Precision Prevention in Obstructive Sleep Apnea.

Sleep-related breathing disorders, encompassing snoring and obstructive sleep apnea (OSA), are highly prevalent worldwide, and there have been important advances in recent years regarding the understanding of underlying pathophysiology mechanisms, diagnosis, and improvement in therapeutic options. The precision medicine and person-centered approaches are based on the concept that every individual is unique and a myriad of elements influence the likelihood of developing the disease, the signs and symptoms expressed, the response to different treatment modalities, and the susceptibility to complications. Thus, health and disease are the result of phenotypic outcomes resulting from interactions between biological factors, environment, and lifestyle.

Management of pharyngeal collapse in patients affected by moderate obstructive sleep apnoea syndrome.

Objective: This study reports our experience in a selected cohort of patients affected by mild-moderate OSAS, without tonsillar obstruction, and treated with pharyngoplasty. Methods: In a case-control retrospective study, we compared modified expansion sphincter pharyngoplasty (MESP) to modified barbed reposition pharyngoplasty (MBRP) in adult patients with oropharyngeal transversal collapse with a BMI ≤ 30 kg/m2, and mild-moderate obstructive sleep apnoea syndrome (OSAS). A clinical evaluation, including collection of anthropometric data and sleep endoscopy, was performed. Six months after surgery, symptoms recording, clinical evaluation and polysomnography (PSG) were repeated. Results: We enrolled 20 patients: 10 treated with MESP and 10 treated with MBRP. Mean apnoea-hypoapnoea index (AHI) was 22.8 (± 5.63). We observed in both groups a significant reduction of AHI and oropharyngeal obstruction (p = 0.01), with a success rate, according with Sher's criteria, of 90% for MESP and 80% for MBRP, respectively. Post-surgical pain and snoring reduction were significantly lower with MBRP. Conclusions: We recorded similar success rates for both techniques. MBRP may be considered better than MESP due to less surgical time, no potential mucosal damage, absence of knots, and faster recovery with less pain.

Japanese Cross-Sectional Multicenter Survey (JAMS) of Oral Appliance Therapy in the Management of Obstructive Sleep Apnea.

We conducted a multicenter survey for oral appliance (OA) therapy to grasp and analyze the current situation of OA therapy, including efficacy, side effects, and follow-up, in Japan. The Japanese cross-sectional multicenter survey (JAMS) for obstructive sleep apnea (OSA) was undertaken by patients in 10 institutions associated with oral appliance therapy during two years, from 2014 to 2015, retrospectively. Age, sex, body mass index (BMI), baseline apnea-hypopnea index (AHI), OA type, adjustment, adverse reactions with OA, and AHI with OA were elicited from the patient clinical record. The number of included OSA patients was 3217. The number of patients with OA therapy was 2947. We evaluated 1600 patients for the OA treatment. The patients treated with OA, both male and female, were most commonly in their 50s. In terms of OSA severity, snoring was 2.3%, mild was 38.5%, moderate was 39.9%, and severe was 19.3%. The use of mono bloc appliance was 91.8%, bi bloc appliance was 7.9%, and tongue-retaining device (TRD) was 0.3%. After OA treatment, AHI decreased from 22.4/h to 9.3/h. The AHI reduction rate with OA was 52.0%. The rate of AHI <5 with OA was 35.6%. Adverse reactions developed in 14.7% of the subjects. OA reassessment was conducted for 54.3%. This study revealed the current situation of efficacy and side effects of OA therapy, and the problem that the reassessment rate of OA was low in Japan.

The Efficacy of Device Designs (Mono-block or Bi-block) in Oral Appliance Therapy for Obstructive Sleep Apnea Patients: A Systematic Review and Meta-Analysis.

Oral appliance (OAm) therapy has demonstrated efficacy in treating obstructive sleep apnea (OSA). The aim of this systematic review was to clarify the efficacy of device designs (Mono-block or Bi-block) in OAm therapy for OSA patients. We performed a meta-analysis using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Two studies (Mono-block OAm versus Bi-block OAm) remained eligible after applying the exclusion criteria. When comparing Mono-block OAm and Bi-block OAm, Mono-block OAm significantly reduced the apnea-hypopnea index (2.92; 95% confidence interval (95%CI), 1.26 to 4.58; p = 0.0006), and patient preference for Mono-block OAm was significantly higher (2.06; 95%CI, 1.44 to 2.06; p < 0.0001). Lowest SpO2, arousal index, non-REM stage 3, sleep efficiency, Epworth Sleepiness Scale (ESS), Snoring Scale, and side effects were not significantly different between the two groups (lowest SpO2: -11.18; 95%CI, -26.90 to 4.54; p = 0.16, arousal index: 4.40; 95%CI, -6.00 to 14.80; p = 0.41, non-REM stage 3: -2.00; 95%CI, -6.00 to 14.80; p = 0.41, sleep efficiency: -1.42, 95%CI, -4.71 to 1.86; p = 0.40, ESS: 0.12; 95%CI, -1.55 to 1.79; p = 0.89, Snoring Scale: 0.55; 95%CI, -0.73 to 1.83, p = 0.55, side effects: 1.00, 95%CI, 0.62 to 1.61, p = 1.00). In this systematic review, the use of Mono-block OAm was more effective than Bi-block OAm for OSA patients.

Mandibular Movement Analysis to Assess Efficacy of Oral Appliance Therapy in OSA.

RATIONALE: The respiratory effort index derived from vertical mandibular movements (MM-REI) is a potential marker of increased respiratory effort during sleep. We evaluated the effectiveness of mandibular advancement splint therapy using MM-REI, in comparison with the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI). METHODS: Fifty-six subjects (median age, 47 years) with OSA treated with a custom mandibular advancement splint (Herbst appliance) were evaluated at the end of the titration procedure when snoring was reported absent by the sleep partner. We employed a magnetometer to capture mandibular movements (Brizzy; Nomics). Mandibular advancement splint efficacy was assessed as the percent change from baseline, using Bayesian multilevel models. RESULTS: At the end of titration, all indices of OSA severity decreased compared with baseline: AHI (-48.9% to -71.1%), ODI (-49.5% to -77.2%), with obstructive hypopnea index and MM-REI showing the largest responses (-70.6% to -88.5% and -69.5% to -96.3%, respectively). MM-REI normalization via reductions in both mandibular movement event rate and duration accurately reflected efficacy of the appliance. CONCLUSIONS: The reduction of vertical respiratory mandibular movements estimated by MM-REI and sleep respiratory effort duration accompanied the decrease in obstructive hypopneas, AHI, and ODI when snoring resolved in subjects with OSA treated with an optimally titrated mandibular advancement splint.

Internal nasal dilatator (Nas-Air®) in patients who snore.

Snoring is a very common human habit, and for this reason it is considered more a social nuisance that a disease symptom. The nasal valve area has the minimal cross-sectional area of the upper airways. A problem at this level may easily induce impaired breathing and consequently snoring, therefore nasal dilation might significantly improve this complaint. Nas-Air® is a new internal nasal dilator which was tested on 41 outpatients who snore. Snoring duration, assessed by smartphone, visual analogue scale for the perception of sleep quality were measured before and during Nas-Air® use. A significant reduction of snoring time and an improvement of sleep quality were achieved during Nas-Air® wearing. In conclusion, the present study demonstrates that Nas-Air® is an internal nasal dilator able to reduce snoring time and improve sleep quality.

Patient-reported outcome: results of the multicenter German post-market study.

PURPOSE: Upper airway stimulation (UAS) is an alternative second-line treatment option for patients with obstructive sleep apnea (OSA). In our substudy of a previous multicentre study of patients implanted with UAS, we focused on patient-related outcomes like Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire (FOSQ), snoring and personal satisfaction 6 and 12 months after the implantation. METHODS: 60 patients, who were initially non-adherent to CPAP and implanted with UAS, were included in a prospective multicentre study. Data were collected preoperative, 6 and 12 months after implantation regarding FOSQ, ESS, snoring, and their experience with the UAS device. RESULTS: Besides relevant Apnoea-Hypopnea Index (AHI) reduction, we saw significant improvements in ESS (p < 0.001), FOSQ (p < 0.001) and snoring under UAS therapy. A strong correlation between AHI results postoperative and the personal satisfaction of the patients after implantation was found as well as between usage results and AHI compared to the preoperative results. CONCLUSION: The more the patients benefit from UAS according to their self-reported outcome, the higher is the therapy use.

Ronco

Ronco é o som causado pela vibração dos tecidos da faringe quando o ar passa por esta região. “Quando dormimos, há um relaxamento natural dessa musculatura que pode vibrar com a passagem do ar”.

Barbed snore surgery for concentric collapse at the velum: The Alianza technique.

Recently, new conservative and non-resective surgical techniques, including palatopharyngeal surgical lifting and suspension (the 'Roman blinds technique') and modular barbed snore surgery (MBSS), have been successfully introduced for the treatment of obstructive sleep apnea syndrome (OSAS). This pilot longitudinal study describes our preliminary experience with the 'Alianza technique' (the simultaneous use of Roman blinds and MBSS) in mild to moderate OSAS patients with concentric pharyngeal collapse at the velum, previously documented by means of drug-induced sleep endoscopy. Effectiveness of the surgical procedure was assessed by means of the Epworth sleepiness scale (ESS), overnight polysomnography, and a 0-10 snoring visual analogue scale (VAS); tolerability was assessed by means of a 0-10 pain VAS. The final analysis relating to 19 patients (18 males; 94.8%), with a mean age of 43.8 ± 8.8 years, showed a statistically significant reduction in mean post-operative apnea-hypopnea indexes (22.3 ± 5.1 vs 7.0 ± 9.4 events/hour; p-value = 0.002) and mean ESS scores (11.3 ± 5.4 vs 3.9 ± 4.0; p-value < 0.001). There was also a significant decrease in mean post-operative snoring VAS scores (9.5 ± 0.7 vs 2.1 ± 1.7; p-value < 0.001). Surgery was well tolerated in most patients (mean pain VAS scores on day seven: 2.4 ± 1.4), and there were no major complications. In experienced hands, the Alianza can be considered an effective and safe technique for the treatment of mild to moderate OSAS.

Actuated bed for a closed loop anti-snoring therapy.

Snoring is a very common often underestimated sleep disorder, which is caused by a partial blockage of the upper airways. It can easily be treated by changing the sleeping posture of the snorer. However, conventional approaches are often perceived as uncomfortable. In order to increase uptake we propose to use an actuated bed, which is equipped with microphones and controlled in closed loop. The inclination of the part of the bed which is supporting the trunk is increased to open the upper airways, whenever snoring sounds are detected. During snoring-free periods the bed goes back to its original position to allow the user to move freely. The principle has successfully been applied in a proof of concept test. During this test night the bed was able to stop the snorer from snoring in four out of five occasions.

The effect on snoring of using a pillow to change the head position.

PURPOSE: Although not a disease, primary snoring often leads to social problems. In an earlier retrospective pilot study, we found hints that individuals were snoring less in a lateral versus a supine head position. The aim of this study is to elucidate on the effect of an anti-snoring pillow which changes the head position. METHODS: We designed an interventional, controlled, and randomized crossover study. It included 22 participants, between 18 and 78 years, who snored, had a BMI ≤ 30, and a sleep partner. Obstructive sleep apnea was ruled out by polysomnography (PSG) or by respiratory polygraphy (PG). Two potential participants dropped out. The first two phases were done at home (4 weeks in total), followed by two nights of polysomnography in our sleep laboratory. During all phases, questionnaires regarding snoring, sleep quality, and pillow tolerance were completed by the patients and, as relevant, by their partners. RESULTS: The PSG parameters revealed a significant reduction in the snoring index (p = 0.03) when on the activated pillow without a deterioration in other respiratory parameters. This correlated well with the visual analog scale (VAS) that showed a significant decrease in snoring with the activated pillow according to the bed partners (p < 0.001). Subjective acceptance of the pillow during the study period was 100%. CONCLUSIONS: This study shows that by using a pillow to change the head position, it is possible to reduce both subjective and objective snoring severity. GERMAN CLINICAL TRIAL NUMBER: DRKS 00008744 AND ETHICS COMMISSION REGISTRY NUMBER REGISTRY NUMBER 2013-406 M-MA.

Long-term results of a modified expansion sphincter pharyngoplasty for sleep-disordered breathing.

Our aim was to evaluate the long-term objective and subjective results of a modified expansion sphincter pharyngoplasty (ESP) technique in patients with sleep-disordered breathing. Single center prospective study of 35 patients underwent an ESP as a primary surgical treatment between June 2012 and September 2015 at the hospital AZ Sint-Jan Bruges-Ostend. Patients were divided into non-OSAS and OSAS (AHI >5). Primary outcome parameters were the Epworth Sleeping Scale (ESS, reduction and score less then 10) and the Visual Analogue Score of snoring (VAS, assessed by partner) evaluated at 3 months and 1 year. In addition, the OSAS group underwent a polysomnography after 6 months to calculate the Apneu-Hypopneu Index (AHI) change. Secondary outcome parameters were possible complications and morbidity rate. The overall Epworth Sleepiness Scale showed a steady total reduction of, respectively, 42 and 48% at the two timepoints. All patients had a post-operative score of less than ten points. The Visual Analogue Score improved in 92% of the patients; of these, the snoring was reduced in 86% and disappeared in 6%. In the OSAS group, we noticed a reduction in AHI of more than 50 in 53% of the patients. A considerable reduction was found in the severe OSAS group, where we found a mean pre-operative average AHI of 41.3/h that was reduced 6 months after the operation to 17.4/h. There were no severe complications or increased morbidity rate observed. This first long-term study shows that the modified ESP seems to be a safe and promising technique in palatal surgery for patients with sleep-disordered breathing. Surgical effectiveness is sustained after 1 year, both in OSAS as in snoring pathology. The technique seems as approachable for the basic ENT surgeon as the uvulopalatopharynoplasty.

Oral Appliances in Obstructive Sleep Apnea.

Oral appliance therapy (OAT) has become an increasingly popular nonsurgical option for the treatment of obstructive sleep disorders. Recent research supports its efficacy and high levels of compliance for patients with obstructive sleep disorders. Common side effects of OAT include temporomandibular joint-related symptoms, bite changes, and tooth movement. These side effects can be minimized by the use of exercises. The American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine have released joint clinical practice guidelines for the treatment of obstructive sleep apnea and snoring with OAT.

Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis.

A small maxilla and/or mandible may predispose children to sleep-disordered breathing, which is a continuum of severity from snoring to obstructive sleep apnea. Preliminary studies have suggested that orthodontic treatments, such as orthopedic mandibular advancement or rapid maxillary expansion, may be effective treatments. The aim is to investigate the efficacy of orthopedic mandibular advancement and/or rapid maxillary expansion in the treatment of pediatric obstructive sleep apnea. Pubmed, Medline, Embase, and Internet were searched for eligible studies published until April 2014. Articles with adequate data were selected for the meta-analysis; other articles were reported in the qualitative assessment. Data extraction was conducted by two independent authors. A total of 58 studies were identified. Only eight studies were included in the review; of these, six were included in the meta-analysis. The research yielded only a small number of studies. Consequently, any conclusions from the pooled diagnostic parameters and their interpretation should be treated carefully. Although the included studies were limited, these orthodontic treatments may be effective in managing pediatric snoring and obstructive sleep apnea. Other related health outcomes, such as neurocognitive and cardiovascular functions have not yet been systematically addressed. More studies are needed with larger sample size, specific inclusion and exclusion criteria and standardized data reporting to help establish guidelines for the orthodontic treatment of pediatric obstructive sleep apnea.

Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial.

BACKGROUND: Snoring is extremely common in the general population and may indicate OSA. However, snoring is not objectively measured during polysomnography, and no standard treatment is available for primary snoring or when snoring is associated with mild forms of OSA. This study determined the effects of oropharyngeal exercises on snoring in minimally symptomatic patients with a primary complaint of snoring and diagnosis of primary snoring or mild to moderate OSA. METHODS: Patients were randomized for 3 months of treatment with nasal dilator strips plus respiratory exercises (control) or daily oropharyngeal exercises (therapy). Patients were evaluated at study entry and end by sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index) and full polysomnography with objective measurements of snoring. RESULTS: We studied 39 patients (age, 46 ± 13 years; BMI, 28.2 ± 3.1 kg/m2; apnea-hypopnea index (AHI), 15.3 ± 9.3 events/h; Epworth Sleepiness Scale, 9.2 ± 4.9; Pittsburgh Sleep Quality Index, 6.4 ± 3.3). Control (n = 20) and therapy (n = 19) groups were similar at study entry. One patient from each group dropped out. Intention-to-treat analysis was used. No significant changes occurred in the control group. In contrast, patients randomized to therapy experienced a significant decrease in the snore index (snores > 36 dB/h), 99.5 (49.6-221.3) vs 48.2 (25.5-219.2); P = .017 and total snore index (total power of snore/h), 60.4 (21.8-220.6) vs 31.0 (10.1-146.5); P = .033. CONCLUSIONS: Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01636856; URL: www.clinicaltrials.gov.

Changes of snoring sound after relocation pharyngoplasty for obstructive sleep apnoea: the surgery reduces mean intensity in snoring which correlates well with apnoea-hypopnoea index.

OBJECTIVE: To investigate objective changes of snoring after surgery in patients with obstructive sleep apnoea (OSA) and correlate these with changes in the apnoea-hypopnoea index (AHI). DESIGN: Prospective case series. SETTING: A novel measurement, Snore Map, was used to analyse full-night snore sounds in terms of the maximal/mean intensity, peak/mean frequency, snoring index and energy type (Snore Map type, 0-4). Snore sound was classified into three bands according to frequency energy spectrum: B1 (40-300 Hz), B2 (301-850 Hz) and B3 (851-2000 Hz). PARTICIPANTS: Thirty-four male and two female OSA patients (mean age, 39 years; mean AHI, 53.1/h; mean body mass index, 26.8 kg/m(2) ) with favourable anatomic structure were consecutively enrolled. MAIN OUTCOME MEASURES: Parameters of polysomnographies and Snore Maps at baseline and six months after operation were compared. Statistical significance was set at P < 0.05. RESULTS: Thirty-two patients completed this study. The mean reduction in the total-snoring index was insignificant but there were significant decreases in total mean intensity, total peak frequency, total mean frequency and Snore Map type after surgery. There were also significant decreases in the mean intensity in all three bands, the snoring index in B2/B3 and the mean frequency in B1 postoperatively. Changes in the total mean intensity, total mean frequency, B2 mean intensity and B3 snoring index positively correlated with change in the AHI. CONCLUSIONS: Relocation pharyngoplasty significantly decreases both the snoring sound intensity and snoring frequency. These reductions are directly proportional to the improvement of OSA.

Impact of head and neck radiotherapy for patients with nasopharyngeal carcinoma on sleep-related breathing disorders.

IMPORTANCE: Little is known about the relationships between sleep-related breathing disorders (SRBDs) and nasopharyngeal carcinoma (NPC). OBJECTIVE: To clarify the impact of head and neck radiotherapy on SRBDs, we performed a pilot study to investigate the change of sleep architecture in patients with NPC before and after treatment. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of a prospective data set of 18 patients with NPC (15 men and 3 women; mean age, 49.8 years) and symptoms of SRBD, who completed radiotherapy and underwent polysomnography before and after treatment at a university-affiliated tertiary referral center. INTERVENTIONS: Radiotherapy and/or chemotherapy were applied based on the NPC stage. MAIN OUTCOMES AND MEASURES: Subjective SRBD symptoms, Epworth sleepiness scale score, snoring severity (visual analog scale, rated 0-10 by bed partner), and objective full-night polysomnographic parameters (apnea-hypopnea index [AHI], AHI in rapid eye movement [REM] sleep, central sleep apnea index, percentage of light sleep, percentage of deep sleep, percentage of REM sleep, sleep efficiency, sleep latency, arousal index, mean oxygen saturation, lowest oxygen saturation, desaturation index, and snoring index) were collected before and at least 6 months after treatment. RESULTS: After treatment, Epworth sleepiness scale and snoring severity scores significantly decreased from a mean (SD) of 11.0 (5.0) to 7.8 (2.3) (P = .005) and 6.0 (3.4) to 2.8 (2.3) (P < .001), respectively. The AHI changed from 26.2 (28.4) to 21.67 (24.15) (P = .28). However, AHI increased in 8 of 18 patients. A statistically significant increase was shown in mean oxygen saturation, from 95.3% (2.0%) to 97.1% (1.4%) (P < .001), though lowest oxygen saturation was not significantly altered. Percentage of light sleep increased significantly from 78.9% (8.8%) to 86.1% (9.6%) (P = .02), and percentage of REM sleep decreased from 17.5% (6.4%) to 12.7% (8.9%) (P = .10). Percentage of deep sleep was not significantly altered. CONCLUSIONS AND RELEVANCE: Although the severity of apnea and hypopnea events and snoring decreased in most of the patients with NPC after treatment, the sleep architecture became disrupted and 8 of 18 of the patients had an increased AHI after treatment. Identification and treatment of obstructive sleep apnea and hypopnea in patients with NPC may be important factors for improving the quality of life.

[Snoring in children. Algorithm for diagnostic approach]. / Schnarchen bei Kindern. Algorithmus zum diagnostischen Vorgehen.

BACKGROUND: Snoring in children is a prevalent symptom and may be an indicator of obstructive sleep apnoea. Despite its importance, there is no national guideline on its appropriate management. OBJECTIVE: To provide recommendations for the management of snoring in children and adolescents treated in a primary care setting. METHODS: A total of 16 national paediatric sleep experts were included in a Delphi process and formulated recommendations in the form of a step-wise work-up procedure. RESULTS: The following 8 steps were developed: (1) Identification of true cases of habitual snoring. (2) Identification of high-risk patients who should undergo polysomnography in a sleep laboratory. (3) Identification of mild cases that may be treated with anti-inflammatory medication. (4) Identification of cases that should be referred to an otorhinolaryngologist for potential surgery. (5) Performance of polysomnography in cases that remain unclear despite steps 3 and 4 to rule out obstructive sleep apnoea. (6) Reconsideration of surgery in cases with moderate to severe obstructive sleep apnoea. (7) Identification of severe sleep apnoea cases requiring continuous positive airway pressure therapy. (8) Identification of cases suitable for orthodontic treatment, craniofacial surgery or speech therapy. CONCLUSION: This guideline should help to improve the management of snoring children and adolescents in Germany.