Clinical Practice Guideline recommendations on examination of the upper airway for adults with suspected obstructive sleep apnoea-hypopnoea syndrome

Quality assessment of clinical practice guidelines for adult obstructive sleep apnea: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) are crucial in standardizing the management of obstructive sleep apnea (OSA) in adults. However, there has been insufficient evaluation of the overall quality of CPGs for adult OSA. This review aimed to comprehensively assess the overall quality of CPGs in the field of adult OSA.

METHODS

A systematic search was conducted on various literature databases, guideline-related databases, and academic websites from January 2013 to December 2023 to select CPGs relevant to adult OSA. The methodological and reporting quality of the eligible CPGs were thoroughly appraised by three reviewers using the AGREE II instrument and RIGHT checklist, respectively.

RESULTS

This review included 44 CPGs, consisting of 42 CPGs in English and 2 CPGs in Chinese. The assessment of methodological quality revealed that four domains attained an average standardized score above 60%. Among the domains, "clarity of presentation" received the highest standardized score of 85.10%, while the lowest standardized score was observed in the "rigor of development" domain with the value of 56.77%. The evaluation of reporting quality indicated an overall reporting rate of 51.30% for the eligible CPGs, with only three domains achieving an average reporting rate higher than 50%. The domain with the highest reporting rate was "basic information" at 60.61%, while the domain with the lowest reporting rate was "review and quality assurance" at 15.91%. Furthermore, a significantly positive correlation was found between the AGREE II standardized scores and the RIGHT reporting rates (r = 0.808, P < 0.001).

CONCLUSIONS

The overall quality of the currently available guidelines for adult OSA demonstrated considerable variability. Researchers should prioritize the utilization of evidence-based methods and adhere to the items listed in the RIGHT checklist when developing CPGs to enhance efficient clinical decision-making and promote the translation of evidence into practice.

Transformative Physiotherapy Approach in an 80-Year-Old Female: A Case Report of Managing Obstructive Sleep Apnea for Improved Quality of Life

Obstructive sleep apnea (OSA) presents a significant challenge to patients' overall health and well-being, characterized by upper airway collapse during sleep leading to fragmented and non-restorative sleep patterns. This case report describes an 80-year-old female patient presenting with breathlessness, obesity (BMI: 43 kg/m2), sleep disturbances, fatigue, attention deficits, reduced chest compliance, and a history of type 2 diabetes mellitus. Clinical findings revealed ongoing sleep disruptions, worsening breathlessness, progressive weakness, and decreased oxygen saturation levels. The therapeutic intervention involved a comprehensive physiotherapy program targeting respiratory muscle training, lung function improvement, peripheral muscle strengthening, and relaxation exercises. The discussion highlights studies supporting physiotherapeutic interventions such as thoracic extension exercises, neuromuscular stimulation, and oropharyngeal exercises for managing OSA symptoms. Overall, this case underscores the importance of tailored physiotherapy interventions in addressing the multifaceted challenges of OSA, aiming to improve patient outcomes and quality of life.

Association between the Obstructive Sleep Apnea and Cephalometric Parameters in Teenagers

BACKGROUND

OSA is a common problem in children and adolescents. Angle class II malocclusion, a tendency toward the vertical type of growth, causes a decrease in the volume of the oral air space, increasing the risk of OSAS. The aim of this study was to evaluate the relationship between cephalometric and OSA parameters, to develop collaborative approaches between orthodontists and somnologists in the treatment of adolescents with OSA.

METHODS

We analyzed data from 41 adolescents with OSA. Their mean age was 15.8 ± 1.08 years. Orthodontic and polysomnographic examinations of patients were conducted. Statistical analysis was performed in SPSS 19.0.0.

RESULTS

Most often in patients with distal occlusion, a violation of the harmony in the development of the dental system was observed. The sagittal incisive fissure, characteristic of a distal occlusion, was absent due to the palatal inclination of the upper incisors in 25 (60.98%) patients. The SNB was 79.4 ± 3.1°, indicating a distal position of the mandible relative to the anterior cranial base. The SNA exceeded the normal value, which is one of the prerequisites for mandibular retrognathia. The ANB angle was 4.3 ± 1.9°. Tonsillar hypertrophy affected 6 patients, 21 had adenoid hypertrophy, and 3 had both of them. Movements of the masticatory muscles during sleep were recorded in 22.0% of patients.

CONCLUSION

To improve the quality of diagnosis and treatment of OSA, a multidisciplinary approach is needed that will correct the processes of child growth and development.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

[Obstructive Sleep Apnea]

Obstructive sleep apnea (OSA) is defined as the presence of an apnea-hyponea index (AHI)>15/h, predominantly obstructive or AHI greater than 5 with symptoms, the classic symptoms are observed apneas, daytime sleepiness and snoring, however, there are many other associated symptoms. To assess the severity of OSA, classically, only the AHI value was considered, but there is increasing evidence to implicate other factors. The predisposition to develop OSA is determined by anatomical and functional features. Having OSA increases the risk of accidents, high blood pressure (HBP) and is associated with cardiovascular risk, diabetes mellitus (DM), cardiac arrhythmia and neoplasms. To assess the probability of OSA, questionnaires and scales have been developed to assess symptoms, the certain diagnosis is obtained by polysomnography (PSG), which is the gold standard test, or polygraphy, which is a simpler and more accessible diagnostic test for diagnosis validated, the use of one or the other will depend on the suspicion and the associated comorbidities. Treatments for sleep apnea increasingly tend to be more individualized based on the characteristics of the patient and all are complementary. Hygienic-dietary measures should be applied in all patients, continuous positive airway pressure (CPAP) is the most effective treatment and with the most evidence, but other treatments are also available such as mandibular advancement devices (MAD), postural therapy and surgical options among others. Telemedicine is advancing in the follow-up of patients with OSA, both from non-face-to-face consultations and control of equipment via Wi-Fi to assess adherence, efficacy and correct control of therapy.

Improving Adherence to Myofunctional Therapy in the Treatment of Sleep-Disordered Breathing

Myofunctional therapy (MT) is used to treat sleep-disordered breathing. However, MT has low adherence-only ~10% in most studies. We describe our experiences with MT delivered through a mobile health app named Airway Gym®, which is used by patients who have rejected continuous positive airway pressure and other therapies. We compared ear, nose, and throat examination findings, Friedman stage, tongue-tie presence, tongue strength measured using the Iowa oral performance instrument (IOPI), and full polysomnography before and after the 3 months of therapy. Participants were taught how to perform the exercises using the app at the start. Telemedicine allowed physicians to record adherence to and accuracy of the exercise performance. Fifty-four patients were enrolled; 35 (64.8%) were adherent and performed exercises for 15 min/day on five days/week. We found significant changes (p < 0.05) in the apnoea-hypopnoea index (AHI; 32.97 ± 1.8 to 21.9 ± 14.5 events/h); IOPI score (44.4 ± 11.08 to 49.66 ± 10.2); and minimum O2 saturation (80.91% ± 6.1% to 85.09% ± 5.3%). IOPI scores correlated significantly with AHI after the therapy (Pearson r = 0.4; p = 0.01). The 19 patients who did not adhere to the protocol showed no changes. MT based on telemedicine had good adherence, and its effect on AHI correlated with IOPI and improvement in tongue-tie.

Correlation between Polysomnographic Parameters and Tridimensional Changes in the Upper Airway of Obstructive Sleep Apnea Patients Treated with Mandibular Advancement Devices

Background. The effectiveness of mandibular advancement devices has been solidly demonstrated in the past. They are considered a valid alternative treatment to continuous positive airway pressure for patients with obstructive sleep apnea. Nevertheless, the relationship between polysomnographic parameters and the increase in the volume of the upper airway in patients with obstructive sleep apnea syndrome has not been clearly established so far. This study aimed to determine the impact of these oral appliances upon the volume of the airway after the device titration phase and correlate it with the degree of mandibular advancement and the improvement of polysomnographic parameters. Methods. All patients were diagnosed by polysomnography and were treated with a customized, titratable mandibular advancement device. Three-dimensional volumetric measurements were performed using cone beam computed tomography. Results. The present study included 45 patients diagnosed with obstructive sleep apnea hypopnea syndrome (mild in 23 patients, moderate in 11 and severe in 11). Forty-four percent of the patients presented with an apnea hypopnea index <5/h at the end of treatment. The volume of the upper airway increased an average of 4.3 ± 5.9 cm³, this represents a percentage increase of 20.9%, which was significantly correlated with an apnea hypopnea index and a minimum oxygen saturation improvement. Conclusions. The mandibular advancement device used was found to be effective in improving polysomnographic parameters. Moreover, the oral appliance was able to significantly increase the tridimensional dimensions of the upper airway. Moreover, this finding was correlated with a reduction in the apnea hypopnea index (p = 0.007) and an increase on minimum oxygen saturation (p = 0.033).

Dimensional analysis of the upper airway in obstructive sleep apnoea syndrome patients treated with mandibular advancement device: A bi- and three-dimensional evaluation

BACKGROUND

The efficiency of the mandibular advancement device (MAD) in patients with obstructive sleep apnoea syndrome (OSAS) has been demonstrated. Nevertheless, the behaviour of the upper airway once MAD is placed and titrated, and its correlation with the apnoea-hypopnoea index (AHI) is still under discussion.

OBJECTIVES

To analyse the morphological changes of the upper airway through a bi- and three-dimensional study and correlate it with the polysomnographic variable, AHI.

METHODS

Patients were recruited from two different hospitals for the treatment of OSAS with a custom-made MAD. A cone-beam computer tomography and a polysomnography were performed at baseline and once the MAD was titrated.

RESULTS

A total of 41 patients completed the study. Treatment with MAD reduced the AHI from 22.5 ± 16.8 to 9.2 ± 11.6 (p ≤ .05). There was a significant increase of the total airway volume with MAD from 21.83 ± 7.05 cm³ to 24.19 ± 8.19 cm³ , at the expense of the oropharynx. Moreover, the correlation between the improvement of the AHI and the augmentation of the volume of the upper airway was not statistically significant.

CONCLUSIONS

The oral device used in this prospective study increased the mean upper pharyngeal airway volume and significantly reduced the AHI. Future studies that measure the muscular tone are needed to completely understand the association between the AHI and the physiological and anatomical response of the upper airway.

Long-term stability of results following surgery for obstructive sleep apnea (OSA)

PURPOSE

Although upper airway surgery in selected patients with obstructive sleep apnea (OSA) has been shown to be beneficial, its long-term effects have been questioned. The main objective was to evaluate whether results following surgery remain stable over time, both in objective and subjective terms. As a secondary aim, such stability was also measured in relation with the type of surgery performed.

METHODS

This work constitutes a retrospective study of OSA adult patients subjected to the following surgical procedures: different types of pharyngoplasties, tongue-base surgery, partial epiglottectomy or hyoid suspension. Those who exclusively underwent tonsillectomy or nasal surgery were excluded. Before surgery, a sleep study, and an assessment of the patients' sleepiness and quality of life were performed, which were repeated at 8, 34, and 48 months after surgery. A total of 153 patients was included.

RESULTS

Following surgery, the apnea-hypopnea index decreased from 34.84/h to 14.54/h and did not vary more than one point in subsequent controls (p = 0.01). The oxygen desaturation index changed from 31.02/h to 14.0/h and remained stable in the second (15.34/h) and third (11.43/h) controls (p = 0.01). Parameters measuring sleepiness and well-being demonstrated the maintenance of long-term benefits. New pharyngoplasties were observed to be more stable than classic pharyngoplasties in the long term (p = 0.04). Single-level surgeries were found to be more stable than multilevel surgeries, although a statistically significant difference was not observed (p = 0.07).

CONCLUSION

The benefits obtained remained stable in the long term. In our sample, modern pharyngoplasty techniques showed superiority over the classic ones regarding long-term stability.

International Consensus Document on Obstructive Sleep Apnea

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).