Improvement In Apnea-hypopnea Index Research Articles

Comparative Study of Myofascial Exercise and the Voluntary Breathing Technique on the Apnea-Hypopnea Index Among Adolescents.

Background Myofunctional therapy has shown promise in addressing sleep-disordered breathing. This study aimed to investigate the efficacy of myofascial exercise and voluntary breathing techniques in reducing the apnea-hypopnea index (AHI) among adolescents. Methodology In this randomized controlled study, adolescents aged 13-18 with sleep-disordered breathing were randomly assigned to one of three groups (n=40 per group): myofascial exercise, voluntary breathing techniques, and a standard care control group. Baseline assessments, including the AHI and sleep quality, were conducted before the interventions. A polysomnography (PSG) sleep study was performed in a sleep laboratory, with recordings conducted over six to eight hours during the night to calculate the AHI. The myofascial exercise and voluntary breathing technique groups received their respective interventions, while the control group received standard care. Post-intervention assessments were conducted to measure changes in AHI and other outcomes. Results The study found no significant differences in age, BMI, and gender among the three groups. However, significant differences were observed in AHI and sleep quality measures. The control group's AHI was 8.72 ± 1.78, whereas the myofascial exercise group (4.82 ± 1.42) and the voluntary breathing group (6.81 ± 1.83) exhibited more substantial reductions (p < 0.001). Similarly, while baseline sleep quality scores did not differ, significant improvements were observed in all groups post-intervention, with more substantial enhancements in the myofascial exercise (4.38 ± 1.19) and voluntary breathing (7.23 ± 1.76) groups. The analysis of baseline AHI categories revealed no significant differences, but at follow-up, significant variations emerged among the groups, indicating greater reductions in AHI categories in the myofascial exercise and voluntary breathing groups compared to the control group. Conclusion These findings indicate that incorporating myofascial exercises or voluntary breathing techniques into treatment plans for adolescents with sleep-disordered breathing can result in significant improvements in AHI and overall sleep quality.

Sleep-disordered breathing in children with Chiari type I malformation.

The objective was to identify clinical and radiological factors associated with sleep-disordered breathing (SDB) in children with Chiari type I malformation (CIM) and to evaluate the efficacy of foramen magnum decompression (FMD) in resolving SDB. A retrospective chart review was conducted for all children evaluated for CIM at a single institution from 2002 to 2022, identifying all children who had undergone nocturnal polysomnography (PSG). Apnea-hypopnea index (AHI) score, sleep apnea type (obstructive, central, mixed, and unspecified), clinical manifestations, and radiological measurements were recorded. SDB was considered present when officially diagnosed in the PSG report. Logistic regression was performed to identify factors correlating with the presence of SDB. For children with SDB who underwent FMD, the Wilcoxon signed-rank test was used to assess AHI improvement. Of the 997 children referred for CIM, 310 completed PSG. SDB was diagnosed in 147 patients (overall prevalence 14.7%, 95% CI 12.7%-17.1%; prevalence among children with PSG 47.4%, 95% CI 41.9%-53%). Specific SDB diagnosis consisted of 33% of patients with central sleep apnea, 27% with obstructive sleep apnea, 9% mixed, and 31% unspecified. Lower cranial nerve (CN) dysfunction (OR 3.891, p = 0.009), tonsillar position (OR 1.049, p = 0.017), Chiari type 1.5 malformation (OR 1.862, p = 0.044), and BMI (OR 1.039, p = 0.036) were significantly associated with presence of SDB. Of the 310 patients who underwent PSG, 47 were originally categorized as asymptomatic: 27 (57%) of these asymptomatic patients were diagnosed with SDB on PSG. Of children diagnosed with SDB, 34 completed PSG before and after FMD. Median AHI score decreased from 6.5 preoperatively to 1.8 postoperatively, with a median (IQR) difference of -2.3 (-11.9 to 0.1) (p = 0.001). Twelve (35%) had resolution of SDB. The authors' findings suggest that the prevalence of SDB in children with CIM is high (15%-47%). Furthermore, lower CN dysfunction, Chiari type 1.5, lower tonsillar position, and higher BMI may be risk factors. Notably, SDB can be present even in the absence of clinical symptoms. This study also demonstrates that surgical intervention has the potential to reduce the severity of SDB. These results could help clinicians identify CIM patients at risk for SDB and those who may benefit from surgical decompression.

Weight reduction and the impact on apnea-hypopnea index: A systematic meta-analysis

Obstructive sleep apnea (OSA) is strongly associated with obesity. While the relationship between weight reduction and apnea-hypopnea index improvement has been documented, to our knowledge, it has not been quantified adequately. Therefore, this study aimed to quantify the relationship between weight reduction and AHI change. MethodsA systematic literature search was performed using meta-analyses (PRISMA) guidelines for studies reporting AHI and weight loss in people with obesity/overweight and OSA between 2000 and 2023. A linear and quadratic model (weighted by treatment arm sample size) predicted percent change from baseline AHI against mean percent change from baseline weight. The quadratic term was statistically significant (P < 0.05), so the quadratic model (with 95 % prediction interval) was used. ResultsThe literature search identified 27 studies/32 treatment arms: 15 using bariatric surgery and lifestyle intervention each and 2 using pharmacological interventions. Included studies were ≥3 months with weight intervention and participants had AHI ≥15/h. Weight reduction in people with OSA and obesity was associated with improvements in the severity of OSA. BMI reduction of 20 % was associated with AHI reduction of 57 %, while further weight reduction beyond 20 % in BMI was associated with a smaller effect on AHI. As the prediction intervals are relatively wide, a precise relationship could not be conclusively established. ConclusionThe degree of AHI index improvement was associated with the magnitude of weight reduction. The model suggests that with progress in weight reduction beyond 20 %, the incremental decrease in BMI appeared to translate to a smaller additional effect on AHI.

Effects of mandibular advancement devices on the evolution of obstructive sleep apnea.

Mandibular advancement devices (MADs) are a treatment for obstructive sleep apnea (OSA). Titration is a necessary component of proper fitting of MADs, yet little is known about what happens at each step of the titration. The objectives of this study were to determine the clinical and paraclinical evolution of OSA at every mm of MAD advancement. Volunteers were fitted with MADs set to 50% of maximum advancement. MAD clinical and paraclinical results were recorded at every additional mm-titration, including apnea-hypopnea index (AHI), as well as symptoms of sleepiness and fatigue. In 20 volunteers with OSA, the MAD had a significant effect on every polygraphic parameter at the onsetof use. The mean AHI with MAD fell by 15.2/h (p < 0.001). The mean Epworth Sleepiness Score and Pichot Fatigue questionnaire with MAD fell by 2.0 (p = 0.0687) and 2.4 (p = 0.1073)respectively. There was no proportionality between clinical gains (drowsiness and fatigue) and AHI improvements. MADs led to a significant improvement inAHI and other polygraphic parameters from the onsetof use. The decrease of clinical symptoms (drowsiness and fatigue) was more complex to interpret because of the small decreasesobserved. The absence of concordance between AHI improvement and clinical symptoms was nevertheless objectively quantified and symptoms were alleviated with advancements. The findings suggest that it may be appropriate to use clinical symptoms as a main aim of titration, sincethe improvement in AHI is reached at the onsetof MAD use.

Alterations of Gut Microbiome Composition and Function Pre- and Post-Adenotonsillectomy in Children with Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) in children is linked with alterations in the gut microbiome. The influence of adenotonsillectomy (AT), a primary intervention for OSA, on gut microbiota dynamics relative to disease severity remains to be elucidated. This study aimed to investigate the impact of OSA severity and AT on the gut microbiome in pediatric patients. A prospective observational study. Tertiary referral center. A cohort of 55 pediatric patients treated with AT for OSA. Total tonsillectomy and adenoidectomy procedures. Comprehensive evaluations included in-laboratory polysomnography and 16S rRNA gut microbiome profiling at baseline, and again at 3rd and 12thmonth following surgery. Initial findings showed uniform α-diversity across different severities of OSA, while β-diversity was significantly elevated in the severe OSA subgroup. Certain gut microbiota taxa (Lachnospiraceae NK4A136 group, Ruminococcaceae UCG-002, Ruminococcaceae UCG-014, Alloprevotella, Christensenellaceae R-7 group, Ruminococcaceae UCG-005, Lactobacillus murinus, and Prevotella nigrescens) were found to inversely correlate with the apnea-hypopnea index (AHI). Significant post-AT improvements in AHI and other polysomnographic metrics were observed. Notably, AHI changes post-AT were positively associated with microbial α-diversity (species richness), β-diversity, and specific bacterial taxa (Enterobacter, Parasutterella, Akkermansia, Roseburia, and Bacteroides plebeius DSM 17135), but negatively with other taxa (Fusicatenibacter, Bifidobacterium, UBA1819, Ruminococcus gnavus group, Bifidobacterium longum subsp. Longum, and Parabacteroides distasonis) and specific metabolic pathways (purine metabolism, transcription factors, and type II diabetes mellitus). The postoperative patterns of α- and β-diversity mirrored baseline values. This study documents significant changes in the gut microbiome of pediatric patients after AT, including variations in α- and β-diversities, bacterial communities, and inferred metabolic functions. These changes suggest a potential association between the surgical intervention and microbiome alterations, although further studies are necessary to discern the specific contributions of AT amidst possible confounding factors such as antibiotic use.

Improving CPAP Therapy with Superimposed Pressure Oscillation

Background: Continuous positive airway pressure (CPAP) is considered the gold standard therapy for Obstructive Sleep Apnea (OSA); however, many side effects, such as uncomfortable high titration pressure (TP) and mouth dryness, are associated with this treatment. This work proposes using pressure oscillations superimposed on a mean pressure to modulate the upper airways, reduce TP, and stimulate the salivary glands to reduce mouth dryness. Methods: Two nonconsecutive overnight randomized controlled clinical trials were designed, one with a standard CPAP setup but reduced TP and the other by adding superimposed pressure oscillations (SIPO) to the reduced TP CPAP setup. 33 OSA patients who usually received CPAP treatment with predetermined TP settings participated in the two trials. Complete polysomnography was performed for sleep and patient assessments. However, a spitting technique protocol was used on 15 randomly selected patients from the same group to investigate the effect of SIPO on mouth dryness. These trials are registered under ACTRN12622001518752. Results: The apnea-hypopnea index (AHI) was significantly reduced from 25.08 ± 2.32 to 17.56 ± 2.11 (p = 0.020*) with SIPO, indicating a 29.95% reduction in AHI and a decrease in breathing obstructions during enhanced therapy. Additionally, SIPO significantly decreased the oxygen desaturation index (ODI) (p = 0.002), maintaining the blood oxygen level within the normal range during the trials. ODI≥3 decreased significantly by 38.04% with SIPO. Saliva test results demonstrated that SIPO significantly increased saliva volume by 23.13% in non-stimulation and by 39.09% during stimulation compared to the CPAP trial. Conclusions: This work demonstrates that SIPO reduces the TP to 70% of its standard clinical setting and stimulates salivary secretion to reduce mouth dryness. Further, significant improvements in AHI, respiratory arousal index (RAI), Arousal index (AI), and sleep efficiency (SE) are observed. This work is proof of concept, and further trials should be undertaken to generalize the proposed technique.

Assessment of Surgical Accuracy in Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea: A Preliminary Analysis.

This retrospective study aimed to: (1) investigate the surgical accuracy of maxillomandibular advancement (MMA) in obstructive sleep apnea (OSA) patients, with a specific focus on maxillary and mandibular advancement and counter-clockwise rotation and (2) investigate the correlation between the amount of achieved advancement and the reduction in the relative apnea hypopnea index (AHI). Sixteen patients, for whom a three-dimensional virtual surgical plan was generated preoperatively and a computed tomography scan (CT) or cone-beam computer tomography (CBCT) was acquired postoperatively, were included. The postoperative CT or CBCT was compared to the virtual surgical plan, and differences in the mandibular and maxillary advancement and counter-clockwise rotation were assessed. Maxillary and mandibular advancement (median 3.1 mm, p = 0.002 and 2.3 mm, p = 0.03, respectively) and counter-clockwise rotation (median 3.7°, p = 0.006 and 4.7°, p = 0.001, respectively) were notably less than intended. A significant correlation was found between the planned maxillary advancement and the difference between the planned and actual maxillary advancement (p = 0.048; adjusted R2 = 0.1979) and also between the planned counter-clockwise rotation and the difference between the planned and actual counter-clockwise rotation for the mandible (p = 0.012; adjusted R2 = 0.3261). Neither the maxilla-first nor the mandible-first surgical sequence proved to be superior in terms of the ability to achieve the intended movements (p > 0.45). Despite a significant reduction (p = 0.001) in the apnea hypopnea index (AHI) from a median of 62.6 events/h to 19.4 events/h following MMA, no relationship was found between the extent of maxillary or mandibular advancement and AHI improvement in this small cohort (p = 0.389 and p = 0.387, respectively). This study underlines the necessity for surgeons and future research projects to be aware of surgical inaccuracies in MMA procedures for OSA patients. Additionally, further research is required to investigate if sufficient advancement is an important factor associated with MMA treatment outcome.

Fluoroscopic-Assisted Tongue Suspension: Advancement and Innovation in the Management of Complex Pediatric Obstructive Sleep Apnea.

The primary aim of this study is to describe a novel surgical technique developed for tongue base suspension (TBS). The second aim of this study is to assess the efficacy of the developed procedure by quantifying preoperative and postoperative polysomnographic outcomes for pediatric patients undergoing fluoroscopic-assisted tongue suspension (FATS) with the Encore System. Our hypothesis is that our FATS technique will provide at least a 50% reduction in the Apnea/Hypopnea Index (AHI), including in the medically complex pediatric population. Retrospective case series. An electronic medical record review was conducted of patients who underwent FATS by a single surgeon at a tertiary care medical center between December 2019 and June 2022. Inclusion criteria included all patients <18 years old with evidence of OSA or sleep-disordered breathing and who had glossoptosis on sleep endoscopy. Data extracted from the medical record included age, gender, medical comorbidity history, reason for referral, history of airway surgeries, length of hospital stay, surgical complications data, and preoperative and postoperative polysomnographic data. Surgical success was defined by at least a 50% reduction in AHI. Thirty patients (53.3% male) with a mean age of 6.3 (±5.3, 0.16-17) years underwent FATS over the study period. Most patients (93%) had an underlying comorbidity: cerebral palsy (37%), chromosomal abnormalities (23%), Down syndrome (13%), Pierre-Robin sequence (10%), and obesity (10%). The majority of patients (77%) were explicitly referred for tracheostomy placement secondary to failed management of OSA. 21 patients completed both preoperative and postoperative polysomnograms. The mean preoperative AHI, obstructive AHI (oAHI), and respiratory disturbance index (RDI) were 28.8 (±19.8), 30.8 (±19.6), and 30.5 (±19.3), respectively. The mean postoperative AHI, oAHI, and RDI were 7.3 (±9.2), 7.5 (±9.1), and 7.9 (±9.3), respectively. The mean change in AHI was -21.5 (±21.4) events/h (p < 0.01, 95% CI -29.0 to -11.4 events/h). The mean percentage decrease in AHI was 74.7%. The mean change in oAHI and RDI were -23.3 (±21.9) events/h (p < 0.01 95% CI- 39.9 to -21.4 events/h) and -22.5 (±21.5) events/h (p < 0.01, 95% CI- 31.5 to -12.4 events/h), respectively. The mean percentage decrease in oAHI and RDI was 75.6% and 73.8%, respectively. Surgical success occurred in 16 of the 21 (76%) patients. Of the 23 patients referred explicitly for tracheostomy placement, 21 (91%) were able to avoid tracheostomy placement secondary to improvements in OSA. Patients undergoing fluoroscopic-assisted TBS revealed statistically significant improvements in AHI, oAHI, and RDI, with an overall surgical success rate of 76%. Complication rates were minimal, despite the complex nature of the study population. FATS should be considered a viable surgical approach in pediatric patients with an identified base of tongue obstruction and OSA. 4 Laryngoscope, 134:S1-S9, 2024.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea.

Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery. A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes. A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005). This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%). Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis.

Orofacial myofunctional therapy (OMT) is an alternative form of treatment of obstructive sleep apnea (OSA), that incorporates various exercises to optimize tongue placement and increase oropharyngeal tone. The objective of this systematic review and meta-analysis is to determine the efficacy of OMT in OSA patients. PubMed/Medline, EMBASE, Cochrane, Web of Science. Using PRISMA guidelines, a directed search strategy was performed for randomized control trials (RCTs) published prior to March 24, 2023, featuring 10+ patients with OSA undergoing mono-therapeutic OMT. The primary outcome of interest was apnea-hypopnea index (AHI). Secondary outcomes included subjective sleepiness, sleep-related quality-of-life, and snoring frequency. Of the 1244 abstracts that were identified, 7 RCTs involving 310 patients met inclusion criteria. Adult OMT patients had a statistically significant improvement in AHI (MD -10.2; 95% CI, -15.6, -4.8, p < 0.05), subjective sleepiness (Epworth Sleepiness Scale; MD -5.66; 95% CI, -6.82, -4.5, p < 0.05), sleep-related quality-of-life (Pittsburgh Sleep Quality Index; MD -3.00; 95% CI, -4.52, -1.49, p < 0.05), and minimum oxygen saturation (MD 2.71; 95% CI, 0.23, 5.18, p < 0.05) when compared with sham OMT or no therapy. Within the single RCT featuring pediatric OMT patients, patients had poor compliance (<50%) and did not show any improvements in AHI, minimum oxygen saturation, or snoring frequency. OMT may provide a reasonable alternative for OSA patients who cannot tolerate CPAP or other more established treatment options. OMT benefits appear limited in children due to poor compliance. More studies are required to evaluate compliance and the long-term effects of OMT on OSA outcomes. 1 Laryngoscope, 134:480-495, 2024.

0572 Weight reduction and the impact on apnea-hypopnea index: a meta-analysis

Abstract Introduction The occurrence of obstructive sleep apnea (OSA) is strongly associated with obesity. Behavioral, pharmacological, and surgical interventions that promote weight reduction can reduce OSA severity and improve other common obesity related complications and quality of life. While the relationship between weight reduction and apnea-hypopnea index (AHI) improvement has been documented, it does not seem to have been quantified adequately. The objective of this analysis was to quantify the association between percent change in body weight and percent change in AHI using results from the literature. Methods A literature search identified 13 studies with AHI and weight measurements before and after weight intervention in people living with obesity and OSA; 6 studies from bariatric surgery, 4 studies from diet and exercise intervention, and 3 studies from anti-obesity medications (including 2 placebo-controlled randomized clinical trials). A polynomial and a linear meta regression model as well as 95% prediction intervals were used to assess the relationship between % weight change from baseline and % change in AHI from baseline. Results Both the polynomial and linear models show, on average, weight reduction in patients living with obesity and OSA has a clinical benefit in reducing AHI. The linear meta-regression model that we developed suggests a mean AHI decrease of 2.6% per 1% weight reduction. As the prediction intervals are relatively wide, a precise relationship could not be established. For example, based on the linear model for a patient with 20% weight reduction we expect to see a mean 52.8% reduction in AHI with a 95% prediction interval (89.8%, 15.8%) AHI reduction. Conclusion Evidence shows that intentional weight reduction in people living with obesity and OSA results in improvements in OSA severity, and this was confirmed by our meta-analysis and modeling. The model shows that the degree of AHI improvement is dependent on the magnitude of weight reduction. However, establishing a precise relationship between percent change in AHI and percent weight reduction is challenging given the sparsity of data, variability in populations studied, and variability in AHI change following weight reduction. Support (if any) Eli Lilly and Company

SP27. Mandibular Distraction in Patients with Pierre Robin Sequence: A Multi-surgeon Experience

PURPOSE: Mandibular distraction osteogenesis (MDO) is rapidly becoming a standard of care for management of patients with severe Pierre Robin Sequence. The tongue is brought forward to alleviate the airway obstruction. This study will look at an institutional, multi-surgeon experience with MDO over ten years. METHODS: This study was conducted as a retrospective chart review including all patients who underwent MDO at the authors’ institution from 2012 to 2022. Demographics, preoperative and postoperative respiratory and feeding status, and distraction data were collected. Primary outcomes were achievement of full oral feeds, avoidance of a gastrostomy tube (GT), avoidance of a tracheostomy, discharge from hospital on room air and complications. A significance value of 0.05 was utilized. RESULTS: Twenty-eight patients met inclusion criteria. Three craniofacial surgeons performed all interventions. The average age at MDO was 135 days, mean activation phase was 13.6 days, mean distraction length was 14.9 mm and mean consolidation phase was 64.2 days. MDO showed a significant improvement in apnea-hypopnea index (AHI) (p < 0.001) and %O2 Nadir (p < 0.001) on postoperative polysomnography. Syndromic patients were associated with discharge with a GT and negatively associated with avoidance of tracheostomy. Patients with preoperatively diagnosed tracheomalacia and subglottic stenosis were negatively associated with avoidance of a tracheostomy. Preoperative diagnosis of gastroesophageal reflux disease (GERD) was negatively associated with extubation immediately to room air (RA) following index procedure. A shorter duration of intubation following index procedure was associated with discharge on RA and a longer duration of intubation was associated with unilateral pan-facial nerve palsy. A longer activation phase was associated with discharge with a GT and a shorter activation phase was associated with discharge on full oral feeds. The ability to discharge on RA was associated with a shorter latency phase, shorter activation phase, and decreased distance of distraction. Repeat MDO was associated with postoperative infection requiring operative management. CONCLUSIONS: The goal of MDO is to achieve full oral feeds with no respiratory support. Several interesting findings are described in this study. When assessing patients preoperatively it is important to note the higher rate of failure to avoid a tracheostomy in patients with a syndrome and those with tracheomalacia and subglottic stenosis noted on airway evaluation. Syndromic patients were also noted to be more likely to be discharged with a GT. Several different latency periods were used in this study, and it appears that not only is a short latency period safe, but that it may be correlated with successful discharge on RA. This should be tempered with the finding that a decreased time spent intubated following surgery, decreased distance distracted and time spent in activation was also associated with discharge on RA, which may be a function of the severity of micrognathia in these patients. Of note, patients that spent a longer period intubated following surgery experienced a higher rate of facial nerve palsy. The reason for this correlation is unclear but may represent more severe cases that resulted in more forced retraction during surgery.

0527 Effectiveness of Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea at a Major Tertiary Academic Sleep Center

Abstract Introduction The use of hypoglossal nerve stimulation (HGNS) for treatment of obstructive sleep apnea (OSA) has been reported to be efficacious in up to 75% of patients with a 68% improvement in the 3% apnea hypopnea index (AHI). Based on these results, HGNS is an increasingly widespread alternative treatment for OSA patients who are intolerant of Positive Airway Pressure (PAP) treatment. It is unknown if HGNS is equally efficacious outside of the highly controlled setting of a clinical trial. Here, we performed a retrospective cohort study from patients who underwent implantation of a hypoglossal nerve stimulator at our academic institution and report the efficacy based on improvement in AHI. Methods Adult subjects with a diagnosis of OSA, who were intolerant of PAP therapy and underwent implantation of HGNS at Barnes Jewish Hospital in St. Louis, Missouri from 6/4/2019 to 6/28/2022 were included in this retrospective cohort study. Only those who were referred for implantation from Washington University Sleep Medicine Center were included. The efficacy of HGNS was evaluated by comparing the 3% AHI on subjects’ polysomnography before and after the HGNS was implanted and activated. Analysis of the data was done using paired t-tests to determine efficacy of HGNS via a reduction of at least 50% of the 3% AHI and a reduction in 3% AHI to less than 20 events per hour. Results 45 subjects were implanted of which 1 subject did not tolerate HGNS, and 8 subjects were lost to follow-up. Of the remaining 36 subjects, the median 3% AHI decreased 79% from 29.5 to 6.5 events per hour (p&amp;lt; 0.0001). There was a reduction of at least 50% of the 3% AHI in 83% of subjects and a reduction of 3% AHI to less than 20 events per hour in 86% of subjects. Conclusion HGNS achieved significant therapeutic results in the majority of patients with OSA who are intolerant of PAP therapy. These results add to the growing body of evidence reproducing the original clinical trial in a “real-world” setting free of any conflict of interest. Future studies examining predictive factors influencing the effectiveness of HGNS are needed. Support (if any)

0988 Vagal Nerve Stimulation and OSA

Abstract Introduction We present a case of obstructive sleep apnea (OSA) worsened by implantation of a vagal nerve stimulator (VNS). A 22-year-old M with PMH of autism and refractory epilepsy s/p VNS implantation was diagnosed with moderate OSA. His parents noted that his sleep-disordered breathing worsened after VNS implantation. He was started on APAP 4-12 cm H2O. Review of adherence data revealed an elevated residual apnea-hypopnea index (AHI) despite nightly usage. PAP titration study was obtained with improvement of AHI on 16 cm H2O. Despite consequent use of determined pressure settings, residual AHI remained elevated. In consultation with the patient’s neurologist, VNS settings were gradually down titrated. Residual AHI improved and remained low as CPAP settings were subsequently weaned. Report of case(s) The vagus nerve is part of the parasympathetic nervous system. Afferent fibers project to cortical regions involved in seizure activity. Vagal nerve activation leads to desynchrony, thereby decreasing seizure activity.3 VNS, an adjunctive non-pharmacologic treatment of refractory epilepsy, consists of a generator with multiple adjustable settings and a lead connected to the left vagus nerve.1 VNS activation, in conjuction with medical therapy, can lead to decreased seizures. However, VNS may cause complications such as vocal cord dysfunction, laryngeal spasm, and dyspnea.2 In this case, VNS was noted to cause OSA due to increased airway obstruction, though the pathophysiological mechanism behind this has not been clearly delineated. 3 Conclusion Based on current evidence of precipitation or worsening OSA with VNS activation, screening and diagnostic testing for OSA in patients under evaluation for VNS placement should be considered. A multidisciplinary approach between Sleep Medicine and Neurology in conjunction with patient goals can lead to a balanced optimization of both epilepsy and OSA management via adjustments of VNS settings, anti-epileptics, and CPAP. Support (if any) 1. VNS therapy epilepsy. Epilepsy Foundation. https://www.epilepsy.com/sites/default/files/atoms/files/516VNS_VNS_FINAL.pdf. December 20, 2022. 2. Ebben MR, Sethi NK, Conte M, Pollak CP, Labar D. Vagus nerve stimulation, sleep apnea, and CPAP titration. J ClinSleepMed. 2008 Oct 15;4(5):471-3. PMID: 18853706. 3. Parhizgar F, Nugent K, Raj R. Obstructive sleep apnea and respiratory complications associated with vagus nerve stimulators. J ClinSleepMed. 2011 Aug 15;7(4):401-7. doi: 10.5664/JCSM.1204. PMID: 21897779.

Targeted Hypoglossal Nerve Stimulation for Patients With Obstructive Sleep Apnea

Evidence is lacking from randomized clinical trials of hypoglossal nerve stimulation in obstructive sleep apnea (OSA). To evaluate the safety and effectiveness of targeted hypoglossal nerve stimulation (THN) of the proximal hypoglossal nerve in patients with OSA. This randomized clinical trial (THN3) was conducted at 20 centers and included 138 patients with moderate to severe OSA with an apnea-hypopnea index (AHI) of 20 to 65 events per hour and body mass index (calculated as weight in kilograms divided by height in meters squared) of 35 or less. The trial was conducted from May 2015 through June 2018. Data were analyzed from January 2022 through January 2023. Implant with THN system; randomized 2:1 to activation at month 1 (treatment) or month 4 (control). All received 11 months of THN with follow-up at months 12 and 15, respectively. Primary effectiveness end points comprised AHI and oxygen desaturation index (ODI) responder rates (RRs). Treatment responses at months 4 and 12/15 were defined as a 50% or greater reduction in AHI to 20 or less per hour and an ODI decrease of 25% or greater. Coprimary end points comprised (1) month 4 AHI and ODI RR in the treatment greater than the control group and (2) month 12/15 AHI and ODI RR in the entire cohort exceeding 50%. Secondary end points included sleep apnea severity (AHI and ODI) and patient-reported outcomes (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and EQ-5D visual analog scale). Among 138 participants, the mean (SD) age was 56 (9) years, and 19 (13.8%) were women. Month 4 THN RRs were substantially greater in those in the treatment vs control group (AHI, 52.3% vs 19.6%; ODI, 62.5% vs 41.3%, respectively) with treatment-control standardized mean differences of 0.725 (95% CI, 0.360-1.163) and 0.434 (95% CI, 0.070-0.843) for AHI and ODI RRs, respectively. Months 12/15 RRs were 42.5% and 60.4% for AHI and ODI, respectively. Improvements in AHI, ODI, Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, and EQ-5D visual analog scale scores were all clinically meaningful (medium to large effect size). Two serious adverse events and 100 nonserious related adverse events were observed from the implant procedure or study protocol. This randomized clinical trial found that THN demonstrated improvements in sleep apnea, sleepiness, and quality of life in patients with OSAs over an extended AHI and body mass index range without prior knowledge of pharyngeal collapse pattern. Clinically meaningful improvements in AHI and patient-reported responses compared favorably with those of distal hypoglossal nerve stimulation trials, although clinically meaningful differences were not definitive for ODI. ClinicalTrials.gov Identifier: NCT02263859.

Effects of continuous positive airway pressure on comprehensive geriatric assessment and cognitive function in elderly patients with obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) can lead to cognitive impairment and depression affecting memory, attention, and executive functions. Continuous positive airway pressure (CPAP) treatment seems to be able to revert changes in brain networks and neuropsychological tests correlated to OSAS. The aim of the present study was to evaluate the effects of a 6-month treatment with CPAP on functional, humoral and cognitive parameters in a cohort of elderly OSAS patients with several comorbidities. We enrolled 360 elderly patients suffering from moderate to severe OSAS and indication for nocturnal CPAP. At baseline the Comprehensive Geriatric Assessment (CGA) revealed a borderline Mini-Mental State Examination (MMSE) score that improved after 6-month treatment with CPAP (25.3 ± 1.6 vs 26 ± 1.5; p < 0.0001), as well as the Montreal Cognitive Assessment (MoCA) showed a mild improvement (24.4 ± 2.3 vs 26.2 ± 1.7; p < 0.0001). Moreover, functionality activities increased after treatment, as documented by a short physical performance battery (SPPB) (6.3 ± 1.5 vs 6.9 ± 1.4; p < 0.0001). Reduction of the Geriatric Depression Scale (GDS) from 6.0 ± 2.5 to 4.6 ± 2.2 (p < 0.0001) was also detected. Changes of homeostasis model assessment (HOMA) index, oxygen desaturation index (ODI), sleep-time spent with saturation below 90% (TC90), peripheral arterial oxyhaemoglobin saturation (SpO2), apnea-hypopnea index (AHI) and estimation of glomerular filtration rate (eGFR), contributed, respectively, to 27.9%, 9.0%, 2.8%, 2.3%, 1.7% and 0.9% of MMSE variability for a total of 44.6% of MMSE variations. GDS score changes were due to the improvement of AHI, ODI and TC90, respectively, for 19.2%, 4.9%, 4.2% of the GDS variability, cumulative responsible for 28.3% of GDS modifications. The present real-world study shows that CPAP treatment is able to improve cognition and depressive symptoms in OSAS elderly patients.

Nocturia as a clinical indicator of severe obstructive sleep apnea syndrome and its response to CPAP or surgical treatment.

Obstructive sleep apnea syndrome (OSAS) is a common condition that has been associated to a number of metabolic, cardiovascular and cognitive consequences. Its diagnosis relies on a polysomnographic or polygraphic study, but clinical findings remain as an important part of the diagnostic process. Nocturia is a common symptom that may indicate severe OSAS, but it is often forgotten in the initial evaluation of these kind of patients. Positive airway pressure (CPAP) is known to reduce nocturia, but the roll of surgery is not clear about it. A case series is presented. We compare 2 groups of male adults with severe OSAS, the first group treated with CPAP for 3 months, while group 2 underwent a multilevel surgical management. Apnea-hypopnea index (AHI) and the nocturia events number (NEN) were assessed before and after the treatment. Frequencies, descriptive statistics and a related sample Student's t-test were performed for statistical analysis. 97 male patients were included, age ranged from 29 to 71 years old. In group 1, treated with CPAP, AHI mean was 54.59 and nocturia mean 4.53 before treatment. With CPAP, the AHI mean was 6.63 and NEN mean 0.51. In group 2, AHI mean before surgery was 40.02, NEN mean 3.78, and after the surgical management AHI mean was 7.74 and NEN mean 0.7. Student's t-test in groups 1 and 2 showed a p=0.000. AHI and NEN were clearly related in both groups, and the improvement of NEN and AHI were consistent in both groups, the CPAP and the surgical treatment. The presence of a NEN value of 4-5 may be an indicator of severe OSAS and should always be clinically evaluated.

Combined Airway and Bariatric Surgery (CABS) for Obstructive Sleep Apnea Patients with Morbid Obesity: A Comprehensive Alternative Preliminary Study.

Although continuous positive airway pressure is the gold standard for obstructive sleep apnea (OSA), it does not improve obesity. By contrast, bariatric surgery significantly improves obesity but with sustained OSA in the majority of patients. This study proposes a comprehensive technique-combined airway and bariatric surgery (CABS)-to improve both obesity and OSA. The aims of the study are to evaluate the feasibility, safety and efficacy of CABS in morbidly obese OSA patients. The retrospective study enrolled 20 morbidly obese OSA patients (13 males; median age, 44 years; median apnea-hypopnea index (AHI), 63.2 event/h; median body mass index (BMI), 41.4 kg/m2). The study population was divided into two groups based on patients' volition after shared decision making. The bariatric surgery (BS) group included laparoscopic sleeve gastrectomy (LSG, n = 8) and laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 2). CABS involved bariatric surgery-LSG (n = 8) and LRYGB (n = 2) in conjunction with airway surgery (concurrent nasal/palatal/lingual surgery [n = 8], concurrent palatal/lingual surgery [n = 2]). Patients received a home sleep apnea test at baseline and one year after surgery. The two patient groups were not different in age, sex, preoperative AHI or preoperative BMI. There was no airway compromise, wound bleeding or infection throughout the postoperative period. One year after surgery, patients in both groups achieved significant improvement in AHI and BMI. Furthermore, the improvement in AHI was significantly higher (p = 0.04) in the CABS group than in the BS group despite the insignificant change in BMI reduction (p = 0.63) between the two groups. In the CABS group, the BMI dropped from 40.4 to 28.4 kg/m2 (p &lt; 0.0001) and the AHI decreased from 75.1 to 4.5 event/h (p = 0.0004). The classic success rate for OSA was 90% and the cure rate was 60% in the CABS group. A perioperative assessment of CABS group patients also revealed a significant improvement in the Epworth sleepiness scale, minimal O2 saturation, snoring index and heart rate. CABS is feasible and safe in treating OSA with morbid obesity. CABS achieves more reduction in AHI than BS alone with high success and cure rates for OSA. CABS can also significantly improve quality of life and general health and offers a comprehensive alternative for morbidly obese OSA patients.

The Effects of Barbed Repositioning Pharyngoplasty in Positional and Non-Positional OSA Patients: A Retrospective Analysis.

The aim of our retrospective study is evaluating the effectiveness of barbed repositioning pharyngoplasty (BRP) in a consecutive cohort of patients and assessing its impact on positional indexes in order to potentially identify specific obstructive sleep apnea (OSA) phenotypes for patients who might benefit more significantly from this intervention. A single-center retrospective study with baseline and follow-up type III sleep tests evaluating the Apnea Hypopnea Index (AHI), supine AHI, non-supine AHI, oxygen desaturation index (ODI), mean SaO2, percentage of time spent at SaO2 below 90% (CT90), and lowest oxygen saturation (LOS) were performed. The patients were then divided into groups according to Sher's criteria and Amsterdam Positional OSA Classification (APOC). Parametric and non-parametric tests and univariate and multivariate analyses were conducted. The study finally included 47 patients. The statistical analysis showed significant improvement in AHI, supine AHI, non-supine AHI, and ODI after surgery. The linear regression showed that high values of baseline AHI, AHI supine, and AHI non supine predict more significant postoperative reductions in AHI, AHI supine, and AHI non supine, respectively. Therapeutic success was achieved in 22 patients out of 47. The logistic regression did not find any independent risk factors for success. The most significant reduction in AHI, supine AHI, and non-supine AHI was observed in the APOC 3 group while the APOC 1 patients experience a substantially lower improvement. BRP appears to be an effective surgical procedure for the treatment of OSA. The non-positional patients might benefit more from BRP in comparison with positional patients. Moreover, OSA severity should not be considered an absolute contra-indication for this surgical procedure.

Comparison of clinical features and surgical outcomes between hypopnea- and apnea-predominant obstructive sleep apnea.

This study is aimed to investigate the differences in the clinical features and surgical outcomes between hypopnea- and apnea-predominant obstructive sleep apnea (OSA). Cohort study. Single tertiary care centre. This study included 190 patients with OSA who underwent multilevel upper airway surgery between September 2012 and September 2021. The patients were divided into two groups according to the proportion of each respiratory event: hypopnea-predominant (n=102) and apnea-predominant (n=88). The primary outcome measure was the percentage improvement in the apnea-hypopnea index (AHI) from baseline AHI after surgery. The apnea-predominant group included more male patients and had higher AHI, respiratory disturbance index (RDI) and oxygen desaturation index (ODI) than the hypopnea-predominant group. Both groups showed significant improvements in AHI, apnea index, RDI, supine AHI, REM AHI, non-REM AHI, ODI, lowest O2 saturation and Epworth Sleepiness Scale scores following the surgery. Notably, hypopnea index increased after surgery in the apnea-predominant OSA group. Although the improvement in the absolute value of AHI by surgery was significantly greater in the apnea-predominant group than in the hypopnea-predominant group, the two groups showed no significant difference in the percentage improvement in AHI from baseline AHI. Patients with apnea-predominant OSA had more severe disease than those with hypopnea-predominant OSA; however, surgical outcomes, as evaluated by percentage AHI improvement, were comparable between the two groups. In addition, multilevel upper airway surgery may induce the transition from apnea to hypopnea in patients with apnea-predominant OSA.