Upper Airway Resistance Syndrome Research Articles

Sleep-disordered breathing and dental sleep medicine: Implications for oral health and overall well-being

Sleep-disordered breathing (SDB) is a prevalent condition that encompasses a range of disorders, such as snoring, obstructive sleep apnea (OSA), and upper airway resistance syndrome. These disorders have significant implications for both oral health and overall well-being. Dental sleep medicine (DSM) plays a crucial role in the identification, diagnosis, and management of SDB, offering effective treatment options for patients. As awareness grows regarding the detrimental effects of airway disorders, particularly obstructive sleep apnea (OSA), as a sleep-related breathing disorder, it becomes important to recognize the potential role of dentists in offering solutions in this field. This recognition gives rise to a new aspect of dentistry known as Dental Sleep Medicine (DSM). DSM focuses on the practice of clinical dentistry with the goal of achieving an ideal jaw relationship and establishing normal oral function and performance. One crucial aspect of function and performance is the airway and breathing, which is among the most vital functions for human beings. Any alterations in the airway and breathing patterns can lead to changes in the posture of the tongue, jaws, and head, ultimately resulting in malocclusion. Early dental treatment not only has a positive impact on the teeth but also helps establish the best possible airway at an early age. Dentists now play a crucial and integral role as part of an interdisciplinary group involved in managing Sleep-Related Breathing Disorders (SRBDs). This review article aims to provide guidance to dentists in identifying children or adults who are suspected or at risk of SRBDs. Additionally, it will explain the roles of dentists and orthodontists in the management and treatment of SRBDs.

Upper Airway Resistance Syndrome : An Underdiagnosed Sleep-related Breathing Disorder

Upper Airway Resistance Syndrome (UARS) is an example of sleep-related breathing disorders. UARS was first reported by Guilleminault in 1992 and it is known as excessive daytime sleepiness without obvious apnea or hypopnea that is characterized by more than 50% of respiratory effort related arousals (RERAs) during sleep. The prevalence of UARS was 15% in population in São Paulo. Although clinical manifestations, electroencephalogram (EEG) findings, and pathogenesis differ between UARS and OSA (Obstructive Sleep Apnea), it still sparked a debate among researchers as to whether UARS should be categorized as a distinct disorder. The International Classification of Sleep Disorders - Third Edition (ICSD3) integrated UARS into OSA diagnosis, resulting in underdiagnosed and undertreated patients with sleep-related breathing disorders who did not necessarily meet OSA criteria. Untreated UARS, on the other hand, has a variety of clinical consequences, including poor weight and height growth, daytime irritability, worsening of quality of life, and cardiovascular complications. Continuous positive airway pressure therapy, oral appliances, surgical management, weight reduction, and positional therapy are all considered as options in management of UARS.

Practice recommendations for the role of physiotherapy in the management of sleep disorders: the 2022 Brazilian Sleep Association Guidelines.

This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.

Upper Airway Resistance Syndrome is associated with high cyclic alternating pattern

Upper Airway Resistance Syndrome is associated with high cyclic alternating pattern

Prevalence of upper airway resistance syndrome in the São Paulo Epidemiologic Sleep Study

ObjectiveTo establish the prevalence of upper airway resistance syndrome (UARS) according to different diagnostic criteria and evaluate its epidemiological characteristics in a representative sample of a large urban center. MethodsThis was a single-center evaluation involving volunteers from EPISONO, an epidemiological study focused on sleep disturbances and related factors in adults from São Paulo, Brazil in 2007. ResultsConsidering the diagnostic criteria for UARS to be an apnea–hypopnea index of <5 events/h, minimum SpO2 ≥ 92%, the presence of airflow limitation during sleep for ≥5% of total sleep time, and daytime symptoms (sleepiness and/or fatigue), we observed a prevalence of the condition of 3.1% (4.4% in women and 1.5% in men). ConclusionsAlthough the diagnostic criteria for UARS, or even its existence as a syndrome, are still a subject of debate in the literature, the findings from this epidemiological study highlights UARS as a non-hypoxic sleep-disordered breathing condition with a significant prevalence in the general population, being more frequent among female young adults.

Expression and clinical significance of IL-33 and its receptor ST2 in children with obstructive sleep apnea syndrome.

BackgroundObstructive sleep apnea syndrome (OSAS) is characterized by a majority population of respiratory sleep disorders, which consists of simple snoring as well as increased upper airway resistance syndrome. Adenoid hypertrophy has been suggested as the main cause of OSAS in children. The role of interleukin-33 (IL-33) and its receptor suppressor of tumorigenicity 2 (ST2) in a variety of pediatric allergic diseases has been confirmed. We hypothesized that IL-33/ST2 path way might play a pivotal role in the pathogenesis of adenoid hypertrophy-associated OSAS in children.MethodsA total of 40 children undergoing adenoidectomy due to OSAS in the Otolaryngology of Tianjin Children’s Hospital were selected as the study participants. The quantity of IL-33 and ST2 positive cells in adenoids was detected by immunohistochemical (IHC) streptavidin-peroxidase conjugate (SP) method.ResultsThe IL-33 positive cells were mainly distributed in the submucosa epithelium and vascular endothelium, and expressed in the nucleus and cytoplasm. Meanwhile, ST2 positive cells were primarily observed in the mucosa and expressed in the nucleus and cytoplasm, with a little expression of intercellular substance. There was a positive correlation between the proportion of adenoids in the posterior nostril diameter and the number of IL-33 positive cells. The expression of IL-33 in adenoids was positively correlated with the level of ST2 (r=0.809, P=0.000). The expression of IL-33 in adenoids was positively correlated with the level of eosinophil granulocyte (r=0.859, P=0.000). Moreover, the expression of ST2 in adenoids was positively correlated with the level of eosinophil granulocyte (r=0.814, P=0.000). The number of IL-33 positive cells was significantly higher in the moderate hypoxemia group than that in the mild hypoxemia group (P<0.05). There was no significant difference in the number of ST2 positive cells between the moderate hypoxemia group and mild hypoxemia group (P>0.05).ConclusionsBoth IL-33 and its receptor ST2 were expressed in adenoids of OSAS children. The severity of airway obstruction caused by adenoid hypertrophy was positively correlated with the expression of IL-33.

Quality of life in upper airway resistance syndrome.

To evaluate the health-related quality of life (HRQoL) in patients with upper airway respiratory syndrome (UARS) and obstructive sleep apnea (OSA) compared to the general population (GP) in Lima, Peru, and to explore the variables associated with differences in HRQoL in patients with UARS. This was a retrospective study of medical and polysomnography records from 2009-2014 in a referral sleep medicine center for patients aged 18-64 years. UARS was defined by polysomnography as follows: apnea-hypopnea index < 5 events/h, oxygen saturation ≥ 92%, respiratory effort-related arousal index ≥ 5. HRQoL was assessed using the 36-Item Short Form Survey (version 1) questionnaire validated in Peru. The GP HRQoL was obtained from a population-based survey. Linear and logistic regression analyses were conducted. We reviewed 1,329 polysomnograms and selected 888. UARS and OSA were diagnosed in 93 and 795 participants, respectively. The GP cohort consisted of 641 participants. Total HRQoL mean scores (95% confidence interval) in patients with UARS, patients with OSA, and the GP were 67.4 (63.7-71.1), 66.9 (65.4-68.4), and 82.9 (81.6-84.3), respectively. Patients with UARS and patients with OSA had a 5.5 times (95% confidence interval, 3.3-9.2) and 6.2 times (95% confidence interval, 4.6-8.4) greater probability of having a low total HRQoL score compared to patients in the GP, respectively. In patients with UARS, muscle pain, use of psychotropic medication, obesity, and depression were negatively correlated with the total HRQoL score. The impact of OSA and UARS on HRQoL is similar between disease groups and markedly worse when compared to the impact in the GP. In patients with UARS, the presence of muscle pain, obesity, female sex, depression, and use of psychotropic medication negatively impacted HRQoL. Vizcarra-Escobar D, Duque KR, Barbagelata-Agüero F, Vizcarra JA. Quality of life in upper airway resistance syndrome. J Clin Sleep Med. 2022;18(5):1263-1270.

Oral appliances: An odds-on in obstructive sleep apnoea management

Breathing affiliated with sleep disorders usually lies between simple snoring without sleepiness, upper airway resistance syndrome, obstructive sleep apnoea (OSA) syndrome, and hypercapnic respiratory failure. Of all these, OSA is very often accompanied with morning symptoms and extension of comorbidities and mortalities with a high prevalence rate. General health implications and an altered quality of living are the major setbacks. Mostly patients with neurologic disorders are affected. There are many surgical and non-surgical approaches concerned with its management. This review article provides a description of oral appliances along with recent treatment modalities, clinical efficacy of alternative treatment modalities of OSA patients.

SYSTEMATIC REVIEW AND META-ANALYSIS OF THE PALATAL SURGERIES IN THE TREATMENT OF OBSTRUCTIVE SLEEP APNEA

Abstract Background The first description of a patient with obstructive sleep apnea was in ‘The Posthumous Papers of the Pickwick Club’ published by English writer Charles Dickens in 18361. The first introduction of the terms ‘sleep apnea syndrome’ and ‘obstructive sleep apnea syndrome’ was by Guilleminault et al in 1967. Subsequently, Guilleminault coined the term ‘upper airway resistance syndrome’ in 19932. Objectives This paper aims to examine published articles between January 2008 and January 2019 on the different palatal surgeries performed on OSA patients and the treatment outcomes, which in turn will be used to determine two things. The first being the effectiveness of various palatal surgical techniques in treating OSAS and the second (if applicable) the most effective of the palatal surgical techniques in treating OSAS. Patients and Methods The current review followed the guidelines of preferred reporting items for systematic reviews and meta-analysis statement 2009 (PRISMA)5. The detailed steps of methods were described elsewhere as well as PRISMA checklist. The quality of relevant studies was assessed using NIH quality assessment tool for observational cohort and cross -sectional studies as well as NIH tool for quality assessment for case series studies. Results Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction on AHI was the lateral pharyngoplasty followed by the Anterior Palatoplasty, with a significant mean reduction of [(SMD= -0.848, 95% CI (-1.209 – -0.487), p-value&amp;lt;0.001) and (SMD= -0.864, 95% CI (-1.234 – -0.494), p-value&amp;lt;0.001), respectively]. The technique responsible for the best improvement in ESS was the Relocation Pharyngoplasty, with a significant mean reduction of [SMD= -0.998, 95% CI (-1.253 – -0.743), p-value&amp;lt;0.001]. Minimal O2 saturation level improved most with the Expansion Sphincter Pharyngoplasty, with a significant mean reduction of [SMD= 1.011, 95% CI (0.581 – 1.440), p-value&amp;lt;0.001]. The surgical procedure that result in the best post-operative VAS was Z-Palatoplasty, with a significant mean reduction of [SMD= -1. 551, 95% CI (-2.049 – -1.052), p-value&amp;lt;0.001]. soft palate length change with a significant mean reduction of [SMD= -2.219, 95% CI (-2.730 – 1.708), p-value&amp;lt;0.001]. Finally, meta-analyses of relevant studies showed that expansion sphincter pharyngoplasty achieved the overall highest success rate [Event rate= 77%, 95% CI (65.4%– 85.5%), p-value&amp;lt;0.001] Conclusion The best procedure for treating OSA varies from patient to patient and there is no universal cure-all. Careful patient selection and pre-operative evaluation are mandatory.

The Role of Myofunctional Therapy in Treating Sleep-Disordered Breathing: A State-of-the-Art Review.

Myofunctional therapy (MFT) may have a role in improving muscle tone and alleviating upper airway collapse in sleep-disordered breathing. The purposes of this state-of-the-art review are to first review systematically the current literature on the effectiveness of MFT in treating sleep-disordered breathing and then to provide an overview of the current understanding of patient selection, side effects, type and duration of exercises, guidance of exercise performance, evaluation of results, and how best to promote adherence. PubMed (Medline), the Cochrane Library, and the EMBASE, Scopus and SciELO databases were checked for relevant studies by three authors, and a total of 23 studies were included. This review focuses only on adults with sleep-disordered breathing. The available evidence shows a positive effect of MFT in reducing sleep apnoea, as measured using polysomnography and clinical variables (including snoring). There is no evidence of the utility of MFT for treating upper airway resistance syndrome, the duration of the effects of MFT, or regarding which MFT protocol is best. Despite these knowledge gaps, the available evidence suggests that MFT is a safe treatment modality.

Upper Airway Resistance Syndrome: a Combined ENT and Dental Approach

Upper Airway Resistance Syndrome: a Combined ENT and Dental Approach

391 Upper Airway Resistance Syndrome is associated with high Cyclic Alternating Pattern

Abstract Introduction Upper Airway Resistance Syndrome (UARS) is suspected in individuals with excessive daytime sleepiness, fatigue, and sleep fragmentation associated with increased respiratory effort. UARS can negatively impact daytime function. Conventional polysomnography parameters do not demonstrate significant abnormalities in UARS patients but increase in RERAs and arousal index. Cyclic alternating pattern (CAP) is a periodic electroencephalogram activity of non-REM sleep that expresses a condition of sleep instability. The objective of the study was to compare CAP components between UARS patients and health individuals. Methods Fifteen subjects with UARS and 15 age- and sex- matched controls had their sleep study blinded analyzed. UARS criteria were the presence of sleepiness (Epworth Sleepiness Scale – ESS - ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea/hypopnea index (AHI) ≤ 5 and a respiratory disturbance index (RDI) &amp;gt; 5 events/hour of sleep, and/or flow limitation in more than 30% of total sleep time. Control group criteria were AHI &amp;lt; 5 events/hour, RDI ≤ 5 events/hour and &amp;lt; 30% of TST with flow limitation and ESS &amp;lt; 10, without sleep, clinical, neurological, or psychiatric disorder. CAP electroencephalogram of both groups was analyzed. Results We found higher CAP rate (p = 0.05) and CAP index in N1 stage (p &amp;lt; 0.001) and in N3 stage (p &amp;lt; 0.001) in UARS patients compared to control group. Considering only CAP phase A1 analysis, UARS patients presented higher CAP rate (p = 0.05) and CAP index in N1 stage (p &amp;lt; 0.001) as well as CAP index in N3 stage (p &amp;lt; 0.001) compared to control group. Considering only CAP phase A2 analysis, UARS patients also presented higher number of CAP in N1 stage (p = 0.05). There was no significant difference for CAP phase A3 between groups. Conclusion Although UARS is associated with high arousal index, we found increase in CAP phase A1 and A2, which do not include necessarily AASM arousals, suggesting not only sleep fragmentation but also sleep instability. Support (if any) Associação Fundo de Incentivo à Pesquisa (AFIP) and Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).

Functional Rhinoplasty and Uvuloplasty for Sleep-Disordered Breathing: A Step-by-Step Guide

Sleep-disordered breathing (SDB) represents a wide range of sleep-related breathing abnormalities including snoring, upper airway resistance syndrome, respiratory event–related arousal, obstructive sleep apnea (OSA), and obstructive sleep apnea syndrome.1 It has been established in the literature that SDB is associated with hypertension, stroke, hyperlipidemia, cardiac dysrhythmias, and excessive daytime sleepiness (EDS).1,2 The therapeutic resolution of these medical maladies has proven nonlinear and less than optimal by most treatment approaches for OSA.

Diagnosis and management of childhood sleep-disordered breathing

Sleep-disordered breathing (SDB) includes disorders of breathing that affect airway patency, which impair children’s sleep and lead to negative consequences. Obstructive sleep apnea, hypoventilation and upper airway resistance syndrome are common causes of morbidity and mortality in childhood. These clinical practice guidelines, intended for use by pediatricians and primary care clinicians, provide a clear recommendation for the diagnosis and management of sleep-disordered breathing, focusing on the most serious disorder, obstructive sleep apnea syndrome (OSAS). These clinical guidelines formulate clear recommendations to identify patients with suspected OSAS. Further, the manuscript will highlight the potential consequences of SBD in children, and how to overcome such difficulties, what could be the therapeutic options, a 12 recommendations and what are the future direction for pediatric sleep medicine.

Long term oral appliance therapy decreases stress symptoms in patients with upper airway resistance syndrome.

To evaluate the long-term effects of a mandibular advancement device (MAD) on stress symptoms and cognitive function in patients with upper airway resistance syndrome (UARS) compared with placebo. This study was a randomized placebo-controlled clinical trial. Thirty UARS patients were randomized into 2 groups: placebo and MAD groups. UARS criteria were the presence of sleepiness (Epworth Sleepiness Scale ≥ 10) and/or fatigue (Modified Fatigue Impact Scale ≥ 38) associated with an apnea-hypopnea index ≤ 5 events/h and a respiratory disturbance index > 5 events/h of sleep, and/or flow limitation in more than 30% of total sleep time. All patients completed the Rey Auditory-Verbal Learning Test, the Logical Memory test, the Stroop Color Test, the Trail Making Test, the Digit Symbol Substitution Test, and Inventory of Stress Symptoms. Cognition protocol was defined based on the most used neuropsychological tests in the literature. Evaluations were performed before and after 1.5 years of treatment. Mean adherence to placebo and to MAD was 6.6 ± 2.6 and 6.1 ± 2.4 h/night, respectively. Side effects reported by MAD group were minor and short-term. There was no statistically significant difference in Rey Auditory-Verbal Learning Test, Logical Memory test, Stroop Color Test, Trail Making Test, and Digit Symbol Substitution Test before and after 1.5 years of treatment in both groups. Inventory of Stress Symptoms score decreased at the alert phase and the resistance phase after 1.5 years of MAD treatment compared to the placebo. Mandibular advancement devices were effective in decreasing stress symptoms in UARS patients after 1.5 years of treatment. Registry: ClinicalTrials.gov; Name: Efficacy of Oral Appliance for Upper Airway Resistance Syndrome; URL: https://clinicaltrials.gov/ct2/show/record/NCT02636621; Identifier: NTC02636621.

1259 Periodic Neck Myoclonus During Sleep (PNMS) is Associated with Upper Airway Resistant Syndrome, but Resolves with CPAP

Abstract Introduction Periodic neck myoclonus during Sleep (PNMS) is a movement disorder of sleep characterized by sudden myoclonic flexion or version of the head that manifest during REM and NREM sleep. While its finding has been attributed to a normal physiologic phenomenon, to the best of our knowledge, our case represents the first report of with PNMS attributed to sleep disordered breathing with resolution using CPAP Report of Case A 22 y/o male with no significant clinical history was referred for evaluation of snoring and excessive sleepiness. Nocturnal polysomnogram coupled with expanded EMG montage demonstrates evidence of upper airway resistance syndrome (UARS), characterized by frequents respiratory effort-related arousals (RERAS), primarily during REM sleep associated with arousals. The majority of these events resulted in sudden myoclonic movements of the neck and head that were associated with arousals and sleep fragmentation. PNMS manifested in the PSG as a flexion myoclonic motor artifact lasting 200-800 ms during REM sleep with an associated EEG arousal. The overall Respiratory Disturbance Index (RDI) was12/hr. The subsequent application of CPAP at a setting of 5-6 cm resolved these movements supporting this origin as a phenomenon of sleep-state instability. Conclusion While previous investigators have explained PNMS as an incidental finding or one common in patients with RBD, our case highlights a potential new mechanism for their appearance. This case helps shed more light on the origin of PNMS as a secondary phenomenon related to sleep state instability due to sleep disordered breathing given the temporal association with RERAS and dramatic resolution with CPAP therapy.

0897 Sleep Disordered Breathing In Pediatric Patients With Turner Syndrome

Abstract Introduction Turner syndrome (TS) is a common genetic disorder that affects phenotypic females with partial or complete absence of one X chromosome. It typically presents with characteristic facial appearance, neck webbing, lymphedema, linear growth failure, and ovarian insufficiency. TS is also associated with other disorders, though sleep related disorders are not commonly reported. We present a case series of pediatric patients diagnosed with TS and assess their risk for sleep disordered breathing. Methods This study utilized retrospective chart review of the electronic medical record at the University of North Carolina at Chapel Hill from April 2014 to January 2019. Only pediatric patients under the age of 18 years who had previously undergone polysomnography and carrying the diagnosis of Turner syndrome were included in this study. Polysomnography results were reviewed. Results Retrospective chart analysis yielded ten (10) patients who qualified for inclusion. The mean age was 8.3 years (age range 1-15 years). Nine (9) patients were found to have sleep disordered breathing ranging from upper airway resistance syndrome to moderate sleep apnea (AHI range 1.2 to 6.2). Six (6) patients were found to have elevated periodic limb movement indices (PLM index range 5.1 to 30). Parasomnias and hypoventilation were not seen. Conclusion Our case series illustrates that sleep disordered breathing may be more common in TS than previously realized. Eklund et al. found that females with TS had more retrognathic mandibles and maxillas, shorter mandibles, and larger cranial base angles. These findings may indicate elevated risk of sleep apnea. Further studies are needed to define the overall risk of sleep disordered breathing in TS. Support None.

Observational Study of Pulse Transit Time in Children With Sleep Disordered Breathing.

Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study.Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and “abnormal other.” Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study.Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62–0.90) and specificity 0.79 (C.I. 0.49–0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67–0.92) and specificity 0.37 (95% C.I. 0.17–0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31–0.46) and specificity 0.98 (C.I. 0.97–1.00).Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.

Mandibular Position As A Predictor of the Upper Airway Resistance Syndrome

Mandibular Position As A Predictor of the Upper Airway Resistance Syndrome

Pediatric Upper Airway Resistance Syndrome: A Usually Missed Suspect (2156)

Pediatric Upper Airway Resistance Syndrome: A Usually Missed Suspect (2156)