Management Of Sleep Apnea Research Articles

P034 An economic evaluation comparing the provision of sleep disorder services via a regional hub-and-spoke model of care to standard care in a metropolitan tertiary hospital

Abstract Introduction A new hub-and-spoke model of care (New-MOC) was introduced in a very remote Queensland region for the management of Obstructive Sleep Apnoea. Standard Care required travel and admission to a major metropolitan hospital. The aims were to increase access to services and ensure the New-MOC was cost-effective for sustainability. Method A cost-utility evaluation was performed from the health service perspective. Administrative and clinical data was collected in the 2-years prior and 1-year post implementation of the New-MOC to compare costs and outcomes. Base-case was modelled using decision tree analysis for a hypothetical cohort of 100 patients over a time horizon that captured 12-months of treatment. One-way sensitivity analyses were performed to evaluate uncertainty of inputs in which a) all costs were adjusted to upper bound b) set up costs were added and c) QALYs were reduced in the New-MOC. Results Under base-case the New-MOC was dominant and projected to save $226,511 of health service costs over 1.2 years and result 0.488 QALYs gained compared Standard Care. The New-MOC remained cost effective under all scenarios modelled. Discussion Whilst the New-MOC was cost effective, primary source data was only available up to diagnosis and therefore modelling relied on assumption around outcomes. Follow-up of patients in relation to treatment compliance would improve the accuracy of the model as would applying a lifetime horizon to capture all outcomes for a chronic condition. However, sufficient evidence exists to support the New-MOC as cost saving and cost-effective. Acknowledgement supported by a Metro North LINK Grant

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.

Barbed Suspension Bridge Pharyngoplasty: Introducing a Novel Technique for Barbed Pharyngoplasty.

Surgical management of Obstructive Sleep Apnea (OSA) and Snoring has undergone many major and minor changes over a period of last decade. The most common surgical approach for OSA is uvulopalatopharyngoplasty (Stuck et al. in Sleep Med 50:152-165, 2018). The main goals of treatment of OSA are to decrease the risk of deleterious health effects and improve quality of sleep (Evans et al. in Otolaryngol Clin North Am 53: 319-328, 2020). Since bimanual surgical techniques in the depth of oral cavity have been tricky, search for a less demanding & easy to learn technique is always on. The surgical technique should also provide long term results with manageable complications. Barbed suture has been in sporadic use for the last decade amongst sleep apnea surgeons for its advantage of knotless application and distributed suture tension. However, the barbed suture which has been used is absorbable and is used only to close the surgical wound on the soft palate. In this paper we are describing our technique of using the 3-0 Polybutester non absorbable barbed suture to perform a novel technique of palatal surgery, in which we suspend the lower part of the soft palate permanently as a suspension bridge between the right and left Pterygomandibular raphae, so that the lower part of the soft palate cannot move posteriorly to touch the posterior pharyngeal wall preventing airway obstruction whereas it can still move superiorly freely while swallowing or during phonation. This technique can prove to be a technically less demanding one which provides excellent long-term results in snoring and OSA with manageable complications.

Chronic Rhinosinusitis After Maxillary Advancement Orthognathic Surgery.

Maxillomandibular advancement (MMA) remains an effective procedure for the management of obstructive sleep apnea (OSA). Maxillary advancement may lead to anatomical changes that impair paranasal sinus drainage, leading to chronic sinus inflammation. The aim of this study was to describe the clinical features and outcomes of patients suffering from chronic rhinosinusitis (CRS) following MMA. This is a retrospective case series study. Our study included subjects diagnosed with CRS following MMA from January 1992 to October 2018 at Stanford Hospital. We screened 730 patients undergoing MMA and identified a total of 57 with CRS after MMA. A descriptive analysis was performed using clinical data including patient demographics, comorbidities, prior surgical history, physical exam manifestations, CT findings, and quality of life outcomes (SNOT-22). Out of 730 patients undergoing MMA, 57(7.8%) were found to have CRS after orthognathic surgery. Presenting symptoms included facial pain (92.5%), nasal drainage (75%), nasal obstruction (67.5%), and hyposmia (20%). Endoscopic examination revealed recirculation (30.5%), purulent discharge (27.7%), polypoid changes (22.2%), and scarring (13.8%). Preoperative CT prior to undergoing endoscopic sinus surgery (ESS) demonstrated mucosal thickening in maxillary (64.2%), anterior ethmoid (39.2%), frontal (14.2%), posterior ethmoid (10.7%), sphenoid sinus (14.2%), and ostiomeatal complex (55.3%). Average Lund-Mackay score was 5.5(±3.8). Additional CT findings included secondary ostium in the inferior meatus (42.8%). Forty patients (70.1%) underwent ESS at a mean of 4.6 years after MMA. Patients undergoing ESS experienced significant improvement in SNOT-22 scores at 12-months post-surgery (P = .018). Patients undergoing maxillary advancement surgery are at risk of developing CRS postoperatively and should be advised of the risk of CRS associated with this procedure. Surgical treatment can be an option for medically refractory CRS related to MMA surgery.

The Importance of Appropriate PAP Silicone Mask Selection in Sleep Apnea Management

Positive airway pressure (PAP) is the standard treatment for patients with moderate to severe obstructive sleep apnea, especially when a correctable anatomic obstacle is not identified. The PAP efficiency strongly depends on the appropriate use during sleep. Despite the recent advancements in PAP interface designs, overall adherence to therapy remains low. The main sources of discomfort consist of air leakage and mask overtightening leading to skin problems. However, these disadvantages have been partially reduced by new interfaces like nasal pillows that have the capacity to reduce the contact of the silicone cushion with the skin, reducing the chances of skin irritation. At the same time, assuring a better seal prevents air leakage and is particularly useful in patients with internal valve insufficiency. We present a case of a 57-year-old patient with severe sleep apnea syndrome whose efficient treatment was delayed by an inadequate PAP mask prescription at diagnosis. Due to low treatment compliance secondary to the perceived adverse effects of the oronasal mask, the patient decided to discontinue treatment for two years with subsequent aggravation of sleep apnea symptoms. The patient’s sensitivity to the silicone mask cushion and treatment ineffectiveness due to internal valve collapse were the main causes of treatment failure. After changing of PAP interface, the patient achieved long-term compliance. Our case report reflects the importance of choosing the most suitable PAP interface in accordance with the patient’s particularities. In the absence of this approach, appropriate treatment might be delayed with detrimental consequences, especially in severe cases. Considering PAP adherence following therapy initiation usually predicts long-term compliance, finding the best mask design from the beginning can predict therapeutic success.

Management of Obstructive Sleep Apnoea with Two Different Mandibular Advancement Devices

Management of Obstructive Sleep Apnoea with Two Different Mandibular Advancement Devices

The Transformative Role of Artificial Intelligence in Obstructive Sleep Apnea Management

The Transformative Role of Artificial Intelligence in Obstructive Sleep Apnea Management

Comparative effectiveness of hypoglossal nerve stimulation and alternative treatments for obstructive sleep apnea: a systematic review and meta-analysis.

Continuous positive airway pressure (CPAP) is the primary therapeutic modality for obstructive sleep apnea (OSA) management. However, despite efforts to encourage patients to comply with CPAP usage, long-term adherence remains low. Consequently, surgical intervention for OSA is considered a secondary option for patients who exhibit non-compliance with CPAP. Therefore, we conducted systematic review and meta-analysis assessed the relative effectiveness of hypoglossal nerve stimulation (HNS) treatment and alternative surgical interventions for managing OSA. Five databases were searched. Studies were included if they measured polysomnography parameters and assessed sleep apnea-related quality of life (Epworth Sleepiness Scale [ESS]) both before and after HNS, and compared these outcomes with control, CPAP, or airway surgery (uvulopalatopharyngoplasty, expansion sphincter pharyngoplasty, or tongue base surgery) groups. A total of 10 studies (2209 patients) met the inclusion criteria. Compared to other airway surgeries, the rates of post-treatment apnea-hypopnea index (AHI) < 10 and < 15 events/h were significantly lower in the HNS group (odds ratio [OR] 5.33, 95% confidence interval [CI] 1.21-23.42; and 2.73, 95% CI 1.30-5.71, respectively). Additionally, postoperative AHI was significantly lower in the HNS group than in all other airway surgery groups (AHI: mean difference [MD] -8.00, 95% CI -12.03 to-3.97 events/h). However, there were no significant differences in the rate of post-treatment AHI < 5 events/h (OR 1.93, 95% CI 0.74-5.06) or postoperative ESS score (MD 0.40, 95% CI-1.52 to 2.32) between the two groups. HNS is an effective option for selected patients with moderate-to-severe OSA and CPAP intolerance.

General practitioner management of comorbid insomnia and sleep apnoea.

Insomnia and obstructive sleep apnoea are the two most common sleep disorders and frequently co-exist. Patients with comorbid insomnia and sleep apnoea experience worse daytime function, mental health and physical health than patients with either disorder alone. General practitioners may face unique challenges in the assessment and management of this prevalent and debilitating condition. This article aims to provide an overview of the prevalence, consequences, assessment and management of patients with comorbid insomnia and sleep apnoea in Australian general practice. Patients with either insomnia or sleep apnoea should be assessed for both conditions. Treatments for both disorders should be offered to patients with both conditions. The recommended treatment for insomnia is cognitive behavioural therapy, whereas the recommended first-line treatment for moderate and severe obstructive sleep apnoea is lifestyle/weight management advice (where relevant) and continuous positive airway pressure therapy.

Drug Induced Sleep Endoscopy, the Key Evaluation Tool in the Surgical Management of Snoring and Obstructive Sleep Apnea: Our Experience in Qatar

Drug Induced Sleep Endoscopy, the Key Evaluation Tool in the Surgical Management of Snoring and Obstructive Sleep Apnea: Our Experience in Qatar

Perioperative management of Obstructive Sleep Apnoea: Present themes and future directions.

Obstructive sleep apnoea (OSA) is an increasingly common pathology that all those involved in perioperative care will come across. Patients with the condition present a challenge at many stages along the perioperative journey, not least because many patients living with OSA are unaware of their diagnosis.Key interventions can be made pre, intra-, and postoperatively to improve outcomes. Knowledge of screening tools, diagnostic tests, and the raft of treatment options are important for anyone caring for these patients. Recent literature has highlighted the increasing complexity of surgical patients and significant underdiagnosis of OSA in this patient population. Work has demonstrated how and why patients with OSA are at a higher perioperative risk and that effective positive airways pressure (PAP) therapy can reduce these risks, alongside evidencing how best to optimise adherence to therapy, a key issue in OSA. OSA, and particularly undiagnosed OSA, presents a huge problem in the perioperative period. Perioperative PAP reduces the risk of postoperative complications but adherence remains an issue. Bespoke perioperative pathways should be developed to identify and optimise high risk patients, although at present evidence on how best to achieve this is lacking.

Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions.

Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions. People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches. It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.

The role of the WatchPAT device in the diagnosis and management of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common condition affecting an estimated 936 million individuals worldwide, leading to a considerable demand for diagnostic services. Polysomnography, the current gold standard for diagnosis, is resource intensive and inconvenient for patients and healthcare providers. The WatchPAT is an unobtrusive device for home OSA diagnosis. It utilizes peripheral arterial tomography in conjunction with heart rate, oximetry, actingraphy, and respiratory movements for the diagnosis of OSA. It has good correlation with polysomnography for OSA diagnosis and also reports sleep time and sleep staging. The WatchPAT device has reported sensitivities of 81–95%, specificities of 66–100%, positive predictive values of 79–96%, and negative predictive values of 92% for the determination of the apnea–hypopnea index (AHI). It has also been studied and its use validated in a variety of patient populations, including children, older adults, pregnant women, and those with comorbid medical conditions. The device has also been adopted for use in screening for cardiac arrhythmia and central sleep apnea, although neither use has become widespread. With the emergence of telemedicine and an increasing demand for sleep services, the WatchPAT device can be a useful aid in OSA diagnostics.

Sleep Testing and Mortality in a Propensity-matched Cohort of Patients with Chronic Obstructive Pulmonary Disease.

Rationale: Many advocate the application of propensity-matching methods to real-world data to answer key questions around obstructive sleep apnea (OSA) management. One such question is whether identifying undiagnosed OSA impacts mortality in high-risk populations, such as those with chronic obstructive pulmonary disease (COPD). Objectives: Assess the association of sleep testing with mortality among patients with COPD and a high likelihood of undiagnosed OSA. Methods: We identified patients with COPD and a high likelihood of undiagnosed OSA. We then distinguished those receiving sleep testing within 90 days of index COPD encounters. We calculated propensity scores for testing based on 37 variables and compared long-term mortality in matched groups. In sensitivity analyses, we compared mortality using inverse propensity weighting and instrumental variable methods. We also compared the incidence of nonfatal events including adverse outcomes (hospitalizations and COPD exacerbations) and routine services that are regularly indicated in COPD (influenza vaccination and pulmonary function testing). We compared the incidence of each nonfatal event as a composite outcome with death and separately compared the marginal probability of each nonfatal event independently, with death as a competing risk. Results: Among 135,958 patients, 1,957 (1.4%) received sleep testing. We propensity matched all patients with sleep testing to an equal number without testing, achieving excellent balance on observed confounders, with standardized differences < 0.10. We observed lower mortality risk among patients with sleep testing (incidence rate ratio, 0.88; 95% confidence interval [CI], 0.79-0.99) and similar results using inverse propensity weighting and instrumental variable methods. Contrary to mortality, we found that sleep testing was associated with a similar or greater risk for nonfatal adverse events, including inpatient COPD exacerbations (subhazard ratio, 1.29; 95% CI, 1.02-1.62) and routine services like influenza vaccination (subhazard ratio, 1.26; 95% CI, 1.17-1.36). Conclusions: Our disparate findings can be interpreted in multiple ways. Sleep testing may indeed cause both reduced mortality and greater incidence of nonfatal adverse outcomes and routine services. However, it is also possible that our findings stem from residual confounding by patients' likelihood of accessing care. Given the limitations of propensity-based analyses, we cannot confidently distinguish these two possibilities. This uncertainty highlights the limitations of using propensity-based analyses to guide patient care and policy decisions.

Oral appliance therapy for the management of obstructive sleep apnea in adults: an umbrella review protocol.

The objective of this review is to summarize the evidence on the effectiveness of oral appliance therapy compared with other therapeutic approaches (continuous positive airway pressure, maxillomandibular and upper airway surgeries, behavioral techniques) for the management of obstructive sleep apnea in adults. For primary snoring, mild to moderate obstructive sleep apnea, and patients with a severe condition who are intolerant of continuous positive airway pressure therapy, an oral appliance is the treatment of choice among conservative procedures. The effectiveness of these appliances is largely determined by a variety of parameters, including the severity of sleep apnea (mild, moderate, severe), materials and methods used to fabricate the appliance, and the degree of mandibular protrusion. Thus, it is important to evaluate the effectiveness of oral appliances in the reduction of sleep apnea. This review will include systematic reviews of quantitative studies reporting on the effectiveness of oral appliances for the treatment of obstructive sleep apnea of any severity, confirmed using polysomnography. The primary outcome will be measured by reduction in the apnea-hypopnea index. A search will be conducted of MEDLINE, Cochrane Database of Systematic Reviews, Scopus, Web of Science, CINAHL, Epistemonikos, Embase, ProQuest Dissertations and Theses, and Shodhganga Dissertations and Theses from database inception until the present, with no language restrictions. Google Scholar will be searched manually. Two independent reviewers will screen titles, abstracts, and full-text articles and perform data extraction. Quality assessment will be conducted using the standard JBI critical appraisal tool. Data will be extracted from systematic reviews and a synthesis of the findings will be presented. The certainty will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). PROSPERO CRD42021258515.

Sociodemographic disparities and healthcare utilization in pediatric obstructive sleep apnea management

ObjectivesWe examined (1) disparities in obstructive sleep apnea (OSA) care by insurance coverage, and by child race and ethnicity among Medicaid-insured children (MIC), and (2) healthcare utilization changes after OSA care. MethodsIBM MarketScan insurance claims were used to index OSA care 1-year before and after initial OSA diagnosis in 2017 among 2-17-year-old children (n = 31,787, MIC: 59%). OSA care and healthcare utilization analyses adjusted for child age, sex, obesity, and complex chronic conditions. ResultsWe identified 8 OSA care pathways, including no care, which occurred in 34.4% of the overall sample. MIC had 13% higher odds of no OSA care compared to commercially-insured children (CIC). MIC had 32–48% lower odds of any treatment pathway involving specialty care, but a 13–46% higher likelihood of receiving surgical care without polysomnogram (PSG) and PSG only. In MIC, non-Latinx Black/African American (Black) and Hispanic/Latinx children were 1.3–2.2 times more likely than White children to receive treatment involving specialty care and/or PSG, while Black children were 31% less likely than White youth to undergo surgery. In the full sample, surgical care was associated with less outpatient and emergency healthcare utilization compared to those untreated or not surgically treated. ConclusionsVaried OSA management by insurance coverage suggests disparities in access to and engagement in care and potentially greater disease burden among MIC. Surgical care is associated with reduced healthcare utilization. The lower odds of surgery in Black MIC should be further evaluated in the context of OSA severity, healthcare biases, and family preferences.

AKT answer relating to management of obstructive sleep apnoea

AKT answer relating to management of obstructive sleep apnoea

AKT question relating to management of obstructive sleep apnoea

AKT question relating to management of obstructive sleep apnoea

The assessment and management of obstructive sleep apnoea–hypopnoea syndrome and obesity hypoventilation syndrome in obesity

Obesity is associated with respiratory dysfunction. It is a key risk and contributory factor in the sleep related breathing disorders, obstructive sleep apnoea/hypopnoea syndrome (OSAHS) and obesity hypoventilation syndrome (OHS). Weight management is an integral part of the management of these disorders, in addition to continuous positive airways pressure (CPAP) and non-invasive ventilation (NIV). Untreated, these conditions are associated with a high disease burden and as treatment is effective, early recognition and referral is critical. Best practice in on-going care is multidisciplinary.

Functional Endoscopic Sinonasal Surgery in Obstructive Sleep Apnea

Abstract Background: Functional Endoscopic Sinonasal Surgery needs indicators to determine success outcomes in the management of nasal obstruction-related obstructive sleep apnea (OSA). Materials and Methods: Preexperimental pretest and posttest designed studies were performed to evaluate the percentage changes value of Visual Analog Scale (VAS) nasal obstruction, Nasal Obstruction Symptom Evaluation (NOSE), Epworth Sleepiness Scale (ESS), polysomnographic parameters, and upper airway collapsibility examined by drug-induced sleep endoscopy. Results: Seventeen patients from 2 studies were recruited with mean Apnea-Hypopnea Index of 3.74 ± 3.30 and respiratory disturbance index of 7.03 ± 3.56. The first study showed a significant percentage change in inferior turbinate size, nasal obstruction VAS, peak nasal inspiratory flow, and ESS Score as well as the second study of significant differences pre- and postoperatively of NOSE (from 49.50 ± 19.2 to 4.50 ± 4.4) and ESS (from 12.60 ± 3.6 to 6.60 ± 3.9). Both studies significantly changed the percentage of the duration of Rapid Eye Movement (REM) to 81.4% ±100% (95% confidence interval − 23.6, 186.3) and a significant difference from preoperative of 4.93 ± 4.40% to post-operative of 11.89 ± 6.19%. Three subjects with preoperative epiglottic collapse (EC) showed a mean value of NOSE 60 ± 5 compared to the non-EC collapse of 45 ± 21.6. In postoperative, there were 4 subjects with EC collapse with a NOSE of 6.25 ± 4.7 and 6 subjects without EC collapse with a NOSE of 3.33 ± 4.1. Conclusion: Functional Endoscopic sinonasal surgery improves NOSE, ESS score, and REM sleep in OSA.