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Serghani MM, Heiser C, Schwartz AR, Amatoury J. Exploring hypoglossal nerve stimulation therapy for obstructive sleep apnea: A comprehensive review of clinical and physiological upper airway outcomes. Sleep Med Rev 2024; 76:101947. [PMID: 38788518 DOI: 10.1016/j.smrv.2024.101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/17/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of upper airway collapse during sleep, which can lead to serious health issues like cardiovascular disease and neurocognitive impairments. While positive airway pressure serves as the standard treatment, intolerance in some individuals necessitates exploration of alternative therapies. Hypoglossal nerve stimulation (HGNS) promises to mitigate OSA morbidity by stimulating the tongue muscles to maintain airway patency. However, its effectiveness varies, prompting research for optimization. This review summarizes the effects of HGNS on upper airway obstruction from human and animal studies. It examines physiological responses including critical closing pressure, maximal airflow, nasal and upper airway resistance, compliance, stiffness, and geometry. Interactions among these parameters and discrepant findings in animal and human studies are explored. Additionally, the review summarizes the impact of HGNS on established OSA metrics, such as the apnea-hypopnea index, oxygen desaturation index, and sleep arousals. Various therapeutic modalities, including selective unilateral or bilateral HGNS, targeted unilateral HGNS, and whole unilateral or bilateral HGNS, are discussed. This review consolidates our understanding of HGNS mechanisms, fostering exploration of under-investigated outcomes and approaches to drive advancements in HGNS therapy.
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Affiliation(s)
- Marie-Michèle Serghani
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon
| | - Clemens Heiser
- Department of Otorhinolaryngology/Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department ENT-HNS, Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Alan R Schwartz
- Department of Otorhinolaryngology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee, USA
| | - Jason Amatoury
- Sleep and Upper Airway Research Group (SUARG), Biomedical Engineering Program, Maroun Semaan Faculty of Engineering and Architecture (MSFEA), American University of Beirut (AUB), Beirut, Lebanon.
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2
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Hsieh YH, Schell AE, Yeh E, Strohl MP, Curado TF, Strohl KP. Neurostimulation in the Management of Obstructive Sleep Apnea. CURRENT SLEEP MEDICINE REPORTS 2022. [DOI: 10.1007/s40675-022-00233-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rodríguez Hermosa JL, Calle M, Guerassimova I, Fernández B, Montero VJ, Álvarez-Sala JL. Noninvasive electrical stimulation of oropharyngeal muscles in obstructive sleep apnea. Expert Rev Respir Med 2021; 15:1447-1460. [PMID: 34038311 DOI: 10.1080/17476348.2021.1935244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Continuous positive airway pressure (CPAP) therapy remains the standard treatment for obstructive sleep apnea. However, its proven effect is useless if the patient does not tolerate the treatment. The electrical stimulation approach has been investigated for several decades now and it seems that the implantable devices for invasive electrical stimulation of hypoglossal nerve are viewed as effective with some of them already approved for human use.Areas covered: in this review, we intent to summarize the existing records of noninvasive stimulation in sleep apnea to make the scientific community aware of the details before deciding on its future. We believe that this is a battle still to fight and more could be done bearing in mind the safety of this method.Expertopinion: noninvasive electrical stimulation has been left behind based on few, small and inconsistent studies using different stimulation parameters. These studies are difficult to compare and to draw conclusions.Electrical stimulation is a field for research in the treatment of obstructive sleep apnea, with many aspects still to be discovered, and which may become a therapeutic alternative to the use of CPAP in certain patients.
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Affiliation(s)
- Juan Luis Rodríguez Hermosa
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Myriam Calle
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Ina Guerassimova
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | | | - Víctor Javier Montero
- Torytrans SL, Innovative and technological-based company, Almagro, Ciudad Real, Spain
| | - José Luis Álvarez-Sala
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
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Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-020-00264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Veasey S. An X on the Map for Sleep Apnea's Holy Grail: Drug Therapy. Am J Respir Crit Care Med 2021; 203:10-11. [PMID: 32750248 PMCID: PMC7781135 DOI: 10.1164/rccm.202007-2785ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sigrid Veasey
- Department of Medicine at the Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania
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Schiefer M, Gamble J, Baskin J, Strohl K. Hypoglossal nerve stimulation in a rabbit model of obstructive sleep apnea reduces apneas and improves oxygenation. J Appl Physiol (1985) 2020; 129:442-448. [PMID: 32702266 DOI: 10.1152/japplphysiol.00828.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Based on a prior anesthetized model, we developed an unanesthetized model to evaluate the effects of hypoglossal nerve stimulation (HNS) during sleep. We prepared three rabbits with injections of hyaluronic acid in the base of tongue to produce upper airway obstruction followed by HNS implant. Two rabbits were saline controls, and one, a passive control. Measures were sleep, airflow, effort, oxygen saturation, and heart rate. HNS with electrodes around the right hypoglossal nerve were adjusted to a level without behaviorally disturbing the animal. During HNS stimulation in the tongue-base injected rabbits, obstructive apneas and hypopneas of intermediate (3 to 7 cycles of respiratory effort) or longer (≥8 cycles) duration were largely eliminated while less clinically relevant shorter events (<3) were unaffected, and oxygen saturation was improved. Control animals exhibited no intermediate or long events. In this model HNS can relieve induced sleep apnea, without disturbing the animal: however, despite being non-canine and of substantial size, the model has its challenges.NEW & NOTEWORTHY This report describes a rabbit model for testing the impact of hypoglossal nerve stimulation (HNS) on obstructive apneas. Obstructive sleep apnea (OSA) is induced by injecting hyaluronic acid (as a filler) into the base of the tongue. HNS reduced the length and rate of obstructions and improved oxygenation during sleep. Our efforts with this model advanced understanding of the complexities of this OSA preclinical model for neurostimulation reversal of sleep-disordered breathing.
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Affiliation(s)
- Matthew Schiefer
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio.,Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida
| | - Jenniffer Gamble
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | - Jonathan Baskin
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | - Kingman Strohl
- Louis Stokes Cleveland Veterans Affairs Medical Center, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
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Ratneswaran D, Guni A, Pengo MF, Al-Sherif M, He B, Cheng MC, Steier J, Schwarz EI. Electrical stimulation as a therapeutic approach in obstructive sleep apnea - a meta-analysis. Sleep Breath 2020; 25:207-218. [PMID: 32388780 DOI: 10.1007/s11325-020-02069-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/23/2020] [Accepted: 03/19/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Electrical stimulation of the upper airway dilator muscles is an emerging treatment for obstructive sleep apnea (OSA). Invasive hypoglossal nerve stimulation (HNS) has been accepted as treatment alternative to continuous positive airway pressure (CPAP) for selected patients, while transcutaneous electrical stimulation (TES) of the upper airway is being investigated as non-invasive alternative. METHODS A meta-analysis (CRD42017074674) on the effects of both HNS and TES on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) in OSA was conducted including published evidence up to May 2018. Random-effects models were used. Heterogeneity and between-study variance were assessed by I2 and τ2, respectively. RESULTS Of 41 identified clinical trials, 20 interventional trials (n = 895) could be pooled in a meta-analysis (15 HNS [n = 808], 5 TES [n = 87]). Middle-aged (mean ± SD 56.9 ± 5.5 years) and overweight (body mass index 29.1 ± 1.5 kg/m2) patients with severe OSA (AHI 37.5 ± 7.0/h) were followed-up for 6.9 ± 4.0 months (HNS) and 0.2 ± 0.4 months (TES), respectively. The AHI improved by - 24.9 h-1 [95%CI - 28.5, - 21.2] in HNS (χ2 79%, I2 82%) and by - 16.5 h-1 [95%CI - 25.1, - 7.8] in TES (χ2 7%, I2 43%; both p < 0.001). The ESS was reduced by - 5.0 (95%CI - 5.9, - 4.1) (p < 0.001). CONCLUSION Both invasive and transcutaneous electrical stimulation reduce OSA severity by a clinically relevant margin. HNS results in a clinically relevant improvement of symptoms. While HNS represents an invasive treatment for selected patients with moderate to severe OSA, TES should be further investigated as potential non-invasive approach for OSA.
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Affiliation(s)
- Deeban Ratneswaran
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.
| | - Ahmad Guni
- Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Martino F Pengo
- Department of Cardiovascular, Sleep Disorder Centre, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Miral Al-Sherif
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Baiting He
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK
| | - Michael Cf Cheng
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK
| | - Joerg Steier
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Esther I Schwarz
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK. .,Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, 8091, Zurich, Switzerland.
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Byun YJ, Yan F, Nguyen SA, Lentsch EJ. Transcutaneous Electrical Stimulation Therapy in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:645-653. [PMID: 32366179 DOI: 10.1177/0194599820917631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with obstructive sleep apnea (OSA). DATA SOURCES Primary studies were identified though PubMed, Scopus, OVID, and Cochrane Library. REVIEW METHODS Systematic review was conducted by querying databases for articles published through July 2019. The search identified randomized controlled trial, randomized comparison, or observational studies pertaining to TENS treatment for OSA. Meta-analysis was performed on pre- and posttreatment apnea-hypopnea index (AHI), mean oxygen saturation (SaO2), lowest oxygen saturation (LSAT), and arousal index (AI). RESULTS Literature search identified 10 studies that reported sufficient outcome measures to be considered for analysis. A total of 198 patients were identified with a mean age of 50.9 years with a male to female ratio of 1.6:1. Average body mass index (BMI) of the cohort was 29.8 kg/m2. Treatment with TENS demonstrated reduction in AHI by 12.9 points (95% confidence interval, -22.3 to -3.43; P = .008). The mean differences in SaO2, LSAT, and AI did not reach statistical significance. CONCLUSION The TENS treatment of upper airway dilator muscles resulted in reduction of AHI in patients with OSA. However, its effects on SaO2, LSAT, and AI were equivocal. Its impact on patients' quality of life could not be assessed due to heterogeneity in outcome measures. Future randomized controlled trials with generalizable standardized outcome measures are needed to assess the efficacy and compliance of TENS.
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Affiliation(s)
- Young Jae Byun
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Flora Yan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric J Lentsch
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Seo J, Yun S, Shim S, Cho SW, Choi JW, Kim JW, Kim SJ. Palatal implant system can provide effective treatment for obstructive sleep apnea by recovering retropalatal patency. J Neural Eng 2020; 17:026017. [DOI: 10.1088/1741-2552/ab7d61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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10
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Venkataraman S, Vungarala S, Covassin N, Somers VK. Sleep Apnea, Hypertension and the Sympathetic Nervous System in the Adult Population. J Clin Med 2020; 9:jcm9020591. [PMID: 32098169 PMCID: PMC7073618 DOI: 10.3390/jcm9020591] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/16/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023] Open
Abstract
Sleep apnea is very common in patients with cardiovascular disease, especially in patients with hypertension. Over the last few decades a number of discoveries have helped support a causal relationship between the two and even resistant hypertension. The role neurogenic mechanisms play has gathered more attention in the recent past due to their immediate bedside utility. Several innovative discoveries in pathogenesis including those exploring the role of baroreflex gain, cardiovascular variability, chemoreceptor reflex activation and the sympathetic nervous system have emerged. In this review, we discuss the epidemiology of sleep apnea and hypertension and the pathogenic mechanisms contributing to neurogenic hypertension. Furthermore, recent management strategies in addition to continuous positive airway pressure (CPAP), such as upper airway stimulation and renal denervation that target these pathogenic mechanisms, are also discussed.
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Oliven A, Dotan Y, Golibroda T, Somri M, Oliven R, Schwartz AR. Electrical stimulation of the whole hypoglossal nerve in patients with obstructive sleep apnea. Sleep Breath 2020; 24:1473-1480. [PMID: 31907824 DOI: 10.1007/s11325-019-02011-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/13/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Electrical stimulation of the whole hypoglossal nerve (HGp-ES) has been demonstrated to enlarge the pharynx and improve pharyngeal stability and patency to airflow in all animals studied, but not in humans. The present study was undertaken to better understand the effect of HGp-ES on the human pharynx. METHODS Eight patients with obstructive sleep apnea who had implanted stimulators with electrodes positioned proximally on the main truck of the hypoglossus were studied under propofol sedation. Pharyngoscopy and air flow measurements at multiple levels of continuous positive airway pressure (CPAP) were performed before and during Hgp-ES. RESULTS HGp-ES that activates both tongue protrusors and retractors narrowed the pharyngeal lumen at the site of collapse (velopharynx in all subjects) from 1.38 ± 0.79 to 0.75 ± 0.44 cm2, p < 0.05 (measured at mid-range of CPAP levels) and lowered airflow (from 8.88 ± 2.08 to 6.69 ± 3.51 l/min, p < 0.05). Changes in critical pressure (Pcrit) and velopharyngeal compliance were not significant, but oropharyngeal compliance decreased (from 0.43 ± 0.18 to 0.32 ± 0.13 cm2/cmH2O, p < 0.05). No correlation was found between the pattern of change in luminal shape (determined as the ratio of a-p vs. lateral diameter when lowering CPAP) or changes in cross-sectional area and airflow during Hgp-ES. CONCLUSIONS Our findings indicate that human retractors dominate when stimulated together with the protrusors during HGp-ES. While co-activation of retractors may be beneficial, it should be limited. We speculate that exercises that augment protrusor force may improve the response to hypoglossal stimulation. The exclusion of patients with concentric pharyngeal obstruction should be re-evaluated.
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Affiliation(s)
- A Oliven
- Department of Medicine, Bnai-Zion Medical Centre, 47 Golomb Str, 31048, Haifa, Israel. .,Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel.
| | - Y Dotan
- St. Luke's Pulmonary & Critical Care Associates, Bethlehem, PA, USA
| | | | - M Somri
- Rappaport School of Medicine, Technion Institute of Technology, Haifa, Israel.,Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel
| | - R Oliven
- Department of Medicine, Bnai-Zion Medical Centre, 47 Golomb Str, 31048, Haifa, Israel
| | - A R Schwartz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Universidad Peruana Cayetano Heredia, Lima, Peru.,Pulmonary and Critical Care Associates of Baltimore, Baltimore, USA
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Kent DT, Carden KA, Wang L, Lindsell CJ, Ishman SL. Evaluation of Hypoglossal Nerve Stimulation Treatment in Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2019; 145:1044-1052. [PMID: 31556927 DOI: 10.1001/jamaoto.2019.2723] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Hypoglossal nerve stimulation is a treatment option for patients with obstructive sleep apnea unable to tolerate continuous positive airway pressure. This study evaluates demographic factors that may be associated with greater improvements in postoperative outcomes of interest. Objective To examine the association of hypoglossal nerve stimulation with obstructive sleep apnea severity, daytime sleepiness, and sleep-related quality of life. Design, Setting, and Participants Patient-level data were pooled from 3 prospective cohorts and 1 retrospective observational cohort comprising 584 adults with moderate to severe obstructive sleep apnea unable to tolerate or benefit from continuous positive airway pressure. The data were gathered from the Stimulation Therapy for Apnea Reduction Trial; a postmarket approval study conducted in Germany; the multicenter, international Adherence and Outcome of Upper Airway Stimulation for OSA Registry; and a retrospective cohort study from 2 sites in the United States. Exposure Hypoglossal nerve stimulation. Main Outcomes and Measures Severity of obstructive sleep apnea was the primary outcome. The apnea-hypopnea index (AHI) (<5, normal; 5-15, mild; 15-30, moderate, and >30, severe) and Epworth Sleepiness Scale (range, 0-24; score >10 indicates pathologic sleepiness) outcomes were available at 2 to 6 months from 2 cohorts (n = 398), at 12 months from 1 cohort (n = 126), and at both times from 1 cohort (n = 60). Sleep-related quality of life and oxygen saturation nadir data were collected where available. Linear mixed-effects models were constructed to examine associations between clinical variables and reported postoperative outcomes at 6 and 12 months with study included as a random effect. Results Of the 584 patients included in the study, 472 were men (80.8%); mean (SD) age was 58.5 (11.0) years. Greater improvement in the postoperative AHI was associated with a higher preoperative AHI (-0.74 events/h; 95% CI, -0.82 to -0.67), older patient age (-0.10 events/h; 95% CI, -0.20 to -0.00), and lower body mass index (0.52; 95% CI, 0.22-0.83). After adjusting for these variables and considering all patients in the analysis, the AHI was statistically higher at 12 months than at 6 months (3.24 events/h; 95% CI, 1.67-4.82 events/h). Conclusions and Relevance Hypoglossal nerve stimulation demonstrated clinically significant improvements in obstructive sleep apnea severity, daytime sleepiness, and sleep-related quality of life in this pooled cohort of patient-level results. Age, body mass index, and preoperative AHI appeared to be associated with treatment outcomes, and these variables may explain some of the difference between 2- to 6-month and 12-month outcomes.
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Affiliation(s)
- David T Kent
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly A Carden
- Sleep Specialists, St Thomas Medical Partners, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Stacey L Ishman
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati, Cincinnati, Ohio
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Peripheral electrical stimulation reduces postoperative hypoxemia in patients at risk for obstructive sleep apnea: a randomized-controlled trial. Can J Anaesth 2019; 66:1296-1309. [DOI: 10.1007/s12630-019-01451-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 04/08/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022] Open
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Effect of Neuromuscular Electrical Stimulation on Labial and Lingual Weakness. TOPICS IN GERIATRIC REHABILITATION 2018. [DOI: 10.1097/tgr.0000000000000185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Durand DM. A Neural Prosthesis for Obstructive Sleep Apnea. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Upper Airway Neurostimulation to Treat Obstructive Sleep Apnea. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tingting X, Danming Y, Xin C. Non-surgical treatment of obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol 2017; 275:335-346. [PMID: 29177626 DOI: 10.1007/s00405-017-4818-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/15/2017] [Indexed: 12/12/2022]
Abstract
Obstructive sleep apnea syndrome (OSAS), a pervasive disease, is closely associated with complications such as cardiovascular diseases, neurocognitive diseases, and metabolic syndromes. Continuous positive airway pressure (CPAP) is the standard treatment for OSAS, with low compliance due to multifarious factors. The two other modes of ventilation, bi-level positive airway pressure (BPAP) and autotitrating positive airway pressure (APAP), which were developed from CPAP, are slightly different from CPAP in specific groups, as well as the corresponding treatment effect and compliance. The compliance of traditional positional therapy is not high, but with the emergence of the neck-based position treatment device, its compliance and indications have changed. Although CPAP is superior to mandibular advancement device (MAD) in improving AHI, MAD seems to be comparable to CPAP in improving other indicators. Corticosteroids and leukotriene receptor antagonists are effective treatments for mild OSAS children. Whether corticosteroids can be used in other OSAS groups and their adjunctive functions to CPAP remains unclear. The combination of these two kinds of drugs appears to be more effective than single drug. Researches on transcutaneous electrical stimulation are still not enough. Its effectiveness and stimulation settings still need further study. This review summarized the various OSAS non-surgical treatments from indications, treatment outcomes, compliance, adverse reactions, and recent progress.
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Affiliation(s)
- Xu Tingting
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Road, Guangzhou, 510282, People's Republic of China
| | - You Danming
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Road, Guangzhou, 510282, People's Republic of China
| | - Chen Xin
- Department of Respiratory Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Road, Guangzhou, 510282, People's Republic of China.
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Bisogni V, Pengo MF, De Vito A, Maiolino G, Rossi GP, Moxham J, Steier J. Electrical stimulation for the treatment of obstructive sleep apnoea: a review of the evidence. Expert Rev Respir Med 2017; 11:711-720. [PMID: 28730908 DOI: 10.1080/17476348.2017.1358619] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Obstructive sleep apnoea is an increasingly prevalent clinical condition with significant impact on individuals and public health. Continuous positive airway pressure therapy is the standard treatment, but adherence is limited and alternative treatments are needed. In this context, non-invasive and invasive methods for the electrical stimulation of upper airway dilator muscles have been demonstrated to be effective in selected patients. Areas covered: This review will cover investigations on the clinical effects, safety, and tolerability of non-invasive and invasive electrical stimulation of the upper airway for the management of obstructive sleep apnoea. Following a search of the relevant literature published on PubMed this review is focused mainly on data obtained from randomized clinical trials and clinical studies. Expert commentary: The available evidence provides a rationale to consider upper airway electrical stimulation as treatment for selected patients with obstructive sleep apnoea, who have poor adherence or experience difficulties with continuous positive airway pressure therapy. Non-invasive stimulation using transcutaneous electrodes and implantable hypoglossal nerve stimulator technologies may provide an alternative to continuous positive airway pressure for the treatment of obstructive sleep apnoea via restoration of neuromuscular tone and improved upper airway patency.
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Affiliation(s)
- Valeria Bisogni
- a Clinica dell'Ipertensione Arteriosa, Department of Internal Medicine - DIMED , University of Padova , Padua , Italy
| | - Martino F Pengo
- b Hypertension Unit, Ospedale S. Bortolo , University of Padova , Vicenza , Italy
| | - Andrea De Vito
- c Special Surgery Department, Head and Neck Department , Ear-Nose-Throat Unit, Morgagni-Pierantoni Hospital , Forlì , Italy
| | - Giuseppe Maiolino
- a Clinica dell'Ipertensione Arteriosa, Department of Internal Medicine - DIMED , University of Padova , Padua , Italy
| | - Gian Paolo Rossi
- a Clinica dell'Ipertensione Arteriosa, Department of Internal Medicine - DIMED , University of Padova , Padua , Italy
| | - John Moxham
- d King's College London , Faculty of Life Sciences and Medicine , London , UK
| | - Joerg Steier
- d King's College London , Faculty of Life Sciences and Medicine , London , UK.,e Guy's and St Thomas' NHS Foundation Trust , Lane Fox Respiratory Unit/Sleep Disorders Centre , London , UK
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Effect of surface neuromuscular electrical stimulation on labial and lingual muscles in healthy volunteers. Int J Rehabil Res 2017; 40:119-126. [DOI: 10.1097/mrr.0000000000000217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Friedman M, Jacobowitz O, Hwang MS, Bergler W, Fietze I, Rombaux P, Mwenge GB, Yalamanchali S, Campana J, Maurer JT. Targeted hypoglossal nerve stimulation for the treatment of obstructive sleep apnea: Six-month results. Laryngoscope 2016; 126:2618-2623. [DOI: 10.1002/lary.25909] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/23/2015] [Accepted: 01/11/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Michael Friedman
- Rush University Medical Center and Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
| | - Ofer Jacobowitz
- ENT and Allergy Associates; Orange Regional Medical Center; Middletown New York U.S.A
| | - Michelle S. Hwang
- Rush University Medical Center and Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
| | | | - Ingo Fietze
- Department of Cardiology; Center of Sleep Medicine, Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Philippe Rombaux
- Saint Luc University Clinics; Department of Oto-Rhino-Laryngology; Institute of Neurosciences; University of Louvain; Brussels Belgium
| | - Gimbada B. Mwenge
- Saint Luc University Clinics; Department of Oto-Rhino-Laryngology; Institute of Neurosciences; University of Louvain; Brussels Belgium
| | - Sreeya Yalamanchali
- Rush University Medical Center and Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center; Chicago Illinois U.S.A
| | - John Campana
- Colorado Head and Neck Specialists; Denver Colorado U.S.A
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Strohl M D KP, Baskin M D J, Lance M D C, Ponsky M D D, Weidenbecher M D M, Strohl B A M, Yamauchi M D M. Origins of and implementation concepts for upper airway stimulation therapy for obstructive sleep apnea. Respir Investig 2016; 54:241-9. [PMID: 27424823 DOI: 10.1016/j.resinv.2016.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 01/16/2016] [Accepted: 01/21/2016] [Indexed: 11/24/2022]
Abstract
Upper airway stimulation, specifically hypoglossal (CN XII) nerve stimulation, is a new, alternative therapy for patients with obstructive sleep apnea hypopnea syndrome who cannot tolerate positive airway pressure, the first-line therapy for symptomatic patients. Stimulation therapy addresses the cause of inadequate upper airway muscle activation for nasopharyngeal and oropharyngeal airway collapse during sleep. The purpose of this report is to outline the development of this first-in-class therapy and its clinical implementation. Another practical theme is assessment of the features for considering a surgically implanted device and the insight as to how both clinical and endoscopic criteria increase the likelihood of safe and durable outcomes for an implant and how to more generally plan for management of CPAP-intolerant patients. A third theme is the team building required among sleep medicine and surgical specialties in the provision of individualized neurostimulation therapy.
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Affiliation(s)
- Kingman P Strohl M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Jonathan Baskin M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Colleen Lance M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Diana Ponsky M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
| | - Mark Weidenbecher M D
- Departments of Medicine and Otolaryngology, Case Western Reserve University, Cleveland, OH, USA.
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Pengo MF, Steier J. Emerging technology: electrical stimulation in obstructive sleep apnoea. J Thorac Dis 2015; 7:1286-97. [PMID: 26380757 DOI: 10.3978/j.issn.2072-1439.2014.04.04] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 12/28/2022]
Abstract
Electrical stimulation (ES) of the upper airway (UAW) dilator muscles for patients with obstructive sleep apnoea (OSA) has been used for several decades, but in recent years research in this field has experienced a renaissance; the results of several studies have triggered a steady rise in the interest in this topic. Prospective trials, although still lacking a sham-controlled and randomised approach, have revealed the potential of ES. Hypoglossal nerve stimulation (HNS) leads to a significant reduction in the apnoea-hypopnoea index and the oxygen desaturation index (ODI). There are similar results published from feasibility studies for transcutaneous ES. A limitation of HNS remains the invasive procedure, the costs involved and severe adverse events, while for the non-invasive approach complications are rare and limited. The limiting step for transcutaneous ES is to deliver a sufficient current without causing arousal from sleep. Despite the progress up to date, numerous variables including optimal stimulation settings, different devices and procedures remain to be further defined for the invasive and the non-invasive method. Further studies are required to identify which patients respond to this treatment. ES of the UAW dilator muscles in OSA has the potential to develop into a clinical alternative to continuous positive airway pressure (CPAP) therapy. It could benefit selected patients who fail standard therapy due to poor long-term compliance. It is likely that international societies will need to review and update their existing guidance on the use of ES in OSA.
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Affiliation(s)
- Martino F Pengo
- 1 Guy's and St. Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK ; 2 Department of Medicine (DIMED), University of Padua, Padua, Italy ; 3 King's College London School of Medicine, London, UK ; 4 King's Health Partners, London, UK
| | - Joerg Steier
- 1 Guy's and St. Thomas' NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK ; 2 Department of Medicine (DIMED), University of Padua, Padua, Italy ; 3 King's College London School of Medicine, London, UK ; 4 King's Health Partners, London, UK
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Heiser C, Maurer JT, Steffen A. Functional outcome of tongue motions with selective hypoglossal nerve stimulation in patients with obstructive sleep apnea. Sleep Breath 2015; 20:553-60. [DOI: 10.1007/s11325-015-1237-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 07/11/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
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Murphey AW, Baker AB, Soose RJ, Padyha TA, Nguyen SA, Xiao CC, Gillespie MB. Upper airway stimulation for obstructive sleep apnea: The surgical learning curve. Laryngoscope 2015; 126:501-6. [DOI: 10.1002/lary.25537] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/08/2015] [Accepted: 07/02/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Alexander W. Murphey
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Andrew B. Baker
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Ryan J. Soose
- Division of Sleep Surgery; Department of Otolaryngology; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Tapan A. Padyha
- Department of Otolaryngology-Head and Neck Surgery; University of South Florida; Tampa Florida U.S.A
| | - Shaun A. Nguyen
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Christopher C. Xiao
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - M. Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
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Dedhia RC, Strollo PJ, Soose RJ. Upper Airway Stimulation for Obstructive Sleep Apnea: Past, Present, and Future. Sleep 2015; 38:899-906. [PMID: 25409109 DOI: 10.5665/sleep.4736] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/18/2014] [Indexed: 12/26/2022] Open
Abstract
ABSTRACT Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects on both personal and public health. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and low morbidity; long-term adherence rates approach 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the results of a large multicenter, prospective trial were recently published. The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This novel approach is the first to combine sleep surgery techniques with a titratable medical device for the treatment of OSA. Further research is required to define optimal patient selection and device performance and to demonstrate long-term effectiveness.
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Affiliation(s)
- Raj C Dedhia
- Department of Otolaryngology, University of Washington School of Medicine, Seattle WA.,Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA
| | - Patrick J Strollo
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ryan J Soose
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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26
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Meadows PM, Whitehead MC, Zaidi FN. Effects of targeted activation of tongue muscles on oropharyngeal patency in the rat. J Neurol Sci 2014; 346:178-93. [PMID: 25190291 DOI: 10.1016/j.jns.2014.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 06/24/2014] [Accepted: 08/16/2014] [Indexed: 02/01/2023]
Abstract
Laboratory rats were acutely implanted with an electrode array composed of eight independently controllable contacts applied to ventral and dorsal aspects of the left and right hypoglossal nerves (HGNs) and their branches. Bipolar intramuscular electromyographic (EMG) electrodes were implanted into the left and right genioglossus, hyoglossus and styloglossus muscles to identify which muscles were activated during stimulation via the contacts. Elicited movements, including changes in the position of the tongue and in the size and the shape of the airway, were documented video-graphically through a surgery microscope and an endoscope. Constant current electrical stimulation activated various combinations of electrode contacts and the stimulation patterns were correlated with corresponding oral movements, airway sizes, and EMG activities. Results demonstrate that graded responses and differential activation of the various tongue muscles are achievable by stimulation of specific contacts in the electrode array. These effects are interpreted to result from the targeted activation of regions of the nerve lying under and between the electrodes. Further testing established that the muscle responses elicited by unilateral electrical stimulation with the present approach can be smoothly graded, that the muscle responses resulted in opening of the airway and could be reliably maintained for long durations.
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Weaver TE, Calik MW, Farabi SS, Fink AM, Galang-Boquiren MT, Kapella MC, Prasad B, Carley DW. Innovative treatments for adults with obstructive sleep apnea. Nat Sci Sleep 2014; 6:137-47. [PMID: 25429246 PMCID: PMC4242689 DOI: 10.2147/nss.s46818] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.
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Affiliation(s)
- Terri E Weaver
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Michael W Calik
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Sarah S Farabi
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Anne M Fink
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Maria T Galang-Boquiren
- Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA ; Department of Orthodontics, University of Illinois at Chicago College of Dentistry, Chicago, IL, USA
| | - Mary C Kapella
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Bharati Prasad
- Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA ; Sleep Center, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - David W Carley
- Biobehavioral Health Science Department, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA ; Center for Narcolepsy, Sleep and Health, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
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Wang Y, Geng HY, Ye YM, Li J. Observation on clinical effects of electroacupuncture therapy for apoplexy with obstructive sleep apnea syndrome. JOURNAL OF ACUPUNCTURE AND TUINA SCIENCE 2013. [DOI: 10.1007/s11726-013-0724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Horner RL. Neural control of the upper airway: integrative physiological mechanisms and relevance for sleep disordered breathing. Compr Physiol 2013; 2:479-535. [PMID: 23728986 DOI: 10.1002/cphy.c110023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The various neural mechanisms affecting the control of the upper airway muscles are discussed in this review, with particular emphasis on structure-function relationships and integrative physiological motor-control processes. Particular foci of attention include the respiratory function of the upper airway muscles, and the various reflex mechanisms underlying their control, specifically the reflex responses to changes in airway pressure, reflexes from pulmonary receptors, chemoreceptor and baroreceptor reflexes, and postural effects on upper airway motor control. This article also addresses the determinants of upper airway collapsibility and the influence of neural drive to the upper airway muscles, and the influence of common drugs such as ethanol, sedative hypnotics, and opioids on upper airway motor control. In addition to an examination of these basic physiological mechanisms, consideration is given throughout this review as to how these mechanisms relate to integrative function in the intact normal upper airway in wakefulness and sleep, and how they may be involved in the pathogenesis of clinical problems such obstructive sleep apnea hypopnea.
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Schwartz AR, Smith PL, Oliven A. Electrical stimulation of the hypoglossal nerve: a potential therapy. J Appl Physiol (1985) 2013; 116:337-44. [PMID: 23813525 DOI: 10.1152/japplphysiol.00423.2013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Obstructive sleep apnea is characterized by recurrent episodes of pharyngeal collapse, which result from a decrease in pharyngeal dilator muscle tone. The genioglossus is a major pharyngeal dilator that maintains airway patency during sleep. Early studies in animal and humans have demonstrated that electrical stimulation of this muscle reduces pharyngeal collapsibility, increases airflow, and mitigates obstructive sleep apnea. These findings impelled the development of fully implantable hypoglossal nerve stimulating systems (HGNS), for which feasibility trial results are now available. These pilot studies have confirmed that hypoglossal nerve stimulation can prevent pharyngeal collapse without arousing patients from sleep. Potentially, a substantial segment of the patient population with obstructive sleep apnea can be treated with this novel approach. Furthermore, the feasibility trial findings suggest that the therapeutic potential of HGNS can be optimized by selecting patients judiciously, titrating the stimulus intensity optimally, and characterizing the underlying function and anatomy of the pharynx. These strategies are currently being examined in ongoing pivotal trials of HGNS.
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Affiliation(s)
- Alan R Schwartz
- Johns Hopkins Sleep Disorders Center, Johns Hopkins School of Medicine, Baltimore, Maryland
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31
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Yao D, Lavigne GJ, Lee JC, Adachi K, Sessle BJ. Jaw-opening reflex and corticobulbar motor excitability changes during quiet sleep in non-human primates. Sleep 2013; 36:269-80. [PMID: 23372275 PMCID: PMC3543051 DOI: 10.5665/sleep.2388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVE To test the hypothesis that the reflex and corticobulbar motor excitability of jaw muscles is reduced during sleep. DESIGN Polysomnographic recordings in the electrophysiological study. SETTING University sleep research laboratories. PARTICIPANTS AND INTERVENTIONS The reflex and corticobulbar motor excitability of jaw muscles was determined during the quiet awake state (QW) and quiet sleep (QS) in monkeys (n = 4). MEASUREMENTS AND RESULTS During QS sleep, compared to QW periods, both tongue stimulation-evoked jaw-opening reflex peak and root mean square amplitudes were significantly decreased with stimulations at 2-3.5 × thresholds (P < 0.001). The jaw-opening reflex latency during sleep was also significantly longer than during QW. Intracortical microstimulation (ICMS) within the cortical masticatory area induced rhythmic jaw movements at a stable threshold (≤ 60 μA) during QW; but during QS, ICMS failed to induce any rhythmic jaw movements at the maximum ICMS intensity used, although sustained jaw-opening movements were evoked at significantly increased threshold (P < 0.001) in one of the monkeys. Similarly, during QW, ICMS within face primary motor cortex induced orofacial twitches at a stable threshold (≤ 35 μA), but the ICMS thresholds were elevated during QS. Soon after the animal awoke, rhythmic jaw movements and orofacial twitches could be evoked at thresholds similar to those before QS. CONCLUSIONS The results suggest that the excitability of reflex and corticobulbar-evoked activity in the jaw motor system is depressed during QS.
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Affiliation(s)
- Dongyuan Yao
- Centre for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Gilles J. Lavigne
- Faculty of Dental Medicine, Université de Montréal, Québec, Canada
- Sleep Research Center and Surgery Department, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Jye-Chang Lee
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Kazunori Adachi
- Department of Pharmacology, Nihon University School of Dentistry, Tokyo, Japan
| | - Barry J. Sessle
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
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Zaidi FN, Meadows P, Jacobowitz O, Davidson TM. Tongue anatomy and physiology, the scientific basis for a novel targeted neurostimulation system designed for the treatment of obstructive sleep apnea. Neuromodulation 2012; 16:376-86; discussion 386. [PMID: 22938390 DOI: 10.1111/j.1525-1403.2012.00514.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a chronic condition that affects millions adults. The effective standard treatment is positive airway pressure (PAP). However, approximately half of the patients that are prescribed PAP are unable or unwilling to comply with this therapy. Untreated OSA ultimately leads to very serious comorbidities. An alternative therapy for this patient population, therefore, is desirable. Hypoglossal nerve (HGN) stimulation is under investigation by multiple groups as a possible alternative therapy for OSA. OBJECTIVE To understand the underlying mechanisms of actions related to HGN stimulation, and the implication of this knowledge for specifying and designing a neurostimulation system for the treatment of OSA. RESULTS Loss of lingual and pharyngeal tone within a narrow airway is the primary mechanism for OSA. Posterior and anterior tongues are different in their anatomy and physiology. Muscle fibers in the posterior tongue are predominantly fatigue resistant that are responsible for the long sustained tonic activities required for maintaining the tongue's position and preventing its mass from falling into the retroglossal airway. The human tongue is a muscular hydrostat and hence would benefit from a sophisticated HGN stimulation system that is capable of achieving a concerted spatio-temporal interplay of multiple lingual muscles, including retrusors. CONCLUSION Targeted neurostimulation of the proximal HGN presents as a viable system approach that is far more versatile and physiologic and quite different than prior systems.
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Affiliation(s)
- Faisal N Zaidi
- Imthera Medical, Inc., San Diego, CA, USA. Hudson Valley Ear, Nose & Throat PC, Middletown, NY, USA. New York Presbyterian Hospital/Columbia University and Attending, Mount Sinai Medical Center and Sleep Surgery and Sleep Medicine, New York, NY, USA. Head & Neck Surgery Clinic, UCSD Hillcrest-Medical Offices North, University of California San Diego, San Diego, CA, USA
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Van de Heyning PH, Badr MS, Baskin JZ, Cramer Bornemann MA, De Backer WA, Dotan Y, Hohenhorst W, Knaack L, Lin HS, Maurer JT, Netzer A, Odland RM, Oliven A, Strohl KP, Vanderveken OM, Verbraecken J, Woodson BT. Implanted upper airway stimulation device for obstructive sleep apnea. Laryngoscope 2012; 122:1626-33. [PMID: 22549513 DOI: 10.1002/lary.23301] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 02/10/2012] [Accepted: 02/22/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success. STUDY DESIGN Two consecutive open prospective studies. METHODS UAS systems were implanted in patients with moderate to severe OSA who failed or were intolerant of continuous positive airway pressure (CPAP). The study was conducted in 2 parts. In part 1, patients were enrolled with broad selection criteria. Apnea hypopnea index (AHI) was collected using laboratory-based polysomnography at preimplant and postimplant visits. Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) were also collected. In part 2, patients were enrolled using selection criteria derived from the experience in part 1. RESULTS In part 1, 20 of 22 enrolled patients (two exited the study) were examined for factors predictive of therapy response. Responders had both a body mass index ≤32 and AHI ≤50 (P < .05) and did not have complete concentric palatal collapse. Part 2 patients (n = 8) were selected using responder criteria and showed an improvement on AHI from baseline, from 38.9 ± 9.8 to 10.0 ± 11.0 (P < .01) at 6 months postimplant. Both ESS and FOSQ improved significantly in part 1 and 2 subjects. CONCLUSIONS The current study has demonstrated that therapy with upper airway stimulation is safe and efficacious in a select group of patients with moderate to severe OSA who cannot or will not use CPAP as primary treatment.
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Affiliation(s)
- Paul H Van de Heyning
- Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium.
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Jafari B, Roux F. Non-positive airway pressure therapy for obstructive sleep apnea. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13665-012-0016-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Akinnusi M, Saliba R, El-Solh AA. Emerging therapies for obstructive sleep apnea. Lung 2012; 190:365-71. [PMID: 22366855 DOI: 10.1007/s00408-012-9380-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 02/03/2012] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a prevalent disorder often associated with daytime sleepiness, cognitive dysfunction, and adverse cardiovascular consequences. Available therapies are limited by either lack of long-term adherence or low response rates. Two emerging therapies hold promise in providing alternatives to patients with OSA. The first stems from the importance of the upper-airway dilator muscles in maintaining pharyngeal stability. Electrical stimulation of the genioglossus muscle improves both upper-airway diameter and ameliorates pharyngeal obstruction. The results of phase I and II clinical trials hold promise, but the reported improvements in the apnea-hypopnea index vary between subjects and concerns about long-term safety await long-term studies. The second technology relies on creating an increased expiratory nasal resistance via a bidirectional valve designed to be worn just inside the nostrils. Initial findings of clinical trials suggest reduction in severity of sleep apnea and subjective daytime sleepiness. Considerable heterogeneity in response to the nasal device was noted despite the high adherence rates. It remains unclear which patients will likely benefit a priori from these devices.
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Affiliation(s)
- Morohunfolu Akinnusi
- The Veterans Affairs Western New York Healthcare System, Buffalo, NY 14215-1199, USA
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Abstract
PURPOSE OF REVIEW Obstructive sleep apnea (OSA) is a common disorder characterized by recurrent pharyngeal collapse secondary to sleep-induced hypotonia of peri-pharyngeal structures. Therapy for OSA is sometimes poorly tolerated and not always effective. The current study reviews a new treatment modality, hypoglossus stimulation, recently evaluated by multiple physiological studies and currently assessed by several clinical studies. RECENT FINDINGS A phase-I, implantable hypoglossus nerve stimulation multicenter study was published in 2001. Significant reduction in apnea-hypopnea index (AHI) was reported in seven of the eight implanted OSA patients, but technical faults precluded prolonged follow-up. Over the past 2 years, three new hypoglossus nerve stimulation systems have been evaluated in more than 60 OSA patients. In adequately selected patients, a more than 50% reduction in AHI was observed. Usually, a decrease in OSA severity from moderate-severe to mild-minimal can be achieved. SUMMARY Ongoing research, including recent initiation of a large multicenter phase-III study, suggests that hypoglossus nerve stimulators are likely to be available as a new treatment modality within a few years. Additional data are needed to define which OSA patients are most likely to benefit from hypoglossus nerve stimulation. Continuous refinement of electrodes design is likely to improve stimulation efficacy in coming years.
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Schwartz AR, Barnes M, Hillman D, Malhotra A, Kezirian E, Smith PL, Hoegh T, Parrish D, Eastwood PR. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J Respir Crit Care Med 2011; 185:420-6. [PMID: 22135343 DOI: 10.1164/rccm.201109-1614oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Hypoglossal nerve stimulation (HGNS) recruits lingual muscles, reduces pharyngeal collapsibility, and treats sleep apnea. OBJECTIVES We hypothesized that graded increases in HGNS relieve pharyngeal obstruction progressively during sleep. METHODS Responses were examined in 30 patients with sleep apnea who were implanted with an HGNS system. Current (milliampere) was increased stepwise during non-REM sleep. Frequency and pulse width were fixed. At each current level, stimulation was applied on alternating breaths, and responses in maximal inspiratory airflow (V(I)max) and inspiratory airflow limitation (IFL) were assessed. Pharyngeal responses to HGNS were characterized by the current levels at which V(I)max first increased and peaked (flow capture and peak flow thresholds), and by the V(I)max increase from flow capture to peak (ΔV(I)max). MEASUREMENTS AND MAIN RESULTS HGNS produced linear increases in V(I)max from unstimulated levels at flow capture to peak flow thresholds (215 ± 21 to 509 ± 37 ml/s; mean ± SE; P < 0.001) with increasing current from 1.05 ± 0.09 to 1.46 ± 0.11 mA. V(I)max increased in all patients and IFL was abolished in 57% of patients (non-IFL subgroup). In the non-IFL compared with IFL subgroup, the flow response slope was greater (1241 ± 199 vs. 674 ± 166 ml/s/mA; P < 0.05) and the stimulation amplitude at peak flow was lower (1.23 ± 0.10 vs. 1.80 ± 0.20 mA; P < 0.05) without differences in peak flow. CONCLUSIONS HGNS produced marked dose-related increases in airflow without arousing patients from sleep. Increases in airflow were of sufficient magnitude to eliminate IFL in most patients and IFL and non-IFL subgroups achieved normal or near-normal levels of flow, suggesting potential HGNS efficacy across a broad range of sleep apnea severity.
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Eastwood PR, Barnes M, Walsh JH, Maddison KJ, Hee G, Schwartz AR, Smith PL, Malhotra A, McEvoy RD, Wheatley JR, O'Donoghue FJ, Rochford PD, Churchward T, Campbell MC, Palme CE, Robinson S, Goding GS, Eckert DJ, Jordan AS, Catcheside PG, Tyler L, Antic NA, Worsnop CJ, Kezirian EJ, Hillman DR. Treating obstructive sleep apnea with hypoglossal nerve stimulation. Sleep 2011; 34:1479-86. [PMID: 22043118 DOI: 10.5665/sleep.1380] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Reduced upper airway muscle activity during sleep is fundamental to obstructive sleep apnea (OSA) pathogenesis. Hypoglossal nerve stimulation (HGNS) counteracts this problem, with potential to reduce OSA severity. STUDY OBJECTIVES To examine safety and efficacy of a novel HGNS system (HGNS, Apnex Medical, Inc.) in treating OSA. PARTICIPANTS Twenty-one patients, 67% male, age (mean ± SD) 53.6 ± 9.2 years, with moderate to severe OSA and unable to tolerate continuous positive airway pressure (CPAP). DESIGN Each participant underwent surgical implantation of the HGNS system in a prospective single-arm interventional trial. OSA severity was defined by apnea-hypopnea index (AHI) during in-laboratory polysomnography (PSG) at baseline and 3 and 6 months post-implant. Therapy compliance was assessed by nightly hours of use. Symptoms were assessed using the Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Calgary Sleep Apnea Quality of Life Index (SAQLI), and the Beck Depression Inventory (BDI). RESULTS HGNS was used on 89% ± 15% of nights (n = 21). On these nights, it was used for 5.8 ± 1.6 h per night. Nineteen of 21 participants had baseline and 6-month PSGs. There was a significant improvement (all P < 0.05) from baseline to 6 months in: AHI (43.1 ± 17.5 to 19.5 ± 16.7), ESS (12.1 ± 4.7 to 8.1 ± 4.4), FOSQ (14.4 ± 2.0 to 16.7 ± 2.2), SAQLI (3.2 ± 1.0 to 4.9 ± 1.3), and BDI (15.8 ± 9.0 to 9.7 ± 7.6). Two serious device-related adverse events occurred: an infection requiring device removal and a stimulation lead cuff dislodgement requiring replacement. CONCLUSIONS HGNS demonstrated favorable safety, efficacy, and compliance. Participants experienced a significant decrease in OSA severity and OSA-associated symptoms. CLINICAL TRIAL INFORMATION NAME: Australian Clinical Study of the Apnex Medical HGNS System to Treat Obstructive Sleep Apnea. REGISTRATION NUMBER NCT01186926. URL: http://clinicaltrials.gov/ct2/show/NCT01186926.
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Bailey EF. Activities of human genioglossus motor units. Respir Physiol Neurobiol 2011; 179:14-22. [PMID: 21558022 DOI: 10.1016/j.resp.2011.04.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/14/2011] [Accepted: 04/17/2011] [Indexed: 01/13/2023]
Abstract
Upper airway muscles play an important role in regulating airway lumen and in increasing the ability of the pharynx to remain patent in the face of subatmospheric intraluminal pressures produced during inspiration. Due to the considerable technical challenges associated with recording from muscles of the upper airway, much of the experimental work conducted in human subjects has centered on recording respiratory-related activities of the extrinsic tongue protudor muscle, the genioglossus (GG). The GG is one of eight muscles that invest the human tongue (Abd-El-Malek, 1939). All eight muscles are innervated by the hypoglossal nerve (cranial nerve XII) the cell bodies of which are located in the hypoglossal motor nucleus (HMN) of the caudal medulla. Much of the earlier work on the respiratory-related activity of XII motoneurons was based on recordings obtained from single motor axons dissected from the whole XII nerve or from whole muscle GG EMG recordings. Detailed information regarding respiratory-related GG motor unit activities was lacking until as recently as 2006. This paper examines key findings that have emerged from the last decade of work conducted in human subjects. Wherever appropriate, these results are compared with results obtained from in vitro and in vivo studies conducted in non-human mammals. The review is written with the objective of facilitating some discussion and some new thoughts regarding future research directions. The material is framed around four topics: (a) motor unit type, (b) rate coding and recruitment, (c) motor unit activity patterns, and (d) a compartment based view of pharyngeal airway control.
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Affiliation(s)
- E Fiona Bailey
- Department of Physiology, College of Medicine, The University of Arizona, Tucson, AZ 85721-0093, USA.
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Kezirian EJ, Boudewyns A, Eisele DW, Schwartz AR, Smith PL, Van de Heyning PH, De Backer WA. Electrical stimulation of the hypoglossal nerve in the treatment of obstructive sleep apnea. Sleep Med Rev 2010; 14:299-305. [PMID: 20116305 DOI: 10.1016/j.smrv.2009.10.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Revised: 10/24/2009] [Accepted: 10/26/2009] [Indexed: 11/17/2022]
Abstract
Upper airway occlusion in obstructive sleep apnea has been attributed to a decline in pharyngeal neuromuscular activity occurring in a structurally narrowed airway. Surgical treatment focuses on the correction of anatomic abnormalities, but there is a potential role for activation of the upper airway musculature, especially with stimulation of the hypoglossal nerve and genioglossus muscle. We present evidence from research on upper airway neuromuscular electrical stimulation in animals and humans. We also present results from eight obstructive sleep apnea patients with a fully implanted system for hypoglossal nerve stimulation, demonstrating an improvement in upper airway collapsibility and obstructive sleep apnea severity. Future research, including optimization of device features and stimulation parameters as well as patient selection, is necessary to make hypoglossal nerve stimulation a viable alternative to positive airway pressure therapy and upper airway surgical procedures.
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Affiliation(s)
- Eric J Kezirian
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco, California, USA.
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Saboisky JP, Chamberlin NL, Malhotra A. Potential therapeutic targets in obstructive sleep apnoea. Expert Opin Ther Targets 2009; 13:795-809. [PMID: 19530985 DOI: 10.1517/14728220903005608] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Obstructive sleep apnoea (OSA) is a disease of ever-increasing importance due to its association with multiple impairments and rising prevalence in an increasingly susceptible demographic. The syndrome is linked with loud snoring, disrupted sleep and observed apnoeas. Serious co-morbidities associated with OSA appear to be reversed by continuous positive airway pressure (CPAP) treatment; however, CPAP is variably tolerated leaving many patients untreated and emphasising the need for alternative treatments. Virtually all OSA patients have airways that are anatomically vulnerable to collapse, but numerous pathophysiological factors underlie when and how OSA is manifested. This review describes how the complexity of OSA requires multiple treatment approaches that are individually targeted. This approach may take the form of more specific diagnoses in terms of the mechanisms underlying OSA as well as rational pharmacological treatment directed toward such disparate ends as arousal threshold and ventilatory control/chemosensitivity, and mechanical treatment in the form of surgery and augmentation of lung volumes.
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Affiliation(s)
- Julian P Saboisky
- Brigham and Women's Hospital, Harvard Medical School, Division of Sleep Medicine, 221 Longwood Avenue, Boston, Massachusetts 02115, USA.
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42
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Durand DM. A Neural Prosthesis for Obstructive Sleep Apnea. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Fregosi RF. Influence of tongue muscle contraction and dynamic airway pressure on velopharyngeal volume in the rat. J Appl Physiol (1985) 2008; 104:682-93. [DOI: 10.1152/japplphysiol.01043.2007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The mammalian pharynx is a collapsible tube that narrows during inspiration as transmural pressure becomes negative. The velopharynx (VP), which lies posterior to the soft palate, is considered to be one of the most collapsible pharyngeal regions. I tested the hypothesis that negative transmural pressure would narrow the VP, and that electrical stimulation of extrinsic tongue muscles would reverse this effect. Pressure (−6, −3, 3, and 6 cmH2O) was applied to the isolated pharyngeal airway of anesthetized rats that were positioned in a 4.7-T MRI scanner. The volume of eight axial slices encompassing the length of the VP was computed at each level of pressure, with and without bilateral hypoglossal nerve stimulation (0.1-ms pulse, one-third maximum force, 80 Hz). Negative pressure narrowed the VP, and either whole hypoglossal nerve stimulation (coactivation of protrudor and retractor muscles) or medial nerve branch stimulation (independent activation of tongue protrudor muscles) reversed this effect, with the greatest impact in the caudal one-third of the VP. The dilating effects of medial branch stimulation were slightly larger than whole nerve stimulation. Positive pressure dilated the VP, but tongue muscle contraction did not cause further dilation under these conditions. I conclude that the narrowest and most collapsible segment of the rat pharynx is in the caudal VP, posterior to the tip of the soft palate. Either coactivation of protrudor and retractor muscles or independent contraction of protrudor muscles caused dilation of this region, but the latter was slightly more effective.
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Oliven A, Odeh M, Geitini L, Oliven R, Steinfeld U, Schwartz AR, Tov N. Effect of coactivation of tongue protrusor and retractor muscles on pharyngeal lumen and airflow in sleep apnea patients. J Appl Physiol (1985) 2007; 103:1662-8. [PMID: 17673558 DOI: 10.1152/japplphysiol.00620.2007] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present study evaluated the effect of coactivation of tongue protrusors and retractors on pharyngeal patency in patients with obstructive sleep apnea. The effect of genioglossus (GG), hyoglossus (HG), and coactivation of both on nasal pressure (Pn):flow relationships was evaluated in a sleep study (SlS, n = 7) and during a propofol anesthesia study (AnS, n = 7). GG was stimulated with sublingual surface electrodes in SlS and with intramuscular electrodes in AnS, while HG was stimulated with surface electrodes in both groups. In the AnS, the cross-sectional area (CSA):Pn relationships was measured with a pharyngoscope to estimate velopharyngeal compliance . In the SlS, surface stimulation of GG had no effect on the critical pressure (Pcrit), HG increased Pcrit from 2.8 +/- 1.7 to 3.7 +/- 1.6 cmH(2)O, but coactivation lowered Pcrit to 0.2 +/- 1.9 cmH(2)O (P < 0.01 for both). In the AnS, intramuscular stimulation of GG lowered Pcrit from 2.6 +/- 1.3 to 1.0 +/- 2.8 cmH(2)O, HG increased Pcrit to 6.2 +/- 2.5 cmH(2)O (P < 0.01), and coactivation had a similar effect to that of GG (Pcrit = 1.2 +/- 2.4 cmH(2)O, P < 0.05). None of the interventions affected significantly velopharyngeal compliance. We conclude that the beneficial effect of coactivation depends on the pattern of GG fiber recruitment: although surface stimulation of GG failed to protrude the tongue, it prevented the occlusive effect of the retractor, thereby improving pharyngeal patency during coactivation. Stimulation of deeper GG fibers with intramuscular electrodes enlarged the pharynx, and coactivation had no additive effect.
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Affiliation(s)
- Arie Oliven
- Dept. of Internal Medicine, Bnai Zion Medical Center, Technion, 47 Golomb St., Haifa, Israel.
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Randerath W, Bauer M, Blau A, Fietze I, Galetke W, Hein H, Maurer JT, Orth M, Rasche K, Ruhle KH, Sanner B, Stuck BA, Verse T. Stellenwert der Nicht-nCPAP-Verfahren in der Therapie des obstruktiven Schlafapnoe-Syndroms. Relevance of Non-CPAP Treatment Options in the Therapy of the Obstructive Sleep Apnoea Syndrome. SOMNOLOGIE 2006. [DOI: 10.1111/j.1439-054x.2006.00082.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Stellenwert der Nicht-nCPAP-Verfahren in der Therapie des obstruktiven Schlafapnoe-Syndroms. SOMNOLOGIE 2006. [DOI: 10.1007/j.1439-054x.2006.00082.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lequeux T, Chantrain G, Bonnand M, Chelle AJ, Thill MP. Physiotherapy in obstructive sleep apnea syndrome: preliminary results. Eur Arch Otorhinolaryngol 2004; 262:501-3. [PMID: 15625609 DOI: 10.1007/s00405-004-0806-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2003] [Accepted: 04/01/2004] [Indexed: 11/29/2022]
Abstract
Apneic patients have hypotonia of the lingual and supra-hyoid muscles. The dysfunction of theses muscles leading to a collapse of the upper airway is responsible for the apnea. The goal of this study, designed as a before-after trial, is to determine the effect of lingual and supra-hyoid muscle strengthening on obstructive sleep apnea. Thirty-four patients with obstructive sleep apnea were included (consecutive sample). Only 16 patients completed the study. The treatment consisted of 30 sessions of transcutaneous neuromuscular stimulation administered to the submental region associated with muscular exercises. The effect on apneic events was analyzed with a polysomnography before and after the treatment. Thirteen patients could be analyzed for the statistical studies. The mean apnea-hypopnea index (AHI) decreased from 32.9 to 20.6 (Wilcoxon rank test: P = 0.017). Seven patients ended the study with an AHI of less than 10, and three more patients decreased their AHI by more than 50%. This treatment significantly decreased the AHI in most of the patients. A larger study with more patients and with a long-term follow-up is necessary to determine the place of physiotherapy in the treatment of obstructive sleep apnea.
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Affiliation(s)
- T Lequeux
- ENT Department, CHU Saint-Pierre, Brussels, Belgium.
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48
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Oliven A, O'Hearn DJ, Boudewyns A, Odeh M, De Backer W, van de Heyning P, Smith PL, Eisele DW, Allan L, Schneider H, Testerman R, Schwartz AR. Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol (1985) 2004; 95:2023-9. [PMID: 14555669 DOI: 10.1152/japplphysiol.00203.2003] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Contraction of the genioglossus (GG) has been shown to improve upper airway patency. In the present study, we evaluated responses in upper airway pressure-flow relationships during sleep to electrical stimulation (ES) of the GG in patients with obstructive sleep apnea. Five patients with chronically implanted hypoglossal nerve (HG) electrodes and nine patients with fine-wire electrodes inserted into the GG were studied. Airflow was measured at multiple levels of nasal pressure, and upper airway collapsibility was defined by the nasal pressure below which airflow ceased ["critical" pressure (Pcrit)]. ES shifted the pressure-flow relationships toward higher flow levels in all patients over the entire range of nasal pressure applied. Pcrit decreased similarly during both HG-ES and GG-ES (deltaPcrit was 3.98 +/- 2.31 and 3.18 +/- 1.70 cmH2O, respectively) without a significant change in upstream resistance. The site of collapse (velo- vs. oropharynx) did not influence the response to GG-ES. Moreover, ES-induced reductions in the apnea-hypopnea index of the HG-ES patients were associated with substantial decreases in Pcrit. Our findings imply that responses in apnea severity to HG-ES can be predicted by characterizing the patient's baseline pressure-flow relationships and response to GG-ES.
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Affiliation(s)
- Arie Oliven
- Department of Medicine B, Bnai Zion Medical Center, Technion, Haifa 31048, Israel.
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Eisele DW, Schwartz AR, Smith PL. Tongue neuromuscular and direct hypoglossal nerve stimulation for obstructive sleep apnea. Otolaryngol Clin North Am 2003; 36:501-10. [PMID: 12956097 DOI: 10.1016/s0030-6665(02)00178-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent studies have shown that neuromuscular stimulation of the genioglossus muscle and direct stimulation of the hypoglossal nerve can be performed selectively and safely. Such stimulation, delivered below the arousal threshold, can modulate airflow during sleep in patients with OSA. The feasibility and potential of upper airway stimulation for the treatment of OSA have been demonstrated. Further studies and stimulation-system refinements are presently underway, with hopes of establishing upper airway stimulation as a therapeutic option for this challenging disorder.
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Affiliation(s)
- David W Eisele
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, 400 Parnassus Avenue, Suite A-730, San Francisco, CA 94143-0342, USA.
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Oliven A, Schnall RP, Pillar G, Gavriely N, Odeh M. Sublingual electrical stimulation of the tongue during wakefulness and sleep. RESPIRATION PHYSIOLOGY 2001; 127:217-26. [PMID: 11504591 DOI: 10.1016/s0034-5687(01)00254-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pharyngeal obstruction in patients with obstructive sleep apnea (OSA) is thought to result from decreased upper airway muscle tone during sleep. The goal of the present study was to estimate the role of the tongue muscles in maintaining pharyngeal patency during sleep. Using non-invasive, sub-lingual surface electrical stimulation (ES), we measured tongue protrusion force during wakefulness and upper airway resistance during sleep in seven healthy subjects and six patients with OSA. During wakefulness, ES produced similar protrusion forces in healthy subjects and patients with OSA. ES of the anterior sublingual surface, causing preferential contraction of the genioglossus, resulted in smaller effects than combined ES of the anterior and lateral surface, which also stimulated tongue retractors. During sleep, trans-pharyngeal resistance decreased and peak inspiratory flow rate increased from 319+/-24 to 459+/-27 and from 58+/-16 to 270+/-35 ml/sec for healthy subjects and OSA patients, respectively (P<0.001). However, ES was usually unsuccessful in reopening the upper airway in the presence of complete apneas. We conclude that non-invasive ES of the tongue improves flow dynamics during sleep. Combined activation of tongue protrusors and retractors may have a beneficial mechanical effect. The magnitude of responses observed suggests that in addition to the stimulated muscles, other muscles and/or forces have a substantial impact on pharyngeal patency.
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Affiliation(s)
- A Oliven
- Department of Internal Medicine B, Bnai Zion Medical Center, Golomb Str. 47, 31048, Haifa, Israel.
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