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Landry SA, Mann DL, Beare R, McIntyre R, Beatty C, Thomson LDJ, Collet J, Joosten SA, Hamilton GS, Edwards BA. Oronasal vs Nasal Masks: The Impact of Mask Type on CPAP Requirement, Pharyngeal Critical Closing Pressure (P crit), and Upper Airway Cross-Sectional Areas in Patients With OSA. Chest 2023; 164:747-756. [PMID: 36990149 DOI: 10.1016/j.chest.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/08/2023] [Accepted: 03/15/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND CPAP delivered via an oronasal mask is associated with lower adherence, higher residual apnea-hypopnea index (AHI), and increased CPAP therapeutic pressure compared with nasal masks. However, the mechanisms underlying the increased pressure requirements are not well understood. RESEARCH QUESTION How do oronasal masks affect upper airway anatomy and collapsibility? STUDY DESIGN AND METHODS Fourteen patients with OSA underwent a sleep study with both a nasal and oronasal mask, each for one-half of the night (order randomized). CPAP was manually titrated to determine therapeutic pressure. Upper airway collapsibility was assessed using the pharyngeal critical closing pressure (Pcrit) technique. Cine MRI was done to dynamically assess the cross-sectional area of the retroglossal and retropalatal airway throughout the respiratory cycle with each mask interface. Scans were repeated at 4 cm H2O and at the nasal and oronasal therapeutic pressures. RESULTS The oronasal mask was associated with higher therapeutic pressure requirements (ΔM ± SEM; +2.6 ± 0.5; P < .001) and higher Pcrit (+2.4 ± 0.5 cm H2O; P = .001) compared with the nasal mask. The change in therapeutic pressure between masks was strongly correlated with the change in Pcrit (r2 = 0.73; P = .003). Increasing CPAP increased both the retroglossal and retropalatal airway dimensions across both masks. After controlling for pressure and breath phase, the retropalatal cross-sectional area was moderately larger when using a nasal vs an oronasal mask (+17.2 mm2; 95% CI, 6.2-28.2, P < .001) while nasal breathing. INTERPRETATION Oronasal masks are associated with a more collapsible airway than nasal masks, which likely contributes to the need for a higher therapeutic pressure.
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Affiliation(s)
- Shane A Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia.
| | - Dwayne L Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Richard Beare
- National Centre for Healthy Ageing and Peninsula Clinical School, Monash University, Melbourne, VIC, Australia; Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Richard McIntyre
- Monash Biomedical Imaging, Monash University, Melbourne, VIC, Australia; Monash Imaging, Monash Health, Clayton, VIC, Australia
| | - Caroline Beatty
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Luke D J Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Monash Partners-Epworth, Clayton, VIC, Australia
| | - Garun S Hamilton
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, VIC, Australia; School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Monash Partners-Epworth, Clayton, VIC, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, VIC, Australia; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
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Van de Perck E, Kazemeini E, Van den Bossche K, Willemen M, Verbraecken J, Vanderveken OM, Op de Beeck S. The effect of CPAP on the upper airway and ventilatory flow in patients with obstructive sleep apnea. Respir Res 2023; 24:143. [PMID: 37259138 DOI: 10.1186/s12931-023-02452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/14/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is the mainstay of treatment for obstructive sleep apnea (OSA). However, data about its effect on the upper airway, especially the epiglottis, are scarce. The aim of this study was to investigate the changes in upper airway dimensions and inspiratory flow in response to incremental pressure levels. METHODS This is a secondary analysis of a prospective clinical trial in which patients with moderate to severe OSA underwent drug-induced sleep endoscopy with simultaneous recordings of flow and mask pressure. CPAP was titrated in small increments. For each pressure level a representative 3-breath segment was selected to determine specific flow features. The corresponding endoscopic footage was reviewed to assess the degree of upper airway collapse in a semi-quantitative manner. RESULTS A total of 214 breath segments were obtained from 13 participants (median [Q1-Q3]; apnea-hypopnea index, 24.9 [20.1-43.9] events/h; body mass index 28.1 [25.1-31.7] kg/m²). CPAP significantly increased cross-sectional dimensions of the soft palate, lateral walls and tongue base, but not of the epiglottis, and induced epiglottis collapse in one subject. Increased pressure improved peak inspiratory flow and median ventilation in all patients, even in the presence of persistent epiglottis collapse. CONCLUSION CPAP does not effectively address epiglottis collapse in patients with OSA. However, it normalizes inspiratory flow regardless of its effect on the epiglottis. This clinical trial was registered on January 18th, 2020 on ClinicalTrials.gov with identifier NCT04232410.
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Affiliation(s)
- Eli Van de Perck
- Faculty of Medicine and Health Sciences, Department of Translational Neurosciences, University of Antwerp, Universiteitsplein 1 - D.T.494, Wilrijk, Belgium.
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.
| | - Elahe Kazemeini
- Faculty of Medicine and Health Sciences, Department of Translational Neurosciences, University of Antwerp, Universiteitsplein 1 - D.T.494, Wilrijk, Belgium
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Karlien Van den Bossche
- Faculty of Medicine and Health Sciences, Department of Translational Neurosciences, University of Antwerp, Universiteitsplein 1 - D.T.494, Wilrijk, Belgium
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, Department of Translational Neurosciences, University of Antwerp, Universiteitsplein 1 - D.T.494, Wilrijk, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
- Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, Department of Translational Neurosciences, University of Antwerp, Universiteitsplein 1 - D.T.494, Wilrijk, Belgium
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, Department of Translational Neurosciences, University of Antwerp, Universiteitsplein 1 - D.T.494, Wilrijk, Belgium
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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He H, Zhang S, Xu J. Impact of occlusal reconstruction positions on airway dimensions in patients with edentulism and long centric occlusion. BMC Oral Health 2023; 23:215. [PMID: 37060039 PMCID: PMC10105404 DOI: 10.1186/s12903-023-02931-1] [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: 08/31/2022] [Accepted: 04/03/2023] [Indexed: 04/16/2023] Open
Abstract
OBJECTIVE To study the airway changes of edentulous patients with a magnitude of long centric (MLC) ≥ 1.5 mm during occlusal reconstruction at the centric relation position (CRP) and muscular position (MP). METHODS The CRP and MP were determined by Gothic arch. The cephalometric analysis was taken at the two occlusal positions. The sagittal distance of each part of the upper airway was measured. The differences between two occlusal positions were compared. The difference values were calculated by subtracting the two. The correlation between the MLC and the difference value was analyzed. RESULTS The sagittal diameters of palatopharynx and glossopharynx airway at MP were statistically larger than those at CRP (P < 0.05). The MLC had a strong correlation with the ANB angle (r = 0.745, P < 0.001). CONCLUSION Compared with the occlusal position of CRP, occlusion reconstruction at MP can provide better airway condition for edentulous patients with large MLC.
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Affiliation(s)
- Huiying He
- Department of Stomatology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No.168 of Litang Road, Changping District, Beijing, 102218, China
| | - Sheng Zhang
- Department of Stomatology, Beijing Huairou Hospital, Beijing, 101400, China
| | - Jun Xu
- Department of Stomatology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No.168 of Litang Road, Changping District, Beijing, 102218, China.
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Cohen O, Kaufman AE, Choi H, Khan S, Robson PM, Suárez-Fariñas M, Mani V, Shah NA. Pharyngeal Inflammation on Positron Emission Tomography/Magnetic Resonance Imaging Before and After Obstructive Sleep Apnea Treatment. Ann Am Thorac Soc 2023; 20:574-583. [PMID: 36476449 PMCID: PMC10112411 DOI: 10.1513/annalsats.202207-594oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/07/2022] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is upper airway inflammation in patients with obstructive sleep apnea (OSA), which reduces with continuous positive airway pressure (CPAP) therapy. Objectives: Validate the use of positron emission tomography (PET)/magnetic resonance imaging (MRI) to quantify metabolic activity within the pharyngeal mucosa of patients with OSA against nasal lavage proteomics and assess the impact of CPAP therapy. Methods: Adults with OSA underwent [18F]-Fluoro-2-deoxy-D-glucose PET/MRI of the neck before and 3 months after initiating CPAP. Nasal lavage samples were collected. Inflammatory protein expression from samples was analyzed using the Olink platform. Upper airway imaging segmentation was performed. Target-to-background ratio (TBRmax) was calculated from target pharyngeal maximum standard uptake values (SUV) and personalized background mean SUV. Most-diseased segment TBRmax was identified per participant at locations with the highest PET avidity. Correlation analysis was performed between baseline TBRmax and nasal lavage proteomics. TBRmax was compared before and after CPAP using linear mixed-effect models. Results: Among 38 participants, the baseline mean age was 46.3 years (standard deviation [SD], 12.5), 21% were female, the mean body mass index was 30.9 kg/m2 (SD, 4.6), and the mean respiratory disturbance index measured by peripheral arterial tonometry was 31 events/h (SD, 16.4). There was a significant positive correlation between pharyngeal mucosa most-diseased segment TBRmax and nasal lavage proteomic inflammation (r = 0.41 [P < 0.001, false discovery rate = 0.002]). Primary analysis revealed a reduction in the most-diseased segment TBRmax after a median of 2.91 months of CPAP therapy (-0.86 [standard error (SE) ± 0.30; P = 0.007]). Stratified analysis by smoking status revealed a significantly decreased most-diseased segment TBRmax after CPAP therapy among never-smokers but not among ever-smokers (-1.01 [SE ± 0.39; P = 0.015] vs. -0.64 [SE ± 0.49; P = 0.201]). Conclusions: CPAP therapy reduces metabolic activity measured by PET/MRI within the upper airway of adults with OSA. Furthermore, PET/MRI measures of upper airway metabolic activity correlate with a noninvasive marker of inflammation (i.e., nasal lavage inflammatory protein expression).
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Affiliation(s)
- Oren Cohen
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | | | - Hyewon Choi
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samira Khan
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | | | - Mayte Suárez-Fariñas
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Neomi A. Shah
- Division of Pulmonary, Critical Care, and Sleep Medicine
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Karaoğullarından A, Okşan Erkan S. The Effects of Anterior Palatoplasty and Functional Expansion Sphincter Pharyngoplasty on Voice Quality in Patients with Obstructive Sleep Apnea. J Voice 2023:S0892-1997(22)00385-X. [PMID: 36641251 DOI: 10.1016/j.jvoice.2022.11.032] [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: 09/25/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES We aimed to examine the effects of anterior palatoplasty (AP) and functional expansion sphincter pharyngoplasty (FESP) on voice quality in patients with OSAS and to compare them with each other. MERHODS The study included 380 patients who came to the Otorhinolaryngology Clinic of our hospital with symptoms of snoring and sleep apnea between April 2020 and April 2022 and were referred to the sleep laboratory for polysomnography (PSG).Forty patients who met the study criteria and underwent AP and 26 patients who underwent FESP were included in the study. All surgeries were performed under general anesthesia by the same otolaryngologist within 1 month at the latest after sleep endoscopy. Acoustic voice analysis was performed using the Praat voice analysis program preoperatively and postoperatively at 6 months. F0, jitter, shimmer, and NHR (noise-to-harmonic ratio) were compared between the groups pre and postoperatively. RESULTS There were 20 females and 20 males in the AP group, 12 females and 14 males in the FESP group, There was no statistically significant difference in sex distribution between the groups (P = 0.952). The difference between the preop and postop F0, jitter, shimmer, and NHR in both the AP and FESP groups was statistically significant (P < 0.01). After AP and FESP surgeries, F0 values increased, jitter, shimmer and NHR values decreased (P < 0.01).F0, jitter, shimmer, and NHR changes were the greatest in the FESP group.(P < 0.01). CONCLUSION Positive changes in F0, jitter, shimmer, and NHR were greatest in the FESP group significantly. FESP surgery affects voice quality more than AP surgery in patients with OSAS.
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Affiliation(s)
- Ayşe Karaoğullarından
- ENT Specialist in Adana City Training and Research Hospital ENT Department, Yüreğir, Adana, Turkey.
| | - Sanem Okşan Erkan
- ENT Specialist in Adana City Training and Research Hospital ENT Department, Yüreğir, Adana, Turkey
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Sleep Endoscopy with Positive Airway Pressure: A Method for Better Compliance and Individualized Treatment of Patients with Obstructive Sleep Apnea. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122108. [PMID: 36556473 PMCID: PMC9788266 DOI: 10.3390/life12122108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
In this study, we aimed to observe the effects of positive airway pressure (PAP) on individual levels of obstruction during drug-induced sleep endoscopy (DISE) of the upper airways (UA), to evaluate at which pressures the obstruction disappeared or worsened, and to identify cases in which PAP was ineffective. This prospective study was conducted from June 2018 to June 2022. PAP testing was performed during DISE in patients with moderate and severe OSA. The pressure was gradually increased over the range from 6.0 to 18.0 hPa. Our findings were evaluated using the VOTE classification. The examination was performed in 56 patients, with a median apnea-hypopnea index (AHI) of 26.4. Complete obstruction of the soft palate was observed in 51/56 patients (91%), oropharyngeal obstruction in 15/56 patients (27%), tongue base obstruction in 23/56 patients (41%), and epiglottic collapse in 16/56 patients (29%). PAP was most effective in cases of complete oropharyngeal obstruction, and least effective in cases of epiglottic collapse, where it was ineffective in 11/16 patients. DISE with PAP is a simple diagnostic method that can be helpful for identifying anatomic and dynamic reasons for PAP intolerance. The main indication is ineffective PAP treatment.
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Adler AC, Chandrakantan A, Musso MF. Continuous Positive Airway Pressure Titration During Pediatric Drug Induced Sleep Endoscopy. Ann Otol Rhinol Laryngol 2021; 131:1085-1091. [PMID: 34706588 DOI: 10.1177/00034894211055527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To observe the degree of airway collapse at varying levels of continuous positive airway pressure (CPAP) during drug pediatric induced sleep endoscopy. METHODS Using our institutional anesthesia protocol for pediatric DISE procedures, patients were anesthetized followed by evaluation of the nasal airway, nasopharynx, velum, hypopharynx, arytenoids, tongue base, and epiglottis. CPAP titration was performed under vision to evaluate the degree of airway collapse at the level of the velum. Comparison was made with pre-operative polysomnography findings. RESULTS Twelve pediatric patients underwent DISE with intraoperative CPAP titration. In 7/12 patients, DISE observed CPAP titration was beneficial in elucidating areas of obstruction that were observed at pressures beyond those recommended during preoperative sleep study titrations. In 3 patients, DISE observations provided a basis for evaluation in children not compliant with sleep study CPAP titration testing. With regard to regions effected, airway collapse was observed at the velum and oropharynx to a greater degree when compared with the tongue base and epiglottis. CONCLUSION DISE evaluation of the pediatric patient with obstructive sleep apnea may present a source for further patient evaluation with respect to CPAP optimization and severity of OSA assessment, particularly in syndromic patients.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Mary Frances Musso
- Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatric Otolaryngology, Texas Children's Hospital, Houston, TX, USA
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Jayakumar K, Bansal S, Markan A, Agarwal A, Bansal R, Mahajan S, Agrawal R, Gupta V. Reversibility of retinochoroidal vascular alteration in patients with obstructive sleep apnea after continuous positive air pressure and surgical intervention. Indian J Ophthalmol 2021; 69:1850-1855. [PMID: 34146042 PMCID: PMC8374762 DOI: 10.4103/ijo.ijo_3150_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose The aim of this work was to study various retinochoroidal parameters in patients with obstructive sleep apnea syndrome (OSAS) and the effect of interventions on these parameters at 6 months follow-up. Methods A total of 36 patients were recruited prospectively from the otorhinolaryngology clinics of a large tertiary center between September 2018 to March 2020. The subjects were divided into three groups depending upon intervention chosen for OSAS: Group A (surgery, i.e., uvulopalatopharyngoplasty), group B (medical therapy, i.e., continuous positive air pressure) and group C (no intervention). Various retinochoroidal parameters which were studied included retinal thickness (RT), choroidal thickness (CT), choroidal vascularity index (CVI), arteriovenous ratio (AVR), capillary density index (CDI) in superficial and deep retina, at baseline and 6 months of follow-up after the intervention. Results In group A, CT increased significantly at 6 months (332.76 ± 86.41 um) compared to baseline (306.28 ± 78.19) (P = 0.0004). Similarly, CDI at both superficial and deep capillary plexus increased significantly at 6 months (superficial CDI: 0.65 ± 0.04, deep CDI: 0.38 ± 0.01) compared to baseline (superficial CDI: 0.62 ± 0.03, deep CDI: 0.36 ± 0.02) (P = 0.004 and 0.002 respectively). In group B, CT increased significantly at 6 months (361.38 ± 78.63 um) compared to baseline (324.21 ± 76.97 um) (P = 0.008). Also, CVI showed a significant decrease at 6 months (65.74 ± 1.84%) compared to baseline (67.36 ± 1.57%) (P = 0.019). In group C, all except CDI in deep capillary plexus showed a significant decrease at 6 months (0.35 ± 0.01) compared to baseline (0.36 ± 0.02) (P = 0.003). Conclusion OSAS alters various retinochoroidal parameters and timely intervention in patients with OSAS can prevent these alterations. Also, these retinochoroidal parameters could serve as one of the markers to monitor the disease progression.
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Affiliation(s)
- Kalaivani Jayakumar
- Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sandeep Bansal
- Otorhinolaryngology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Markan
- Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Aniruddha Agarwal
- Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Reema Bansal
- Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sarakshi Mahajan
- School of Medicine, St Joseph Mercy Hospital, Oakland, Pontiac, Michigan, USA
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Department of Ophthalmology, Tan Tock Seng Hospital; Singapore Eye Research Institute, Singapore
| | - Vishali Gupta
- Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Yui MS, Tominaga Q, Lopes BCP, Eckeli AL, de Almeida LA, Rabelo FAW, Küpper DS, Valera FCP. Can drug-induced sleep endoscopy (DISE) predict compliance with positive airway pressure therapy? A pilot study. Sleep Breath 2021; 26:109-116. [PMID: 33829370 DOI: 10.1007/s11325-021-02360-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/07/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Drug-induced sleep endoscopy (DISE) has been poorly explored as an examination to assess positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA). The present study aimed to identify by DISE possible characteristics related to low compliance with PAP therapy due to respiratory complaints. METHODS Patients using PAP for OSA underwent DISE in two conditions: (1) baseline (without PAP) and (2) PAP (with the same mask and airway pressure used at home). We compared patients reporting low compliance to PAP due to respiratory complaints to those well-adapted to therapy. VOTE classification (assessment of velopharynx, oropharynx, tongue base, and epiglottis) and TOTAL VOTE score (the sum of VOTE scores at each anatomical site) were assessed. ROC curve analyzed the accuracy of TOTAL VOTE to predict low compliance due to persistent pharyngeal obstruction in both conditions. RESULTS Of 19 patients enrolled, all presented multilevel pharyngeal obstruction at baseline condition, with no difference between groups at this study point. When PAP was added, the median VOTE value was higher in the epiglottis (P value=0.02) and tended to be higher at the velum and tongue base in the poorly adapted group; TOTAL VOTE score was also significantly increased in patients with low compliance (P value<0.001). ROC curve demonstrated that patients with TOTAL VOTE scored 2.5 or more during DISE with PAP presented a 4.6-fold higher risk for low compliance with PAP therapy due to pharyngeal obstruction (AUC: 0.88±0.07; P value<0.01; sensitivity: 77%; specificity: 83%). CONCLUSIONS Adding PAP during a DISE examination may help to predict persistent pharyngeal obstruction during PAP therapy.
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Affiliation(s)
- Mariane S Yui
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil
| | - Quedayr Tominaga
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil
| | - Bruno C P Lopes
- Anesthesiology Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Alan L Eckeli
- Neurosciences Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Leila A de Almeida
- Neurosciences Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Daniel S Küpper
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil
| | - Fabiana C P Valera
- ENT Division, Clinics Hospital, Ribeirao Preto Medical School, University of Sao Paulo, Av. Bandeirantes, 3900-12o andar, CEP 14049-900, Ribeirão Preto, São Paulo, Brazil.
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Effect of body weight on upper airway findings and treatment outcome in children with obstructive sleep apnea. Sleep Med 2020; 79:19-28. [PMID: 33465738 DOI: 10.1016/j.sleep.2020.12.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE/BACKGROUND Surgical interventions for obstructive sleep apnea (OSA) are less effective in obese than in normal-weight children. However, the mechanisms that underpin this relationship are not fully understood. Therefore, this study aimed to explore how body weight influences upper airway collapse and treatment outcome in children with OSA. METHODS We conducted a retrospective analysis of prospectively collected data on polysomnography, drug-induced sleep endoscopy (DISE), and treatment outcome in otherwise healthy children with OSA. Associations between body mass index (BMI) z-score and upper airway collapse during DISE were assessed using logistic regression modelling. Treatment success was defined as obstructive apnea-hypopnea index (oAHI) < 5 events/hour and cure as oAHI < 2 events/hour with obstructive apnea index < 1 event/hour. RESULTS A total of 139 children were included [median (Q1─Q3); age 4.5 (3.1─8.4) years; BMI z-score 0.3 (-0.8 to 1.4); oAHI 10.8 (6.8─18.0) events/hour]. Twenty-five of them were overweight and 21 were obese. After adjusting for age and history of upper airway surgery, BMI z-score was significantly correlated with circumferential upper airway collapse during DISE (odds ratio 1.67; 95% confidence interval 1.12─2.65; P = 0.011). Outcome of DISE-directed treatment was similar in normal-weight (success: 91.4%; cure: 78.5%), overweight (success: 88.0%; cure: 80.0%), and obese (success: 90.5%; cure: 76.5%) children. Children with circumferential collapse responded better to continuous positive airway pressure than to (adeno)tonsillectomy. CONCLUSION Increasing body weight is associated with circumferential upper airway collapse during DISE and, accordingly, may require treatment strategies other than (adeno)tonsillectomy.
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Rondelli V, Guarracino A, Iacobellis P, Grasso S, Stripoli T, Lacitignola L, Auriemma E, Romano F, Araos JD, Staffieri F. Evaluation of the effects of helmet continuous positive airway pressure on laryngeal size in dogs anesthetized with propofol and fentanyl using computed tomography. J Vet Emerg Crit Care (San Antonio) 2020; 30:543-549. [PMID: 32649044 DOI: 10.1111/vec.12977] [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] [Received: 06/24/2018] [Revised: 03/31/2019] [Accepted: 04/29/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the effect of 5 cm H2 O of continuous positive airway pressure (CPAP) on laryngeal size in spontaneously breathing anesthetized dogs via computed tomography (CT). DESIGN Prospective, randomized, cross-over clinical study. SETTING University teaching hospital and referral private practice. ANIMALS Eight healthy client-owned dogs undergoing CT. INTERVENTIONS Dogs were sedated with acepromazine 20 μg/kg IM and induced with fentanyl 2 μg/kg and propofol 3-5 mg/kg IV before being maintained on fentanyl (5 μg/kg/h) and propofol (0.3 mg/kg/min) constant rate infusion. Dogs received an air/oxygen mixture with (CPAP) and without (NO-CPAP) 5 cm H2 O of CPAP in a random order. Each study step lasted 15 minutes. MEASUREMENTS AND MAIN RESULTS Ten minutes after the beginning of each study period, a CT scan of the laryngeal region was obtained at end-expiration. CT images were analyzed to determine the laryngeal cross-sectional area (CSA; cm2 ), total volume (VTOT ; cm3 ), and laterolateral and dorsoventral diameters (DLL and DDV , respectively; cm). Differences between the 2 treatments were analyzed with t-test for paired data (P < 0.05). Compared to the NO-CPAP, during CPAP the CSA increased by 53.3 ± 23.1% (ie, from 3.3 ± 0.8 to 5.1 ± 1.3 cm2 , P = 0.0004), VTOT increased by 52.4 ± 13.6% (from 6.2 ± 1.7 to 9.4 ± 2.4 cm3 , P < 0.0001), and DLL and DDV were 55.5 ± 13.3% (3.6 ± 0.8 vs 2.4 ± 0.5 cm, P = 0.006) and 20.3 ± 8.8% larger (3.2 ± 0.7 vs 2.7 ± 0.6 cm, P = 0.0002), respectively. CONCLUSIONS Laryngeal volume and cross sectional area increased during the application of 5 cm H2 O of helmet CPAP in spontaneously breathing anesthetized dogs.
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Affiliation(s)
| | - Alessandro Guarracino
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplants, University of Bari Aldo Moro, Bari, Italy
| | - Pierpaolo Iacobellis
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplants, University of Bari Aldo Moro, Bari, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplants, University of Bari Aldo Moro, Bari, Italy
| | - Tania Stripoli
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplants, University of Bari Aldo Moro, Bari, Italy
| | - Luca Lacitignola
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplants, University of Bari Aldo Moro, Bari, Italy
| | | | | | - Joaquin D Araos
- Centre Hospitalier Universitaire Veterinaire, Faculte de Medecine Veterinaire, Universite de Montreal, Montreal, Québec, Canada
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplants, University of Bari Aldo Moro, Bari, Italy
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Dieleman E, Veugen CCAFM, Hardeman JA, Copper MP. Drug-induced sleep endoscopy while administering CPAP therapy in patients with CPAP failure. Sleep Breath 2020; 25:391-398. [PMID: 32378031 PMCID: PMC7987634 DOI: 10.1007/s11325-020-02098-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/21/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
Study objectives To study the pattern of upper airway collapse in patients with CPAP failure by performing DISE while administering CPAP therapy and to determine the reason for CPAP failure accordingly. Methods This observational retrospective study comprised 30 patients diagnosed with OSA and CPAP failure, who underwent DISE while administering CPAP therapy. During DISE, the upper airway was assessed with and without CPAP therapy using the VOTE classification. Additionally, a jaw thrust maneuver was performed, in order to mimic the effect of an additional mandibular advancement device (MAD) in combination with CPAP therapy. Consequently, the outcome of DISE was translated into a clinically relevant categorization. Results Eleven patients (37%) had a persistent anteroposterior (AP) collapse, including a collapse at velum, tongue base, or epiglottis level and multilevel collapse. Eight patients (27%) had a floppy epiglottis. Five patients (17%) had a persistent complete concentric collapse (CCC) and three patients had a persistent laryngeal collapse (10%). In three patients (10%), no airway collapse was found after CPAP administration. Conclusions Based on the results of the reported study, in most cases, the potential cause of CPAP failure can be determined by this new diagnostic method. Consequently, suggestions can be made for additional therapy.
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Affiliation(s)
- E Dieleman
- Department of Otorhinolaryngology Head and Neck Surgery, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Department of Otorhinolaryngology Head and Neck Surgery, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - C C A F M Veugen
- Department of Otorhinolaryngology Head and Neck Surgery, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands. .,Department of Otorhinolaryngology Head and Neck Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - J A Hardeman
- Department of Pulmonology, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - M P Copper
- Department of Otorhinolaryngology Head and Neck Surgery, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
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13
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de Vries GE, Hoekema A, Claessen JQPJ, Stellingsma C, Stegenga B, Kerstjens HAM, Wijkstra PJ. Long-Term Objective Adherence to Mandibular Advancement Device Therapy Versus Continuous Positive Airway Pressure in Patients With Moderate Obstructive Sleep Apnea. J Clin Sleep Med 2019; 15:1655-1663. [PMID: 31739856 PMCID: PMC6853388 DOI: 10.5664/jcsm.8034] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVES Comparable health effects of mandibular advancement device (MAD) and continuous positive airway pressure (CPAP) therapy have been attributed to higher adherence with MAD compared with CPAP therapy. The objective of this study was to make a direct comparison of the objective adherence between MAD and CPAP in patients with moderate obstructive sleep apnea (OSA). METHODS Adherence was monitored for 12 months in 59 patients with moderate OSA (apnea-hypopnea index 15-30 events/h) as part of a randomized controlled trial. Objective adherence with MAD was assessed using the TheraMon microsensor. Objective adherence with CPAP was assessed using the built-in registration software with readout on SD card. Self-reported adherence with both therapies was assessed using a questionnaire. RESULTS Forty patients (68%) completed the study with the therapy to which they were randomly assigned. Median (interquartile range) objective adherence (h/night) in the 3rd month was 7.4 (5.2-8.2) for MAD and 6.8 (5.7-7.6) for CPAP (P = .41), compared to 6.9 (3.5-7.9) with MAD and 6.8 (5.2-7.6) with CPAP (P = .85) in the 12th month. There were no significant changes between the 3rd and 12th month for both MAD (P = .21) and CPAP (P = .46). Changes in adherence were not significantly different between MAD and CPAP (P = .51). Self-reported adherence was significantly higher with MAD than CPAP at all follow-ups. Self-reported adherence with CPAP was lower than objective CPAP adherence at the 6th and 12th month (P = .02). CONCLUSIONS Objective adherence with MAD and CPAP is comparable and consistent over time. Self-reported adherence is higher with MAD than with CPAP giving rise to interesting discrepancy between objective and self-reported adherence with CPAP. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Identifier: NCT01588275.
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Affiliation(s)
- Grietje E de Vries
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aarnoud Hoekema
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam, MOVE Research Institute Amsterdam, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | | | - Cornelis Stellingsma
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn Stegenga
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Deceased October 27, 2018
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Center for Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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14
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Al-Qawasmi R, Parsons S, Wetherill L. Heritability of the pharyngeal airway volume and dimensions as assessed from siblings with overt malocclusions. Int Orthod 2019; 17:660-666. [PMID: 31466929 DOI: 10.1016/j.ortho.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To quantify the relative contributions of genetic and environmental factors to airway volume and dimensions in orthodontic patients. MATERIALS AND METHODS One hundred and twenty-five siblings from 57 families were selected. Cone beam computed tomography scans were taken as part of the orthodontic records and the Dolphin3D © imaging software was used to determine airway volume and dimensions. SOLAR program was implemented to calculate heritability. RESULTS The heritability of the airway volume was negligible but increased significantly from 5% to 72% (95% confidence interval was 27% to 100%) when anterior-posterior (AP) dimension was controlled in the calculating model. CONCLUSION The capacity to maintain, rather than having proper AP dimension of the airway, seems to be the most critical mark of a proper airway volume.
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Affiliation(s)
- Riyad Al-Qawasmi
- Department of Orthodontics, University of Detroit Mercy School of Dentistry, 2700 Martin Luther King Jr. Blvd Detroit, MI 48208, USA.
| | - Sade Parsons
- Department of Orthodontics, University of Detroit Mercy School of Dentistry, 2700 Martin Luther King Jr. Blvd Detroit, MI 48208, USA
| | - Leah Wetherill
- Department of Statistics, Applied Statistician II, 410W, 10th St, HS 4000, Indianapolis, IN 46202, USA
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15
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Passos UL, Genta PR, Marcondes BF, Lorenzi-Filho G, Gebrim EMMS. State-dependent changes in the upper airway assessed by multidetector CT in healthy individuals and during obstructive events in patients with sleep apnea. ACTA ACUST UNITED AC 2019; 45:e20180264. [PMID: 31432889 PMCID: PMC6733715 DOI: 10.1590/1806-3713/e20180264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/23/2019] [Indexed: 12/02/2022]
Abstract
Objective: To determine whether airway narrowing during obstructive events occurs predominantly at the retropalatal level and results from dynamic changes in the lateral pharyngeal walls and in tongue position. Methods: We evaluated 11 patients with severe obstructive sleep apnea (OSA) and 7 healthy controls without OSA during wakefulness and during natural sleep (documented by full polysomnography). Using fast multidetector CT, we obtained images of the upper airway in the waking and sleep states. Results: Upper airway narrowing during sleep was significantly greater at the retropalatal level than at the retroglossal level in the OSA group (p < 0.001) and in the control group (p < 0.05). The retropalatal airway volume was smaller in the OSA group than in the control group during wakefulness (p < 0.05) and decreased significantly from wakefulness to sleep only among the OSA group subjects. Retropalatal pharyngeal narrowing was attributed to reductions in the anteroposterior diameter (p = 0.001) and lateral diameter (p = 0.006), which correlated with an increase in lateral pharyngeal wall volume (p = 0.001) and posterior displacement of the tongue (p = 0.001), respectively. Retroglossal pharyngeal narrowing during sleep did not occur in the OSA group subjects. Conclusions: In patients with OSA, upper airway narrowing during sleep occurs predominantly at the retropalatal level, affecting the anteroposterior and lateral dimensions, being associated with lateral pharyngeal wall enlargement and posterior tongue displacement.
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Affiliation(s)
- Ula Lindoso Passos
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Pedro Rodrigues Genta
- . Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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16
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Barbieri M, Missale F, Incandela F, Fragale M, Barbieri A, Roustan V, Canevari FR, Peretti G. Barbed suspension pharyngoplasty for treatment of lateral pharyngeal wall and palatal collapse in patients affected by OSAHS. Eur Arch Otorhinolaryngol 2019; 276:1829-1835. [PMID: 30993468 DOI: 10.1007/s00405-019-05426-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/09/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study is to analyze the efficacy of a new modified pharyngoplasty technique with barbed sutures: barbed suspension pharyngoplasty (BSP). METHODS We enrolled patients affected by obstructive sleep apnea-hypopnea syndrome (OSAHS), having the main site of obstruction at the palatal and lateral pharyngeal walls, who refused or failed to tolerate CPAP therapy and underwent non-resective pharyngoplasty with barbed sutures between January 2014 and October 2017. Two surgical techniques with barbed sutures were used: barbed reposition pharyngoplasty (BRP) and BSP; the main characteristics of the latter are a double passage of the needle, each side, through the soft palate. RESULTS Forty-two patients met the study inclusion criteria and were included in the analysis. Twenty-two patients underwent BRP and 20 BSP. Patients treated with both BRP and BSP achieved significant improvement in polysomnographic parameters: AHI, ODI, t90%, and daily sleepiness tested by the ESS questionnaire (p < 0.001). There were no significant differences between groups considering gender, age, or severity of OSAHS (p > 0.05). Outcomes were also comparable (p = 0.10) in the two groups; patients who underwent BSP had successful treatment in 100% of cases, compared to 86% with BRP, with a cure rate of 40% vs. 18%. CONCLUSIONS BSP is a novel surgical technique that is effective in treating oropharyngeal collapse and can be tailored for patients with high collapsibility of the soft palate who might benefit from the palatal stiffness given by multiple passages of the suture inside it.
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Affiliation(s)
- Marco Barbieri
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Francesco Missale
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy.
| | - Fabiola Incandela
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Marco Fragale
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Andrea Barbieri
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Valeria Roustan
- Department of Otorhinolaryngology, Ospedale Santa Maria Delle Croci, Ravenna, Italy
| | - Frank Rikki Canevari
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Giorgio Peretti
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
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17
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Otto-Yáñez M, Torres-Castro R, Sarmento A, Rivera Lillo GB, Resqueti VR, Fregonezi GAF. Nasal continuous positive airway pressure for sleep-disordered breathing after stroke. Hippokratia 2018. [DOI: 10.1002/14651858.cd013161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Matias Otto-Yáñez
- Universidad Autónoma de Chile; School of Physical Therapy; Santiago Chile
- Clínica Los Coihues; Centro de Estudios Integrados en Neurorrehabilitación; Santiago Chile
| | | | - Antonio Sarmento
- PneumoCardioVascular Lab, Onofre Lopes University Hospital, Brazilian Company of Hospital Services (EBSERH) & Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil; Natal Brazil
| | | | - Vanessa R Resqueti
- Federal University of Rio Grande do Norte; PneumoCardioVascular Lab, Onofre Lopes University Hospital, Brazilian Company of Hospital Services (EBSERH) & Department of Physical Therapy; Campus Universitario Lagoa Nova Caixa Postal 1524 Natal Rio Grande do Norte Brazil 59078-970
| | - Guilherme AF Fregonezi
- Onofre Lopes University Hospital, Brazilian Company of Hospital Services (EBSERH); PneumoCardioVascular Lab; Natal Rio Grande do Norte Brazil 59078-970
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18
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Lim KG, Morgenthaler TI, Katzka DA. Sleep and Nocturnal Gastroesophageal Reflux: An Update. Chest 2018; 154:963-971. [PMID: 29859888 DOI: 10.1016/j.chest.2018.05.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/09/2018] [Accepted: 05/21/2018] [Indexed: 02/07/2023] Open
Abstract
Nocturnal gastroesophageal reflux has been associated with poor sleep quality. Normal physiological adaptations of the aerodigestive system to sleep prolong and intensify nocturnal reflux events. This occurrence leads to sleep disruption, as well as to esophageal, laryngeal, and laryngopharyngeal reflux. Controversy exists on whether OSA and nocturnal reflux are causally linked or merely associated because of shared risk factors. Advances in diagnostic technology have provided new insights into gastroesophageal reflux and the mechanisms of nocturnal reflux during sleep. This update reviews new data on causal links between sleep and gastroesophageal reflux disease.
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Affiliation(s)
- Kaiser G Lim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Allergic Diseases, Mayo Clinic, Rochester, MN.
| | | | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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19
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Sorrenti G, Pelligra I, Albertini R, Caccamo G, Piccin O. Functional expansion pharyngoplasty: Technical update by unidirectional barbed sutures. Clin Otolaryngol 2018; 43:1419-1421. [PMID: 29575572 DOI: 10.1111/coa.13105] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2018] [Indexed: 11/29/2022]
Affiliation(s)
- G Sorrenti
- Department of Otolaryngology Head and Neck Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - I Pelligra
- Department of Otolaryngology Head and Neck Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - R Albertini
- Department of Otolaryngology Head and Neck Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - G Caccamo
- Department of Otolaryngology Head and Neck Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - O Piccin
- Department of Otolaryngology Head and Neck Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
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20
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Surgical outcomes of overlapping lateral pharyngoplasty with or without coblator tongue base resection for obstructive sleep apnea. Eur Arch Otorhinolaryngol 2018; 275:1189-1196. [DOI: 10.1007/s00405-018-4940-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 03/14/2018] [Indexed: 11/26/2022]
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21
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Pengo MF, Bonafini S, Fava C, Steier J. Cardiorespiratory interaction with continuous positive airway pressure. J Thorac Dis 2018; 10:S57-S70. [PMID: 29445529 PMCID: PMC5803058 DOI: 10.21037/jtd.2018.01.39] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/09/2018] [Indexed: 12/27/2022]
Abstract
The treatment of choice for obstructive sleep apnoea (OSA) is continuous positive airway pressure therapy (CPAP). Since its introduction in clinical practice, CPAP has been used in various clinical conditions with variable and heterogeneous outcomes. In addition to the well-known effects on the upper airway CPAP impacts on intrathoracic pressures, haemodynamics and blood pressure (BP) control. However, short- and long-term effects of CPAP therapy depend on multiple variables which include symptoms, underlying condition, pressure used, treatment acceptance, compliance and usage. CPAP can alter long-term cardiovascular risk in patients with cardiorespiratory conditions. Furthermore, the effect of CPAP on the awake patient differs from the effect on the patients while asleep, and this might contribute to discomfort and removal of the use interface. The purpose of this review is to highlight the physiological impact of CPAP on the cardiorespiratory system, including short-term benefits and long-term outcomes.
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Affiliation(s)
- Martino F. Pengo
- King’s College London, Faculty of Life Sciences and Medicine, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
| | - Sara Bonafini
- Department of Medicine, General Medicine and Hypertension Unit, University of Verona, Italy
| | - Cristiano Fava
- Department of Medicine, General Medicine and Hypertension Unit, University of Verona, Italy
| | - Joerg Steier
- King’s College London, Faculty of Life Sciences and Medicine, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, Lane Fox Respiratory Unit/Sleep Disorders Centre, London, UK
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22
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Lan MC, Hsu YB, Lan MY, Huang YC, Kao MC, Huang TT, Chiu TJ, Yang MC. The predictive value of drug-induced sleep endoscopy for CPAP titration in OSA patients. Sleep Breath 2017; 22:949-954. [DOI: 10.1007/s11325-017-1600-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 11/23/2017] [Accepted: 11/29/2017] [Indexed: 12/12/2022]
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23
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O'donoghue FJ, Meaklim H, Bilston L, Hatt A, Connelly A, Jackson G, Farquharson S, Sutherland K, Cistulli PA, Brown DJ, Berlowitz DJ. Magnetic resonance imaging of the upper airway in patients with quadriplegia and obstructive sleep apnea. J Sleep Res 2017; 27:e12616. [PMID: 29082563 DOI: 10.1111/jsr.12616] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 08/24/2017] [Indexed: 11/29/2022]
Abstract
The aim of this study was to investigate upper airway anatomy in quadriplegics with obstructive sleep apnea. Fifty subjects were recruited from three hospitals in Australia: people with quadriplegia due to spinal cord injury and obstructive sleep apnea (n = 11), able-bodied people with obstructive sleep apnea (n = 18), and healthy, able-bodied controls (n = 19). All underwent 3-Tesla magnetic resonance imaging of their upper airway. A subgroup (n = 34) received a topical vasoconstrictor, phenylephrine and post-phenylephrine magnetic resonance imaging. Mixed-model analysis indicated no significant differences in total airway lumen volume between the three groups (P = 0.086). Spinal cord injury-obstructive sleep apnea subjects had a significantly larger volume of soft palate (P = 0.020) and retroglossal lateral pharyngeal walls (P = 0.043) than able-bodied controls. Able-bodied-obstructive sleep apnea subjects had a smaller mandible volume than spinal cord injury-obstructive sleep apnea subjects and able-bodied control subjects (P = 0.036). No differences were seen in airway length between groups when controlling for height (P = 0.055). There was a marginal increase in velopharyngeal volume across groups post-phenylephrine (P = 0.050), and post hoc testing indicated the difference was confined to the able-bodied-obstructive sleep apnea group (P < 0.001). No other upper airway structures showed significant changes with phenylephrine administration. In conclusion, people with obstructive sleep apnea and quadriplegia do not have a structurally smaller airway than able-bodied subjects. They did, however, have greater volumes of soft palate and lateral pharyngeal walls, possibly due to greater neck fat deposition. The acute response to upper airway topical vasoconstriction was not enhanced in those with obstructive sleep apnea and quadriplegia. Changes in upper airway anatomy likely contribute to the high incidence in obstructive sleep apnea in quadriplegic subjects.
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Affiliation(s)
- Fergal J O'donoghue
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Vic, Australia.,Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia.,Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Vic, Australia
| | - Hailey Meaklim
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Vic, Australia.,Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia
| | - Lynne Bilston
- Neuroscience Research Australia, Randwick, NSW, Australia.,University of New South Wales, Randwick, NSW, Australia
| | - Alice Hatt
- Neuroscience Research Australia, Randwick, NSW, Australia
| | - Alan Connelly
- Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia
| | - Graeme Jackson
- Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia.,Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Vic, Australia
| | - Shawna Farquharson
- Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia
| | - Kate Sutherland
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Peter A Cistulli
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Douglas J Brown
- Spinal Research Institute, Austin Health, Heidelberg, Vic, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Vic, Australia.,Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Vic, Australia.,Spinal Research Institute, Austin Health, Heidelberg, Vic, Australia
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Mantovani M, Carioli D, Torretta S, Rinaldi V, Ibba T, Pignataro L. Barbed snore surgery for concentric collapse at the velum: The Alianza technique. J Craniomaxillofac Surg 2017; 45:1794-1800. [PMID: 28941735 DOI: 10.1016/j.jcms.2017.08.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/10/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022] Open
Abstract
Recently, new conservative and non-resective surgical techniques, including palatopharyngeal surgical lifting and suspension (the 'Roman blinds technique') and modular barbed snore surgery (MBSS), have been successfully introduced for the treatment of obstructive sleep apnea syndrome (OSAS). This pilot longitudinal study describes our preliminary experience with the 'Alianza technique' (the simultaneous use of Roman blinds and MBSS) in mild to moderate OSAS patients with concentric pharyngeal collapse at the velum, previously documented by means of drug-induced sleep endoscopy. Effectiveness of the surgical procedure was assessed by means of the Epworth sleepiness scale (ESS), overnight polysomnography, and a 0-10 snoring visual analogue scale (VAS); tolerability was assessed by means of a 0-10 pain VAS. The final analysis relating to 19 patients (18 males; 94.8%), with a mean age of 43.8 ± 8.8 years, showed a statistically significant reduction in mean post-operative apnea-hypopnea indexes (22.3 ± 5.1 vs 7.0 ± 9.4 events/hour; p-value = 0.002) and mean ESS scores (11.3 ± 5.4 vs 3.9 ± 4.0; p-value < 0.001). There was also a significant decrease in mean post-operative snoring VAS scores (9.5 ± 0.7 vs 2.1 ± 1.7; p-value < 0.001). Surgery was well tolerated in most patients (mean pain VAS scores on day seven: 2.4 ± 1.4), and there were no major complications. In experienced hands, the Alianza can be considered an effective and safe technique for the treatment of mild to moderate OSAS.
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Affiliation(s)
- Mario Mantovani
- Otolaryngology Unit, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico (Chief Prof. Lorenzo Pignataro, MD), Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Daniela Carioli
- Otolaryngology Unit, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico (Chief Prof. Lorenzo Pignataro, MD), Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Sara Torretta
- Otolaryngology Unit, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico (Chief Prof. Lorenzo Pignataro, MD), Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - Vittorio Rinaldi
- Otolaryngology Unit, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico (Chief Prof. Lorenzo Pignataro, MD), Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Tullio Ibba
- Otolaryngology Unit, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico (Chief Prof. Lorenzo Pignataro, MD), Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Lorenzo Pignataro
- Otolaryngology Unit, Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico (Chief Prof. Lorenzo Pignataro, MD), Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Torre C, Liu SY, Kushida CA, Nekhendzy V, Huon LK, Capasso R. Impact of continuous positive airway pressure in patients with obstructive sleep apnea during drug-induced sleep endoscopy. Clin Otolaryngol 2017; 42:1218-1223. [PMID: 28207995 DOI: 10.1111/coa.12851] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The primary objective of the study was to understand the differential impact of continuous positive airway pressure (CPAP) on the location, degree and pattern of airway collapse in obstructive sleep apnea (OSA) patients utilizing drug-induced sleep endoscopy (DISE). STUDY DESIGN Non-randomized trial. SETTING University Medical Center. PARTICIPANTS Fifteen consecutive OSA patients undergoing DISE. MAIN OUTCOMES AND MEASURES The patterns of airway collapse were videorecorded at baseline and under differential application of nasal CPAP (nCPAP) at 5, 10 and 15 cm H2 O. For each modality, the pattern and degree of airway collapse were analyzed by three independent observers using the velum, oropharynx, tongue base, epiglottis (VOTE) classification system. RESULTS The modest nCPAP pressures (10 cm H2 O) had the greatest impact on the lateral walls of the pharynx, followed by the palatal region. The collapsibility of the tongue base and epiglottis demonstrated significant resistance to nCPAP application, which was overcome by increasing nCPAP to 15 cm H2 O. Compared to 5 cm H2 O, nCPAP pressures of 10 and 15 cm H2 O improved complete collapse at least at one level of the upper airway (P=.016 and .001, respectively). Increased nCPAP pressures also led to changes in the configuration of airway collapse at the level of the velum. CONCLUSIONS The differential nCPAP effects observed in this study may help to understand some of the mechanisms responsible for inadequate patient response and poor nCPAP compliance. The use of DISE in combination with CPAP may serve as a first step in optimizing patients that failed to adapt to treatment with CPAP. This approach can help the physician identify patterns of airway collapse that may require varying pressures different from the one the patient is using, as well as anatomical factors that may be corrected to help with compliance.
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Affiliation(s)
- C Torre
- Department of Otolaryngology-Head and Neck Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA.,Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA.,Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford Hospital and Clinics, Stanford, CA, USA
| | - S Y Liu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - C A Kushida
- Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford Hospital and Clinics, Stanford, CA, USA
| | - V Nekhendzy
- Department of Anesthesia, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - L K Huon
- Department of Otolaryngology, Head and Neck Surgery, Cathay General Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - R Capasso
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
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Abstract
In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.
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Bilici S, Engin A, Ozgur Y, Ozlem Onerci C, Ahmet Gorkem Y, Aytul Hande Y. Submental Ultrasonographic Parameters among Patients with Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2017; 156:559-566. [DOI: 10.1177/0194599816684109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective This study aimed to determine the value of submental ultrasonography (US) parameters for diagnostic workup among patients with obstructive sleep apnea (OSA) and to determine whether there is a correlation between US findings and the severity of OSA. Study Design Cross-sectional analysis. Setting Tertiary education hospital. Subjects and Methods The study included 147 patients with suspected OSA who underwent submental US to evaluate various parameters following overnight polysomnography. US findings were compared with the apnea-hypopnea index and other parameters. Results All US parameters, except for subcutaneous tissue thickness, were significantly different among patients with OSA. Of note, distance between lingual arteries (DLA), geniohyoid muscle thickness (GMT), and lateral parapharyngeal wall thickness (LPWT) were significantly greater in the patients with severe OSA than those with mild and moderate OSA ( P < .001). GMT had the strongest correlation with OSA ( r = 0.419, P < .001); LPWT and DLA also had high correlation coefficient values ( r = 0.343, P < .001, and r = 0.342, P < .001, respectively). Stepwise regression analysis showed that GMT (beta = 0.243, P = 0.004), LPWT (beta = 0.236, P = 0.004), and DLA (beta = 0.204, P = 0.008) were the most significant factors for predicting the severity of OSA according to the apnea-hypopnea index. Conclusion Submental US can be used to determine whether there is a correlation between US findings and severity of OSA. GMT could be considered a novel parameter for determining the severity of OSA.
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Affiliation(s)
- Suat Bilici
- Department of Otorhinolaryngology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Acioglu Engin
- Department of Otorhinolaryngology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yigit Ozgur
- Department of Otorhinolaryngology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Celebi Ozlem Onerci
- Department of Otorhinolaryngology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yasak Ahmet Gorkem
- Department of Otorhinolaryngology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yardimci Aytul Hande
- Department of Radiology, Istanbul Training and Research Hospital, Istanbul, Turkey
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Long-term results of a modified expansion sphincter pharyngoplasty for sleep-disordered breathing. Eur Arch Otorhinolaryngol 2016; 274:1665-1670. [DOI: 10.1007/s00405-016-4395-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Souza FJFDB, Evangelista AR, Silva JV, Périco GV, Madeira K. Cervical computed tomography in patients with obstructive sleep apnea: influence of head elevation on the assessment of upper airway volume. J Bras Pneumol 2016; 42:55-60. [PMID: 26982042 PMCID: PMC4805388 DOI: 10.1590/s1806-37562016000000092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 11/30/2015] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Obstructive sleep apnea syndrome (OSAS) has a high prevalence and carries significant cardiovascular risks. It is important to study new therapeutic approaches to this disease. Positional therapy might be beneficial in reducing the apnea-hypopnea index (AHI). Imaging methods have been employed in order to facilitate the evaluation of the airways of OSAS patients and can be used in order to determine the effectiveness of certain treatments. This study was aimed at determining the influence that upper airway volume, as measured by cervical CT, has in patients diagnosed with OSAS. METHODS This was a quantitative, observational, cross-sectional study. We evaluated 10 patients who had been diagnosed with OSAS by polysomnography and on the basis of the clinical evaluation. All of the patients underwent conventional cervical CT in the supine position. Scans were obtained with the head of the patient in two positions (neutral and at a 44° upward inclination), and the upper airway volume was compared between the two. RESULTS The mean age, BMI, and neck circumference were 48.9 ± 14.4 years, 30.5 ± 3.5 kg/m2, and 40.3 ± 3.4 cm, respectively. The mean AHI was 13.7 ± 10.6 events/h (range, 6.0-41.6 events/h). The OSAS was classified as mild, moderate, and severe in 70%, 20%, and 10% of the patients, respectively. The mean upper airway volume was 7.9 cm3 greater when the head was at a 44° upward inclination than when it was in the neutral position, and that difference (17.5 ± 11.0%) was statistically significant (p = 0.002). CONCLUSIONS Elevating the head appears to result in a significant increase in the caliber of the upper airways in OSAS patients.
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Nikander K, von Hollen D, Larhrib H. The size and behavior of the human upper airway during inhalation of aerosols. Expert Opin Drug Deliv 2016; 14:621-630. [PMID: 27547842 DOI: 10.1080/17425247.2016.1227780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The mouth, the pharynx and the larynx are potential sites of aerosol deposition in the upper airway during inhalation of aerosolized drugs. The right angle bend of the lumen at the back of the mouth, the position of the tongue, the variable size and shape of the lumen in the pharynx and the larynx, and the breathing pattern could increase aerosol deposition in the upper airway and decrease lung deposition. Areas covered: In this review, the anatomy of the upper airway from the oral cavity to the glottis and the impact of mandibular protrusion and incisal opening on the size of the upper airway are highlighted. In addition, the impact of inhalation maneuvers, inhaler mouthpiece geometries and a stepped mouthpiece on the size of the upper airway are discussed. Expert opinion: The structure of the upper airway lumen does not have a fixed cross sectional area and is susceptible to both constriction and distension during inhalation. The size of the upper airway can be enlarged through mandibular protrusion and/or incisal opening which might decrease aerosol deposition in the upper airway and increase lung deposition.
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Affiliation(s)
| | - Dirk von Hollen
- b Respironics Inc., a Philips Healthcare Company , Murrysville , PA , USA
| | - Hassan Larhrib
- c Department of Pharmacy and Pharmaceutical Sciences , University of Huddersfield , Huddersfield , UK
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Sleep apnea is associated with an increased risk of mood disorders: a population-based cohort study. Sleep Breath 2016; 21:243-253. [PMID: 27495797 DOI: 10.1007/s11325-016-1389-x] [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: 04/05/2016] [Revised: 07/07/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The symptoms of sleep apnea, such as sleep fragmentation and oxygen desaturation, might be risk factors for subsequent mood disorder (MD), but associations between sleep apnea and MD remain unclear. This nationwide population-based study thus aimed to identify the risk of MD in patients with vs. without sleep apnea. METHODS This cohort study used data from the National Health Insurance database. In total, 5415 patients diagnosed with sleep apnea between 2000 and 2010 were evaluated, and 27,075 matched non-sleep apnea enrollees were included as a comparison cohort. All subjects were followed until 2011. The Cox proportional hazard ratio (HR) was used to investigate the relationship between MD and sleep apnea while controlling covariates and comorbidities of sleep apnea. RESULTS Of 5415, 154 patients with sleep apnea (2.84 %) were diagnosed with MD during the follow-up period in comparison with 306 of 27,075 individuals (1.13 %) without antecedent sleep apnea. After adjusting for the selected factors and comorbidities, we found that patients with sleep apnea were from 1.82- to 2.07-fold greater risk of MD than the comparisons. Of the three subcategories of MD (major depressive disorder, bipolar disorder, and unspecified MD), sleep apnea had the highest predisposing risk with respect to major depressive disorder (adjusted HR from 1.82 to 2.07) and bipolar disorder (adjusted HR from 2.15 to 3.24). CONCLUSIONS There is a greater likelihood of MD manifesting in patients with a history of sleep apnea. Health professionals are thus advised to carefully monitor the psychological impacts of sleep apnea.
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Upper airway structural changes induced by CPAP in OSAS patients: a study using drug-induced sleep endoscopy. Eur Arch Otorhinolaryngol 2016; 274:247-252. [PMID: 27473293 DOI: 10.1007/s00405-016-4233-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
We studied upper airway structural changes induced by continuous positive airway pressure (CPAP) in obstructive sleep apnea syndrome (OSAS) patients using drug-induced sleep endoscopy (DISE). This prospective study was conducted at an academic secondary referral center. In total, 28 male OSAS patients (mean age 41.1 years) with only retropalatal level obstructions were enrolled. Measurements of the obstruction site were obtained in two steps: first a measurement was taken of the obstruction site in accordance with sleep apnea, then, a measurement was taken of the obstruction site in accordance with DISE-assisted CPAP titration, including quantitative changes in the occlusion site before and after CPAP in pixel format using an area calculation program. There was a tendency for persistent closing in cases of antero-posterior (AP) obstruction versus cases of lateral (Lat) obstruction in the CPAP titration. Lat obstructions showed a tendency to be wider than AP obstructions in the quantitative analysis. These results show that the pattern and degree of airway expansion after CPAP differ in accordance with the obstruction site.
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Gillis E, Rampersaud C, Pease E, Buscemi P. A novel implantable device for a minimally invasive surgical treatment of obstructive sleep apnea: design and preclinical safety assessment. Nat Sci Sleep 2016; 8:249-58. [PMID: 27499652 PMCID: PMC4959767 DOI: 10.2147/nss.s99353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In obstructive sleep apnea (OSA), occlusion of the upper airway by soft tissue causes intermittent hypoxemia and can have serious sequelae. A novel implantable medical device for OSA is composed of a linear silicone elastic element held in an extended state by a bioabsorbable external sheath. The implant is delivered to the tongue base or soft palate via a minimally invasive approach. Normal tissue healing anchors the device at the attachment points before the bioabsorbable material dissolves and the elastic element contracts to stabilize the surrounding tissue. METHODS Device prototypes were evaluated in multiple investigations: 1) a finite elements analysis model simulated the movement of the tongue base during sleep with and without the implant; 2) dynamic mechanical testing simulated 10 years' normal use; 3) cadaveric implantations were conducted; 4) an ovine study in which implants of varying design were evaluated via gross pathology and histological assessment; and 5) a canine study in which implants of varying design in the tongue base and soft palate were evaluated via gross pathology and histological assessment. RESULTS 1) The implant was capable of reducing ~95% of tongue base movement during simulated sleep; 2) implants remained intact throughout the testing with no evidence of creep fatigue or change in dynamic modulus; 3) the device could be reliably deployed in the desired placement locations and was appropriate for various anatomies; and 4) all implants were well tolerated through 1 year, with minimal inflammatory responses. CONCLUSION This new minimally invasive device for OSA has been demonstrated, through various bench and animal testing, to be safe, well tolerated, suitable for long-term use, and to function as intended. No adverse health consequences were observed in the animals, and histological evaluation indicated good healing. This study establishes proof of concept and supports human trials.
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Rosário HD, Oliveira GMS, Freires IA, Matos FDS, Paranhos LR. Reply to the comment on: "Efficiency of bimaxillary advancement surgery in increasing the volume of the upper airways: a systematic review of observational studies and meta-analysis". Eur Arch Otorhinolaryngol 2016; 274:587-588. [PMID: 27272051 DOI: 10.1007/s00405-016-4119-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 05/24/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Henrique Damian Rosário
- Department of Orthodontics, Faculdades Integradas do Norte de Minas-FUNORTE, Florianópolis, SC, Brazil
| | | | - Irlan Almeida Freires
- Department of Physiological Sciences, Piracicaba Dental School, University of Campinas, Piracicaba, SP, Brazil
| | - Felipe de Souza Matos
- Postgraduate Program in Restorative Dentistry, Endodontic Division, State University of São Paulo, São José dos Campos, SP, Brazil
| | - Luiz Renato Paranhos
- Department of Dentistry, Federal University of Sergipe, Lagarto, SE, Brazil. .,Residencial Vista do Atlântico, Ap. 1402, Jordão de Oliveira St., 996, Atalaia, Aracaju, SE, 49037-330, Brazil.
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Emara TA, Hassan MH, Mohamad AS, Anany AM, Ebrahem AE. Anterolateral Advancement Pharyngoplasty: A New Technique for Treatment of Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2016; 155:702-7. [PMID: 27221568 DOI: 10.1177/0194599816648127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 04/14/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the efficacy of anterolateral advancement pharyngoplasty to enlarge pharyngeal airspace and to decrease palatal and lateral pharyngeal wall collapse in the treatment of obstructive sleep apnea (OSA). STUDY DESIGN Prospective study. SETTING University medical hospital. SUBJECTS AND METHOD Forty-one patients underwent an anterolateral advancement pharyngoplasty procedure according to the following criteria: body mass index <30 kg/m(2), Friedman stage II or III, type I Fujita, nocturnal polysomnography diagnostic of OSA, retropalatal and lateral pharyngeal collapse, and diagnosis with flexible nasoendoscopy during a Müller's maneuver based on a 5-point scale. Patients with retroglossal airway collapse were excluded from the study. The principle of this technique is to advance and fix the palatopharyngeus muscle with the superior pharyngeus constrictor muscle without transecting any of their fascicules anterolateral to the pterygomandibular raphe and anterosuperior to the levator veli palatine muscle. RESULTS Pre- and postoperative polysomnography findings (mean ± SD) showed significant statistical differences: apnea hypopnea index (AHI) decreased from 42.1 ± 16.34 to 16.3 ± 10.3 (P ≤ .001); percentage of time with oxyhemoglobin saturation <90% decreased from 18.5% ± 4.2% to 10.1% ± 1.3% (P ≤ .001); and lowest oxygen saturation level increased from 79.9% ± 14.8% to 89.3% ± 11.1% (P ≤ .05). The mean time for patients to return to a normal diet was 12.2 days. There was no postoperative bleeding, velopharyngeal insufficiency, speech alternations, or taste loss. Based on a threshold of a 50% reduction in AHI and AHI <20, surgical success was 86.8%. CONCLUSION Anterolateral advancement pharyngoplasty appears to be an effective technique with a high surgical success rate in the treatment of OSA patients with lateral pharyngeal wall collapse.
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Nandalike K, Arens R. Ventilator Support in Children with Obstructive Sleep Apnea Syndrome. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Donovan LM, Boeder S, Malhotra A, Patel SR. New developments in the use of positive airway pressure for obstructive sleep apnea. J Thorac Dis 2015; 7:1323-42. [PMID: 26380760 DOI: 10.3978/j.issn.2072-1439.2015.07.30] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/03/2015] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea (OSA) is a disorder which afflicts a large number of individuals around the world. OSA causes sleepiness and is a major cardiovascular risk factor. Since its inception in the early 1980's, continuous positive airway pressure (CPAP) has emerged as the major treatment of OSA, and it has been shown to improve sleepiness, hypertension, and a number of cardiovascular indices. Despite its successes, adherence with treatment remains a major limitation. Herein we will review the evidence behind the use of positive airway pressure (PAP) therapy, its various modes, and the methods employed to improve adherence. We will also discuss the future of PAP therapy in OSA and personalization of care.
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Affiliation(s)
- Lucas M Donovan
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Schafer Boeder
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Atul Malhotra
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjay R Patel
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA ; 2 Department of Medicine, 3 Department of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA ; 4 Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Joosten SA, Edwards BA, Wellman A, Turton A, Skuza EM, Berger PJ, Hamilton GS. The Effect of Body Position on Physiological Factors that Contribute to Obstructive Sleep Apnea. Sleep 2015; 38:1469-78. [PMID: 25761982 DOI: 10.5665/sleep.4992] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/31/2015] [Indexed: 01/21/2023] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) resolves in lateral sleep in 20% of patients. However, the effect of lateral positioning on factors contributing to OSA has not been studied. We aimed to measure the effect of lateral positioning on the key pathophysiological contributors to OSA including lung volume, passive airway anatomy/collapsibility, the ability of the airway to stiffen and dilate, ventilatory control instability (loop gain), and arousal threshold. DESIGN Non-randomized single arm observational study. SETTING Sleep laboratory. PATIENTS/PARTICIPANTS 20 (15M, 5F) continuous positive airway pressure (CPAP)-treated severe OSA patients. INTERVENTIONS Supine vs. lateral position. MEASUREMENTS CPAP dial-downs performed during sleep to measure: (i) Veupnea: asleep ventilatory requirement, (ii) passive V0: ventilation off CPAP when airway dilator muscles are quiescent, (iii) Varousal: ventilation at which respiratory arousals occur, (iv) active V0: ventilation off CPAP when airway dilator muscles are activated during sleep, (v) loop gain: the ratio of the ventilatory drive response to a disturbance in ventilation, (vi) arousal threshold: level of ventilatory drive which leads to arousal, (vii) upper airway gain (UAG): ability of airway muscles to restore ventilation in response to increases in ventilatory drive, and (viii) pharyngeal critical closing pressure (Pcrit). Awake functional residual capacity (FRC) was also recorded. RESULTS Lateral positioning significantly increased passive V0 (0.33 ± 0.76L/min vs. 3.56 ± 2.94L/min, P < 0.001), active V0 (1.10 ± 1.97L/min vs. 4.71 ± 3.08L/min, P < 0.001), and FRC (1.31 ± 0.56 L vs. 1.42 ± 0.62 L, P = 0.046), and significantly decreased Pcrit (2.02 ± 2.55 cm H2O vs. -1.92 ± 3.87 cm H2O, P < 0.001). Loop gain, arousal threshold, Varousal, and UAG were not significantly altered. CONCLUSIONS Lateral positioning significantly improves passive airway anatomy/collapsibility (passive V0, pharyngeal critical closing pressure), the ability of the airway to stiffen and dilate (active V0), and the awake functional residual capacity without improving loop gain or arousal threshold.
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Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia.,Ritchie Centre, Monash Institute of Medical Research/Prince Henry Institute, Monash University, Clayton, Victoria, Australia
| | - Bradley A Edwards
- Division of Sleep Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anthony Turton
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia
| | - Elizabeth M Skuza
- Ritchie Centre, Monash Institute of Medical Research/Prince Henry Institute, Monash University, Clayton, Victoria, Australia
| | - Philip J Berger
- Ritchie Centre, Monash Institute of Medical Research/Prince Henry Institute, Monash University, Clayton, Victoria, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Health, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
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Barbed Roman blinds technique for the treatment of obstructive sleep apnea: how we do it? Eur Arch Otorhinolaryngol 2015; 273:517-23. [PMID: 26194006 DOI: 10.1007/s00405-015-3726-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
Abstract
Retro-palatal obstruction is often involved in the pathogenesis of obstructive sleep apnea syndrome (OSAS), which is currently treated by means of various surgical procedures. The aim of this paper is to describe our preliminary results using a new, minimally invasive and non-resective procedure called the "barbed Roman blinds technique" (BRBT), which was used to treat severe OSAS due to retro-palatal obstruction. The apnea-hypopnea index (AHI), time with <90 % O2 saturation, and Epworth Sleepiness Scale (ESS) of 32 consecutive adult outpatients (mean age 47.3 ± 8.6 years) were compared before and after surgery. The tolerability of the procedure was assessed using a 0-10 visual analog scale (VAS). All of the treated patients experienced a clinical and subjective improvement as documented by the significant differences (P < 0.001) in their pre- and post-BRBT AHI, time with <90 % O2 saturation, and ESS scores. There were no minor or major adverse events, and the good tolerability of the procedure was documented by the short mean hospital stay (1.2 ± 0.5 days) and the mean VAS value of 4.3 ± 0.7. The mean follow-up period was 12.2 ± 2.0 months. The preliminary results indicate that the BRBT is safe and effective, but long-term follow-up and comparative studies of larger case series are needed to confirm these encouraging findings.
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Joosten SA, Sands SA, Edwards BA, Hamza K, Turton A, Lau KK, Crossett M, Berger PJ, Hamilton GS. Evaluation of the role of lung volume and airway size and shape in supine-predominant obstructive sleep apnoea patients. Respirology 2015; 20:819-27. [DOI: 10.1111/resp.12549] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/06/2015] [Accepted: 02/16/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Simon A. Joosten
- Monash Lung and Sleep; Monash Health; Monash Medical Centre; Melbourne Australia
- Ritchie Centre; Monash Institute of Medical Research; Monash University; Melbourne Australia
| | - Scott A. Sands
- Division of Sleep Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts USA
| | - Bradley A. Edwards
- Division of Sleep Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts USA
- Department of Physiology and School of Psychological Sciences; Monash University; Melbourne Australia
| | - Kais Hamza
- School of Mathematical Sciences; Monash University; Melbourne Australia
| | - Anthony Turton
- Monash Lung and Sleep; Monash Health; Monash Medical Centre; Melbourne Australia
| | - Kenneth K. Lau
- Department of Diagnostic Imaging; Monash Health; Melbourne Australia
| | - Marcus Crossett
- Department of Diagnostic Imaging; Monash Health; Melbourne Australia
| | - Philip J. Berger
- Ritchie Centre; Monash Institute of Medical Research; Monash University; Melbourne Australia
| | - Garun S. Hamilton
- Monash Lung and Sleep; Monash Health; Monash Medical Centre; Melbourne Australia
- School of Clinical Sciences; Monash University; Melbourne Australia
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Kairaitis K, Foster S, Amatoury J, Verma M, Wheatley JR, Amis TC. Pharyngeal mucosal wall folds in subjects with obstructive sleep apnea. J Appl Physiol (1985) 2015; 118:707-15. [PMID: 25635002 DOI: 10.1152/japplphysiol.00691.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Mechanical processes underlying pharyngeal closure have not been examined. We hypothesized that the pharyngeal mucosal surface would fold during closure, and lowering the upper airway lining liquid surface tension would unfold areas of mucosal apposition, i.e., folds. We compared baseline pharyngeal fold numbers and response to reduction in upper airway liquid surface tension in healthy and obstructive sleep apnea (OSA) subjects. Awake, gated magnetic resonance pharyngeal airway images of 10 healthy and 11 OSA subjects were acquired before and after exogenous surfactant administration (beractant). Upper airway liquid surface tension was measured at the beginning and end of image acquisition and averaged. Velopharyngeal and oropharyngeal images were segmented and analyzed separately for average cross-sectional area, circumference, and fold number. Compared with healthy subjects, at baseline, velopharynx for OSA subjects had a smaller cross-sectional area (98.3 ± 32.5 mm(2) healthy, 52.3 ± 23.6 mm(2) OSA) and circumference (46.5 ± 8.1 mm healthy, 30.8 ± 6.1 mm OSA; both P < 0.05, unpaired t-test), and fewer folds (4.9 ± 1.6 healthy, 3.1 ± 1.8 OSA, P < 0.03). There were no differences in oropharynx for cross-sectional area, circumference, or folds. Reduction in upper airway liquid surface tension from 61.3 ± 1.2 to 55.3 ± 1.5 mN/m (P < 0.0001) did not change cross-sectional area or circumference for velopharynx or oropharynx in either group; however, in OSA subjects, oropharyngeal folds fell from 6.8 ± 3.1 to 4.7 ± 1.2 (n = 8, P < 0.05), and velopharyngeal folds from 3.3 ± 1.9 to 2.3 ± 1.2 (P = 0.08), and were unchanged in healthy subjects. Subjects with OSA have fewer velopharyngeal wall folds, which decrease further when surface tension falls. We speculate that reduced pharyngeal wall folds contribute to an increase in pharyngeal collapsibility.
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Affiliation(s)
- Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Sheryl Foster
- Department of Radiology, Westmead Hospital, Westmead, New South Wales, Australia; and University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Jason Amatoury
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Manisha Verma
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia
| | - John R Wheatley
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
| | - Terence C Amis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, Westmead, New South Wales, Australia; University of Sydney at Westmead Hospital, Westmead, New South Wales, Australia
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Vroegop AVMT, Smithuis JW, Benoist LBL, Vanderveken OM, de Vries N. CPAP washout prior to reevaluation polysomnography: a sleep surgeon's perspective. Sleep Breath 2014; 19:433-9. [PMID: 25487311 DOI: 10.1007/s11325-014-1086-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/26/2014] [Accepted: 11/11/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is characterized by repetitive upper airway collapse during sleep, leading to decreased oxygen blood levels and arousal from sleep. The gold standard treatment option for moderate to severe OSA is considered continuous positive airway pressure (CPAP). In case primary treatment with CPAP fails, a reevaluation of disease severity [by means of the apnea/hypopnea-index (AHI)] can be required. A subset of patients that prefer a CPAP alternative is still using CPAP until the reevaluation polysomnography (PSG), and a so-called washout effect is not ruled out. The purpose of this study is to evaluate the evidence on the existence and duration of this washout effect and its clinical relevance for current practice. METHODS To identify papers for this review, an extensive literature search was run electronically through MEDLINE and EMBASE databases. RESULTS An overview of currently available literature on this washout effect and the findings of 13 studies on this topic are discussed. CONCLUSION There is some evidence that CPAP washout exists in patients with a stable BMI throughout the follow-up period. However, the intensity and duration of this effect remains unclear. Within the limitations of the present study, it seems reasonable to maintain a washout period of 1 week, in case alternative treatments options are considered and especially when a baseline PSG (and subsequent repeat PSG after treatment) is needed in case of clinical trials.
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Affiliation(s)
- Anneclaire V M T Vroegop
- Department of ENT, Head and Neck Surgery, Saint Lucas Andreas Hospital, Jan Tooropstraat 164, 1061 AE, Amsterdam, The Netherlands,
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Chi L, Comyn FL, Keenan BT, Cater J, Maislin G, Pack AI, Schwab RJ. Heritability of craniofacial structures in normal subjects and patients with sleep apnea. Sleep 2014; 37:1689-98. [PMID: 25197806 PMCID: PMC4173925 DOI: 10.5665/sleep.4082] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/17/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Accumulating evidence has shown that there is a genetic contribution to obstructive sleep apnea (OSA).The objectives were to use magnetic resonance imaging (MRI) cephalometry to (1) confirm heritability of craniofacial risk factors for OSA previously shown by cephalometrics; and (2) examine the heritability of new craniofacial structures that are measurable with MRI. DESIGN A sib pair "quad" design examining apneics, apneic siblings, controls, and control siblings. The study design used exact matching on ethnicity and sex, frequency matching on age, and statistical control for differences in age, sex, ethnicity, height, and weight. SETTING Academic medical center. PATIENTS We examined 55 apneic probands (apnea-hypopnea index [AHI]: 46.8 ± 33.5 events/h), 55 proband siblings (AHI: 11.1 ± 15.9 events/h), 55 controls (AHI: 2.2 ± 1.7 events/h), and 55 control siblings (AHI: 4.1 ± 4.0 events/h). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Five independent domains reflecting different aspects of the craniofacial structure were examined. We confirmed heritability of sella-nasion-subspinale (38%, P = 0.002), saddle angle (55%, P < 0.0001), mandibular length (24%, P = 0.02) and lower facial height (33%, P = 0.006) previously measured by cephalometry. In addition, the current study added new insights by demonstrating significant heritability of mandibular width (30%, P = 0.005), maxillary width (47%, P < 0.0001), distance from the hyoid bone to the retropogonion (36%, P = 0.0018) and size of the oropharyngeal space (31%, P = 0.004). Finally, our data indicate that heritability of the craniofacial structures is similar in normal patients and those with apnea. CONCLUSIONS The data support our a priori hypothesis that the craniofacial structures that have been associated with obstructive sleep apnea (OSA) are heritable. We have demonstrated heritability for several intermediate craniofacial phenotypes for OSA. Thus, we believe that future studies should be able to identify genes associated with these intermediate craniofacial phenotypes.
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Affiliation(s)
- Luqi Chi
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Francois-Louis Comyn
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Brendan T. Keenan
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jacqueline Cater
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Greg Maislin
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Allan I. Pack
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Richard J. Schwab
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine, Philadelphia, PA
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Osadnik CR, McDonald CF, Holland AE. Advances in airway clearance technologies for chronic obstructive pulmonary disease. Expert Rev Respir Med 2014; 7:673-85. [PMID: 24224510 DOI: 10.1586/17476348.2013.847368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Techniques to promote clearance of sputum from the airways (airway clearance techniques; ACTs) have existed in clinical practice for more than a century. This review examines current evidence and clinical recommendations regarding ACTs for individuals with chronic obstructive pulmonary disease. Comparisons between this literature and reports of current practice suggest that discrepancies may exist in relation to the clinical management of sputum in individuals with COPD. The novel application of newer technologies has enhanced our ability to assess the complex physiological processes underpinning airway clearance therapy. The potential for physiologically tailored ACT prescription may, however, depend on the capacity for translation of such technology from the research setting into the clinical environment. Future directions regarding this common form of therapy will be discussed, including identification of the key research priorities to optimize evidence-based practice in this area.
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Abstract
OSA (obstructive sleep apnoea), the most common respiratory disorder of sleep, is caused by the loss of upper airway dilating muscle activity during sleep superimposed on a narrow upper airway. This results in recurrent nocturnal asphyxia. Termination of these events usually requires arousal from sleep and results in sleep fragmentation and hypoxaemia, which leads to poor quality sleep, excessive daytime sleepiness, reduced quality of life and numerous other serious health consequences. Furthermore, patients with untreated sleep apnoea are at an increased risk of hypertension, stroke, heart failure and atrial fibrillation. Although there are many predisposing risk factors for OSA, including male gender, endocrine disorders, use of muscle relaxants, smoking, fluid retention and increased age, the strongest risk factor is obesity. The aim of the present review is to focus on three cutting-edge topics with respect to OSA. The section on animal models covers various strategies used to simulate the physiology or the effects of OSA in animals, and how these have helped to understand some of the underlying mechanisms of OSA. The section on diabetes discusses current evidence in both humans and animal models demonstrating that intermittent hypoxia and sleep fragmentation has a negative impact on glucose tolerance. Finally, the section on cardiovascular biomarkers reviews the evidence supporting the use of these biomarkers to both measure some of the negative consequences of OSA, as well as the potential benefits of OSA therapies.
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Hsieh YJ, Liao YF, Chen NH, Chen YR. Changes in the calibre of the upper airway and the surrounding structures after maxillomandibular advancement for obstructive sleep apnoea. Br J Oral Maxillofac Surg 2014; 52:445-51. [PMID: 24629456 DOI: 10.1016/j.bjoms.2014.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 02/07/2014] [Indexed: 11/27/2022]
Abstract
Maxillomandibular advancement (MMA) is effective in the treatment of obstructive sleep apnoea. We aimed to assess changes in the calibre of the upper airway, facial skeleton, and surrounding structural position after MMA and their association with improvement in symptoms. Sixteen consecutive adults with moderate-to-severe apnoea were treated by primary MMA. Polysomnography and computed tomography (CT) of the head and neck were done before and at least 6 months after MMA. The calibre of the upper airway, the facial skeleton, and the surrounding structures were measured with image analysis software. After MMA, patients had a significant reduction in their apnoea-hypopnoea index (31.2 (18.8)number of events (n)/hour (h)). The mean (SD) volume of the airway increased significantly in the velopharynx (p<0.01), oropharynx (p=0.001), and hypopharynx (p<0.001) (by 2.3 (2.4), 2.1 (2.6), and 1.7 (1.1)cm(3), respectively) and the length of the airway was significantly decreased (by 3.1 (3.5)mm p<0.01). The soft palate (p<0.001), tongue (p<0.001), and hyoid (p=0.001) moved significantly anteriorly (by 4.4 (2.0), 7.5 (2.8), and 5.7 (5.0)mm, respectively), and these movements were related to the MMA (r=0.6-0.8). The improvement in the apnoea-hypopnoea index was associated with both maxillary advancement and anterior movements of the soft palate and hyoid (r=0.6-0.7). The results of this study suggest that MMA increases the volume in the upper airway and reduces its length. Improvement in obstructive sleep apnoea is associated with the extent of the anterior movements of the maxilla, soft palate, and hyoid.
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Affiliation(s)
- Yuh-Jia Hsieh
- Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Fang Liao
- Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ning-Hung Chen
- Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Ray Chen
- Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
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Ito E, Tsuiki S, Namba K, Takise Y, Inoue Y. Upper airway anatomical balance contributes to optimal continuous positive airway pressure for Japanese patients with obstructive sleep apnea syndrome. J Clin Sleep Med 2014; 10:137-42. [PMID: 24532996 PMCID: PMC3899315 DOI: 10.5664/jcsm.3438] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The aim of this study was to examine whether the upper airway anatomical balance, as reflected by tongue size relative to maxillomandibular size, is related to optimal nasal continuous positive airway pressure (PnCPAP). METHODS Sixty-six male Japanese obstructive sleep apnea syndrome (OSAS) patients (median apnea-hypopnea index [AHI] = 33.9 episodes/h [10th/90th percentile = 19.5/59.9], median body mass index [BMI] = 25.1 kg/m(2) [10th/90th percentile = 21.2/30.4]) were recruited. All patients underwent standard polysomnography (PSG), and PnCPAP was determined by nasal continuous positive airway pressure (nCPAP) titration. The anatomical balance was defined as the tongue area (TG) divided by the lower face cage (LFC) measured on cephalometry. A predictive equation of PnCPAP was created using demographic, polysomnographic, and cephalometric variables. RESULTS Significant correlations were found between PnCPAP and descriptive variables, including BMI, AHI, lowest SpO2, distance from the anterosuperior point of the hyoid bone to the mandibular plane (MP-H), and TG/LFC. Stepwise multiple regression analysis revealed that AHI and TG/LFC were independent predictors of PnCPAP. The predictive equation was: PnCPAP = 1.000 + 0.043 × AHI + 9.699 × TG / LFC, which accounted for 28.0% of the total variance in PnCPAP (R(2) = 0.280, p < 0.01). CONCLUSIONS Anatomical balance of upper airway in addition to the severity of OSAS is an important contributing factor for PnCPAP in Japanese OSAS patients.
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Affiliation(s)
- Eiki Ito
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Yoyogi Sleep Disorder Center, Tokyo, Japan
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Satoru Tsuiki
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Yoyogi Sleep Disorder Center, Tokyo, Japan
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | | | | | - Yuichi Inoue
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Yoyogi Sleep Disorder Center, Tokyo, Japan
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
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Ha JG, Min HJ, Ahn SH, Kim CH, Yoon JH, Lee JG, Cho HJ. The dimension of hyoid bone is independently associated with the severity of obstructive sleep apnea. PLoS One 2013; 8:e81590. [PMID: 24312562 PMCID: PMC3846888 DOI: 10.1371/journal.pone.0081590] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction We hypothesized that the size of the hyoid bone itself may affect the severity of sleep apnea. The aim of this study was to identify the relationship between hyoid bone dimensions and the severity of sleep apnea using computerized tomography (CT) axial images. Methods We retrospectively measured the hyoid bone in axial images of neck CTs and correlated these measurements with results of polysomnography in a total of 106 male patients. The new hyoid bone parameters studied in this study were as follows: distance between bilateral lesser horns (LH-d), distance between bilateral greater horns (GH-d), distance from the most anterior end of the hyoid arch to GH-d (AP), distance from the greater to the lesser horn on right and left sides (GH-LH), and the anterior angle between bilateral extensive lines from the greater to the lesser horn (H-angle). Data was analyzed using univariate and multivariate logistic regression, and Pearson correlation tests. Results We found a significant inverse correlation between the apnea-hypopnea index (AHI) and GH-d or AP. Neither the LH-d, GH-LH, nor H-angle were associated with the AHI. The patient group that met the criteria of both GH-d<45.4 and AP<33.4 demonstrated the most severe AHI. Conclusion The lateral width or antero-posterior length of hyoid bone was associated with AHI and predicted the severity of sleep apnea in male patients. This finding supports the role of expansion hyoidplasty for treatment of sleep apnea. Pre-operative consideration of these parameters may improve surgical outcomes in male patients with sleep apnea.
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Affiliation(s)
- Jong Gyun Ha
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jin Min
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyeon Ahn
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Hoon Kim
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Airway Mucus Istitute, Yonsei University College of Medicine, Seoul, Korea
| | - Joo-Heon Yoon
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Airway Mucus Istitute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeung-Gweon Lee
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung-Ju Cho
- Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Airway Mucus Istitute, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
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Abstract
Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive collapse of the pharyngeal airway during sleep. Control of pharyngeal patency is a complex process relating primarily to basic anatomy and the activity of many pharyngeal dilator muscles. The control of these muscles is regulated by a number of processes including respiratory drive, negative pressure reflexes, and state (sleep) effects. In general, patients with OSA have an anatomically small airway the patency of which is maintained during wakefulness by reflex-driven augmented dilator muscle activation. At sleep onset, muscle activity falls, thereby compromising the upper airway. However, recent data suggest that the mechanism of OSA differs substantially among patients, with variable contributions from several physiologic characteristics including, among others: level of upper airway dilator muscle activation required to open the airway, increase in chemical drive required to recruit the pharyngeal muscles, chemical control loop gain, and arousal threshold. Thus, the cause of sleep apnea likely varies substantially between patients. Other physiologic mechanisms likely contributing to OSA pathogenesis include falling lung volume during sleep, shifts in blood volume from peripheral tissues to the neck, and airway edema. Apnea severity may progress over time, likely due to weight gain, muscle/nerve injury, aging effects on airway anatomy/collapsibility, and changes in ventilatory control stability.
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Affiliation(s)
- David P White
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA.
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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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