Management Of Obstructive Sleep Apnea Syndrome Research Articles

Pediatric Obstructive Sleep Apnea Syndrome: Guidelines, Evidence, and Nuance

Program Description: Pediatric obstructive sleep apnea syndrome (OSAS) is one of the most common referrals for otolaryngologists. Over the past three years, clinical practice guidelines have been published by the AAO-HNS, American Academy of Pediatrics, and American Academy of Sleep Medicine regarding the diagnosis and management of OSAS. This presentation will begin with a comparison of these guidelines and the evidence used to reach the recommendations. Panelists, through case examples and examination of current literature, will then discuss nuanced issues of pediatric OSA to include short- and long-term perioperative management, obese children with sleep apnea, and subtleties of formal polysomnography in children. Educational Objectives: 1) Compare similarities and differences in the practice guidelines by the various subspecialties involved in the management of children with OSAS and the evidence used to make these recommendations. 2) Evaluate the evidence supporting current perioperative management strategies in children undergoing surgical treatment for OSAS. 3) Improve management of OSAS in obese children and the growing evidence that suggests these children carry increased perioperative risk.

閉塞性睡眠時無呼吸症候群に対する鼻中隔矯正術および下鼻甲介切除術の効果

Obstructive sleep apnea syndrome (OSAS) is thought to be closely related to nasal airway resistance, which accounts for approximately one half of total upper airway resistance. This retrospective study aimed at elucidating the effect of endoscopic endonasal surgery on OSAS. Nine consecutive patients with OSAS complaining of nasal obstruction who underwent endoscopic endonasal surgery were enrolled. They were 8 men and 1 woman ranging from 34-73 years of age with an average of 53.2 years. All patients had chronic hypertrophic rhinitis and nasal septal deviation, and underwent septoplasty and submucous turbinectomy. The severity of OSAS was assessed by 8 sleep apnea indices of polysomnography before and after surgery. The indices included the apnea-hypopnea index (AHI), maximum apnea time, mean apnea time, minimum blood oxygen saturation, mean blood oxygen saturation, blood oxygen saturation decline index, awakening response index, and ratio of snoring time to sleep time. Significant decrease in the AHI (27.6 +/- 5.3 vs. 20.7 +/- 5.5/hr; p = 0.033), in the awakening response index (30.5 +/- 3.3 vs. 21.2 +/- 5.3/hr; p = 0.028), and increase in the mean blood oxygen saturation (95.1 +/- 0.7 vs. 96.0 +/- 0.7%; p = 0.023) were observed postoperatively. There was no significant change in the other 5 indices. In addition, nasal airflow resistance measured by acoustic rhinometry had significantly reduced during the periods of both inhalation (474.4 +/- 49.0 vs. 842.7 +/- 50.2cm3/s; p = 0.002) and exhalation (467.3 +/- 57.3 vs. 866.0 +/- 80.6 cm3/s; p = 0.004). The pre- and postoperative body mass indices did not differ statistically from each other. These results indicate that endoscopic endonasal surgery alone has a potential effect on sleep-disordered breathing in OSAS patients with nasal obstruction. We should be aware of such a positive impact of endonasal surgery upon the management of OSAS.

A Rational Approach to the Management of Obstructive Sleep Apnea Syndrome

Snoring & obstructive sleep apnea syndrome (OSAS) is a globally prevalent problem which is on the rise in recent times. The treatment modalities include medical appliances and surgery. It is mandatory to have a rational approach in the management of OSAS, by meticulously analyzing both anatomical and physiological parameters causing the disorder. To define a rational approach for the management of OSAS, by devising a comprehensive protocol with assessment of anatomical level of obstruction by dynamic MRI and physiological factors by Epworth sleepiness scale (ESS) and Polysomnography. A prospective study in 110 patients was conducted over a period of 2years, at our institute. All patients in the study group were evaluated with dynamic MRI and ESS and Polysomnography. As per the management protocols defined in the study, surgery was advocated in 46 patients (Group 1) with severe compromise in airway, while another group of 64 patients (Group 2) were provided continuous positive airway pressure support (CPAP). Successful outcomes among these 110 patients were analyzed at the end of the study period. A few patients required multimodal therapy which included surgery and CPAP support. Among 46 patients, surgical treatment proved successful in 41 patients in whom AHI reduced from 46.96 to 12.88 (improved by 62%) and ESS improved by almost ten points. Among 64 patients in CPAP group, AHI reduced from 54.2 to 11.3 (improved by 79%) and ESS improved by 11 points in all the patients, but six of them had poor compliance. Five patients among the surgical group had persistence of symptoms. Inferences derived from the above results proved the success of formulating a rational approach in the management of OSAS. Critical analysis of the anatomical and physiological factors inducing obstructive episodes and an appropriate treatment plan is vital, to produce successful outcomes in patients with OSAS. Failure of surgical procedures, are often due to improper case selection. A small group of patients may require multimodal therapy with surgery and CPAP.

Lifestyle modifications and the resolution of obstructive sleep apnea syndrome: a case report

Objective This purpose of this case study is to describe a natural method to help in management of obstructive sleep apnea syndrome (OSAS), which is known to be a common and debilitating condition. Clinical Features Obstructive sleep apnea syndrome is typically managed with a continuous positive airway pressure (CPAP) device, which the patient wears during sleep to help maintain respiration. This report describes the chiropractic management and resolution of OSAS with dietary modifications in a 55-year-old man who wore a CPAP for 10 years. Intervention and Outcome After adhering to dietary modifications for 3 months, the patient no longer required the use of the CPAP device and continues to have a normal active lifestyle almost 7 years later. Conclusion Dietary modifications may be an effective tool to improve the management of OSAS.

Portable monitoring in sleep apnoea: the way forward?

Population-based epidemiological studies estimate the prevalence of obstructive sleep apnoea syndrome (OSAS) to be at least 2% of adult females and 4% of adult males in the developed world based on an apnoea/hypopnoea frequency (AHI) of >5 events·h−1 associated with excessive daytime sleepiness. However, a substantial proportion of these individuals are undiagnosed 1–3. Furthermore, it is very likely that these epidemiological data, now dating back many years, underestimate the current prevalence of OSAS given the dramatic increase in obesity over recent decades 4. Existing evidence points to OSAS as an independent risk factor for motor vehicle accidents, neurocognitive deficits, and cardiovascular morbidity and mortality 5–8. Substantial evidence also supports the argument that appropriate treatment of OSAS reduces the risk of these consequences 9–11. Since the diagnosis of OSAS requires both clinical assessment and objective monitoring of sleep-disordered breathing 12, there are major resource implications for the management of patients with suspected sleep apnoea. However, the perceived need in many healthcare systems to perform costly and labour-intensive polysomnography (PSG) in a sleep laboratory limits patient access to diagnosis and treatment 13. Commercially available and relatively inexpensive portable monitors might facilitate earlier recognition of disease and faster initiation of treatment, thereby reducing the healthcare burden associated with OSAS 14. Interest in the clinical application of portable monitoring devices is growing rapidly, and is being used as a mainstay approach to the management of OSAS in some settings. This interest is also supported by the lack of obvious clinical benefit when using full PSG rather than simplified monitoring, as evidenced in a US health technology assessment 15. An international workshop to determine the research priorities in ambulatory management of adults with OSAS was held on October 15–16, 2007, …

Growth hormone/insulin-like growth factor-I axis in obstructive sleep apnea syndrome: An update

Obstructive sleep apnea syndrome (OSAS) is a serious, prevalent condition that has significant mortality and morbidity when untreated. It is strongly associated with obesity and is characterized by changes in the serum levels or secretory patterns of several hormones. In particular, obese patients with OSAS show a peculiar reduction of both spontaneous and stimulated GH secretion coupled with reduced IGF-I concentrations and impaired peripheral sensitivity to GH. These endocrine abnormalities are more marked than those observed in non-apneic obese subjects, and are likely to be due to the effects of hypoxia and sleep fragmentation on hormone secretory pattern. The GH/IGF-I axis activity disruption can be responsible, at least in part, for metabolic alterations, which are common in OSAS and increase the risk of cardiovascular events as well as mortality. Effective assessment and management of OSAS may correct endocrine changes, improve quality of life, and prevent associated morbidity or death.

Inflammation and Sleep Disordered Breathing in Children: A State‐of‐the‐Art Review

Sleep disordered breathing (SDB) represents a spectrum of breathing disorders, ranging from snoring to obstructive sleep apnea syndrome (OSAS), that disrupt nocturnal respiration and sleep architecture. OSAS is a common disorder in children, with a prevalence of 2-3%. It is associated with neurobehavioral, cognitive, and cardiovascular morbidities. In children, adenotonsillectomy is the first choice for treatment and is reserved for moderate to severe OSAS, as defined by an overnight polysomnography. In adults, OSAS is the result of mechanical dysfunction of the upper airway, manifesting as severity-dependent nasal, oropharyngeal, and systemic inflammation that decrease after continuous positive airway pressure therapy. Inflammatory changes have been reported in upper airway samples from children with OSAS, and systemic inflammation, as indicated by high-sensitivity C-reactive protein (hsCRP) levels, has been shown to decrease in children with OSAS after adenotonsillectomy. Anti-inflammatory treatments for children with mild OSAS are associated with major improvements in symptoms, polysomnographic respiratory values, and radiologic measures of adenoid size. Inflammation is correlated to some extent with OSAS-related neurocognitive morbidity, but the role of inflammatory markers in the diagnosis and management of OSAS, and the role of anti-inflammatory treatments, remains to be clarified. This review examines the role of inflammation in the pathophysiology of sleep-disordered breathing in pediatric patients and the potential therapeutic implications.

Efficacy of two mandibular advancement appliances in the management of snoring and mild-moderate sleep apnea: A cross-over randomized study

Background Mandibular advancement appliances (MAA) are a recognized alternative treatment to continuous positive airway pressure (CPAP) for mild-moderate obstructive sleep apnea syndrome (OSAS). The aim of this study is to assess the efficacy of and subject satisfaction with two MAA in the management of OSAS. Methods Five women and 11 men (47.9 ± 1.6 years), previously untreated with CPAP, were recruited from a sleep disorders clinic following a polysomnographic diagnosis of mild-moderate OSAS with Respiratory Disturbance Index (RDI) of 9.4 ± 1.1. A randomized single blind cross-over study was completed with both Klearway and Silencer (three months for each study arm). Subjects completed standardized questionnaires on sleep quality, sleepiness and functional outcomes (Functional Outcome Sleep Questionnaire: FOSQ). MAA satisfaction (e.g., comfort) and efficacy (e.g., reduction of respiratory noises, headache) were assessed by subjects and sleep partner. Results The two MAA (Silencer 4.7 ± 0.9 and Klearway 6.5 ± 1.3) significantly reduced the RDI compared to the baseline night (10.0 ± 1.2, respectively p < 0.001 and p < 0.01). The RDI was slightly lower with the Silencer ( p ⩽ 0.05) but subjects’ preference for comfort was in favor of the Klearway (Klearway 7.0 ± 0.4 vs Silencer 5.8 ± 0.4, p = 0.04). The Epworth score, FOSQ, respiratory noise and morning headache were also improved following use of both appliances ( p ⩽ 0.05 to 0.001). Conclusion Although both MAA decreased RDI and subjective daytime sleepiness in a similar manner, the choice between various types of MAA needs to be taken into account when considering the benefit of RDI reduction over the benefit of subject compliance. The long term benefit of increased RDI reduction vs. a better subject compliance needs to be assessed in prospective studies.

Radiofrequency tongue-base reduction for sleep apnea: Comparison of different techniques

Objectives: This pilot study investigates the feasibility, safety, and efficacy of radiofrequency base-of-tongue reduction (RFBOT) for patients with obstructive sleep apnea syndrome (OSAS). It evaluates differences between traditional radiofrequency reduction (Somnoplasty®) and low-temperature radiofrequency molecular disassociation (Coblation®), and discusses the role of RFBOT in multi-level management of OSAS. Methods: A retrospective chart review identified OSAS patients who received RFBOT (either Somnoplasty® or Coblation®) for treatment of retroglossal obstruction. Patient characteristics, treatment variables, and adverse effects were recorded to assess safety and efficacy of RFBOT. Results: Preliminary review identified more than 40 patients (>200 procedures) who received RFBOT. Most patients (>90%) were male, and ages ranged from 32–75 years. Different treatment times led to an evolution from use of Somnoplasty® early in the study to use of Coblation®. Equivalent delivery of 750 Joules per site took >3 minutes for Somnoplasty® and 12–15 seconds for Coblation®. Patients received between 1–5 RFBOT sessions, with between 3–7 sites treated each session. The majority of patients (>80%) indicated resolution or marked improvement of OSAS symptoms following completion of treatment. Analysis of pre- and posttreatment RDI continues, but early analysis reveals an average improvement of 72% (range 24%-100%). Of the >200 procedures done overall, there were 5 complications; only 1 required inpatient management. Complication rates and efficacy did not differ between RFBOT technique. Conclusions: This pilot study supports the safety and efficacy of RFBOT, using either traditional radiofrequency (Somnoplasty®) or low-temperature radiofrequency molecular disassociation (Coblation®) techniques. The more rapid tissue effect with Coblation® may promote increased patient acceptance.

Distraction osteogenesis in adult obstructive sleep apnea surgery: A preliminary report

Purpose: This study evaluated the potential application of distraction osteogenesis (DO) for skeletal expansion in the management of adult patients with obstructive sleep apnea syndrome (OSAS). Patients and Methods: Five consecutive adult patients (3 male, 2 female) underwent a DO procedure with intraoral distraction devices for the management of OSAS. The surgical procedures were mandibular advancement (n = 4, with 3 bilateral advancement and 1 unilateral advancement) and simultaneous maxillomandibular advancement (n = 1). Starting 7 days after surgery, the distraction devices were activated 4 times daily at a rate of 1.0 mm/d until the desired skeletal expansion was achieved. All of the patients underwent pre- and postoperative radiographic analysis and polysomnography. The distraction devices were removed 3 months after the completion of the distraction process. Results: The amount of skeletal advancement by distraction ranged from 5.5 to 12.5 mm, with the mean distance being 8.1 mm. The postoperative polysomnographic results showed improvement of OSAS in all 5 patients with an improvement of the mean RDI from 49.3 events per hour to 6.6 events per hour. The lowest oxygen saturation improved from 79.8% to 85.8%. The mean follow-up period was 12 months. Complications included localized inflammation at the distraction device site (n = 2), temporary temporomandibular joint (TMJ) discomfort during distraction process (n = 1), and temporary paresthesia of the inferior alveolar nerve distribution (n = 2). A moderate amount of pain during the activation of the distraction devices was reported (n = 3) and was adequately treated with analgesics. None of the complications led to permanent problems. Conclusion: This limited case series shows that DO is applicable in selected adult patients for skeletal advancement in the treatment of OSAS. However, there are disadvantages with the use of DO, and further investigations are necessary to determine the potential of this technique. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:6-10, 2002

Delayed muscle detachment after genial tubercle advancement in a patient with obstructive sleep apnea

The consequences and health implications of obstructive sleep apnea syndrome (OSAS) continue to evolve, as do the various treatments. However, no single universal treatment protocol has been established.1 Medical management of OSAS principally consists of weight loss, nasal continuous positive airway pressure (CPAP), and dental appliances.2 Surgical management has evolved over the past several decades into a variety of staged protocols that incorporate procedures aimed at eliminating obstruction in the nasal cavity, that caused by the soft palate or base of the tongue/ hypopharynx, and that related to deficiencies in the maxillofacial skeleton. The initial phase of treatment generally involves procedures on the soft palate, such as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP) performed alone or in combination with septoplasty or genial tubercle advancement osteotomy (with or without hyoid myotomy/ suspension). Patients failing this initial phase of treatment are then treated by maxillomandibular advancement or tracheostomy. The recent literature has suggested that skeletal osteotomies (maxillomandibular advancement) may be useful as the initial phase of treatment as well.1,3-6 This case report describes a complication in a patient in the initial phase of treatment who underwent a genial tubercle advancement and had spontaneous detachment of the genial musculature 11 days postoperatively. Report of Case

Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome

Cautery-assisted palatal stiffening operation (CAPSO) is a recently developed single office-based procedure performed with local anesthesia for the treatment of palatal snoring. A midline strip of soft palate mucosa is removed, and the wound is allowed to heal by secondary intention. The flaccid palate is stiffened, and palatal snoring ceases. This prospective study evaluated the ability of CAPSO to treat obstructive sleep apnea syndrome (OSAS). Twenty-five consecutive patients with OSAS underwent CAPSO. Responders were defined as patients who had a reduction in apnea-hypopnea index (AHI) of 50% or more and an AHI of 10 or less after surgery. By these strict criteria, 40% of patients were considered to have responded to CAPSO. Mean AHI improved from 25.1 ± 12.9 to 16.6 ± 15.0 (P = 0.010). The Epworth Sleepiness Scale, a subjective measure of daytime sleepiness, improved from 12.7 ± 5.6 to 8.8 ± 4.6 (P < 0.001). These results indicate that CAPSO is as effective as other palatal surgeries in the management of OSAS. (Otolaryngol Head Neck Surg 2000;123:55-60.)

Short-term objective and long-term subjective results of laser-assisted uvulopalatoplasty for obstructive sleep apnea.

To determine the short-term and long-term effects of laser-assisted uvulopalatoplasty (LAUP) on symptoms and polysomnographic measures in patients with obstructive sleep apnea syndrome (OSAS). Prospective assessment of outcomes after LAUP in patients with OSAS. Fifty-nine patients with OSAS underwent LAUP, and 36 completed postoperative sleep studies. Questionnaires ranking snoring and apneic symptoms were completed by the patient and bed partner before LAUP, 6 to 12 weeks after LAUP, and in the long term (> 2 years). The apnea index decreased from 14.4 to 5.8 (P = .0012), respiratory disturbance index (RDI) decreased from 28.1 to 7.9 (P = .0046), and the mean lowest oxyhemoglobin saturation increased from 80.6% to 84.0% (P = .055). The RDI was reduced to 10 or less in 44.4% of patients. Subjective questionnaires showed statistically significant improvements in snoring, morning fatigue, morning headaches, daytime somnolence, and daytime psychometric measures. The symptomatic improvement persisted in the long term. LAUP is an effective method for the management of OSAS. We have demonstrated short-term improvement in polysomnographic measures and short-term and long-term improvement in subjective measures.

Therapy with nasal CPAP (continuous positive airway pressure) in patients with obstructive sleep apnea syndrome (OSAS). II: Side-effects of nCPAP therapy. Effect on long-term acceptance

nCPAP is a well established method for the management of OSAS. The aim of this study was to evaluate long-term side effects and complications of nCPAP therapy and their influence on the patients compliance with treatment. Forty-one patients with OSAS were interviewed by questionnaire to elucidate the problems and adverse effects of their nCPAP therapy. The patients were divided into responders and non-responders. Non-responding OSAS patients were using their nCPAP devices less then 5 hours each night by definition. The number of side effects and type of complication during nCPAP therapy were the same in both the responding and non-responding groups. The most frequently reported problems were a tender region on the bridge of the nose and discomfort associated with a dry nasal mucosa. Although nCPAP treatment was initially accepted by most patients, adverse effects and other difficulties decreased patient compliance, with time, in many cases. Despite there being no difference between responders and non-responders with respect to the number and severity of complications, it should not be presumed that these side effects do not influence long-term patient compliance with nCPAP therapy. Patients who suffer from symptoms of OSAS tend to accept these adverse effects, while those who do not feel limited by their disease are less persistent in their use of this treatment modality. Identification and elimination of the problems associated with the use of nCPAP equipment may increase longterm patient compliance. Close monitoring in the outpatient department combined with intermittent inpatient assessment in the sleep laboratory will also help to improve acceptance of nCPAP therapy.

Laser‐Assisted Uvulopalatoplasty for Obstructive Sleep Apnea

Laser-assisted uvulopalatoplasty (LAUP) can reduce snoring by sequentially removing excessive vibratory tissue of the velopharynx. The procedure can be performed under local anesthesia in an office setting. Since the appearance of the soft palate is similar after both LAUP and uvulopalatopharyngoplasty, LAUP may also be efficacious in the management of obstructive sleep apnea syndrome (OSAS). LAUP was performed in 34 consecutive prospectively evaluated patients with OSAS. Of the 34 patients, 28 (82%) were male; the mean age was 53 years, and the mean body mass index was 31.1. In the study population of 13 patients who completed preoperative and postoperative sleep studies, the apnea index decreased from 19.4 to 4.2 (P = .006), the respiratory disturbance index (RDI) decreased from 31.2 to 15.7 (P = .092), and mean lowest oxyhemoglobin saturation increased from 82.3% to 85.0% (P = .581). The RDI fell to 10 or lower in 38.5% of patients and was reduced by at least 50% in 53.8% of the study group. Snoring was significantly reduced in 92.3% of patients (P < .001). These early results suggest that LAUP may be efficacious in the management of OSAS.

The efficacy of laser-assisteduvulopalatoplasty in the management of obstructive sleep apnea and upper airway resistance syndrome

Laser-assisted uvulopalatoplasty (LAUP) is an effective method for treating patients experiencing loud habitual snoring. LAUP is reserved for patients with either simple snoring or mild sleep apnea. The procedure is performed in several stages in an ambulatory setting under local anesthesia using a CO₂ laser with a special handpiece. One major advantage of LAUP over uvulopalatopharyngoplasty (UPPP) is the ability to titrate tissue removal without the risk of overresection. We have achieved an 85% success rate for reduction or elimination of snoring in over 450 patients. Of our patients evaluated for snoring, 71% had polysomnography before surgical treatment. Various degrees of obstructive sleep apnea syndrome (OSAS) were found in most of these patients. The initial treatment of choice for moderate to severe OSAS is continuous positive airway pressure (CPAP). CPAP and weight control in conjunction with extended LAUP is the recommended long-term management. The primary reason for lack of response to LAUP in the management of OSAS is usually lingual tonsil hypertrophy. Laser surgery directed to the tongue base may be the preferred method of treatment for these patients, as opposed to skeletal advancement procedure. Upper airway resistance syndrome (UARS) can be managed by CPAP or surgery directed at the site creating the maximum resistance. Most commonly these procedures include LAUP and/or intranasal surgery. OSAS and snoring are ongoing disease processes. Snoring, once thought to be only a social problem, may actually be a precursor to subsequent OSAS, a concept that we are now prospectively studying. Therefore, patients with the diagnosis of OSAS and snoring must be followed up throughout their lifetime. Preliminary data from this study show a significant association between weight loss and the apnea index (AHI) regardless of the treatment used.

Obstructive sleep apnea syndrome: a frequent complication of obesity

Obstructive sleep apnea syndrome (OSAS) is a major health problem, not only because of its consequences in terms of morbidity and mortality, but also because of its social impact in the form of car accidents and industrial accidents. These facts stress the necessity of screening OSAS among the population, particularly in patients suffering from obesity or hypertension, diseases frequently associated with OSAS. This review will focus on the epidemiology and the pathophysiology of this syndrome, its clinical features with a view to screening OSAS, and the main examination used to confirm the diagnosis. The management of OSAS will be discussed.