difference of 11.3 events/h (54% reduction) in apnea-hypopnea index and 33.6% (84% reduction) in percentage total sleeping time in the supine position. The standardized mean difference for both parameters demonstrated a large magnitude of effect (> 0.8 in both cases). CONCLUSIONS There is strong evidence that the new generation of devices for PT are effective in reducing the apnea-hypopnea index during short-term follow-up. These devices are simple-to-use for patients and clinicians and are reversible. Under study conditions with short-term follow-up, compliance is high; however, long-term compliance cannot be assessed because of lack of reliable data. Additional long-term, high-quality studies are needed to confirm the role of PT as a single or as a combination treatment modality for OSA patients and to assess long-term compliance.
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Affiliation(s)
| | - David White
- Department of Sleep Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Raphael Heinzer
- Center for Investigation and Research in Sleep (CIRS), University Hospital of Lausanne, Switzerland
| | - Arie Oksenberg
- Sleep Disorders Unit, Loewenstein Hospital -Rehabilitation Center, Raanana, Israel
| | - Jean-Louis Pépin
- Department of Physiology and Sleep, Albert Michallon Hospital, Grenoble, France
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14
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Abstract
Snoring and suspected sleep apneas are the most frequent causes for referral for a sleep study. Snoring varies across night and is usually recorded in all body postures. Here we report a unique patient showing continuous and loud snoring only in the supine posture.
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Affiliation(s)
- Arie Oksenberg
- Sleep Disorders Unit, Loewenstein Hospital - Rehabilitation Center, POB 3 Raanana, Israel
| | - Natan Gadoth
- Sleep Disorders Unit, Loewenstein Hospital - Rehabilitation Center, POB 3 Raanana, Israel
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15
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Abstract
Obstructive sleep apnoea (OSA) is a common disorder characterized by repetitive episodes of nocturnal breathing cessation due to upper airway collapse. OSA causes severe symptoms, such as excessive daytime somnolence, and is associated with a significant cardiovascular morbidity and mortality. Different treatment options are now available for an effective management of this disease. After more than three decades from its first use, continuous positive airway pressure (CPAP) is still recognized as the gold standard treatment. Nasal CPAP (nCPAP) is highly effective in controlling symptoms, improving quality of life and reducing the clinical sequelae of sleep apnoea. Other positive airway pressure modalities are available for patients intolerant to CPAP or requiring high levels of positive pressure. Mandibular advancement devices, particularly if custom made, are effective in mild to moderate OSA and provide a viable alternative for patients intolerant to CPAP therapy. The role of surgery remains controversial. Uvulopalatopharyngoplasty is a well established procedure and can be considered when treatment with CPAP has failed, whereas maxillar-mandibular surgery can be suggested to patients with a craniofacial malformation. A number of minimally invasive procedures to treat snoring are currently under evaluation. Weight loss improves symptoms and morbidity in all patients with obesity and bariatric surgery is an option in severe obesity. A multidisciplinary approach is necessary for an accurate management of the disease.
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Affiliation(s)
- Lucia Spicuzza
- UO Pneumologia, Azienda Policlinico, Via Santa Sofia 187, 95123 Catania, Italy
| | - Daniela Caruso
- Respiratory Unit, AOU Policlinico, University of Catania, Catania, Italy
| | - Giuseppe Di Maria
- Respiratory Unit, AOU Policlinico, University of Catania, Catania, Italy
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16
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de Vries GE, Hoekema A, Doff MHJ, Kerstjens HAM, Meijer PM, van der Hoeven JH, Wijkstra PJ. Usage of positional therapy in adults with obstructive sleep apnea. J Clin Sleep Med 2015; 11:131-7. [PMID: 25406271 DOI: 10.5664/jcsm.4458] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 10/13/2014] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Many positional therapy (PT) strategies are available for treating positional obstructive sleep apnea (OSA). PT is primarily supplied to selected patients as a secondary treatment option when other therapies have failed. To our knowledge this is the largest study to date to assess effectiveness and long-term compliance of PT (both commercial waistband and self-made constructions, mimicking the tennis ball technique) as primary treatment in patients with different positional OSA severities. METHODS PT was used by 53 patients, of which 40 patients underwent a follow-up polygraphic evaluation under treatment after a median time interval of 12 weeks. Patients were routinely contacted regarding their clinical status and treatment compliance. RESULTS PT was successful in 27 out of 40 patients (68%). Overall AHI reduced significantly from a median (interquartile range [IQR]) AHI of 14.5 (10.7-19.6) to 5.9 (3.1-8.5), p < 0.001. The commercial waistband and self-made constructions were equally effective (median (IQR) reduction in overall AHI (Δ9.6 (5.5-11.9) and Δ6.8 (3.2-11.3) respectively), p = 0.22). Short-term compliance was good as most patients used PT more than 7 hours/night (mean 7.2 ± SD 1.4) and more than 6 days/ week (mean 6.5 ± SD 1.3). However, after mean 13±5 months, 26 patients (65%) reported they no longer used PT, especially patients with moderate positional OSA (89%). CONCLUSIONS On the short-term, PT using the tennis ball technique, is an easy method to treat most patients with positional OSA, showing significant reductions in AHI. Unfortunately, long-term compliance is low and close follow-up of patients on PT with regard to their compliance is necessary.
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Affiliation(s)
- Grietje E de Vries
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, the Netherlands: University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
| | - Aarnoud Hoekema
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, the Netherlands
| | - Michiel H J Doff
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, the Netherlands
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, the Netherlands: University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
| | - Petra M Meijer
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, the Netherlands: University of Groningen, University Medical Center Groningen, Center for Home Mechanical Ventilation, Groningen, the Netherlands
| | - Johannes H van der Hoeven
- University of Groningen, University Medical Center Groningen, Department of Clinical Neurophysiology, Groningen, the Netherlands
| | - Peter J Wijkstra
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Medicine and Tuberculosis, Groningen, the Netherlands: University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands: University of Groningen, University Medical Center Groningen, Center for Home Mechanical Ventilation, Groningen, the Netherlands
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17
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Levendowski DJ, Seagraves S, Popovic D, Westbrook PR. Assessment of a neck-based treatment and monitoring device for positional obstructive sleep apnea. J Clin Sleep Med 2014; 10:863-71. [PMID: 25126032 DOI: 10.5664/jcsm.3956] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [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: 11/13/2022]
Abstract
STUDY OBJECTIVES A majority of patients diagnosed with obstructive sleep apnea are position dependent whereby they are at least twice as severe when sleeping supine (POSA). This study evaluated the accuracy and efficacy of a neck-worn device designed to limit supine sleep. The study included nightly measurements of snoring, sleep/wake, time supine, and the frequency and duration of feedback to monitor compliance. METHODS Thirty patients between ages 18 and 75 years, BMI ≤ 35 with an overall apnea-hypopnea index (AHI) ≥ 5 and an overall AHI ≥ 1.5 times the non-supine AHI, and an Epworth score ≥ 5 were prospectively studied. Subjective reports and polysomnography were used to assess efficacy resulting from 4 weeks of in-home supine-avoidance therapy and to measure device accuracy. From 363 polysomnography reports, 209 provided sufficient positional data to estimate one site's prevalence of positional OSA. RESULTS In 83% of participants exhibiting > 50% reduction in overall AHI, the mean and median reductions were 69% and 79%. Significant reductions in the overall and supine AHI, apnea index, percent time SpO2 < 90%, and snoring contributed to significant improvements in stage N1 and N2 sleep, reductions in cortical arousals and awakenings, and improved depression scores. Supine position was under-detected by > 5% in 3% of cases. Sleep efficiency by neck actigraphy was within 10% of polysomnography in 87% of the studies when position feedback was delivered. The prevalence of POSA was consistently > 70% when the overall AHI was < 60. CONCLUSIONS The neck position therapy device is accurate and effective in restricting supine sleep, improving AHI, sleep architecture and continuity, and monitoring treatment outcomes.
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18
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Jung S, Zaremba S, Heisig A, Eikermann M. Elevated body position early after delivery increased airway size during wakefulness, and decreased apnea hypopnea index in a woman with pregnancy related sleep apnea. J Clin Sleep Med 2014; 10:815-7. [PMID: 25024663 DOI: 10.5664/jcsm.3886] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 11/13/2022]
Abstract
We report a patient with pregnancy related obstructive sleep apnea ([OSA]; apnea hypopnea index [AHI] 18/h) early after delivery, with improvement of AHI by 87% following 45-degree elevation in body position compared with the non-elevated position. Improvement associated with this position may be explained, at least in part, by an increased upper airway diameter (as measured during wakefulness). Sleep apnea in this patient resolved at 9 months postpartum. This observation suggests that 45-degree elevated body position may be an effective treatment of pregnancy related OSA during the postpartum period.
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Affiliation(s)
- Stefanie Jung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA ; Department of Pediatric Surgery and Pediatric Urology, DRK- Kinderklinik Siegen, Teaching Hospital of Philipps University, Marburg, Germany
| | - Sebastian Zaremba
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA ; Sleep Medicine, Department of Neurology, University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Anne Heisig
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA ; Department of Anesthesia and Critical Care, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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19
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van Maanen JP, de Vries N. Long-term effectiveness and compliance of positional therapy with the sleep position trainer in the treatment of positional obstructive sleep apnea syndrome. Sleep 2014; 37:1209-15. [PMID: 25061249 DOI: 10.5665/sleep.3840] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [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: 12/22/2022] Open
Abstract
STUDY OBJECTIVES To investigate effectiveness, long-term compliance, and effects on subjective sleep of the Sleep Position Trainer (SPT) in patients with position-dependent obstructive sleep apnea syndrome (POSAS). DESIGN Prospective, multicenter cohort study. PATIENTS OR PARTICIPANTS Adult patients with mild and moderate POSAS were included. INTERVENTIONS Patients were [corrected] asked to use the SPT for 6 mo. At baseline and after 1, 3, and 6 mo, questionnaires would be completed: Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), and questions related to SPT use. MEASUREMENTS AND RESULTS One hundred forty-five patients were included. SPT use and SPT data could not be retrieved in 39 patients. In the remaining 106 patients, median percentage of supine sleep decreased rapidly during SPT's training phase (day 3 to 9) to near-total avoidance of supine sleep. This decrease was maintained during the following months of treatment (21% at baseline versus 3% at 6 mo). SPT compliance, defined as more than 4 h of nightly use, was 64.4%. Regular use, defined as more than 4 h of usage over 5 nights/w, was 71.2%. Subjective compliance and regular use were 59.8% and 74.4%, respectively. Median ESS (11 to 8), PSQI (8 to 6), and FOSQ (87 to 103) values significantly improved compared with baseline. CONCLUSIONS Positional therapy using the Sleep Position Trainer (SPT) effectively diminished the percentage of supine sleep and subjective sleepiness and improved sleep related quality of life in patients with mild to moderate position-dependent obstructive sleep apnea syndrome. SPT treatment appeared to have sustained effects over 6 months. SPT compliance and regular use rate were relatively good. Subjective and objective compliance data corresponded well. The lack of a placebo-controlled group limited the efficacy of conclusions. CITATION van Maamen JP, de Vries N. Long-term effectiveness and compliance of positional therapy with the Sleep Position Trainer in the treatment of positional obstructive sleep apnea syndrome.
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Affiliation(s)
- J Peter van Maanen
- Department of Otolaryngology/Head Neck Surgery, Sint Lucas Andreas Hospital, Amsterdam, the Netherlands
| | - Nico de Vries
- Department of Otolaryngology/Head Neck Surgery, Sint Lucas Andreas Hospital, Amsterdam, the Netherlands
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20
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Oksenberg A, Gadoth N. Are we missing a simple treatment for most adult sleep apnea patients? The avoidance of the supine sleep position. J Sleep Res 2013; 23:204-10. [PMID: 24118690 DOI: 10.1111/jsr.12097] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 07/31/2013] [Indexed: 11/30/2022]
Abstract
Obstructive sleep apnea (OSA) is a sleep disorder which has been gradually accepted as an important cause of increased morbidity and mortality. The treatment of moderate-severe OSA has improved dramatically since the introduction of continuous positive airway pressure (CPAP) devices; however, the adherence of patients to CPAP treatment is relatively low. Adherence appears to be even worse in patients with mild or asymptomatic OSA. The failure to identify and treat mildly symptomatic or asymptomatic OSA patients may be costly, as such patients comprise about 20% of the general adult population. OSA patients could be divided into positional and non-positional patients. Positional patients show most of their breathing abnormalities while sleeping in the supine position. Simply, by sleeping in the lateral postures, they eliminate or reduce significantly the number of apneas and hypopneas. On the contrary, non-positional patients suffer from breathing abnormalities in the supine and lateral postures, and as a consequence those are the most severe OSA patients for whom CPAP is the treatment of choice. In this paper we intend to argue that positional therapy, i.e., avoidance of the supine posture during sleep, could represent a valuable therapy mainly for mild-moderate OSA. Considering the fact that the vast majority of mild-moderate OSA patients are positional patients (between 65 and 87%), positional therapy may be a simple, cheap and effective solution for them. High-quality research regarding this issue is needed to evaluate the real effectiveness of this mode of therapy.
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Affiliation(s)
- Arie Oksenberg
- Sleep Disorders Unit, Loewenstein Hospital, Rehabilitation Center, Raanana, Israel
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Abstract
Although continuous positive airway pressure, oral appliances and surgical modifications of the airway are considered as part of the routine management of patients with obstructive sleep apnea, many new and unconventional therapies exist. Many of the trials using these new alternatives have been limited by insufficient data, poor trial design, small sample size, unclear inclusion criteria, lack of randomization, and lack of blinding, and on occasion are biased by retrospective design. Bariatric surgery, positional therapy, auto-titrating positive airway pressure, serotonin agents, wake promoting agents, genioglossus stimulation surgery, supplemental oxygen, nasal dilators, nasal expiratory resistor devices and oropharyngeal exercises will be reviewed. As obstructive sleep apnea impacts the individual and society at large, further research is needed to explore new therapeutic treatment options for obstructive sleep apnea. Therapeutic trials for obstructive sleep apnea must be of rigorous design to prove clinical effectiveness while taking into account both patient satisfaction and cost effectiveness.
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Affiliation(s)
- Jose Angelo A. De Dios
- Department of Pulmonary, Critical Care & Sleep Medicine, UC Davis Medical Center, Sacramento, CA USA
- The Medical Group, Carolina Pines Regional Medical Center, 701 Medical Park Drive, Suite 303, Hartsville, SC 29550 USA
| | - Steven D. Brass
- Department of Neurology, UC Davis Health System, 4860 Y Street — Suite 3700, Sacramento, CA 95817 USA
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Bignold JJ, Mercer JD, Antic NA, McEvoy RD, Catcheside PG. Accurate position monitoring and improved supine-dependent obstructive sleep apnea with a new position recording and supine avoidance device. J Clin Sleep Med 2012; 7:376-83. [PMID: 21897774 DOI: 10.5664/jcsm.1194] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [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: 11/13/2022]
Abstract
STUDY OBJECTIVES Approximately 30% of obstructive sleep apnea (OSA) patients have supine-predominant OSA, and simply avoiding supine sleep should normalise respiratory disturbance event rates. However, traditional supine-avoidance therapies are inherently uncomfortable, and treatment adherence is poor and difficult to monitor objectively. This study evaluated the efficacy of a novel, potentially more acceptable position monitor and supine-avoidance device for managing supine-predominant OSA and snoring. DESIGN AND SETTING In-laboratory evaluation of position recording accuracy versus video recordings (validation study), and randomized controlled crossover trial of active versus inactive supine-avoidance therapy in the home setting (efficacy study). PATIENTS 17 patients undergoing in-laboratory sleep studies (validation) and 15 patients with supine-predominant OSA (efficacy). INTERVENTIONS EFFICACY STUDY: 1 week of inactive and 1 week of active treatment in randomized order, separated by 1 week. MEASUREMENTS AND RESULTS Agreement between 30-sec epoch-based posture classifications from device versus video records was high (median κ 0.95, interquartile range: 0.88-1.00), and there was good supine time agreement (bias 0.3%, 95%CI: -4.0% to 4.6%). In the efficacy study, apnea-hypopnea index (AHI) and snoring frequency were measured in-home using a nasal pressure and microphone based system during inactive and active treatment weeks. The position monitoring and supine alarm device markedly inhibited supine time (mean ± SEM 19.3% ± 4.3% to 0.4% ± 0.3%, p < 0.001) and reduced AHI (25.0 ± 1.7 to 13.7 ± 1.1 events/h, p = 0.030) but not snoring frequency. CONCLUSIONS This new position monitoring and supine alarm device records sleep position accurately and improves OSA but not snoring in patients with supine-predominant OSA.
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Affiliation(s)
- James J Bignold
- Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, Adelaide, South Australia
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Permut I, Diaz-Abad M, Chatila W, Crocetti J, Gaughan JP, D'Alonzo GE, Krachman SL. Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. J Clin Sleep Med 2010; 6:238-243. [PMID: 20572416 PMCID: PMC2883034] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
STUDY OBJECTIVES We hypothesized that positional therapy would be equivalent to continuous positive airway pressure (CPAP) at normalizing the apnea-hypopnea index (AHI) in patients with positional obstructive sleep apnea (OSA). METHODS Thirty-eight patients (25 men, 49 +/- 12 years of age, body mass index 31 +/- 5 kg/m2) with positional OSA (nonsupine AHI <5 events/h) identified on a baseline polysomnogram were studied. Patients were randomly assigned to a night with a positional device (PD) and a night on CPAP (10 +/- 3 cm H2O). RESULTS Positional therapy was equivalent to CPAP at normalizing the AHI to less than 5 events per hour (92% and 97%, respectively [p = 0.16]). The AHI decreased from a median of 11 events per hour (interquartile range 9-15, range 6-26) to 2 (1-4, 0-8) and 0 events per hour (0-2, 0-7) with the PD and CPAP, respectively; the difference between treatments was significant (p < 0.001). The percentage of total sleep time in the supine position decreased from 40% (23%-67%, 7%-82%) to 0% (0%-0%, 0%-27%) with the PD (p < 0.001) but was unchanged with CPAP (51% [36%-69%, 0%-100%]). The lowest SaO2 increased with the PD and CPAP therapy, from 85% (83%-89%, 76%-93%) to 89% (86%-9%1, 78%-95%) and 89% (87%-91%, 81%-95%), respectively (p < 0.001). The total sleep time was unchanged with the PD, but decreased with CPAP, from 338 (303-374, 159-449) minutes to 334 (287-366, 194-397) and 319 (266-343, 170-386) minutes, respectively (p = 0.02). Sleep efficiency, spontaneous arousal index, and sleep architecture were unchanged with both therapies. CONCLUSION Positional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA, with similar effects on sleep quality and nocturnal oxygenation.
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Affiliation(s)
- Irene Permut
- Temple University School of Medicine, Philadelphia, PA
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Bignold JJ, Deans-Costi G, Goldsworthy MR, Robertson CA, McEvoy D, Catcheside PG, Mercer JD. Poor long-term patient compliance with the tennis ball technique for treating positional obstructive sleep apnea. J Clin Sleep Med 2009; 5:428-430. [PMID: 19961026 PMCID: PMC2762713] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
STUDY OBJECTIVES Little is known regarding long-term patient compliance with the tennis ball technique (TBT), one of the original simple methods of positional therapy (i.e., avoiding the supine posture during sleep) for posture-dependent obstructive sleep apnea patients. The purpose of this study was to investigate long-term patient compliance with TBT. METHODS A follow-up questionnaire was mailed to all patients prescribed TBT at the Adelaide Institute for Sleep Health between July 2004 and March 2008 (n = 108). RESULTS Sixty-seven patients replied to the questionnaire. Baseline demographic/clinical characteristics were not significantly different from non-respondents. Among the respondents, follow-up time was (mean +/- SD) 2.5 +/- 1.0 years. Four (6.0%) reported they were still using TBT (group A); 9 (13.4%) were no longer using TBT, claiming to have learned to avoid the supine position during sleep (group B); and 54 (80.6%) were neither using TBT nor avoiding the supine posture (group C). The main reason for ceasing TBT use in group C was that TBT was too uncomfortable (34/54 patients). CONCLUSIONS Long-term patient compliance with TBT appears to be very poor, with less than 10% of patients reporting continued use (group A) approximately 30 months after prescription. With most TBT non-compliers reporting it to be too uncomfortable, alternative forms of positional therapy appear to be needed.
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Affiliation(s)
- James J Bignold
- Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, Adelaide, Australia.
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Goettler CE, Pryor JP, Hoey BA, Phillips JK, Balas MC, Shapiro MB. Prone positioning does not affect cannula function during extracorporeal membrane oxygenation or continuous renal replacement therapy. Crit Care 2002; 6:452-5. [PMID: 12398787 PMCID: PMC130148 DOI: 10.1186/cc1814] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2002] [Accepted: 08/05/2002] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Prone positioning in respiratory failure has been shown to be a useful adjunct in the treatment of severe hypoxia. However, the prone position can result in dislodgment or malfunction of tubes and cannulae. Certain patients receiving extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) may also benefit from positional therapy. The impact of cannula-related complications in these patients is potentially disastrous. The safety and efficacy of prone positioning of these patients has not been previously reported. MATERIALS AND METHODS A retrospective chart review evaluated ECMO or CRRT cannula location, and displacement or malfunction during positional change or while prone. The study was set in a General Surgery and Trauma Intensive Care Unit. The subjects were all patients at our institution who simultaneously underwent ECMO or CRRT and prone positioning from July 1996 to July 2001. There were no interventions. RESULTS Ten patients underwent ECMO and 42 patients underwent CRRT during the study period. Seven patients underwent simultaneous prone positioning and either ECMO (4/10) or CRRT (4/42). A total of 68 turning events (prone to supine or supine to prone) were recorded, with each patient averaging 9.7 (range, 4-16) turning episodes. Turning was performed with sheets and extra nursing personnel; no special mechanical assist devices were used. No patients experienced inadvertent cannula removal during turning. Two patients had poor flow through their cannulae. In one patient, this occurred in the supine position and required repositioning of the cannula. In the second patient, cannulae were changed twice and flow was poor in both the supine and the prone positions. All ECMO and CRRT patients received venous cannulae. Cannula location (seven internal jugular and 11 femoral) did not the affect risk of malfunction. DISCUSSION AND CONCLUSIONS Patients with venous cannulae for ECMO or CRRT can be safely placed in the prone position. Flow rates are maintained in this position. Potential cannula complications of ECMO and CRRT are not a contraindication to prone positioning in severely ill patients.
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Affiliation(s)
- Claudia E Goettler
- Assistant Professor of Surgery, Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - John P Pryor
- Assistant Professor of Surgery, Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brian A Hoey
- Assistant Professor of Surgery, Division of Traumatology and Surgical Critical Care, Department of Surgery, St Luke's Hospital, Bethlehem, Pennsylvania, USA
| | - JoAnne K Phillips
- Clinical Nurse Specialist, Critical Care, Surgical Critical Care Nursing, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle C Balas
- Senior Critical Care Nurse, Surgical Critical Care Nursing, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael B Shapiro
- Associate Professor of Surgery, Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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