Perioperative Care of Patients With Obstructive Sleep Apnea Undergoing Upper Airway Surgery: A Review and Consensus Recommendations.

IMPORTANCE: To date, no consensus exists regarding optimal perioperative care of patients with obstructive sleep apnea (OSA) undergoing upper airway (UA) surgery. These patients are at risk related to anesthesia and postoperative analgesia, among other risks associated with difficult airway control, and may require intensified perioperative management. OBJECTIVE: To provide a consensus-based guideline by reviewing available literature and collecting expert opinion during an international consensus meeting with experts from relevant speciliaties. EVIDENCE REVIEW: In a consensus meeting conducted on April 4, 2018, a total of 47 questions covering preoperative, intraoperative, and postoperative care were formulated by 12 international experts with extensive clinical experience in the field of UA surgery for OSA. Systematic literature searches were performed by an independent information specialist and 6 researchers according to the Oxford and GRADE systems, and 164 articles published on or before December 31, 2011, were included in the analysis. Two moderators chaired the meeting according to the Amsterdam Delphi Method, including iteration of literature conclusions, expert discussion, and voting rounds. Consensus was reached when there was 70% or more agreement among experts. FINDINGS: Of 47 questions, 35 led to a recommendation or statement. The remaining 12 questions provided no additional information and were excluded in the judgment of experts. Consensus was reached for 32 recommendations. For 1 question there was less than 70% agreement among experts; therefore, consensus was not achieved. Highlights of these recommendations include (1) postoperative bleeding is a complication described for all types of UA surgery; (2) OSA is a relative risk factor for difficult mask ventilation and intubation, and plans for difficult airway management should be considered and implemented; (3) safe perioperative care should be provided, with aspects such as OSA severity, adherent use of positive airway pressure, type of surgery, and comorbidities taken into account; (4) although there is no direct evidence to date, in patients undergoing UA surgery, preoperative treatment with positive airway pressure may reduce the risk of postoperative airway complications; and (5) alternative pain management options perioperatively to reduce opioid use should be considered. CONCLUSIONS AND RELEVANCE: This consensus contains 35 recommendations and statements on the perioperative care of patients with OSA undergoing UA surgery and may be used as a guideline in daily practice.

[Hypoglossal nerve stimulation for obstructive sleep apnoea; technique, indication and future prospects]. / Stimulatie van tongzenuw bij obstructieve slaapapneu.

Hypoglossal nerve stimulation for obstructive sleep apnoea; technique, indication and future prospects Continuous positive airway pressure (CPAP) is the treatment of first choice in patients with moderate to severe obstructive sleep apnoea (OSA); however, 1 in 3 patients does not tolerate CPAP. Upper airway stimulation (UAS) is an alternative for CPAP. This is a new treatment, intended for patients with CPAP intolerance or failure. The muscles responsible for protrusion of the tongue are activated by unilateral stimulation of the hypoglossal nerve, resulting in opening up of the pharynx. Since April 2017, UAS treatment has been reimbursed for a select group of patients by the National Healthcare Institute in the Netherlands, leading to an increase in demand for UAS.

Durability of treatment effects of the Sleep Position Trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial.

PURPOSE: The Sleep Position Trainer (SPT) is a new option for treating patients with positional obstructive sleep apnea (POSA). This study investigated long-term efficacy, adherence, and quality of life during use of the SPT device compared with oral appliance therapy (OAT) in patients with POSA. METHODS: This prospective, multicenter trial randomized patients with mild to moderate POSA (apnea-hypopnea index [AHI] 5-30/h) to SPT or OAT. Polysomnography was performed at baseline and after 3 and 12 months' follow-up. The primary endpoint was OSA severity; adherence, quality of life, and adverse events were also assessed. RESULTS: Ninety-nine patients were randomized and 58 completed the study (29 in each group). Median AHI in the SPT group decreased from 13.2/h at baseline to 7.1/h after 12 months (P < 0.001); corresponding values in the OAT group were 13.4/h and 5.0/h (P < 0.001), with no significant between-group difference (P = 1.000). Improvements throughout the study were maintained at 12 months. Long-term median adherence was also similar in the two treatment groups; the proportion of patients who used their device for ≥ 4 h for 5 days in a week was 100% in the SPT group and 97.0% in the OAT group (P = 0.598). CONCLUSIONS: The efficacy of SPT therapy was maintained over 12 months and was comparable to that of OAT in patients with mild to moderate POSA. Adherence was relatively high, and similar in the two groups. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02045576).

Correction to: Durability of treatment effects of the sleep position trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial.

The article "Durability of treatment effects of the Sleep Position Trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial", by M. H. T. de Ruiter et al., was originally published online in SpringerLink on 15 September 2017 without open access.

CPAP washout prior to reevaluation polysomnography: a sleep surgeon's perspective.

PURPOSE: Obstructive sleep apnea (OSA) is characterized by repetitive upper airway collapse during sleep, leading to decreased oxygen blood levels and arousal from sleep. The gold standard treatment option for moderate to severe OSA is considered continuous positive airway pressure (CPAP). In case primary treatment with CPAP fails, a reevaluation of disease severity [by means of the apnea/hypopnea-index (AHI)] can be required. A subset of patients that prefer a CPAP alternative is still using CPAP until the reevaluation polysomnography (PSG), and a so-called washout effect is not ruled out. The purpose of this study is to evaluate the evidence on the existence and duration of this washout effect and its clinical relevance for current practice. METHODS: To identify papers for this review, an extensive literature search was run electronically through MEDLINE and EMBASE databases. RESULTS: An overview of currently available literature on this washout effect and the findings of 13 studies on this topic are discussed. CONCLUSION: There is some evidence that CPAP washout exists in patients with a stable BMI throughout the follow-up period. However, the intensity and duration of this effect remains unclear. Within the limitations of the present study, it seems reasonable to maintain a washout period of 1 week, in case alternative treatments options are considered and especially when a baseline PSG (and subsequent repeat PSG after treatment) is needed in case of clinical trials.