1
|
Bender BG, Crooks J, Gerald JK, Hudson B, King DK, Kobernick A, Liu AH, Lowe AA, Morgan W, Nez P, Phan H, Wightman P, Gerald LB. Childhood asthma exacerbations on the Navajo Nation. J Allergy Clin Immunol Pract 2024:S2213-2198(24)00429-X. [PMID: 38697473 DOI: 10.1016/j.jaip.2024.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 04/09/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024]
|
2
|
Wilson AM, Ravi P, Pargas NT, Gerald LB, Lowe AA. School health systems under strain: an example of COVID-19 experiences & burnout among school health staff in Pima County, Arizona. BMC Public Health 2023; 23:1626. [PMID: 37626343 PMCID: PMC10463464 DOI: 10.1186/s12889-023-16532-8] [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: 02/14/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND School health staff lead and provide a variety of care for children in schools. As school districts have navigated the COVID-19 pandemic, school health staff have faced unprecedented challenges in protecting the health of students and school staff. Our objective was to qualitatively characterize these pandemic challenges and experiences of school health staff in Pima County, Arizona to identify gaps in school health staff support for improving future emergency preparedness. METHODS We conducted two focus group discussions (FGDs) with 48 school health staff in Pima County, Arizona in two school districts using a discussion guide including ten open-ended questions. The FGDs were audio recorded and transcribed verbatim. We used the socioecological model (SEM) to organize the thematic analysis and generate codes and themes; data were analyzed using Atlas.ti software. FINDINGS The pandemic has significantly challenged school health staff with new pandemic-related job tasks: managing isolation, vaccination, and developing/implementing new and evolving COVID-19 guidelines. School health staff also reported increased stress related to interactions with parents and school administration as well as frustrations with rapid changes to guidance from the health department and policy makers. A common issue was not having enough staff or resources to complete regular job responsibilities, such as providing care for students with non-COVID-19 related health issues. CONCLUSIONS Increased workload for school health staff resulted in physical burnout, mental distress, and disruption of core functions with long term implications for children's health. These focus groups highlight the need for improved emergency preparedness in schools during pandemics or infectious disease outbreaks. These include basic infrastructure changes (e.g., personnel support from health departments for tasks such as contact tracing to enable school nurses to continue core functions), and increased funding to allow for hazard pay and more school health personnel during emergency situations. In addition, basic school health infrastructure is lacking, and we should include a licensed school health nurse in every school.
Collapse
Affiliation(s)
- Amanda M Wilson
- Department of Community, Environment & Policy, Mel & Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave. A233, Tucson, AZ, 85721, USA.
| | - Priyanka Ravi
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Nicole T Pargas
- Health Services Department, Marana Unified School District, Marana, AZ, USA
| | - Lynn B Gerald
- Office of Population Health Sciences in the Office of the Vice Chancellor for Health Affairs, University of Illinois Chicago, Chicago, IL, USA
| | - Ashley A Lowe
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
- Asthma & Airway Disease Research Center, University of Arizona Health Sciences, Tucson, AZ, USA
| |
Collapse
|
3
|
Broas E, Lowe AA, Ivich K, Garcia M, Ward J, Hollister J, Gerald LB. The Implementation and Evaluation of a Stock Epinephrine for Schools Program in Maricopa County, Arizona. J Sch Nurs 2023:10598405231172957. [PMID: 37157790 DOI: 10.1177/10598405231172957] [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] [Indexed: 05/10/2023] Open
Abstract
The increasing rate of food allergies in children, combined with the role of food as an integral part of the school day has led to the emergence of anaphylaxis as a daily threat to students, regardless of prior allergy diagnosis. Stock epinephrine-non-patient specific epinephrine auto-injectors that may be used during emergencies-is a means for schools to prepare for anaphylactic events and protect children with allergies. The Maricopa County Department of Public Health initiated the School Surveillance and Medication Program (SSMP), a data capture program, to facilitate the process of stocking epinephrine in schools. Spearheaded by the implementation efforts of the Kyah Rayne Foundation, program enrollment increased 146% between the 2020-2021 and 2021-2022 school years. The increased proportion of schools enrolled in the SSMP and the number of school personnel trained to administer epinephrine demonstrates the feasibility of school-centered stock epinephrine programs and validates strategies for increasing program uptake.
Collapse
Affiliation(s)
- Erin Broas
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ashley A Lowe
- Asthma & Airway Disease Research Center, University of Arizona Health Sciences, University of Arizona, Tucson, AZ, USA
| | - Kimberly Ivich
- Maricopa County Department of Public Health, Phoenix, AZ, USA
| | - Melissa Garcia
- Maricopa County Department of Public Health, Phoenix, AZ, USA
| | - Jackie Ward
- Maricopa County Department of Public Health, Phoenix, AZ, USA
| | - James Hollister
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Lynn B Gerald
- Asthma & Airway Disease Research Center, University of Arizona Health Sciences, University of Arizona, Tucson, AZ, USA
- Office of the Vice Chancellor for Health Affairs, University of Illinois Chicago, Chicago, IL, USA
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW School-based asthma management is an important component of pediatric asthma care that has the potential to provide more universal evidence-based asthma care to children and mitigate asthma-related health inequities. The purpose of this review is to highlight relevant developments in school-based asthma management over the past 2 years. RECENT FINDINGS There have been considerable recent scientific advances in school-based asthma management including robust clinical trials of environmental interventions in the classroom setting, school-nurse led interventions, stock albuterol policy changes, school-based telemedicine approaches and innovative methods to engage community stakeholders in research that have pushed the frontiers of school-based asthma care. SUMMARY Recent scientific work in school-based asthma management demonstrates the potential power of schools in providing access to guideline-based asthma care for all children with asthma and in improving their health outcomes. Future work should focus on the evaluation of methods to promote the adoption of school-based asthma management strategies in real-world practice and support evidence-based policy change and strategic partnerships to improve asthma health outcomes and produce meaningful public health impact for diverse children and families.
Collapse
Affiliation(s)
- Ashley A. Lowe
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
- Asthma & Airway Disease Research Center, University of Arizona Health Sciences, University of Arizona, Tucson, Arizona, USA
| | - Ina St Onge
- Department of Pediatrics, Division of Pulmonary Medicine, University of Massachusetts Chan Medical School, UMass Memorial Children’s Medical Center, Worcester, MA, USA
| | - Michelle Trivedi
- Department of Pediatrics, Division of Pulmonary Medicine, University of Massachusetts Chan Medical School, UMass Memorial Children’s Medical Center, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical Center, Worcester, MA, USA
- Child Health Equity Center, Department of Pediatrics, UMass Chan Medical School, UMass Memorial Children’s Medical Center, Worcester, MA, USA
| |
Collapse
|
5
|
Ellingson KD, Hollister J, Porter CJ, Khan SM, Feldstein LR, Naleway AL, Gaglani M, Caban-Martinez AJ, Tyner HL, Lowe AA, Olsho LEW, Meece J, Yoon SK, Mak J, Kuntz JL, Solle NS, Respet K, Baccam Z, Wesley MG, Thiese MS, Yoo YM, Odean MJ, Miiro FN, Pickett SL, Phillips AL, Grant L, Romine JK, Herring MK, Hegmann KT, Lamberte JM, Sokol B, Jovel KS, Thompson MG, Rivers P, Pilishvili T, Lutrick K, Burgess JL, Midgley CM, Fowlkes AL. Risk Factors for Reinfection with SARS-CoV-2 Omicron Variant among Previously Infected Frontline Workers. Emerg Infect Dis 2023; 29:599-604. [PMID: 36703252 PMCID: PMC9973698 DOI: 10.3201/eid2903.221314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
In a cohort of essential workers in the United States previously infected with SARS-CoV-2, risk factors for reinfection included being unvaccinated, infrequent mask use, time since first infection, and being non-Hispanic Black. Protecting workers from reinfection requires a multipronged approach including up-to-date vaccination, mask use as recommended, and reduction in underlying health disparities.
Collapse
|
6
|
Gerald LB, Simmons B, Lowe AA, Liu AH, Nez P, Begay E, Bender B. COVID-19 on the Navajo Nation: experiences of Diné families of children with asthma. J Asthma 2023; 60:565-573. [PMID: 35549973 DOI: 10.1080/02770903.2022.2073550] [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] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The first case of COVID-19 on the Navajo Nation (NN) was found on March 17, 2020. Even with strong public health efforts, NN saw the highest per capita infection rate in the US during May of 2020 with 2450/100,000. To determine the impact of COVID-19 on families of children with asthma on the NN, families participating in the NHLBI funded Community Asthma Program were contacted to see if they would share their experiences. METHODS Sixty-six of 193 families (34%) were interviewed.Results: The average age of the child with asthma was 13.5 (SD = 3.9) and 33% were female. Most Diné children with asthma in our study did not contract COVID-19. However, the pandemic had a significant impact on them and their families. Many family members contracted COVID-19, some children lost family members, and half of interviewed parents reported a decline in their child's mental health. Twenty-five percent of families sought the help of a traditional healer. Many accessed medical care through telehealth and most were able to obtain asthma medications when needed.Conclusions: Despite significant challenges, our research indicated resilience among Navajo families.
Collapse
Affiliation(s)
- Lynn B Gerald
- Health Promotion Sciences, Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Bryan Simmons
- Center for Health Promotion, National Jewish Health, Denver, CO
| | - Ashley A Lowe
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Andrew H Liu
- Breathing Institute, Section of Pediatric Pulmonary & Sleep Medicine, Children's Hospital Colorado, National Jewish Health, University of Colorado School of Medicine,Denver, CO
| | - Peter Nez
- National Jewish Health, Denver, CO, USA
| | - Elvira Begay
- Asthma and Airway Disease Research Center, University of Arizona, AZ, USA
| | - Bruce Bender
- Department of Pediatrics, National Jewish Health, Denver, CO, USA
| |
Collapse
|
7
|
Herring MK, Romine JK, Wesley MG, Ellingson KD, Yoon SK, Caban-Martinez AJ, Meece J, Gaglani M, Grant L, Olsho LEW, Tyner HL, Naleway AL, Khan SM, Phillips AL, Schaefer Solle N, Rose S, Mak J, Fuller SB, Hunt A, Kuntz JL, Beitel S, Yoo YM, Zheng PQ, Arani G, Mayo Lamberte J, Edwards T, Thompson MG, Sprissler R, Thornburg NJ, Lowe AA, Pilishvili T, Uhrlaub JL, Lutrick K, Burgess JL, Fowlkes AL. SARS-CoV-2 infection history and antibody response to three COVID-19 mRNA vaccine doses. Clin Infect Dis 2022; 76:1822-1831. [PMID: 36578137 DOI: 10.1093/cid/ciac976] [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: 10/08/2022] [Revised: 12/07/2022] [Accepted: 12/23/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Three doses of coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccines produce robust antibody responses, but data are limited among individuals previously infected with SARS-CoV-2. From a cohort of health care personnel (75.5%), first responders (4.6%), and other frontline workers (19.8%) in 6 US states, we longitudinally assessed antibody waning after dose-2, and response to dose-3, according to SARS-CoV-2 infection history. METHODS Participants submitted sera every three months, after SARS-CoV-2 infection, and after each COVID-19 vaccine dose. Sera were tested for antibodies and reported quantitatively as area under the serial dilution curve (AUC). Changes in the AUC values over time were compared as fold-changes using a linear mixed model. RESULTS Analysis included 388 participants who received dose-3 by November 2021. Three comparison groups: (1) vaccine only with no known prior SARS-CoV-2 infection (n = 224); (2) infection prior to dose-1 (n = 123); and (3) infection after dose 2 and before dose-3 (n = 41). The interval from dose 2 and dose 3 was approximately 8-months. After dose-3, antibody levels rose 2.5-fold (95%CI = 2.2-3.0) in group 2, and 2.9-fold (95%CI = 2.6-3.3) in group 1. Those infected within 90 days before dose-3 (and median 233 days (IQR = 213-246) after dose-2) did not increase significantly after dose-3. CONCLUSIONS A third dose of mRNA vaccine typically elicited a robust humoral immune response among those with primary vaccination regardless of SARS-CoV-2 infection >3 months prior to boosting. Those with infection < 3 months prior to boosting did not have a significant increase in antibody concentrations in response to a booster.
Collapse
Affiliation(s)
| | - James K Romine
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | | | - Katherine D Ellingson
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Sarang K Yoon
- University of Utah Health, Rocky Mountain Center for Occupational and Environmental Health, Salt Lake City, Utah
| | | | | | - Manjusha Gaglani
- Baylor Scott and White Health, Temple, Texas.,Texas A&M University College of Medicine, Temple, Texas
| | - Lauren Grant
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | | | - Allison L Naleway
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Sana M Khan
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Andrew L Phillips
- University of Utah Health, Rocky Mountain Center for Occupational and Environmental Health, Salt Lake City, Utah
| | | | | | - Josephine Mak
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | - Angela Hunt
- St. Luke's Regional Health Care System, Duluth, Minnesota
| | - Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Shawn Beitel
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Young M Yoo
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | - Gayatri Arani
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Julie Mayo Lamberte
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Taylor Edwards
- University of Arizona Genetics Core, Office for Research, Innovation and Impact, University of Arizona, Tucson, ArizonaUSA
| | - Mark G Thompson
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Ryan Sprissler
- University of Arizona Genetics Core, Office for Research, Innovation and Impact, University of Arizona, Tucson, ArizonaUSA
| | - Natalie J Thornburg
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Ashley A Lowe
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Tamara Pilishvili
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Jennifer L Uhrlaub
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Karen Lutrick
- College of Medicine - Tucson, University of Arizona, Tucson, Arizona
| | - Jefferey L Burgess
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Ashley L Fowlkes
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| |
Collapse
|
8
|
Lowe AA, Gerald JK, Clemens C, Gerald LB. Compliance to a Standardized Protocol for Stock Albuterol Medication among School Staff. J Sch Nurs 2022:10598405221128053. [PMID: 36215303 DOI: 10.1177/10598405221128053] [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] [Indexed: 11/15/2022] Open
Abstract
A stock inhaler program provided access to rescue medication (albuterol sulfate) for school children. School staff were provided with a standardized protocol for medication administration. We hypothesized licensed nurses were more likely to report compliant events compared to unlicensed school staff. Stock inhaler events were defined as either compliant or non-compliant. A school protocol compliance score was calculated using the total number of compliant events divided by the total number of all events. The protocol for administration indicated 4 puffs for mild respiratory distress and 8 puffs for severe respiratory distress; therefore, events were defined as compliant if the dose of medication was divisible by 4. A Cragg Poisson hurdle regression was used to examine the association between compliance score and school staff experience. One-hundred fifty-two schools reported 999 stock inhaler events. Of these events, 28% were compliant and 72% of events were non-compliant. After controlling for school organizational type, grades served, and school size, school staff experience was not predictive of protocol compliance. Future efforts should focus on improving protocol compliance among licensed nurses and unlicensed school staff.
Collapse
Affiliation(s)
- Ashley A Lowe
- Asthma & Airway Disease Research Center, 8041University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joe K Gerald
- Mel and Enid Zuckerman College of Public Health, Department of Community, Environment & Policy, 8041University of Arizona, Tucson, AZ, USA
| | - Conrad Clemens
- College of Medicine - Tucson Campus, Department of Pediatrics, 8041University of Arizona, Tucson, AZ, USA
| | - Lynn B Gerald
- Asthma & Airway Disease Research Center, 8041University of Arizona Health Sciences, Tucson, AZ, USA
| |
Collapse
|
9
|
Lowe AA, Ravi P, Gerald LB, Wilson AM. The Changing Job of School Nurses during the COVID-19 Pandemic: A Media Content Analysis of Contributions to Stress. Ann Work Expo Health 2022; 67:101-117. [PMID: 36111528 PMCID: PMC9494455 DOI: 10.1093/annweh/wxac053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/09/2022] [Accepted: 07/22/2022] [Indexed: 01/14/2023] Open
Abstract
School nurses and unlicensed assistive personnel (UAPs) are essential to the health and wellness of school children. However, most US schools do not have a full-time licensed nurse. During the COVID-19 pandemic, school nurses and UAPs have been integral in ensuring that the health needs of students were met. They have seen a marked increase in their responsibilities included implementing COVID-19 mitigation strategies, screening for symptoms, testing students and staff, conducting contact tracing and data collection, and ensuring the implementation of rapidly changing COVID-19 guidelines and protocols for schools. The objective of this study was to explore COVID-19 occupational changes and their contributions to stress among school nurses and UAPs through a content analysis of local and national media articles. A Google search of articles published between February 2020 and September 2021 was conducted using the following search terms: 'school nurse', 'COVID-19', 'health aide', 'stress', and 'experiences'. A search was also conducted in Nexis Uni. Articles were included if the topic discussed school nurses or UAPs and COVID-19. All articles that examined nurses in other settings were excluded from the review. We examined topics and themes temporally (from February 2020 to September 2021) and spatially (i.e. the frequency by US state). Overall, 496 media articles discussing school nurses and COVID-19 were included in our review. The highest volume of articles was from September 2021 (22%, 111/496). Other months with relatively high volume of articles included August 2020 (9%, 43/496), January 2021 (10%, 47/496), February 2021 (9%, 44/496), and August 2021 (8%, 39/496). These larger article volumes coincided with notable COVID-19 events, including returning to school in the fall (August 2020 and August 2021), school nurses assisting with vaccine rollouts among adults in the USA (January/February 2021), concerns regarding the delta variant (August/September 2021), and vaccine rollouts for children ages 12-15 (September 2021). The representation of articles spatially (national, state, regional, or local) was 66 (13%) articles at national level, 217 (44%) state level, 25 (5%) regional level, and 188 (38%) local news at the city and/or village level. Pennsylvania had the highest frequency of articles, but when standardized to the state population, Alaska had the highest rate of media per 100 000 people. Three major themes were identified in our analysis: (i) safety; (ii) pandemic-related fatigue/stress; and (iii) nursing shortage/budget. The most represented theme for articles before September 2021 was that of safety. Over time, the themes of pandemic-related fatigue/stress and nursing shortage/budget increased with the most notable increase being in September 2021. The COVID-19 pandemic has resulted in new occupational risks, burdens, and stressors experienced by school nurses and UAPs. School nurses play a critical role in disease surveillance, disaster preparedness, wellness and chronic disease prevention interventions, immunizations, mental health screening, and chronic disease education. Furthermore, they provide a safety net for our most vulnerable children. Given that school nurses were already over-burdened and under-resourced prior to the pandemic, characterization of these new burdens and stressors will inform emergency preparedness resources for school health personnel during future pandemics or outbreaks.
Collapse
Affiliation(s)
- Ashley A Lowe
- Author to whom correspondence should be addressed. Tel: +1-520-626-8814; e-mail:
| | - Priyanka Ravi
- Asthma & Airway Disease Research Center, University of Arizona Health Sciences, 1501 N. Campbell Avenue, P.O. Box 245030, Tucson, AZ 85724, USA,Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave. Tucson, AZ 85724, USA
| | - Lynn B Gerald
- Asthma & Airway Disease Research Center, University of Arizona Health Sciences, 1501 N. Campbell Avenue, P.O. Box 245030, Tucson, AZ 85724, USA,Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave. Tucson, AZ 85724, USA
| | - Amanda M Wilson
- Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave. Tucson, AZ 85724, USA
| |
Collapse
|
10
|
Lutrick K, Fowlkes A, Rivers P, Herder K, Santibanez TA, LeClair L, Groover K, Lamberte JM, Grant L, Odame-Bamfo L, Ferraris MV, Phillips AL, Sokol B, Lowe AA, Mathenge C, Pubillones FA, Cottam B, McLeland-Wieser H, Jovel KS, Ochoa JS, Mckell J, Berry M, Khan S, Solle NS, Rai RP, Nakayima FM, Newes-Adeyi G, Porter C, Baccam Z, Ellingson KD, Burgess JL, Gaglani M, Gwynn L, Caban-Martinez A, Yoon S. Parental Intentions and Perceptions Toward COVID-19 Vaccination Among Children Aged 4 Months to 4 Years — PROTECT Cohort, Four States, July 2021–May 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1109-1114. [PMID: 36048723 PMCID: PMC9472774 DOI: 10.15585/mmwr.mm7135a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
|
11
|
Burns J, Rivers P, LeClair LB, Jovel KS, Rai RP, Lowe AA, Edwards LJ, Khan SM, Mathenge C, Ferraris M, Kuntz JL, Lamberte JM, Hegmann KT, Odean MJ, McLeland-Wieser H, Beitel S, Odame-Bamfo L, Schaefer Solle N, Mak J, Phillips AL, Sokol BE, Hollister J, Ochoa JS, Grant L, Thiese MS, Jacoby KB, Lutrick K, Pubillones FA, Yoo YM, Rentz Hunt D, Ellingson K, Berry MC, Gerald JK, Lopez J, Gerald LB, Wesley MG, Krupp K, Herring MK, Madhivanan P, Caban-Martinez AJ, Tyner HL, Meece JK, Yoon SK, Fowlkes AL, Naleway AL, Gwynn L, Burgess JL, Thompson MG, Olsho LE, Gaglani M. Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT): Protocol for a Multisite Longitudinal Cohort Study. JMIR Res Protoc 2022; 11:e37929. [PMID: 35635842 PMCID: PMC9377426 DOI: 10.2196/37929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Assessing the real-world effectiveness of COVID-19 vaccines and understanding the incidence and severity of SARS-CoV-2 illness in children are essential to inform policy and guide health care professionals in advising parents and caregivers of children who test positive for SARS-CoV-2. OBJECTIVE This report describes the objectives and methods for conducting the Pediatric Research Observing Trends and Exposures in COVID-19 Timelines (PROTECT) study. PROTECT is a longitudinal prospective pediatric cohort study designed to estimate SARS-CoV-2 incidence and COVID-19 vaccine effectiveness (VE) against infection among children aged 6 months to 17 years, as well as differences in SARS-CoV-2 infection and vaccine response between children and adolescents. METHODS The PROTECT multisite network was initiated in July 2021, which aims to enroll approximately 2305 children across four US locations and collect data over a 2-year surveillance period. The enrollment target was based on prospective power calculations and accounts for expected attrition and nonresponse. Study sites recruit parents and legal guardians of age-eligible children participating in the existing Arizona Healthcare, Emergency Response, and Other Essential Workers Surveillance (HEROES)-Research on the Epidemiology of SARS-CoV-2 in Essential Response Personnel (RECOVER) network as well as from surrounding communities. Child demographics, medical history, COVID-19 exposure, vaccination history, and parents/legal guardians' knowledge and attitudes about COVID-19 are collected at baseline and throughout the study. Mid-turbinate nasal specimens are self-collected or collected by parents/legal guardians weekly, regardless of symptoms, for SARS-CoV-2 and influenza testing via reverse transcription-polymerase chain reaction (RT-PCR) assay, and the presence of COVID-like illness (CLI) is reported. Children who test positive for SARS-CoV-2 or influenza, or report CLI are monitored weekly by online surveys to report exposure and medical utilization until no longer ill. Children, with permission of their parents/legal guardians, may elect to contribute blood at enrollment, following SARS-CoV-2 infection, following COVID-19 vaccination, and at the end of the study period. PROTECT uses electronic medical record (EMR) linkages where available, and verifies COVID-19 and influenza vaccinations through EMR or state vaccine registries. RESULTS Data collection began in July 2021 and is expected to continue through the spring of 2023. As of April 13, 2022, 2371 children are enrolled in PROTECT. Enrollment is ongoing at all study sites. CONCLUSIONS As COVID-19 vaccine products are authorized for use in pediatric populations, PROTECT study data will provide real-world estimates of VE in preventing infection. In addition, this prospective cohort provides a unique opportunity to further understand SARS-CoV-2 incidence, clinical course, and key knowledge gaps that may inform public health. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/37929.
Collapse
Affiliation(s)
- Joy Burns
- Abt Associates, Atlanta, GA, United States
| | - Patrick Rivers
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Krystal S Jovel
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Ashley A Lowe
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Sana M Khan
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | - Clare Mathenge
- College of Medicine, Texas A&M University, Temple, TX, United States
| | - Maria Ferraris
- Leonard M Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
| | - Julie Mayo Lamberte
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kurt T Hegmann
- Rocky Mountain Center for Occupational and Environmental Health, Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT, United States
| | - Marilyn J Odean
- St. Luke's Regional Health Care System, Duluth, MN, United States
- Whiteside Institute for Clinical Research, St. Luke's, Duluth, MN, United States
| | | | - Shawn Beitel
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | - Leah Odame-Bamfo
- College of Medicine, Texas A&M University, Temple, TX, United States
| | | | - Josephine Mak
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Andrew L Phillips
- Rocky Mountain Center for Occupational and Environmental Health, Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT, United States
| | | | - James Hollister
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | - Jezahel S Ochoa
- Leonard M Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Lauren Grant
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Matthew S Thiese
- Rocky Mountain Center for Occupational and Environmental Health, Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT, United States
| | | | - Karen Lutrick
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | - Felipe A Pubillones
- Leonard M Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Young M Yoo
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Katherine Ellingson
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Joe K Gerald
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Lynn B Gerald
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Karl Krupp
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Purnima Madhivanan
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | | | - Harmony L Tyner
- St. Luke's Regional Health Care System, Duluth, MN, United States
| | - Jennifer K Meece
- Marshfield Clinic Research Institute, Marshfield, WI, United States
| | - Sarang K Yoon
- Rocky Mountain Center for Occupational and Environmental Health, Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT, United States
| | - Ashley L Fowlkes
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Allison L Naleway
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States
| | - Lisa Gwynn
- Leonard M Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jefferey L Burgess
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
| | - Mark G Thompson
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Manjusha Gaglani
- College of Medicine, Texas A&M University, Temple, TX, United States
- Baylor Scott and White Health, Temple, TX, United States
| |
Collapse
|
12
|
Wilson AM, Ogunseye OO, DiGioia O, Gerald LB, Lowe AA. Barriers to COVID-19 Intervention Implementation in K-5 Classrooms: A Survey of Teachers from a District with Mask Mandates despite a Statewide Mask Mandate Ban. Int J Environ Res Public Health 2022; 19:ijerph19148311. [PMID: 35886159 PMCID: PMC9316596 DOI: 10.3390/ijerph19148311] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 02/04/2023]
Abstract
The study objective was to characterize K-5 teachers' risk perceptions and experiences with CDC COVID-19 classroom guidance in an Arizona school district with a mask mandate, conflicting with a statewide mask mandate ban. METHODS Public school teachers (n = 111) were recruited between 14 December 2021, and 31 January 2022, for an anonymous online survey with questions on seven important topics related to: (1) population demographics, (2) teachers' perceptions of COVID-19 in the workplace, (3) masks, (4) physical distancing, (5) surface transmission routes, (6) air flow, and (7) contact tracing protocols. Descriptive statistics were calculated, and statistically significant differences in categorical responses by grade level taught were investigated with Fisher's exact test. RESULTS There were 76 complete responses. No significant differences across grade levels were found. More than half (53%, 43/81) reported not feeling protected from occupational COVID-19 exposure. Lack of mask usage/enforcement was the most frequently listed reason (40%, 17/42). Physical distancing barriers included large student-teacher ratios. CONCLUSIONS Consistent mask guidance at state and local levels, increased financial support, and lower student-teacher ratios may improve the implementation of CDC guidance for classrooms. Conflicting statewide and district-level school mask policies may negatively impact teachers' risk perceptions.
Collapse
Affiliation(s)
- Amanda M. Wilson
- Department of Community, Environment and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85721, USA;
- Correspondence:
| | - Olusola O. Ogunseye
- Department of Community, Environment and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85721, USA;
| | - Olivia DiGioia
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85721, USA; (O.D.); (L.B.G.)
| | - Lynn B. Gerald
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85721, USA; (O.D.); (L.B.G.)
- Asthma & Airway Disease Research Center, Tucson, AZ 85724, USA;
| | - Ashley A. Lowe
- Asthma & Airway Disease Research Center, Tucson, AZ 85724, USA;
| |
Collapse
|
13
|
Lowe AA, Gerald JK, Clemens C, Gerald LB. School-based Stock Inhaler Programs and Neighborhood Disadvantage. J Health Care Poor Underserved 2022; 33:1083-1093. [DOI: 10.1353/hpu.2022.0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
14
|
Lowe AA, Phan H, Hall-Lipsy E, O'Shaughnessy S, Nash B, Volerman A, Gerald LB. School Stock Inhaler Statutes and Regulations in the United States: A Systematic Review. J Sch Health 2022; 92:396-405. [PMID: 35285022 DOI: 10.1111/josh.13142] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/20/2021] [Accepted: 10/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Children with asthma should have immediate access to rescue medication. Yet, <15% of children have access to this life-saving drug while at school. METHODS A search was conducted in the all states database of Westlaw to identify which the US states, territories, and the District of Columbia have a law for K-12 schools. Terms searched included (inhaler or asthma/s medic!) and school and (prescription or order) from conception to December 2020. Demographic data from states with and without a policy were compared. All policies were examined for the following components: (1) type of law (statute or regulation); (2) type of school (charter, private/parochial or public); (3) training requirements; (4) devices; (5) prescriptive authority/safe harbor; (6) medication requirements; and (7) mandated documentation, reporting and funding. RESULTS Our systematic search revealed 15 locations with existing laws. States with a law had a higher percentage of children under 17-years than states without a law (p = .02). Common components described were the applicability to various types of schools, training requirements for those empowered to administer, and civil liability protections for trained school personnel. CONCLUSIONS Existing stock inhaler laws differ vastly across the United States that may impact access to stock albuterol for children at their schools.
Collapse
Affiliation(s)
- Ashley A Lowe
- Instructor, , Mel and Enid Zuckerman College of Public Health, University of Arizona, 1501 N. Campbell Ave., Box 245030, Tucson, AZ 85724
- Professor, , Mel and Enid Zuckerman College of Public Health, University of Arizona, 1501 N. Campbell Ave., Box 245030, Tucson, AZ 85724
| | - Hanna Phan
- Pediatric Pulmonary Clinical Associate Professor, , College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109
| | - Elizabeth Hall-Lipsy
- Assistant Professor, , James E. Rogers College of Law, University of Arizona, 1201 E. Speedway Blvd., Tucson, AZ 85721
| | - Scott O'Shaughnessy
- Pharmacy Student, , College of Pharmacy, University of Arizona, 1295 N. Martin Ave., P.O. Box 210202, Tucson, AZ 85721
| | - Bradley Nash
- Pharmacy Student, , College of Pharmacy, University of Arizona, 1295 N. Martin Ave., P.O. Box 210202, Tucson, AZ 85721
| | - Anna Volerman
- Associate Program Director, , Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, MC 7082, Chicago, IL 60637
| | - Lynn B Gerald
- Professor, , Mel and Enid Zuckerman College of Public Health, University of Arizona, 1501 N. Campbell Ave., Box 245030, Tucson, AZ 85724
| |
Collapse
|
15
|
Volerman A, Lowe AA, Pappalardo AA, Anderson CMC, Blake KV, Bryant-Stephens T, Carr T, Carter H, Cicutto L, Gerald JK, Miller T, Moore NS, Phan H, Sadreameli SC, Tanner A, Winders TA, Gerald LB. Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement. Am J Respir Crit Care Med 2021; 204:508-522. [PMID: 34499024 PMCID: PMC8491259 DOI: 10.1164/rccm.202106-1550st] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Rationale: For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access. Objectives: To provide policy recommendations and outline steps for passing and implementing stock albuterol laws. Methods: We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups—legislation and implementation—on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders. Main Results: We offer several recommendations for crafting state legislation and facilitating program implementation. 1) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. 2) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. 3) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature’s health or education committee. 4) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments. Conclusions: Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.
Collapse
|
16
|
Lowe AA, Gerald JK, Clemens C, Gaither C, Gerald LB. Medication Administration Practices in United States' Schools: A Systematic Review and Meta-synthesis. J Sch Nurs 2021; 38:21-34. [PMID: 34223784 DOI: 10.1177/10598405211026300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Schools often provide medication management to children at school, yet, most U.S. schools lack a full-time, licensed nurse. Schools rely heavily on unlicensed assistive personnel (UAP) to perform such tasks. This systematic review examined medication management among K-12 school nurses. Keyword searches in three databases were performed. We included studies that examined: (a) K-12 charter, private/parochial, or public schools, (b) UAPs and licensed nurses, (c) policies and practices for medication management, or (d) nurse delegation laws. Three concepts were synthesized: (a) level of training, (b) nurse delegation, and (c) emergency medications. One-hundred twelve articles were screened. Of these, 37.5% (42/112) were comprehensively reviewed. Eighty-one percent discussed level of training, 69% nurse delegation, and 57% emergency medications. Succinct and consistent policies within and across the United States aimed at increasing access to emergency medications in schools remain necessary.
Collapse
Affiliation(s)
- Ashley A Lowe
- Asthma & Airway Disease Research Center, 22165University of Arizona, Tucson, AZ, USA
| | - Joe K Gerald
- Department of Community Environment and Policy, Mel and Enid Zuckerman College of Public Health, Asthma & Airway Disease Research Center, 8041University of Arizona, Tucson, AZ, USA
| | - Conrad Clemens
- Department of Pediatrics, College of Medicine, 20878University of Arizona, Tucson, AZ, USA
| | | | - Lynn B Gerald
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, Asthma & Airway Disease Research Center, 8041University of Arizona, Tucson, AZ, USA
| |
Collapse
|
17
|
Lowe AA, Gerald JK, Clemens CJ, Stern DA, Gerald LB. Managing respiratory emergencies at school: A county-wide stock inhaler program. J Allergy Clin Immunol 2021; 148:420-427.e5. [PMID: 33581200 DOI: 10.1016/j.jaci.2021.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND A total of 15 states allow schools to manage respiratory emergencies among multiple students by using a single albuterol inhaler (stock inhaler) paired with a disposable holding chamber. OBJECTIVE Our aim was to evaluate implementation barriers and facilitators, as well as satisfaction with a stock inhaler program across K through12 schools in Pima County, Arizona. METHODS All public, charter, private, and parochial schools were offered supplies, web-based training, and technical assistance at no cost. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate program implementation. School documentation logs were reviewed, school health personnel were surveyed, and a convenience sample of health personnel were interviewed. Chi-square tests evaluated categoric outcomes and Poisson hurdle regression examined stock inhaler use by school organization type, grade levels served, and type of school health personnel employed. RESULTS In all, 229 schools (68%) participated, reaching 82% of students in the county. A total of 152 schools (66%) used a stock inhaler, accounting for 1038 events. The mean number of puffs administered was 2.7 (SD = 1.2) per event, and most events (79%) involved students with asthma. Although most events (83.9%) resulted in the student returning to class, 15.6% resulted in students being sent home. Only 6 events resulted in 911 calls, and 5 of these led to an ambulance transport. School health personnel reported high levels of satisfaction, and all schools renewed participation for a second year. Program costs were $156 per school. CONCLUSION With technical assistance, stock inhaler programs can be feasibly implemented by schools in a wide range of settings, thereby increasing their capacity to safely manage respiratory emergencies.
Collapse
Affiliation(s)
- Ashley A Lowe
- Department of Health Promotion Sciences, the Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Ariz; Asthma & Airway Disease Research Center, The University of Arizona, Tucson, Ariz.
| | - Joe K Gerald
- Asthma & Airway Disease Research Center, The University of Arizona, Tucson, Ariz; Department of Community Environment and Policy, the Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Ariz
| | - Conrad J Clemens
- Department of Health Promotion Sciences, the Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Ariz; Department of Pediatrics, The University of Arizona College of Medicine, The University of Arizona, Tucson, Ariz
| | - Debra A Stern
- Asthma & Airway Disease Research Center, The University of Arizona, Tucson, Ariz
| | - Lynn B Gerald
- Department of Health Promotion Sciences, the Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, Ariz; Asthma & Airway Disease Research Center, The University of Arizona, Tucson, Ariz
| |
Collapse
|
18
|
Abstract
In a curved tube, the amount of airflow appears to be influenced by the amount of curvature. The purpose of this study was to investigate changes in obstructive sleep apnoea (OSA) severity and awake velopharyngeal curvature in response to an anteriorly titrated mandibular position in 20 male OSA patients. Baseline supine cephalometry was obtained before the initial insertion of a titratable oral appliance and follow-up supine cephalometry was undertaken after titration of the mandibular position with the appliance in place. The mean apnoea/hypopnea index (AHI) before treatment (31.6 +/- 13.0 events x h(-1)) was significantly reduced (9.8 +/- 7.4 events x h(-1)) after titration of the mandibular position in all 20 patients. There was a significant increase in the anteroposterior calibre and the radius of the curvature of the anterior wall of the velopharynx in 14 good responders who exhibited an AHI reduction to < or = 15. Similar observations were not found in six poor responders. To conclude, an anteriorly titrated mandibular position reduced obstructive sleep apnoea severity, enlarged the velopharynx and diminished the curvature of the anterior velopharyngeal wall in good responders. It is proposed that this change in the upper airway curvature associated with mandibular advancement may effect obstructive sleep apnoea severity through its effect on airflow dynamics.
Collapse
Affiliation(s)
- S Tsuiki
- Dept of Oral Health Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | |
Collapse
|
19
|
Liu Y, Lowe AA, Fleetham JA, Park YC. Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2001; 120:639-47. [PMID: 11742309 DOI: 10.1067/mod.2001.118782] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to investigate whether any physiologic or cephalometric parameters could be used to predict the efficacy of an adjustable mandibular advancement appliance for treating obstructive sleep apnea (OSA). Forty-two male and 5 female patients with OSA were recruited on the basis of baseline polysomnography with a documented Apnea and Hypopnea Index (AHI) greater than 15 per hour. Repeat polysomnography was performed with the appliance in place. Baseline cephalometry was performed for each patient, and follow-up cephalometry was completed for 19 of the subjects. The subjects were divided into 3 groups on the basis of the degree of change in the AHI with oral appliance therapy: good response (> 75% decrease in AHI), moderate response (25% to 75% decrease in AHI), and poor response (< 25% decrease in AHI). Patients with a good response were younger and had smaller upper airways. In a linear regression analysis, the change in AHI (%) was associated with physiologic (age and body mass index), cephalometric (overjet, height of the maxillary molars, vertical height of the hyoid bone), and airway variables. However, changes in either overbite or overjet were not related to changes in any of the polysomnographic variables for the 19 subjects. A stepwise regression analysis revealed a better treatment response with the adjustable mandibular advancement appliance in patients who were younger and had a lower body mass index, a longer maxilla, a smaller oropharynx, a smaller overjet, less erupted maxillary molars, and a larger ratio of vertical airway length to the cross-sectional area of the soft palate.
Collapse
Affiliation(s)
- Y Liu
- Division of Orthodontics, Department of Oral Health Sciences, The University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3
| | | | | | | |
Collapse
|
20
|
Tsuiki S, Hiyama S, Ono T, Imamura N, Ishiwata Y, Kuroda T, Lowe AA. Effects of a titratable oral appliance on supine airway size in awake non-apneic individuals. Sleep 2001; 24:554-60. [PMID: 11480653 DOI: 10.1093/sleep/24.5.554] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES To define morphological changes in the upper airway and its surrounding structures after the insertion of a titratable mandibular repositioner. DESIGN Ten non-apneic adult males participated in this study. A set of supine lateral cephalograms was taken for each subject at the end of expiration with a titratable oral appliance in place in four mandibular positions: most retruded (RP), maximum protrusion (MAX), 33% of MAX (MAX33), and 67% of MAX (MAX67). Changes in the anteroposterior width of the upper airway, positions of the hyoid bone and the third cervical vertebra were compared between the four mandibular positions. An ANOVA was used to test for statistical significance. SETTING N/A. PATIENTS OR PARTICIPANTS N/A. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS The anteroposterior width of the velopharynx significantly increased when the mandible was advanced from RP to MAX67 and MAX. However, there were no significant changes in the anteroposterior width of the oropharynx. Significant forward displacement of the hyoid bone and third cervical vertebra together with the mandible was found in MAX67 and MAX compared to RP. CONCLUSION Especially in MAX67 and MAX, the titratable oral appliance significantly enlarges upper airway size in the velopharynx and results in a forward displacement of the hyoid bone and the third cervical vertebra.
Collapse
Affiliation(s)
- S Tsuiki
- Maxillofacial Orthognathics, Maxillofacial Reconstruction, Division of Maxillofacial/Neck Reconstruction, Graduate School, Tokyo Medical and Dental University, Japan.
| | | | | | | | | | | | | |
Collapse
|
21
|
Liu Y, Lowe AA. Factors related to the efficacy of an adjustable oral appliance for the treatment of obstructive sleep apnea. Chin J Dent Res 2000; 3:15-23. [PMID: 11314530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
AIM The purpose of this study was to investigate whether any physiological or cephalometric parameters could be used to predict the efficacy of the Klearway oral appliance (OA) for the treatment of obstructive sleep apnea (OSA). METHODS Forty-two male and 5 female patients with OSA were recruited on the basis of baseline polysomnography with a documented Apnea and Hypopnea Index (AHI) > 15 per hour. Repeat polysomnography was performed with the appliance in place. Baseline cephalometry was performed for each patient. Subjects were divided into 3 groups on the basis of the degree of change in AHI with OA therapy: good response (> 75% decrease in AHI), moderate response (25% to 75% decrease range in AHI), and poor response (< 25% decrease in AHI). RESULTS Patients with a good response were younger and had smaller upper airways. A stepwise regression analysis revealed that a better treatment response with the Klearway appliance was obtained in patients who were younger and had a lower body mass index, a longer maxilla, a smaller oropharynx, a smaller overjet, less erupted maxillary molars, and larger ratio of vertical airway length to the cross-sectional area of the soft palate.
Collapse
Affiliation(s)
- Y Liu
- Department of Orthodontics, College and Hospital of Stomatology, Tongji University, Shanghai 200072, P. R. China.
| | | |
Collapse
|
22
|
Abstract
The aim was to test the hypothesis of a direct association between sleep-disordered breathing and sleep bruxism. The frequency of masseter contraction (MC) episodes and rhythmic jaw movements (RJM) was measured in patients with mild and moderate obstructive sleep apnoea (OSA). The diagnosis of sleep bruxism was made from a combination of questionnaire, clinical observation and all-night polysomnographic recording which included masseter electromyography. A total of 21 patients (19 males/two females, mean age 40.0 years+/-9.2 SD) were randomly selected from a provisional diagnosis of snoring and OSA by a sleep physician. In the patients with mild OSA [n=11, mean apnoea hypopnoea index (AHI)=8.0+/-4.1 SD, body mass index (BMI)=29.1+/-5.0], the diagnosis of sleep bruxism was made in six out of 11 patients (54%); similarly, four out of 10 patients (40%) with moderate OSA (n=10, mean AHI=34.7+/-19.1, BMI=30.6+/-5.0) were identified as bruxists. Although the combination of clinical, subjective estimation and nocturnal electromyographic recording of masseter muscle might provide a more solid base for the diagnosis of sleep bruxism, the result is biased by the variation in the bruxing activity. MC episodes were associated with the termination of apnoea or hypopnoea episodes in only 3.5% of the mild group and 14.4% of the moderate group (p<0.05). It appears that sleep bruxism is rarely directly associated with apnoeic events, but is rather related to the disturbed sleep of OSA patients.
Collapse
Affiliation(s)
- T T Sjöholm
- Department of Oral Health Sciences, The University of British Columbia, Vancouver, Canada
| | | | | | | | | |
Collapse
|
23
|
Lowe AA. The durability of intraoral devices for snoring and sleep apnea: another view. J Can Dent Assoc 2000; 66:486-7. [PMID: 11070626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- A A Lowe
- Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia
| |
Collapse
|
24
|
Abstract
The purpose of this study was to investigate the effects of a mandibular repositioner on airway, sleep, and respiratory variables in patients with obstructive sleep apnea. Twenty-two patients selected for this study were confirmed with a diagnosis of obstructive sleep apnea based on initial nocturnal polysomnography. The patients were fitted with a mandibular repositioner designed to hold the mandible anteroinferiorly. Six months later, an outcome polysomnographic study was undertaken for each patient with the appliance in place. Lateral cephalometric radiographs in the upright position were also obtained before and after 6 months of treatment. The respiratory disturbance index decreased in 21 of the 22 patients with the appliance in place. The mean respiratory disturbance index of the 22 patients decreased significantly from 40.3 to 11.7 events per hour (P <.01). Some 59.1% of subjects were considered a treatment success with follow-up respiratory disturbance index < 10 events per hour. The mean minimum blood oxygen saturation level during sleep also improved significantly from 73.4% to 81.3% (P <. 01). The mandibular repositioner was constructed to position the mandible at 75% of the maximal mandibular advancement and with a 7 mm opening between the upper and lower incisors, and no aberrant effect on temporomandibular joint was noted. The retropalatal airway space increased and the cross-sectional area of the soft palate and the vertical distance of the hyoid bone to the mandibular plane decreased significantly. The tongue posture became significantly flatter. A significant linear correlation was found between the reduction in apnea index and specific craniofacial skeletal structures (length of anterior cranial base, mandibular plane angle, and upper to lower facial height ratios, P <.05). Subjects with a smaller reduction in apnea index tended to have shorter anterior cranial bases, steeper mandibular planes, and smaller upper to lower facial height ratios. We conclude that a mandibular repositioner may be an effective treatment alternative for obstructive sleep apnea and that a reduction in the frequency of apneic episodes is mainly attributed to the effects of the appliance on oropharyngeal structures.
Collapse
Affiliation(s)
- Y Liu
- Department of Orthodontics, School of Stomatology, Beijing Medical University, Beijing, China
| | | | | | | | | |
Collapse
|
25
|
Lowe AA, Sjöholm TT, Ryan CF, Fleetham JA, Ferguson KA, Remmers JE. Treatment, airway and compliance effects of a titratable oral appliance. Sleep 2000; 23 Suppl 4:S172-8. [PMID: 10893096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
STUDY OBJECTIVES To measure the effects of a titratable anterior mandibular repositioner on airway size and Obstructive Sleep Apnea (OSA) and to evaluate its compliance. DESIGN Before and after insertion sleep studies were obtained in a total of 38 OSA patients of varying severity from three different sites. Covert compliance was measured by means of a newly-developed, miniaturized, temperature-sensitive, imbedded monitor. Validity testing was completed in six adult volunteers who wore monitors imbedded into small acrylic appliances. MEASUREMENTS AND RESULTS The mean RDI before treatment was 32.6 (SEM 2.1) and after the insertion of the appliance, the RDI was reduced to 12.1 (SEM 1.7, p<0.001). RDI was reduced to less than 15/hour in 80% of a group of moderate OSA patients (RDI 15 to 30) and in 61% of a group of severe OSA patients (RDI > 30) with respect to baseline RDI. Fiber optic video endoscopy was performed on 9 OSA patients with and without the appliance. No significant differences in hypopharynx or oropharynx cross sectional areas were found, but at the level of the velopharynx, the airway size was significantly increased (p<0.05). The index of agreement was 0.99 between the monitor clock time and the subject's log sheets. Compliance data from eight OSA subjects instructed to wear the appliance during sleep indicated that it was worn for a mean of 6.8 hours with a range of 5.6 to 7.5 hours per night. CONCLUSION The titratable adjustable mandibular advancement appliance, made from thermoelastic acrylic, significantly reduces RDI in moderate to severe OSA patients, has a direct effect on airway size and is well worn throughout the night.
Collapse
Affiliation(s)
- A A Lowe
- Department of Oral Health Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada.
| | | | | | | | | | | |
Collapse
|
26
|
Liu Y, Lowe AA, Zeng X, Fu M, Fleetham JA. Cephalometric comparisons between Chinese and Caucasian patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2000; 117:479-85. [PMID: 10756275 DOI: 10.1016/s0889-5406(00)70169-7] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to compare two groups of adult men from different ethnic backgrounds and with obstructive sleep apnea; they were selected by matching age, gender, skeletal pattern, body mass index, and respiratory disturbance index. Pretreatment cephalometric radiographs and overnight polysomnograms of 30 Chinese and 43 Caucasian patients with Class II, Division 1 malocclusions were analyzed to investigate if there were craniofacial and upper airway structural differences between the two ethnic groups. The Chinese group, when compared with the group of Caucasian patients, revealed more severe underlying craniofacial skeletal discrepancies with significantly smaller maxilla and mandibles, more severe mandibular retrognathism, proclined lower incisors, increased total and upper facial heights, and steeper and shorter anterior cranial bases. However, no significant differences were found between the two groups in posterior facial height, ratio of upper to lower anterior facial height, and the position of hyoid bone, maxilla, and upper incisors. With regard to soft tissue and upper airway measurements, there were no significant ethnic differences in tongue and soft palate size, vertical length of oropharynx, and anteroposterior dimensions of the upper airway at most of the levels except for a larger super-posterior airway space, a larger nasopharynx and oropharynx cross-sectional area, and a smaller tongue height in the Chinese group. We conclude that there are a number of craniofacial and upper airway structures that differ between the two ethnic groups that may be relevant to the treatment of obstructive sleep apnea in various ethnic groups.
Collapse
Affiliation(s)
- Y Liu
- Department of Oral Health Sciences, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada
| | | | | | | | | |
Collapse
|
27
|
Ryan CF, Love LL, Peat D, Fleetham JA, Lowe AA. Mandibular advancement oral appliance therapy for obstructive sleep apnoea: effect on awake calibre of the velopharynx. Thorax 1999; 54:972-7. [PMID: 10525554 PMCID: PMC1745384 DOI: 10.1136/thx.54.11.972] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The mechanisms of action of oral appliance therapy in obstructive sleep apnoea are poorly understood. Videoendoscopy of the upper airway was used during wakefulness to examine whether the changes in pharyngeal dimensions produced by a mandibular advancement oral appliance are related to the improvement in the severity of obstructive sleep apnoea. METHODS Fifteen patients with mild to moderate obstructive sleep apnoea (median (range) apnoea index (AI) 4(0-38)/h, apnoea-hypopnoea index (AHI) 28(9-45)/h) underwent overnight polysomnography and imaging of the upper airway before and after insertion of the oral appliance. Images were obtained in the hypopharynx, oropharynx, and velopharynx at end tidal expiration during quiet nasal breathing in the supine position. The cross sectional area and diameters of the upper airway were measured using image processing software with an intraluminal catheter as a linear calibration. RESULTS AI decreased to a median (range) value of 0 (0-6)/h (p<0.01) and AHI to 8 (1-28)/h (p<0.001) following insertion of the oral appliance. The median (95% confidence interval) cross sectional area of the upper airway increased by 18% (3 to 35) (p<0.02) in the hypopharynx and by 25% (11 to 69) (p<0.005) in the velopharynx, but not significantly in the oropharynx. Although in general the shape of the pharynx did not change following insertion of the oral appliance, the lateral diameter of the velopharynx increased to a greater extent than the anteroposterior diameter. Following insertion of the oral appliance the reduction in AHI was related to the increase in cross sectional area of the velopharynx (p = 0.01). CONCLUSIONS A mandibular advancement oral appliance increases the cross sectional area of the upper airway during wakefulness, particularly in the velopharynx. Assuming this effect on upper airway calibre is not eliminated by sleep, mandibular advancement oral appliances may reduce the severity of obstructive sleep apnoea by maintaining patency of the velopharynx, particularly in its lateral dimension.
Collapse
Affiliation(s)
- C F Ryan
- Departments of Medicine and Clinical Dental Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | |
Collapse
|
28
|
Lowe AA. Titratable oral appliances for the treatment of snoring and obstructive sleep apnea. J Can Dent Assoc 1999; 65:571-4. [PMID: 10612935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- A A Lowe
- Department of Oral Health Science, Faculty of Dentistry, University of British Columbia
| |
Collapse
|
29
|
Abstract
Vertical mandibular posture is thought to be related to narrowing of the upper airway, because mouth opening is associated with an inferior-posterior movement of the mandible and the tongue which influences pharyngeal airway patency. To test whether the mandibular posture is related to the occurrence and/or termination of obstructive sleep apnoea (OSA), the vertical mandibular position was recorded intraorally using a magnet sensor during a standard sleep study in seven patients with OSA. Measurements were recorded during sleep both in the supine and lateral recumbent positions. The percentage of total sleep time spent with mandibular opening greater than 5 mm was significantly larger (p<0.001) in patients with OSA (69.3+/-23.3%) compared with our previous results obtained from healthy adults without OSA (11.1+/-11.6%). The stage of sleep affected the vertical mandibular posture during sleep in the supine position, but not in the lateral recumbent position in patients with OSA. In non-rapid eye-movement sleep, mandibular opening increased progressively during apnoeic episodes and decreased at the termination of apnoeic episodes. In contrast, no significant change in mandibular posture occurred in apnoeic episodes during rapid eye-movement sleep. It was concluded that the vertical mandibular posture is more open during sleep in patients with OSA than in healthy adults and that mandibular opening increases progressively during apnoeic episodes and decreases at the termination of those episodes.
Collapse
Affiliation(s)
- K Miyamoto
- Department of Oral Health Sciences, Vancouver Hospital and Health Sciences Centre, The University of British Columbia, Canada
| | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
Clinicians have long suspected that tongue shape differs between obstructive sleep apnea (OSA) patients and normal subjects. The purpose of this study was to determine whether such differences exist. Because of the difficulty in specifying reproducible homologous landmarks for the tongue, a morphometric technique-the eigenshape analysis-was used. The eigenshape analysis transforms an outline contour into a set of discrete numbers that are tangent angles of the curvature along the outline at each digitized point on the outline. Pairs of cephalograms were taken of 80 male patients in upright and supine positions. The subjects were subgrouped into four categories according to severity of symptoms. The contour of the tongue was traced, digitized, and subgrouped. When the major portion of the tongue shape variations in the supine position were graphically compared between subgroups, variations in the nonapneic group were distinguished from those in the apneic groups. The results suggest that the eigenshape analysis on cephalograms in the supine position may be a useful tool to distinguish OSA subjects from nonapneic subjects.
Collapse
Affiliation(s)
- E K Pae
- Department of Orthodontics, The University of Connecticut Health Center, USA.
| | | |
Collapse
|
31
|
Pae EK, Lowe AA, Fleetham JA. Shape of the face and tongue in obstructive sleep apnea patients--statistical analysis of coordinate data. Clin Orthod Res 1999; 2:10-8. [PMID: 10534974 DOI: 10.1111/ocr.1999.2.1.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the shape difference of the face and tongue of obstructive sleep apnea (OSA) patients, in comparison to those of non-apneic patients. DESIGN Retrospective analysis of observational data on a cohort of patients. SETTING A university teaching hospital and sleep referral center. SAMPLE POPULATION AND METHOD: Eighty patients referred for overnight polysomnography and lateral cephalometry and who met the selection criteria were included. Upright and supine cephalograms were obtained and subgrouped based on the severity of clinical symptoms. Shape differences between the groups were assessed by a multiple analysis of variance and a Hotelling's T2. MEASUREMENTS AND RESULTS A set of anatomical landmarks were selected for outlines of the face and the tongue on cephalograms. X and Y coordinates of each landmark were utilized as variables. As symptoms become severe, the hyoid bone and the submental area positioned inferiorly and the fourth vertebra relocated posteriorly with respect to the lower mandibular border. When subjects changed their body position from the upright to the supine, the posterior part of the tongue appeared to sink down. The hyoid bone position to epiglottis-retrognathion line in the supine position distinguishes OSA patients from non-apneic subjects. CONCLUSION Despite many limitations, we demonstrate that the supine cepahlometrics during wakefulness can be a useful adjunctive diagnostic tool for OSA, when cephalograms are analyzed in a coordinate data form.
Collapse
Affiliation(s)
- E K Pae
- Department of Orthodontics, School of Dental Medicine, University of Connecticut Health Center, Farmington 06030, USA
| | | | | |
Collapse
|
32
|
Abstract
Mandibular deficiency may be a factor in reduced oropharyngeal airway (OAW) dimensions and related impaired respiratory function. The purpose of this study was to evaluate the use of functional-orthopedic devices in increasing OAW dimensions in children with Class II skeletal patterns (ANB > 4) and clinically deficient mandibles. Comparisons were made between two groups, one comprising 26 treated patients and the other comprising 15 controls. Student's t-tests, paired t-tests, discriminant analyses, and Pearson's r-correlation coefficients were performed to evaluate group differences and to search for characteristics that might suggest which patients would be better candidates for significant increase in OAW dimensions. Compared with controls, OAW dimensions increased significantly in treated patients, especially those with sagittally smaller and more retrognathic maxillomandibular complexes and smaller OAW dimensions.
Collapse
Affiliation(s)
- M M Ozbek
- Department of Orthodontics, University of Ankara, Turkey.
| | | | | | | | | |
Collapse
|
33
|
Abstract
Enlarged tonsils, adenoids, and chronic respiratory problems have been associated with the compensatory adaptations of natural head posture (NHP) in children. Recently, it has been shown that adult patients with Obstructive Sleep Apnoea (OSA) also tend to exhibit a craniocervical extension (CCE) with a forward head posture (FHP). This study was designed to search for some characteristics of OSA patients that may be related to these adaptive changes in NHP. Overnight polysomnographic, demographic, and cephalometric records of 252 adult male subjects with various types of skeletal patterns and dental conditions were examined. Apnoea Index (AI) and Apnoea + Hypopnoea Index (AHI) variables were assessed to separate the non-apnoeic snorers (n = 35), and mild (n = 101), moderate (n = 63), and severe (n = 53) OSA groups. Results of the Tukey tests revealed that severe OSA patients had a greater tendency to exhibit a CCE with a FHP (P < or = 0.05 to P < or = 0.001). Differences in head extension (NSL.VER) between groups could not be identified. Pearson's 'r' correlation coefficients revealed that the CCE and FHP in OSA patients were associated with a higher disease severity, a longer and larger tongue, a lower hyoid bone position in relation to the mandibular plane, a smaller nasopharyngeal and a larger hypopharyngeal cross-sectional area, and a higher body mass index (P < or = 0.05 to P < or = 0.001). It is concluded that a CCE with a FHP is more likely to be seen in severe and obese OSA patients with certain morphological characteristics of the upper airway and related structures.
Collapse
Affiliation(s)
- M M Ozbek
- Department of Oral Health Sciences, University of British Columbia, Vancouver, Canada
| | | | | | | |
Collapse
|
34
|
Abstract
To test whether the mandible opens more during deep sleep and whether the mandibular position is affected by body position during sleep, the vertical mandibular position was recorded intraorally using a magnet sensor at the same time as a standard sleep study in seven normal healthy male adults. Measurements were recorded during the period before sleep onset (WAKE) and during sleep. Two-way ANOVA showed that vertical mandibular position was significantly affected by sleep stage but not by body position (supine vs lateral recumbent). The proportion of time during which the mandible was in a near-closed position (0-2.5 mm) significantly and progressively decreased, and significantly more time was spent at wider gaps (2.5-5 mm) as non-rapid-eye-movement (NREM) sleep deepened. In REM sleep, the proportion of time during which the mandible was at wider gaps was significantly greater than in WAKE and stage 1 (but not later stages) of NREM sleep. It was concluded that mandibular posture during sleep in healthy adults is significantly influenced by sleep stage but not by body position. Mandibular opening progressively increases with the depth of NREM sleep stage, and the mandible is more open in REM sleep than in light NREM sleep.
Collapse
Affiliation(s)
- K Miyamoto
- Department of Oral Health Sciences, Faculty of Dentistry, Vancouver Hospital and Health Sciences Centre, The University of British Columbia, Canada
| | | | | | | | | | | | | |
Collapse
|
35
|
Abstract
The shape characteristics of the face and tongue in obstructive sleep apnea (OSA) patients were investigated using thin-plate (TP) splines. A relatively new analytic tool, the TP spline method, provides a means of size normalization and image analysis. When shape is one's main concern, various sizes of a biologic structure may be a source of statistical noise. More seriously, the strong size effect could mask underlying, actual attributes of the disease. A set of size normalized data in the form of coordinates was generated from cephalograms of 80 male subjects. The TP spline method envisioned the differences in the shape of the face and tongue between OSA patients and nonapneic subjects and those between the upright and supine body positions. In accordance with OSA severity, the hyoid bone and the submental region positioned inferiorly and the fourth vertebra relocated posteriorly with respect to the mandible. This caused a fanlike configuration of the lower part of the face and neck in the sagittal plane in both upright and supine body positions. TP splines revealed tongue deformations caused by a body position change. Overall, the new morphometric tool adopted here was found to be viable in the analysis of morphologic changes.
Collapse
Affiliation(s)
- E K Pae
- Faculty of Dentistry, University of Western Ontario, London, Canada.
| | | | | |
Collapse
|
36
|
Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax 1997; 52:362-8. [PMID: 9196520 PMCID: PMC1758547 DOI: 10.1136/thx.52.4.362] [Citation(s) in RCA: 237] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although oral appliances are effective in some patients with obstructive sleep apnoea (OSA), they are not universally effective. A novel anterior mandibular positioner (AMP) has been developed with an adjustable hinge that allows progressive advancement of the mandible. The objective of this prospective crossover study was to compare efficacy, side effects, patient compliance, and preference between AMP and nasal continuous positive airway pressure (nCPAP) in patients with symptomatic mild to moderate OSA. METHODS Twenty four patients of mean (SD) age 44.0 (10.6) years were recruited with a mean (SD) body mass index of 32.0 (8.2) kg/m2, Epworth sleepiness score 10.7 (3.4), and apnoea/hypopnoea index 26.8 (11.9)/hour. There was a two week wash-in and a two week wash-out period and two treatment periods (AMP and nCPAP) each of four months. Efficacy, side effects, compliance, and preference were evaluated by a questionnaire and home sleep monitoring. RESULTS One patient dropped out early in the study and three refused to cross over so treatment results are presented on the remaining 20 patients. The apnoea/hypopnoea index (AHI) was lower with nasal CPAP 4.2 (2.2)/hour than with the AMP 13.6 (14.5)/hour (p < 0.01). Eleven of the 20 patients (55%) who used the AMP were treatment successes (reduction of AHI to < 10/hour and relief of symptoms), one (5%) was a compliance failure (unable or unwilling to use the treatment), and eight (40%) were treatment failures (failure to reduce AHI to < 10/hour and/or failure to relieve symptoms). Fourteen of the 20 patients (70%) who used nCPAP were treatment successes, six (30%) were compliance failures, and there were no treatment failures. There was greater patient satisfaction with the AMP (p < 0.01) than with nCPAP but no difference in reported side effects or compliance. CONCLUSIONS AMP is an effective treatment in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nCPAP.
Collapse
Affiliation(s)
- K A Ferguson
- Division of Respiratory Medicine, University of British Columbia, Vancouver, Canada
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
BACKGROUND Snoring and obstructive sleep apnoea (OSA) are worse or may only occur in the supine position. The effect of body position on upper airway size has been reported, but the effect on tongue posture has not previously been examined. METHODS Detailed measurements were made of tongue posture from upright and supine lateral cephalograms on 24 men with OSA and 13 men with non-apnoeic snoring matched for age, body mass index, and craniofacial skeletal pattern. Patients with OSA had apnoea/hypopnoea indices (AHI) of > 50/hour and/or apnoea indices (AI) of > 25/hour while non-apnoeic snorers had AHI of < 10/hour and AI of < 5/hour. RESULTS In non-apnoeic snorers the tongue depth measurements for the superior-posterior portion of the tongue were larger in the supine than in the upright position (p < 0.05). There was no significant difference in tongue depth measurements between the upright and the supine position in the patients with OSA. CONCLUSIONS When awake patients with OSA move from the upright to the supine position they maintain their upright tongue posture which may tend to protect against upper airway collapse secondary to the increased gravitational load on the tongue. In contrast, when awake non-apnoeic snorers move from the upright to the supine position a significant dorsal movement in the superior-posterior portion of the tongue is observed.
Collapse
Affiliation(s)
- K Miyamoto
- Department of Clinical Dental Sciences, University of British Columbia, Vancouver, Canada
| | | | | | | |
Collapse
|
38
|
Lowe AA, Ozbek MM, Miyamoto K, Pae EK, Fleetham JA. Cephalometric and demographic characteristics of obstructive sleep apnea: an evaluation with partial least squares analysis. Angle Orthod 1997; 67:143-53. [PMID: 9107379 DOI: 10.1043/0003-3219(1997)067<0143:cadcoo>2.3.co;2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Obstructive sleep apnea (OSA) is caused by repeated obstruction of the upper airway during sleep. The purpose of this study was to test the relative contributions of specific demographic and cephalometric measurements to OSA severity. Demographic, cephalometric, and overnight polysomnographic records of 291 male OSA patients and 49 male nonapneic snorers were evaluated. A partial least squares (PLS) analysis was used for statistical evaluation. The results revealed that the predictive powers of obesity and neck size variables for OSA severity were higher than the cephalometric variables used in this study. Compared with other cephalometric characteristics, an extended and forward natural head posture, lower hyoid bone position, increased soft palate and tongue dimensions, and decreased nasopharyngeal and velopharyngeal airway dimensions had relatively higher associations with OSA severity. The respiratory disturbance index (RDI) was the OSA outcome variable that was best explained by the demographic and cephalometric predictor variables. We conclude that the PLS analysis can successfully summarize the correlations between a large number of variables, and that obesity, neck size, and certain cephalometric measurements may be used together to evaluate OSA severity.
Collapse
Affiliation(s)
- A A Lowe
- Department of Clinical Dental Sciences, University of British Columbia, Vancouver, Canada
| | | | | | | | | |
Collapse
|
39
|
Abstract
A narrow pharyngeal pathway may be one of the most significant predisposing factors for obstructive sleep apnea (OSA). Accordingly, the objectives of many treatment modalities are focused on widening the constricted part of the pharynx. Despite the obvious limitations as a two-dimensional imaging technique, cephalometrics has been used more recently as a clinical screening tool for OSA. This study was designed to investigate whether pharyngeal variables more reliable than a single measurement of the most constricted area exist in cephalograms. A total of 80 pairs of upright and supine cephalograms were obtained and subclassified into four groups, in accordance with OSA severity. A medial axis program conveniently provided the variables for the study by transforming digitized outlines of the pharyngeal structure. The results indicate that the pharyngeal length and the pharyngeal width below the most constricted area may be the most important variables. We observed that the pharynx becomes considerably longer in the apneic group after a body position change from upright to supine. Pharyngeal length in the supine position may be more important than a one-dimensional measurement of the most constricted area in the diagnosis and treatment of OSA.
Collapse
Affiliation(s)
- E K Pae
- Division of Orthodontics and Paediatric Dentistry, University of Western Ontario, London, Canada.
| | | | | |
Collapse
|
40
|
Lowe AA, Ono T, Ferguson KA, Pae EK, Ryan CF, Fleetham JA. Cephalometric comparisons of craniofacial and upper airway structure by skeletal subtype and gender in patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1996; 110:653-64. [PMID: 8972813 DOI: 10.1016/s0889-5406(96)80043-6] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To investigate whether patients with obstructive sleep apnea (OSA) have abnormalities in their craniofacial and upper airway (UA) structures compared with normal subjects, cephalometric comparisons were systematically performed in both the upright and the supine positions in subjects with and without OSA, who were then grouped according to their craniofacial skeletal type and gender. A total of 347 patients with OSA and 101 control subjects were divided into male and female groups and then classified into Class I (CI), Class II, Division 1 (CII/1), Class II, Division 2 (CII/2), and Class III (CIII) skeletal subtypes. In the upright position, the most atypical craniofacial and UA structure was shown in male patients with CI OSA. In patients with OSA, the degree of UA abnormalities was less in the supine position regardless of skeletal subtype. In the supine position, the most atypical craniofacial and UA structure was also shown in male patients with CI OSA; there were no significant differences between male patients with CII/2 OSA and control subjects or between female patients with CI OSA and control subjects. With a change in body position from upright to supine, distinctive changes in the UA structure in both patients with OSA and control subjects occurred, according to skeletal subtype and gender. We conclude that there are a series of characteristics of craniofacial and UA structure that differ between patients with OSA and control subjects matched for skeletal subtype and gender. These differences may predispose to UA obstruction during sleep in patients with OSA.
Collapse
Affiliation(s)
- A A Lowe
- Department of Clinical Dental Sciences, The University of British Columbia, Vancouver, Canada.
| | | | | | | | | | | |
Collapse
|
41
|
Abstract
A variety of oral appliances (OA) are now available for the treatment of obstructive sleep apnea (OSA), OA therapy is effective in some patients with mild to moderate OSA and is associated with greater patient satisfaction than nasal CPAP. Adjustable OA are associated with improved treatment success and fewer compliance failures compared to non-adjustable OA. Large randomized clinical trials are necessary to further determine the precise indications, benefits, and risks of each OA in the treatment of OSA.
Collapse
Affiliation(s)
- J A Fleetham
- Division of Respiratory Medicine, University of British Columbia, Vancouver, Canada
| | | | | | | |
Collapse
|
42
|
Ono T, Lowe AA, Ferguson KA, Pae EK, Fleetham JA. The effect of the tongue retaining device on awake genioglossus muscle activity in patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1996; 110:28-35. [PMID: 8686675 DOI: 10.1016/s0889-5406(96)70084-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Knowledge of how dental appliances alter upper airway muscle activity when they are used for the treatment of snoring and/or obstructive sleep apnea (OSA) is very limited. The purpose of this study was to define the effect of a tongue retaining device (TRD) on awake genioglossus (GG) muscle activity in 10 adult subjects with OSA and in 6 age and body mass index (BMI) matched symptom-free control subjects. The TRD is a custom-made appliance designed to allow the tongue to remain in a forward position between the anterior teeth by holding the tongue in an anterior bulb with negative pressure, during sleep. This pulls the tongue forward to enlarge the volume of the upper airway and to reduce upper airway resistance. In this study, two customized TRDs were used for each subject. The TRD-A did not have an anterior bulb but incorporated lingual surface electrodes to record the GG electromyographic (EMG) activity. The TRD-B contained an anterior bulb and two similar electrodes. The GG EMG activity was also recorded while patients used the TRD-B but were instructed to keep their tongue at rest outside the anterior bulb; this condition is hereafter referred to as TRD-X. The GG EMG activity and nasal airflow were simultaneously recorded while subjects used these customized TRDs during spontaneous awake breathing in both the upright and supine position. The following results were obtained and were consistent whether subjects were in the upright or the supine position. The GG EMG activity was greater with the TRD-B than with the TRD-A in control subjects (p < 0.05), whereas the GG EMG activity was less with the TRD-B than with the TRD-A in subjects with OSA (p < 0.01). Furthermore, there was no significant difference between the GG EMG activity of the TRD-A and the TRD-X in control subjects, whereas there was less activity with the TRD-X than with the TRD-A in subjects with OSA (p < 0.05). On the basis of these findings, it was concluded that the TRD has different effects on the awake GG muscle activity in control subjects and patients with OSA. The resultant change in the anatomic configuration of the upper airway caused by the TRD may be important in the treatment of OSA because such a change may alleviate the impaired upper airway function.
Collapse
Affiliation(s)
- T Ono
- Department of Clinical Dental Sciences, The Faculty of Dentistry, The University of British Columbia, Vancouver, B.C., Canada
| | | | | | | | | |
Collapse
|
43
|
Ono T, Lowe AA, Ferguson KA, Fleetham JA. Associations among upper airway structure, body position, and obesity in skeletal Class I male patients with obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1996; 109:625-34. [PMID: 8659472 DOI: 10.1016/s0889-5406(96)70074-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Interactions between upper airway structure and posture in relation to obesity were studied in a sample of 61 adult Class I skeletal type male patients with obstructive sleep apnea (OSA) and 10 homologous control subjects. A pair of upright and supine lateral cephalometric films were taken for each subject. A Pearson correlation analysis identified significant r values for several demographic variables in patients with OSA such as apnea and hypopnea index, percentage of predicted neck circumference, minimum arterial oxygen saturation, and body mass index (BMI). The difference between cephalometric variables identified in upright and supine subjects was calculated. When patients with OSA changed their posture from upright to supine, significant correlations were observed between the cranial base to upper cervical column angle and the hypopharynx cross-sectional area and BMI. Moreover, the mandibular plane angle and the sella-nasion plane was significantly correlated with BMI. This occurred along with a significant positive correlation between the sella-nasion plane angle and BMI and a significant inverse correlation between the mandibular plane angle in reference to the absolute vertical and horizontal planes, with BMI after the positional change. Such correlations were not observed in control subjects. No correlations were observed between the variables related to the position of the hyoid bone with BMI in either patients with OSA or control subjects after the change in posture. On the basis of these findings, we propose that when patients with OSA change their body position from upright to supine (1) the patient's neck is more extended, and (2) the hyoid bone moves more anterosuperiorly in conjunction with an upward and forward rotation of the mandible. This change in craniofacial structure may be a compensatory geometrical change in the upper airway to secure its patency.
Collapse
Affiliation(s)
- T Ono
- Department of Clinical Dental Sciences, University of British Columbia, Vancouver, Canada
| | | | | | | |
Collapse
|
44
|
Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest 1996; 109:1269-75. [PMID: 8625679 DOI: 10.1378/chest.109.5.1269] [Citation(s) in RCA: 307] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
STUDY OBJECTIVE To compare efficacy, side effects, patient compliance, and preference between oral appliance (OA) therapy and nasal-continuous positive airway pressure (N-CPAP) therapy. DESIGN Randomized, prospective, crossover study. SETTING University hospital and tertiary sleep referral center. PATIENTS Twenty-seven unselected patients with mild-moderate obstructive sleep apnea (OSA). INTERVENTIONS There was a 2-week wash-in and a 2-week wash-out period, and 2 x 4-month treatment periods (OA and N-CPAP). Efficacy, side effects, compliance, and preference were evaluated by a questionnaire and home sleep monitoring. MEASUREMENTS AND RESULTS Two patients dropped out early in the study and treatment results are presented on the remaining 25 patients. The apnea/hypopnea index was lower with N-CPAP (3.5 +/- 1.6) (mean +/- SD) than with the OA (9.7 +/- 7.3) (p < 0.05). Twelve of the 25 patients who used the OA (48%) were treatment successes (reduction of apnea/hypopnea to <10/h and relief of symptoms), 6 (24%) were compliance failures (unable or unwilling to use the treatment), and 7 (28%) were treatment failures (failure to reduce apnea/hypopnea index to <10/h and/or failure to relieve symptoms). Four people refused to use N-CPAP after using the OA. Thirteen of the 21 patients who used N-CPAP were overall treatment successes (62%), 8 were compliance failures (38%), and there were no treatment failures. Side effects were more common and the patients were less satisfied with N-CPAP (p < 0.005). Seven patients were treatment successes with both treatments, six of these patients preferred OA, and one preferred N-CPAP as a long-term treatment. CONCLUSIONS We conclude that OA is an effective treatment in some patients with mild-moderate OSA and is associated with fewer side effects and greater patient satisfaction than N-CPAP.
Collapse
Affiliation(s)
- K A Ferguson
- Department of Clinical Dental Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | |
Collapse
|
45
|
Abstract
STUDY OBJECTIVE To evaluate the interaction between craniofacial structure and obesity in male patients with obstructive sleep apnea (OSA). DESIGN Retrospective analysis of a cohort of OSA patients. The relationships between neck circumference (NC), body mass index, apnea severity, and craniofacial and upper airway soft-tissue measurements from upright lateral cephalometry were examined. Patients were divided into groups; small to normal NC (group A), intermediate NC (group B), or large NC (group C). SETTING A university teaching hospital and tertiary sleep referral center. PATIENTS A consecutive series of patients with OSA who underwent polysomnography and lateral cephalometry. MEASUREMENTS AND RESULTS Group A patients were less obese and had more craniofacial abnormalities such as a smaller mandible and maxilla and a more retrognathic mandible. Group B patients had both upper airway soft-tissue and craniofacial abnormalities. Group C patients were more obese with larger tongues and soft palates, and an inferiorly placed hyoid. Group C patients also had fewer craniofacial abnormalities than group A or B patients. There was no difference in airway size among the three groups. CONCLUSIONS We conclude that there is a spectrum of upper airway soft-tissue and craniofacial abnormalities among OSA patients: obese patients with increased upper airway soft-tissue structures, nonobese patients with abnormal craniofacial structure, and an intermediate group of patients with abnormalities in both craniofacial structure and upper airway soft-tissue structures.
Collapse
Affiliation(s)
- K A Ferguson
- Division of Respiratory Medicine, University of British Columbia, Vancouver, Canada
| | | | | | | | | |
Collapse
|
46
|
Abstract
The interaction between craniofacial structure assessed by lateral cephalometry, and tongue, soft palate, and upper airway size determined from computed tomography (CT) scans was examined in 25 control subjects and 80 patients with obstructive sleep apnea (OSA). On the basis of the cephalometric analyses, the patients with OSA had retruded mandibles with larger ANB angle differences, elongated maxillary and mandibular incisors and mandibular molars, and high total upper and lower face heights The computed tomographic evaluations revealed that patients with OSA also had larger tongue, soft palate, and upper airway volumes. Men with OSA and skeletal Class I malocclusions had significantly larger soft palates than comparable controls. Both tongue and soft palate volumes were positively correlated with body mass index. A principal component analysis reduced the database, and one significant correlation was identified. Subjects with high total, upper and lower face heights, elongated maxillary and mandibular teeth, and proclined lower incisors were observed to have large tongue, soft palate, and upper airway volumes, to have a higher apnea index and to be obese. Linear regression analysis indicated that a high apnea index was seen in association with large tongue and soft palate volumes, a retrognathic mandible, an anteroposterior discrepancy between the maxilla and mandible, an open bite tendency between the incisors, and obesity.
Collapse
Affiliation(s)
- A A Lowe
- University of British Columbia, Vancouver, Canada
| | | | | | | |
Collapse
|
47
|
Pae EK, Lowe AA, Sasaki K, Price C, Tsuchiya M, Fleetham JA. A cephalometric and electromyographic study of upper airway structures in the upright and supine positions. Am J Orthod Dentofacial Orthop 1994; 106:52-9. [PMID: 8017350 DOI: 10.1016/s0889-5406(94)70021-4] [Citation(s) in RCA: 130] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Obstructive sleep apnea (OSA) is characterized by recurrent upper airway obstruction during sleep, usually in the supine position. To investigate the relationship between upper airway size and genioglossus (GG) muscle activity, upright and supine cephalograms were obtained in 20 OSA patients and 10 symptom-free control subjects. Tongue electromyographic (EMG) recordings were obtained with surface electrodes, and pressure transducers were placed in the 10 symptom-free controls. The tongue cross-sectional area increased 4.3% (p < 0.05), and the oropharyngeal area decreased 36.5% (p < 0.01) when the OSA patients changed their body position from upright to supine. No changes were observed in the tongue area, but soft palate thickness increased (p < 0.01) when the control subjects changed from the upright to the supine position. Furthermore, the oropharyngeal cross-sectional area decreased 28.8% (p < 0.01) despite a 34% increase (p < 0.05) in resting GG EMG activity. Posterior tongue pressure increased 17% (p < 0.05) with the change from upright to supine. On the basis of these findings, we propose that body posture has a substantial effect on upper airway structure and muscle activity. This postural effect should be taken into account when assessing upper airway size in the erect posture (conventional cephalography) and in the supine position (computed tomography). The vertical and anteroposterior position of the tongue and its relationship to airway size may be more important than soft palate size in the pathogenesis of OSA.
Collapse
Affiliation(s)
- E K Pae
- University of British Columbia, Department of Clinical Dental Sciences, Vancouver, Canada
| | | | | | | | | | | |
Collapse
|
48
|
Affiliation(s)
- A A Lowe
- Department of Clinical Dental Sciences, University of British Columbia, Vancouver, Canada
| |
Collapse
|
49
|
Abstract
Atypical tongue muscle activity during sleep may contribute to the development of obstructive sleep apnea (OSA). Inspiratory genioglossus (GG) muscle activity was investigated in 10 OSA adults and 4 symptom-free controls. On the basis of overnight monitoring during nonREM sleep, the duration of the inspiratory GG activity and the total GG activity cycle is shorter in patients with OSA. The duration of inspiration and the duration of one total respiratory cycle is also shorter in patients with OSA. The commencement time lag between inspiratory GG activity and the onset of inspiration is shorter in patients with OSA during nonapneic breathing which indicates that inspiratory GG activity is activated relatively later in these patients. Furthermore, the inspiratory GG activity occurs after inspiration during an apnea, but the timing of GG activity onset progressively advances during the apnea. Earlier GG reactivation occurs before inspiration during the first nonoccluded breath at the end of an apnea. During subsequent tidal breathing, the timing of the GG onset progressively decreases after the onset of inspiration until the next obstructive apnea occurs. This observation suggests that the timing relationship between GG inspiratory activity and inspiratory effort is of physiologic importance in the pathogenesis of OSA. Furthermore, it may explain why dental appliances, such as the tongue retaining device, are highly effective in the resolution of OSA in selected patients.
Collapse
Affiliation(s)
- S Adachi
- Faculty of Dentistry, University of British Columbia, Vancouver, Canada
| | | | | | | | | |
Collapse
|
50
|
Abstract
A sample of 84 adult male patients with obstructive sleep apnea (OSA) were classified by a cluster analysis on the basis of apnea index (AI) and body mass index (BMI). Demographic, cephalometric, tongue, soft palate, and upper airway-size data were evaluated for the two subgroups of OSA patients and for 18 control subjects. One OSA group consisted of 43 patients with a high AI and low BMI ratio, the other group was comprised of 41 patients with a low AI and high BMI ratio. The patients with a high AI and low BMI ratio had retruded mandibles with high mandibular plane angles and proclined lower incisors. The patients with a low AI and high BMI ratio had inferior hyoid bones and large soft palates. A multiple regression analysis was performed between AI (the dependent variable) and the other variables (independent variables) for each of the subgroups. In the patients with a high AI and low BMI ratio, a high AI was related to a large skeletal anteroposterior discrepancy, a steep mandibular plane, and an inferoanterior position of the hyoid bone. In the patients with a low AI and high BMI ratio, a high AI was related to a large tongue and a small upper airway. In both groups, BMI was the major contributor to AI. In conclusion, these two groups may represent distinct subgroups of OSA patients and provide some insight into the contribution of obesity to the pathogenesis of OSA. The patients with a high AI and low BMI ratio have a skeletal mismatch, whereas the patients with a low AI and high BMI have atypical soft tissue structures.
Collapse
Affiliation(s)
- M Tsuchiya
- University of British Columbia, Department of Clinical Dental Sciences, Vancouver, Canada
| | | | | | | |
Collapse
|