A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea

OBJECTIVE

To compare the effectiveness of positional therapy (PT) with the sleep position trainer (SPT) to oral appliance therapy (OAT) in patients with mild-to-moderate positional obstructive sleep apnea (POSA).

METHODS

Multicenter, prospective, randomized, controlled trial. Patients with mild-to-moderate POSA (apnea-hypopnea index (AHI) ≥5 ≤ 30/hour sleep) were randomized for PT or OAT. Polysomnography was repeated after 3 months. Efficacy, adherence, mean disease alleviation (MDA), quality of life, dropouts and adverse events were evaluated.

RESULTS

A total of 177 patients were screened for the study; 99 underwent randomization and 81 completed the study. Intention-to-treat (ITT) analysis of median [IQR] AHI showed a reduction in the PT group from 13.0 [9.7-18.5] to 7.0 [3.8-12.8], p < 0.001 and in the OAT group from 11.7 [9.0-16.2] to 9.1 [4.9-11.7], p < 0.001. Mean adherence (≥4 h/night, ≥5 days/week) was 89.3 ± 22.4% for SPT versus 81.3 ± 30.0% in OAT patients, p = 0.208.

CONCLUSIONS

Oral appliance therapy and positional therapy were equally effective in reducing the median AHI in patients with mild-to-moderate POSA. The results of this study have important implications for future OSA treatment guidelines and daily clinical practice. CLINICALTRIALS.

GOV NUMBER

NCT02045576.

Two subtypes of positional obstructive sleep apnea: Supine-predominant and supine-isolated

OBJECTIVES

The body position has a strong influence on obstructive sleep apnea (OSA). The purpose of this study is to compare the clinical features of two subtypes of positional OSA (POSA), namely supine-predominant OSA (spOSA) and supine-isolated OSA (siOSA), so as to discuss whether the two groups can be classified separately.

METHODS

A total of 279 consecutive patients with OSA were enrolled. The POSA was defined as having an overall apnea-hypopnea index (AHI) ⩾ 5 with supine AHI > 2 times the non-supine AHI. Only those with ⩾ 30 min spent in the supine and non-supine sleeping positions were included, and split night studies were excluded from the study. Patients were considered spOSA unless their non-supine AHI was negligible (<5) (siOSA). The clinical and polysomnographic characteristics of both groups were compared.

RESULTS

Two hundred and sixteen subjects (77.4%) met the criteria for POSA, with 158 (73.1%) of them classified as spOSA, and 58 (26.9%) as siOSA. The siOSA patients had lower arousal indices, but poorer quality of sleep, and were more depressed and anxious compared with the spOSA subjects.

CONCLUSIONS

Those with siOSA and spOSA show different clinical features.

SIGNIFICANCE

These findings suggest that a more detailed sub-classification of POSA is needed.

Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: A multi-arm, parallel-group randomized controlled trial

OBJECTIVES

We explored whether a new combination of eye mask sleep position therapy (SPT) and oral appliance therapy (OAT) was more effective at treating positional obstructive sleep apnea (POSA) than was the use of either device alone.

METHODS

In this randomized controlled trial, 60 POSA subjects diagnosed by standard polysomnography (PSG) were divided into three groups (ratio 1:1:1): SPT, OAT, and SPT combined with OAT (SOT). Participants underwent hospital-based follow-ups during months 1 and 6 after beginning treatment. The primary outcome was the decline in the apnea hypopnea index (AHI) at month 6. The secondary outcomes were changes in oxygen-derived parameters and the curative effect at month 6.

RESULTS

After 6 months of treatment, PSG showed that SPT, OAT, and SOT all improved the AHI and oxygen-derived parameters. The AHI decline was significantly better in the SOT group than in the OAT or SPT group (71.58% [50.56-84.84%] for SOT, 44.42% [21.23-67.52%] for OAT, and 33.24% [19.03-54.62%] for SPT at 6 months) (P = 0.018 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). In terms of oxygen-derived parameters, only the sleep apnea-specific hypoxic burden (SASHB) improved more in the SOT group (76.89% [57.43-85.91%]) than in the other groups (44.73% [32.38-72.69%] for OAT and 41.82% [15.40-65.24%] for SPT, P = 0.002 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). The efficacies of SPT, OAT, and SOT were 36.84%, 50%, and 80% at 6 months; the SOT group evidenced the highest value (rate ratio [95% confidence interval] 1.78 (1.05-3.03), P = 0.048 and 2.17 (1.16-4.07), P = 0.010, for the comparisons of SOT with OAT and SOT with SPT, respectively).

CONCLUSION

The combination of SPT and OAT was better than either treatment alone and may represent a good option for the treatment of POSA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn/showproj.aspx?proj=42,852; No. ChiCTR1900025584.

Short-term effects of a vibrotactile neck-based treatment device for positional obstructive sleep apnea: preliminary data on tolerability and efficacy

BACKGROUND

Positional supine obstructive sleep apnea syndrome (OSAS) characterizes a subgroup of patients suffering from OSAS. Several devices designed to limit supine position have been developed, but evidences of their efficacy and safety are lacking. It is unclear whether a neck-worn vibrating device could induce positional change in patients with positional OSAS. We evaluated the efficacy of a neck-worn device to induce supine avoidance positional feedback over a short-term trial in OSAS patients and its impact on sleep quality and polysomnographyc indexes.

METHODS

Twenty patients with positional apneas/hypopneas were prospectively studied. Baseline characteristics of daytime somnolence and risk of sleep apnea were screened and the efficacy of a 3-day trial of supine-avoidance therapy by vibrotactile neck worn device assessed by reporting the self-perceived change in quality of sleep and performing cardio-respiratory polysomnography. Comparison between baseline and treatment results was performed.

RESULTS

The neck device produced a reduction in overall apnea-hypopnea index (AHI) (mean AHI pre =16.8/h and post =4.4/h, P<0.0001), oxygen desaturation (pre =13.7/h and post =3.8/h, P<0.0001) and Respiratory Disturbance Indexes (RDI) (20.0/h vs. 5.2/h; P<0.0001).The time spent in supine position decreased from 62.1% to 33.7% of the total (P<0.001). However, the impact on the perceived quality of sleep was unpredictable.

CONCLUSIONS

The neck position therapy device is effective in restricting supine sleep, improving AHI and related polysomnographic indexes. However, at least in a short-term trial, it seems unable to improve the patient's sleep quality.

Older Age is Associated With Positional Obstructive Sleep Apnea

OBJECTIVES

Untreated obstructive sleep apnea (OSA) is associated with cognitive dysfunction; however studies report low adherence rates to standard continuous positive airway pressure (CPAP) treatment in the elderly. Positional OSA (p-OSA) is a subset that can be cured by positional therapy of avoiding supine sleep. However, there is no well-established criteria to identify patients who could benefit from positional therapy as an alternative or adjunct to CPAP. This study investigates if older age is related to p-OSA using different diagnostic criteria.

DESIGN

Cross-sectional study.

PARTICIPANTS

Participants aged 18 years old or more who underwent polysomnography for clinical reasons at University of Iowa Hospitals and Clinics over a 1-year period from July 2011 to June 2012 were enrolled retrospectively.

MEASUREMENT

P-OSA was defined as a high supine-position dependency of obstructive breathing events with potential resolution of OSA in nonsupine positions [high apnea-hypopnea index on supine positions (s-AHI)/ AHI on nonsupine positions (ns0AHI) combined with ns-AHI < 5/hour]. Different cutoff points (2, 3, 5, 10, 15, 20) were applied to determine a meaningful ratio of supine-position dependency of obstructions [s-AHI/ns-AHI]. We compared the proportion of patients with p-OSA between the older age group (≥65 years old) and the propensity score (PS)-matched (upto 1:4) younger age group (<65 years old) using logistic regression analyses.

RESULTS

In total, 346 participants were included. The older age group had a higher s-AHI/ns-AHI ratio than the younger age group (mean 31.6 [SD 66.2] versus 9.3 [SD 17.4], median 7.3 [interquartile range [IQR], 3.0-29.6) versus 4.1 (IQR, 1.9-8.7). After PS-matching, the older age group (n = 44) had higher proportion of those with a high s-AHI/ns-AHI ratio and ns-AHI< 5/hour compared with the younger age group (n = 164). (s-AHI/ns-AHI≥10: 54.6% versus 31.7%, OR 2.44 (95% CI, 1.22-4.90); s-AHI/ns-AHI≥15: 47.7% versus 26.2%, OR 2.24 (95% CI, 1.14-4.37); s-AHI/ns-AHI≥20: 40.9% versus 19.5%, OR 2.52 (95% CI, 1.22-5.20)) CONCLUSION: Older patients with OSA are more likely to have severe position dependent OSA, that is potentially more treatable with positional therapy. Thus, clinicians treating older, cognitively impaired geriatric patients unable to tolerate CPAP therapy should consider positional therapy as an adjunct or alternative.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparing the diagnostic value of the positional obstructive sleep apnea definitions

Several definitions were proposed to diagnose Positional Obstructive Sleep Apnea (pOSA). However, the comparison between these definitions according to their diagnostic value is scarce in the literature. Thus, we decided to conduct this study to compare between the four criteria according to their diagnostic value. Between 2016 and 2022, 1092 sleep studies were performed at the sleep lab at the Jordan University Hospital. Patients who had an AHI <5 were excluded. pOSA was described according to the four definitions; Amsterdam Positional OSA Classification (APOC), supine AHI twice the non-supine AHI (Cartwright), Cartwright plus the non-supine AHI <5 (Mador), and overall AHI severity at least 1.4 times the non-supine severity (Overall/NS-AHI). Furthermore, 1033 polysomnographic sleep studies were retrospectively analyzed. The prevalence of pOSA according to the reference rule was 49.9% among our sample. The Overall/Non-Supine definition had the highest sensitivity, specificity, positive predictive value, and negative predictive value, which were 83.5%, 99.81%, 99.77%, and 85.88% respectively. The Overall/Non-Supine definition also had the highest accuracy among the four definitions (91.68%). Our study showed that all the criteria had a diagnostic accuracy above 50%, indicating that they were accurate in forming the diagnosis of pOSA. The Overall/Non-Supine criteria had the highest sensitivity, specificity, diagnostic odds ratio, and positive likelihood ratio as well as the lowest negative likelihood ratio, indicating the superiority of this criterion over the other definitions. Choosing the right criteria for diagnosing pOSA would result in fewer patients being assigned to CPAP and more being assigned to positional therapy methods.

Development of positional obstructive sleep apnea (POSA) after upper airway surgery in OSA patients

PURPOSE

Positional therapy (PT) has become more reliable for obstructive sleep apnea (OSA) patients with the use of new devices. The objectives of this study were to determine the preoperative prevalence of positional OSA (POSA) in our population of surgically treated patients and the proportion of patients who developed POSA after surgery and might improve with additional positional therapy.

METHODS

This was a retrospective study of surgically treated OSA patients from 1999 to 2017. The Cartwright definition was used to define POSA. All patients completed a sleep study before and 6 months after surgery and a complete upper airway (UA) exploration (awake ± DISE). A total of 125 patients were included.

RESULTS

The global prevalence of POSA before surgery was 31.2%. In those who were cured by surgery, the preoperative prevalence of POSA was 38.3%. Having POSA was not related with surgical success outcome. For patients not cured by surgery, the proportion of POSA significantly increased from 25.64 to 53.85% after surgery. Eighteen patients of them (23.1%) achieved AHI < 5/h in a lateral position. In those patients, PT with Night-Shift™ was suggested, 50% of them accepted it and 88.9% of them experienced excellent satisfaction. Lateral velum collapse and the absence of concentric collapse at the tongue base had statistical relationships with the development of POSA.

CONCLUSIONS

The prevalence of POSA is increased after surgery in patients with persistent OSA after surgery. In these patients, the development of POSA gives an extra therapeutic chance as 23.1% of these cases can be successfully treated by using PT.

Preliminary study on clinical characteristics of Chinese patients with positional obstructive sleep apnea

PURPOSE

The objective of this study was to evaluate the prevalence, the clinical characteristics, and the possible predictors of Chinese patients with positional obstructive sleep apnea (POSA) according to the Amsterdam Positional Obstructive Sleep Apnea Classification (APOC).

METHODS

A retrospective study in the sleep unit of Peking Union Medical College Hospital was conducted to analyze the clinical and polysomnography data of Chinese patients with obstructive sleep apnea (OSA).

RESULTS

Of 372 patients with OSA, 54% met the APOC criteria for POSA. The prevalence of POSA was significantly higher in women with OSA than in men. Chinese patients with POSA had a lower apnea-hypopnea index, oxygen desaturation index, and the percentage of time spent at oxygen saturation below 90% in total sleep time; and a higher mean oxygen saturation (SaO₂) and minimum SaO₂ during sleep, which were remarkable in the APOC I group. By multivariate logistic regression analyses, the higher mean SaO₂ (≥95%) during sleep and mild and moderate OSA were positive predictors of POSA. Mild and moderate OSA was the independent predictor of POSA in women. Higher mean SaO₂ (≥95%) during sleep was the independent predictor of POSA in men.

CONCLUSION

According to the APOC, the prevalence of POSA is high in Chinese patients with OSA, especially in women. Chinese patients with POSA had less severe OSA and a lower degree of nocturnal hypoxia, which was remarkable in the APOC I group.

Positional sleep apnea phenotyping using machine learning and digital oximetry biomarkers

STUDY OBJECTIVES

To examine the feasibility of using digital oximetry biomarkers (OBMs) and body position to identify positional obstructive sleep apnea (POSA) phenotypes.

METHODS

A multiclass extreme gradient boost (XGBoost) was implemented to classify between three POSA phenotypes, i.e., positional patients (PP), including supine-predominant OSA (spOSA), and supine-isolated OSA (siOSA), and non-positional patients (NPP). A total of 861 individuals with OSA from the multi ethnic study of atherosclerosis (MESA) dataset were included in the study. Overall, 43 OBMs were computed for supine and non-supine positions and used as input features together with demographic and clinical information (META). Feature selection, using mRMR, was implemented, and nested cross validation was used for the model's performance evaluation.

RESULTS

The best performance for the multiclass classification yielded a median weighted F1 of 0.79 with interquartile range (IQR) of 0.06. Binary classification between PP to NPP achieved weighted F1 of 0.87 (0.04).

CONCLUSION

Using OBMs computed in PP and NPP with OSA, it is possible to distinguish between the different phenotypes of POSA. This data-driven algorithm may be embedded in portable home sleep tests.

Clinical characteristics and outcomes of positional obstructive sleep apnea: the sleep heart health study

PURPOSE

Positional obstructive sleep apnea (POSA) is common among obstructive sleep apnea (OSA) patients and exhibits distinct clinical features. This study aimed to analyze the clinical characteristics and associated factors of POSA, as well as compare the outcomes between POSA and non-POSA (NPOSA).

METHODS

OSA subjects aged over 40 years from the Sleep Heart Health Study were included in this study. OSA was classified into POSA and NPOSA according to the Cartwright criteria. Univariate and multivariable logistic regression analyses were conducted to identify predictors of POSA. The incidence of outcome events across the two groups was assessed using cumulative hazard curves and compared with the log-rank test.

RESULTS

A total of 1,080 OSA subjects were included, with 412 in the NPOSA group and 668 in the POSA group. In the univariate analysis, body mass index, diabetes, apnea-hypopnea index (AHI), the percentage of sleep time with oxygen saturation below 90% (CT90) and arousal index were inversely associated with POSA, average oxygen saturation during sleep and minimum oxygen saturation during sleep were positively associated with POSA. In the multivariate analysis, AHI (OR 0.98, 95% CI 0.97 to 0.99, p = 0.006) and CT90 (OR 0.98, 95% CI 0.96 to 1.00, p = 0.027) remained significantly inversely associated with POSA after adjusting for other variables. There was no significant difference in the cumulative hazard of myocardial infarction, stroke, congestive heart failure, or all-cause mortality between the two groups during the mean follow-up period of 11 years.

CONCLUSIONS

This study identified AHI and CT90 as independent predictive factors for POSA. There was no significant difference in the incidence of myocardial infarction, stroke, congestive heart failure, or all-cause mortality between POSA and NPOSA.

Robotic beds for the treatment of positional obstructive sleep apnea - A randomized cross-over pilot trial

BACKGROUND

Interventions leading to avoidance of supine position and thus reducing the likelihood of upper airway collapse during sleep are a treatment approach for positional obstructive sleep apnea (POSA). The aim of this randomized cross-over trial was to assess the effect of two actuated beds (trunk-elevation and sideward-tilting) on OSA severity and sleep fragmentation in POSA.

METHODS

After baseline polysomnography, adult patients with POSA were randomly assigned to two nights of intervention in the intelligent sleep apnea bed ISABel1 and ISABel2. In the case of obstructive apnea or hypopnea, ISABel1 elevated the upper body by 50° and ISABel2 induced a unilateral bed tilt of 40°, with both interventions lasting 10 min. Sustained trunk elevations without sliding down (ISABel1) and position change from supine to non-supine (ISABel2) were defined as successful interventions.

RESULTS

Six adult men (57 ± 11 years, BMI 28 ± 4 kg/m2, AHI 39 ± 15/h) with POSA were included. Neither trunk elevation (ISABel1) nor side tilt (ISABel2) - approximately 10 interventions per night - significantly reduced apnea-hypopnea index (AHI), whereas trunk elevation showed a tendency to reduce supine AHI. Actuated beds had no effect on sleep efficiency and arousals. Only 13 % of side tilts in ISABel2 resulted in a successful shift to a non-supine position. The time to the next respiratory event after bed movement was longer in the trunk elevating bed than in the side-tilting bed.

CONCLUSION

Trunk elevating beds decrease supine AHI and both side-tilting and trunk elevating beds increase the time to the next obstructive apnea or hypopnea.

Positional therapy for the treatment of positional obstructive sleep apnea in children: A randomized controlled crossover trial

BACKGROUND

Obstructive sleep apnea (OSA) is prevalent in children, but many children remain untreated. Up to one half of children with OSA have positional OSA, a phenotype characterized by the predominance of airway obstruction while supine. Positional devices that prevent sleeping supine may be beneficial for positional OSA. We evaluated the efficacy of positional devices for treating positional OSA in children.

STUDY DESIGN AND METHODS

This was a randomized crossover trial of children aged 4-18 years old with positional OSA. There were two treatment periods separated by 1-4 weeks. Each period consisted of a one-night in-laboratory polysomnogram with the experimental intervention (positional device with inflated cushions) or the inactive control (positional device with no cushions). The primary outcome was the difference in the obstructive apnea-hypopnea index (OAHI) between positional therapy and the control.

RESULTS

24 participants were randomized (median age = 9.0 years, 63% males). The adjusted relative percentage difference in the OAHI (positional therapy minus control) was -29.9% (95% CI -55.9% to 11.6%; p = 0.13). The adjusted relative percentage differences for the desaturation index, arousal index, and percentage of total sleep time supine were -23.4% (95% CI -45.0% to 6.7%; p = 0.11), -16.7% (95% CI -30.8% to 0.22%; p = 0.053), and -65.9% (95% CI -79.3% to -43.9%; p<0.001), respectively. There were no significant differences in comfort scores or adverse events.

INTERPRETATION

Positional therapy reduced supine sleep time, but did not reduce the OAHI in all participants. Future studies with larger sample sizes to evaluate heterogeneity of treatment effects are warranted.

The Rematee Bumper Belt(®) positional therapy device for snoring and obstructive sleep apnea: Positional effectiveness in healthy subjects

The present study was designed to investigate body position changes resulting from wearing a Rematee Bumper Belt (Rematee, Canada) during sleep. The majority of obstructive sleep apnea (OSA) patients will experience up to two times as many apneas and hypopneas while supine relative to lateral or prone body positions during sleep. It has been suggested that a positional therapy device could reduce the number of apneas and hypopneas in such patients. The present study was conducted to determine whether the Rematee Bumper Belt positional therapy device could prevent healthy subjects from sleeping in the supine position. Test subjects wore the belt for one to two nights. Each belt was equipped with an accelerometer that was used to measure the orientation of the belt relative to the horizontal plane. The results suggest that the belt creates an exclusion zone approximately 80° wide centred near the supine orientation, where subjects are effectively prevented to enter. Results of the present preliminary study suggests that the Rematee Bumper Belt positional therapy device is effective at limiting healthy subjects from sleeping in a supine position. The device appears to be most effective between 150° and 230°. A device with this capability may provide an inexpensive and potentially effective alternative treatment option for patients with OSA. This device has the capacity for reducing snoring and the apnea-hypopnea index in individuals with positional OSA.

Upper airway morphology in adults with positional obstructive sleep apnea

PURPOSE

To compare the anatomical balance and shape of the upper airway in the supine position between adults with positional obstructive sleep apnea (POSA) and adults with non-positional OSA (NPOSA).

METHODS

Adults diagnosed with OSA (apnea-hypopnea index (AHI) > 10 events/h) were assessed for eligibility. POSA was defined as the supine AHI more than twice the AHI in non-supine positions; otherwise, patients were classified as NPOSA. Cone beam computed tomography (CBCT) imaging was performed for every participant while awake in the supine position. The anatomical balance was calculated as the ratio of the tongue size to the maxillomandibular enclosure size. The upper airway shape was calculated as the ratio of the anteroposterior dimension to the lateral dimension at the location of the minimal cross-sectional area of the upper airway (CSAmin-shape).

RESULTS

Of 47 participants (28 males, median age [interquartile range] 56 [46 to 63] years, median AHI 27.8 [15.0 to 33.8]), 34 participants were classified as having POSA (72%). The POSA group tended to have a higher proportion of males and a lower AHI than the NPOSA group (P = 0.07 and 0.07, respectively). After controlling for both sex and AHI, the anatomical balance and CSAmin-shape were not significantly different between both groups (P = 0.18 and 0.73, respectively).

CONCLUSION

Adults with POSA and adults with NPOSA have similar anatomical balance and shape of their upper airway in the supine position.

TRIAL REGISTRATION

This study was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR Trial ACTRN12611000409976).