European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea

Treatment of obstructive sleep apnea syndrome (OSAS) with mandibular advancement devices-A statement of the Portuguese Society of Pulmonology, the Portuguese Society of Stomatology and Dental Medicine, the Portuguese Dental Association, and the Portuguese Society of Temporomandibular Disorders, Orofacial Pain and Sleep

With the purpose of establishing a consensus around clinical orientations for professionals involved in managing patients with sleep breathing disorders (SBD), an interdisciplinary group of scientific societies involved in this field discussed and reviewed all the published international guidelines from the American Dental Association, American Academy of Sleep Medicine, American Academy of Dental Sleep Medicine and the European counterparts. Treatment of SBD is multidisciplinary and should be made in concert with the patient, the sleep physician, and the qualified dentist to solve the individual, social, and economic burden of the disease. This consensus document represents the current thinking of a team of Portuguese experts on managing patients with SBD based on the available evidence.

Obesity and sleep disorders: A bidirectional relationship

AIMS

Obesity and sleep disorders are highly prevalent conditions with profound implications for public health. Emerging evidence highlights a bidirectional relationship between these two conditions, with each exacerbating the other in a complex interplay of behavioral, physiological, and hormonal mechanisms. Sleep deprivation and poor sleep quality contribute to energy imbalance through dysregulation of appetite hormones (e.g., leptin and ghrelin), increased caloric intake, and reduced physical activity. Conversely, sleep disorders such as obstructive sleep apnea syndrome (OSAS), insomnia, and restless leg syndrome (RLS) are significantly more common in individuals with obesity.

DATA SYNTHESIS

This review explores the pathophysiological mechanisms underlying this relationship, including the roles of inflammation, autonomic dysregulation, and neuroendocrine pathways. Sleep loss exacerbates metabolic syndrome components, including insulin resistance and dyslipidemia, further perpetuating weight gain. Similarly, obesity-induced sleep disorders lead to pro-inflammatory states, vascular dysfunction, and sympathetic overactivation, compounding cardiometabolic risks. Specific conditions like OSA and RLS are examined as models of this interdependence, emphasizing their shared pathways and clinical implications.

CONCLUSIONS

The bidirectional link between obesity and sleep disorders underscores the importance of integrating sleep assessment and management into obesity treatment strategies. Addressing this relationship could mitigate the progression of cardiometabolic comorbidities and improve overall health outcomes. Moreover, the intertwined dynamics between obesity, sleep disorders, and mental health-mediated by inflammatory pathways, hormonal dysregulation, and neurobehavioral factors-highlight the critical need for integrated treatment approaches targeting physical, psychological, and sleep-related dimensions to enhance health and quality of life.

Robotic beds for the treatment of positional obstructive sleep apnea - A randomized cross-over pilot trial

BACKGROUND

Interventions leading to avoidance of supine position and thus reducing the likelihood of upper airway collapse during sleep are a treatment approach for positional obstructive sleep apnea (POSA). The aim of this randomized cross-over trial was to assess the effect of two actuated beds (trunk-elevation and sideward-tilting) on OSA severity and sleep fragmentation in POSA.

METHODS

After baseline polysomnography, adult patients with POSA were randomly assigned to two nights of intervention in the intelligent sleep apnea bed ISABel1 and ISABel2. In the case of obstructive apnea or hypopnea, ISABel1 elevated the upper body by 50° and ISABel2 induced a unilateral bed tilt of 40°, with both interventions lasting 10 min. Sustained trunk elevations without sliding down (ISABel1) and position change from supine to non-supine (ISABel2) were defined as successful interventions.

RESULTS

Six adult men (57 ± 11 years, BMI 28 ± 4 kg/m2, AHI 39 ± 15/h) with POSA were included. Neither trunk elevation (ISABel1) nor side tilt (ISABel2) - approximately 10 interventions per night - significantly reduced apnea-hypopnea index (AHI), whereas trunk elevation showed a tendency to reduce supine AHI. Actuated beds had no effect on sleep efficiency and arousals. Only 13 % of side tilts in ISABel2 resulted in a successful shift to a non-supine position. The time to the next respiratory event after bed movement was longer in the trunk elevating bed than in the side-tilting bed.

CONCLUSION

Trunk elevating beds decrease supine AHI and both side-tilting and trunk elevating beds increase the time to the next obstructive apnea or hypopnea.

Estimating the costs and analysing the precision of several diagnostic and treatment approaches for obstructive sleep apnea patients in the Netherlands, using timed automata modelling

Obstructive Sleep Apnea (OSA) is a (highly) prevalent medical condition, linked to severe negative health consequences. In the Netherlands, diagnosis of OSA presently has long waiting times and both diagnosis and treatment have high costs. This article introduces a so-called timed automata model (UPPAAL tool) for analysing diagnostic and treatment approaches for OSA. This model is used for assessing the Dutch current traditional approach, as well as multiple alternative approaches for OSA diagnosis and treatment. The analysis shows that one alternative approach can lower the costs and waiting lists, while maintaining diagnostic precision. In this manuscript the best alternative approach is a combination of Oxygen Desaturation Index (ODI) measurement obtained by nocturnal pulse oximetry and a questionnaire to diagnose the patient. Of course, it is important that, although timed automata modelling is a reliable tool, these outcomes are meant to start a discussion regarding the above-mentioned problems and are not proven outcomes yet. The healthcare system in the Netherlands is in danger of becoming unaffordable. Therefore, this initial exploration has been carried out to see whether alternatives to the current OSA-care can be devised.

The impact of acetazolamide and dronabinol on the physiological endotypes responsible for obstructive sleep apnea

STUDY OBJECTIVES

To investigate the effect of differing doses of the combination of acetazolamide and dronabinol (Aceta-Dro) on the obstructive sleep apnea (OSA) endotypes and their relationship to OSA severity.

METHODS

We retrospectively analysed data from a double-blind, randomized, placebo-controlled trial of 3 different doses of Aceta-Dro [Low(125mg/2.5 mg), Medium(250mg/5 mg), High(500mg/10 mg)] in OSA patients. OSA endotypes (collapsibility [VPASSIVE], Loop gain [LG], Arousal threshold [ArTH], and muscle compensation [VCOMP]) were extracted from polysomnography signals using validated algorithms. Linear mixed models were employed to assess the impact of treatment condition on the endotypes. Linear regressions assessed the relationship between the changes in endotypes vs. apnea-hypopnea index (AHI) and to predict treatment response from baseline endotypes.

RESULTS

Relative to placebo, Aceta-Dro dose-dependently reduced LG by 11 % (p = 0.18), 18.5 % (p = 0.022) and 20.5 % (p = 0.016). The reduction in LG was associated with a decrease in AHI in only the high dose condition (R2 = 0.78, p = 0.004). Aceta-Dro improved VPASSIVE in the low dose condition (+13 %, p = 0.005) only, which was strongly associated with AHI reduction (R2 = 0.71, p = 0.005). Aceta-Dro had no impact on VCOMP or ArTH. A higher baseline LG predicted treatment response in the high dose (R2 = 0.56, p = 0.03), with a similar trend observed in the low dose group. More severe collapsibility (lower VPASSIVE) predicted treatment response to both low (R2 = 0.46, p = 0.07) and medium dose (R2 = 0.50, p = 0.03) conditions.

CONCLUSIONS

Mechanistically, our findings suggest that medium and high doses of Aceta-Dro primarily reduce OSA severity by lowering loop gain, while the efficacy of the low dose was due to improved airway collapsibility.

The Association Between Craniofacial Morphological Parameters and the Severity of Obstructive Sleep Apnea: A Multivariate Analysis Using the Apnea-Hypopnea Index and Nocturnal Oxygen Desaturation

Background: Obstructive sleep apnea (OSA) is characterized by repetitive complete or partial closure of the upper airway during sleep, which is a potentially life-threatening disorder. A cephalogram is a simple and effective examination to predict the risk of OSA in orthodontic clinical practice. This study aims to analyze the relationship between craniofacial characteristics and the severity of OSA using polysomnography and cephalogram data. Gender differences in these parameters are also investigated. Methods: This study included 112 patients who underwent a complete clinical examination, standard polysomnography study, and cephalometric analysis to diagnose obstructive sleep apnea. This study divided the participants into male and female groups to study the correlation between cephalometric parameters and the severity of OSA. The analysis involved 39 cephalometric parameters. The severity of obstructive sleep apnea was evaluated by the apnea-hypopnea index (AHI) and the lowest nocturnal oxygen saturation (LSaO2). Results: The final assessment included 112 adult participants (male/female = 67:45, mean age: 28.4 ± 7.29 years, mean male age: 28.8 ± 7.62 years, mean female age: 27.8 ± 6.79 years). Multivariate analysis revealed that the mandibular position, incisor inclination, facial height, and maxillary first molar position were strongly associated with OSA severity. Gender-specific differences in cephalometric predictors were identified, with distinct parameters correlating with the AHI and LSaO2 in males and females. Notably, the LSaO2 demonstrated stronger associations with craniofacial morphology in females than males. Conclusions: Cephalometric analysis can be effective in assessing the risk and severity of OSA based on the correlation between cephalometric parameters and the AHI/LSaO2. There is a clear difference between the cephalometric parameters associated with OSA severity in male and female individuals. This gender-dependent pattern may assist the personalized diagnosis and management of OSA in clinical practice.

Splintless maxillomandibular advancement for edentulous sleep apnoea patients: surgical accuracy and efficacy

The primary aim of this study was to assess the accuracy and predictability of a splintless treatment protocol for edentulous patients with moderate to severe obstructive sleep apnoea (OSA) undergoing maxillomandibular advancement (MMA). Ten consecutive edentulous patients treated with MMA were enrolled in this retrospective study. All cases were virtually planned, followed by computer-aided design of individual osteotomy cutting guides and patient-specific implants. For the maxilla, the mean discrepancy between the planned and achieved right to left, posterior to anterior, and cranial to caudal translations was 0.3 ± 0.2 mm, 1.0 ± 0.6 mm, and 0.8 ± 0.6 mm, respectively. There was a mean discrepancy of 0.5° ± 0.5°, 2.5° ± 2.0°, and 0.3° ± 0.4° for roll, pitch, and yaw of the maxilla, respectively. The mean discrepancy of the mandible osteotomy gap was 1.2 ± 1.0 mm on the right side and 0.8 ± 0.5 mm on the left. Surgical success was achieved in nine patients, one of whom met the criteria for surgical cure. On average, the apnoea-hypopnea index was reduced by 72%. The results of this study indicate that the splintless treatment protocol for MMA applied in edentulous OSA patients is highly accurate, predictable, and effective in the treatment of OSA.

Understanding the clinical management of co-occurring sleep-related bruxism and obstructive sleep apnea in adults: A narrative and critical review

Sleep-related bruxism (SRB) is a motor oral behavior characterized by tooth grinding and jaw clenching activity, reported by 8%-12% of the adult general population and 3% of older individuals. The frequency of one of its biomarkers, rhythmic masticatory muscle activity (RMMA), remains elevated across ages. Obstructive sleep apnea (OSA) is associated with the brief and repetitive pause of breathing (apnea) and with transient reduction in oxygen (hypoxia). OSA is observed at all ages and in about 50% of older individuals with a male preponderance. SRB clinical assessment is based on self-reporting of tooth grinding sound, awareness of clenching, jaw pain or headache, and clinical observation of tooth damage. OSA clinical assessment is based on sleepiness and fatigue, snoring, sleep quality, and awareness of breathing cessation, plus clinical examination of anatomical factors (e.g., obesity, retrognathia, large tonsil, macroglossia), age, gender, and body mass. Although the literature does not support association or causality between these two conditions, the co-occurrence is reported in about 30%-50% of adults. To confirm a diagnosis of co-occurring SRB and OSA, home sleep testing (HST) may be indicated. A sleep test is performed using electromyography (EMG) of jaw muscle (masseter or temporalis) and cardio-respiratory variables (e.g., air flow, respiratory effort, oxygen level, heart rate). The management of co-occurring SRB and OSA for individuals with prosthodontic needs is challenging to prevent compromising the oro-pharyngeal space and breathing efficiency. OSA treatment in the presence of SRB includes continuous positive airway pressure (CPAP) use alone or with an occlusal splint or mandibular advancement device (MAD). In addition, the following may be considered: supine sleep correction device, myofuncional therapy, medications, and surgeries. All have limitations and risks. Individual variability suggests that phenotyping is mandatory to select the most efficient and personalized treatment.

Continuous positive airway pressure and mandibular advancement splints: the CHOICE multicentre, open-label randomised clinical trial

BACKGROUND

Adherence to continuous positive airway pressure (CPAP) for obstructive sleep apnoea (OSA) continues to be low with high termination rates. Alternative therapies to CPAP are needed. Our objective was to compare objective adherence to CPAP and mandibular advancement splints (MAS) and to evaluate their effectiveness, and additionally to identify treatment usage patterns and the clinical effectiveness of having both therapies.

METHODS

This multicentre, double-randomised, three-phase trial (titration/crossover/observation) was conducted at three Canadian universities. Eligible participants were treatment-naïve with mild-to-severe OSA. The primary outcome was objectively measured adherence (hours per night) during the crossover phase. Secondary outcomes included efficacy during the crossover phase; adherence during the observational phase; and patient-centred outcomes, blood pressure and side-effects during the crossover and observational phases. Duration of the crossover and observational phase was 2.5 and 6 months, respectively.

RESULTS

81 participants were enrolled in the first randomisation. 79 entered the adaptation/titration phase (mean±sd age 52.3±10.8 years; 58 males), 73 entered the crossover phase (included in the intention-to-treat analysis) and 64 completed the observational phase. Mean objective adherence over 1 month: MAS showed higher adherence than CPAP, 6.0 versus 5.3 h·night-1 (difference 0.7 (95% CI 0.3-1.2) h·night-1; p<0.001). Mean CPAP-MAS difference in efficacy: 10.4 (95% CI 7.8-13.0) events·h-1; p<0.001. During the observational phase 55% (35 out of 64) of participants chose to alternate therapies. All treatments led to substantial improvement in patient-centred outcomes.

CONCLUSIONS

Despite the higher efficacy of CPAP and higher adherence to MAS, both demonstrate comparable clinical effectiveness on patient-centred outcomes. Having both CPAP and MAS can improve long-term management of OSA.

The influence of atmospheric temperature on long-term CPAP-usage in patients with obstructive sleep apnea

BACKGROUND

Although seasonal variations in CPAP-usage are often attributed to changes in temperature, no real-world study has evaluated the influence of temperature on long-term CPAP-usage.

METHODS

The TempCPAP study is a retrospective real-life cohort study. Adult patients newly treated and undergoing at least 1 month of CPAP were included. Daily 12-PM temperature data from the nearest weather station was assigned to each patient and CPAP-usage was collected using telemonitoring data. The primary objective of the study was to investigate the relationship between temperature and CPAP-usage.

RESULTS

8151 patients (37.2 % women) with a median age of 61 (IQ25-75: 51-71) years, initial AHI of 36 (29-49.6) events/h, treated for a median duration of 1.6 years (0.7-3.0), and with a CPAP-usage of 5.4 (3.0-6.9) h/day were included. The relationship between CPAP-usage and temperature was non-linear. The best model found two breakpoints at 18 °C and 29 °C. CPAP-usage dropped drastically when the temperature exceeded 29 °C, as each 1 °C increase was associated with a 3.6-min reduction in CPAP-usage. Compared to temperatures of less than 5 °C, temperatures above 30 °C resulted in a mean reduction in CPAP-usage of 30.3 (confidence interval (CI95 %): 29.3-31.4) minutes/day, achieving the minimal clinically important difference of 30 min in 46.6 % of patients.

CONCLUSION

In patients undergoing long-term CPAP therapy, temperatures over 29 °C at 12-PM were associated with reduced CPAP-usage.

TRIAL REGISTRATION

TempCPAP is registered with health data hub (n°20475117).

Treatable Traits-Based Pharmacologic Treatment of Sleep Apnea

Obstructive sleep apnea (OSA) is a heterogeneous condition characterized by diverse endotypic traits and clinical phenotypes. A recent randomized controlled trial evaluating a glucagon-like peptide-1 receptor agonist showed promising results, potentially making it the first on-label drug treatment for OSA. Phase II/III clinical trials investigating combinations of noradrenergic and antimuscarinic agents, as well as carbonic anhydrase inhibitors, are ongoing. Future drug treatments for OSA, either as monotherapy or combined with other treatment modalities, will be personalized and based on treatable traits to address underlying mechanisms, comorbid conditions, and patient-reported outcome measures.

Added value of technician intervention to improve mask management for apneic patients treated with long-term CPAP

PURPOSE

Long-term management of sleep apnea patients treated with CPAP raises questions about the cost-effectiveness of certain resources. With the growing use of remote CPAP monitoring and patient questionnaires, the importance of direct patient supervision by technicians is being challenged. To date, no real-life study has investigated the long-term additional value of a technician in evaluating common CPAP side effects compared to patient-reported side effects.

METHODS

InterfaceVent-CPAP is a prospective real-life cross-sectional study conducted in a cohort of apneic adults treated with CPAP for at least 3 months. Three common CPAP side effects (pain, erythema, and leaks) were independently assessed by the patient and the technician on visual analogue scales and diagrams, respectively. CPAP-reported leaks were also collected. Gwet's concordance coefficient was used to analyze concordance between patient and technician assessments of CPAP side effects.

RESULTS

1484 patients (median age 67 years (IQ25-75: 60-74)) were evaluated by 32 technicians. Correlation between CPAP-reported leaks and technician-reported leaks was weak. For pain and erythema, moderate to high concordance was observed between technician and patient responses, while no concordance was found for leaks. Univariate linear regression analyses examining the effect of technician-reported areas of pain, erythema and leaks on the Epworth-Sleepiness-Scale revealed statistically significant associations between sleepiness in women and certain technician-reported areas of mask leaks and mask pain.

CONCLUSION

Direct supervision of chronic apneic patients by technicians adds value in managing mask-related issues. Long-term care should include a combination of remote CPAP monitoring, patient-reported outcomes, and technician direct supervision.

TRIAL REGISTRATION

InterfaceVent is registered with ClinicalTrials.gov (NCT03013283). First registration date is 2016-12-23.

Roles of vitamins and nutrition in obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, with a prevalence that rises alongside with the increasing prevalence of obesity. OSA is characterized by a low-inflammatory state and is followed by cardiovascular and metabolic sequelae. Continuous positive airway pressure (CPAP) represents the cornerstone of treatment for severe OSA. However, poor compliance with CPAP treatment renders OSA treatment a challenging venture. Weight loss and exercise are recommended as adjunctive treatment options for OSA. Several diets have proven to facilitate weight loss, and to alleviate the inflammatory status in patients with OSA. Moreover, several vitamins exhibit antioxidant properties that beneficially affect OSA pathology and reduce the risk of cardiovascular complications.

AREA COVERED

This narrative review aims to summarize the current knowledge regarding the effect of nutrition and vitamin deficiencies on OSA. Included were publications, relevant to the topic, with different types of design (i.e. cross-sectional studies, cohort studies, clinical trials, systematic reviews, meta-analyses, etc.) and indexed in PubMed database until 31 March 2024.

EXPERT OPINION

In addition to weight loss, other food components, such as proteins, carbohydrates, anti-inflammatory agents, vitamins A, B, C, D, E, and sodium, may play a beneficial role in the incidence and severity of OSA.

Bidirectional interplay of sleep apnea syndrome and cardio-vascular disorders in diabetes

Although often overlooked sleep apnea has emerged as a significant public health concern. Obstructive sleep apnea (OSA) and diabetes commonly co-exist with a vicious cycle worsening the incidence and severity of both conditions. OSA has many implications including cardiometabolic disorders and impaired cardiovascular (CV) prognosis. OSA combined with diabetes generates a cumulative effect on CV outcomes. The association of OSA with several comorbidities including CV disease and heart failure is bi-directional meaning that some of them are likely to contribute to OSA. In patients with diabetes, OSA treatment should be integrated in a holistic strategy of prevention of CV and microvascular complications. This article provides some clues to advance the understanding of the interplay between OSA and CV disorders in diabetes and to consider the role of some CV risk markers like cardiac autonomic neuropathy and artery stiffness and of novel metrics for hypoxic-related events in CV risk stratification, and offers a discussion on the effects of medical approaches including weight loss strategies, GLP1-receptor agonists and sodium-glucose cotransporter 2 inhibitors. It provides a guidance to improve screening and diagnosis of OSA, and adherence to OSA treatment in patients with diabetes.

Evaluating the Benefit of Home Support Provider Services for Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea: Protocol for an Ambispective International Real-World Study

BACKGROUND

Adherence and persistence to positive airway pressure (PAP) therapy are key factors for positive health outcomes. Home support providers participate in the home implementation and follow-up of PAP therapy for patients with obstructive sleep apnea (OSA). In Europe, home support provider service levels are country (or area) specific, resulting in differences in content and frequency of patient interactions. However, no robust evaluation of the impact of these differences on clinical and patient outcomes has been performed.

OBJECTIVE

The AWAIR study aims to evaluate and compare the impact of different home support provider service levels on PAP adherence and persistence in 4 European countries.

METHODS

This real-world, ambispective, cohort study-conducted in France, Belgium, Spain, and Portugal-will recruit adults with OSA who started PAP therapy between 2019 and 2023 and were followed by an Air Liquide Healthcare home support provider. Given the large number of eligible participants (around 150,000), the study will use a decentralized and digital approach. A patient video will present the study objectives and the participation process. A secure electronic solution will be used to manage patient information and consent, as well as to administer a web-based questionnaire. Retrospective data, collected during routine patient follow-up by home support providers, include the level of service and device data, notably PAP use. Prospective data collected using an electronic patient-reported outcome tool include health status, OSA-related factors, patient-reported outcomes including quality of life and symptoms, OSA and PAP literacy, patient-reported experience, and satisfaction with PAP therapy and service. Hierarchical models, adjusted for preidentified confounding factors, will be used to assess the net effect of home support provider services on PAP adherence and persistence while minimizing real-world study biases and considering the influence of country-level contextual factors. We hypothesize that higher levels of home support provider services will be positively associated with adherence and persistence to PAP therapy.

RESULTS

As of December 2024, the study has received approval in France, Portugal, and 2 regions of Spain. The study began enrollment in France in October 2024. Results are expected in the second quarter of 2025.

CONCLUSIONS

The AWAIR study has a unique design, leveraging an unprecedented number of eligible participants, decentralized technologies, and a real-world comparative methodology across multiple countries. This approach will highlight intercountry differences in terms of patient characteristics, PAP adherence, and persistence, as well as patient-reported outcomes, patient-reported experiences, and satisfaction with the home service provider. By assessing the added value of home support provider services, the results will support best practices for patient management and for decision-making by payers and authorities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/65840.

Positional obstructive sleep apnea in children prescribed continuous positive airway pressure therapy for obstructive sleep-disordered breathing

Positional obstructive sleep apnea, in which there is a ≥ 2:1 predominance of obstructive events in the supine position, is a sleep-disordered breathing phenotype with a targeted treatment in the form of positional device therapy. We sought to determine the prevalence of positional obstructive sleep apnea in a cohort of children prescribed continuous positive airway pressure therapy, ascertain risk factors for the condition, and determine the associated continuous positive airway pressure treatment adherence rate. A retrospective cohort study of all children > 2 years old from a single tertiary paediatric centre prescribed continuous positive airway pressure therapy over an 8-year period was conducted. Positional obstructive sleep apnea prevalence was established by analysing positional and respiratory event data from the participants' original diagnostic polysomnography. Continuous positive airway pressure therapy adherence was determined using data from machine download. Univariable and multivariable logistic regression modelling was used to determine participant demographic and clinical factors associated with positional obstruction. Positional obstructive sleep apnea (defined by Bignold's criteria modified for paediatric use) prevalence in the cohort of 237 analysed participants was 38%. Suboptimal continuous positive airway pressure adherence was noted in 30% of this group based on initial machine download, performed a median of 96 days post-treatment initiation. Higher age and lower obstructive apnea-hypopnea index were independent predictors of positional obstructive sleep apnea, whereas neurodevelopmental diagnosis, presence/absence of rapid eye movement-related obstructive sleep apnea, overweight/obesity status and history of adenoidectomy/adenotonsillectomy were not. For children, positional device therapy is a treatment option worthy of further consideration and research.

Polysomnographic phenotypes: predictors of treatment response in Obstructive Sleep Apnea with Mandibular Advancement devices

PURPOSE

This non-randomized clinical study aims to identify polysomnographic phenotypic characteristics that differentiate responders from non-responders to mandibular advancement devices (MAD) treatment for obstructive sleep apnea (OSA) and to establish a predictive model of treatment response for OSA using oral devices based on the set of anthropometric, demographic, and polysomnographic phenotypic characteristics.

METHODS

This study was registered under the identifier number: NCT02724865. It prospectively analyzed patients receiving MAD treatment for six years. The MADs used were two-piece adjustable appliances following a standardized protocol. Treatment response was defined according to the latest International Consensus Statement on OSA severity. The study analyzed polysomnographic phenotypes, categorizing them into positional phenotype, sleep-stage phenotype (REM/NREM-OSA), and airway collapsibility phenotype. A logistic regression model and a classification and regression tree were implemented.

RESULTS

A total of 112 patients completed the study (64 responders and 48 non-responders). Positional-OSA patients had higher response rates than non-positional (64.1% vs. 35.9; p 0.032). REM-OSA and apnea-predominant phenotype showed a lower response (p < 0.001). In these phenotypes, most patients were women, with higher body mass index, higher scores in the Epworth Sleepiness Scale, lower minSaO2 in REM-OSA phenotype, and higher T90% in apnea-predominant phenotype.

CONCLUSION

This study underscores the importance of hypoxic burden in the severity of OSA. The parameters T90% and POSA formed predictive model. Additionally, MAD appears to be less effective in the REM-OSA phenotype. Moreover, although patients with an apnea-predominant phenotype responded less favorably, there was a conversion from apneas to hypopneas, reducing severity.

Chinese herbal medicine for obstructive sleep apnoea: a systematic review with meta-analysis

PURPOSE

Chinese Herbal Medicine (CHM) may have a place in the treatment of obstructive sleep apnoea (OSA), but the evidence has not been systematically assessed. The objective of this study is to evaluate the evidence for the effectiveness of CHM for OSA.

METHODS

CENTRAL, EMBase, PubMed, CINAHL, CNKI, Wanfang and Chongqing VIP were searched from database inception to the 13th of August 2023. Randomised-controlled trials in which the effect of CHM on sleep variables was tested in the treatment of OSA were selected. The primary outcomes of this review and meta-analysis were the apnoea hypopnoea index (AHI) measured with polysomnography.

RESULTS

A total of 58 studies, involving 4,590 participants, were included. The meta-analysis showed that CHM reduced AHI more significantly than placebo (mean difference = -7.10 events/hour, 95% CI = -11.95, -2.25, P < 0.01, 7 studies, 583 participants) and the combination of CHM and Continuous Positive Airway Pressure (CPAP) more effective than CPAP alone (mean difference = -4.71 events/hour, 95% CI = -5.62, -3.80, P < 0.001, 28 studies, 2,267 participants). CHM improved sleepiness, quality of life, body weight, oxidative biomarkers, inflammatory biomarkers, cognitive function, blood pressure and respiratory function.

CONCLUSION

Our results suggest that CHM, alone and as an adjunct treatment, can improve various aspects of OSA and its comorbidities and is therefore a viable therapeutic option for OSA.

The Swedish sleep apnea registry (SESAR) cohort - "Real world data" on a national level

INTRODUCTION

The Swedish Sleep Apnea Registry (SESAR) collects clinical data from individual obstructive sleep apnea (OSA) patients since 2010. SESAR has recently been integrated with additional national healthcare data. The current analysis presents the SESAR structure and representative clinical data of a national sleep apnea cohort.

METHODS

Clinical data from unselected patients with a diagnosis of OSA are submitted to the SESAR registry. 48 sleep centers report data from diagnosis, treatment starts with Continuous Positive Airway Pressure (CPAP), oral devices (OD), and Upper Airway Surgery (UAS). Data from follow-up are included. SESAR is linked to mandatory national healthcare data (mortality, comorbidities, procedures, prescriptions) and diagnosis-specific quality registries (e.g. stroke, heart failure, diabetes) within the DISCOVERY project.

RESULTS

83,404 OSA patients have been reported during the diagnostic workup (age 55.4 ± 14.1 years, BMI 30.8 ± 6.5 kg/m2, AHI 25.8 ± 21.6n/h, respectively). At least one cardiometabolic and respiratory comorbidity is recognized in 57 % of female and 53 % of male OSA patients with a linear increase across OSA severity. In 54,468, 7,797, and 390 patients, start of CPAP, OD or UAS treatment is reported, respectively. OD patients have 4 units lower BMI and 10 units lower AHI compared to patients started on CPAP. UAS patients are characterized by 10 years lower age. The degree of daytime sleepiness is comparable between treatment groups with mean Epworth Sleepiness Scale Scores between 9 and 10.

CONCLUSION

SESAR is introduced as a large national registry of OSA patients. SESAR provides a useful tool to highlight OSA management and to perform relevant outcome research.

Avoid overstepping the bounds of evidence: the role of the orthodontist in managing pediatric Obstructive Sleep Apnea

Introduction

Pediatric Obstructive Sleep Apnea (OSA) is a common sleep-related breathing disorder often linked to distinct craniofacial features and malocclusions. While orthodontic treatments, particularly maxillary expansion and mandibular advancement, have been suggested for managing this condition, the results remain controversial and are based on low-quality evidence. This paper aims to summarize the ongoing debates on this topic by reviewing relevant literature and highlighting the role of the orthodontist in diagnosing and managing OSA in daily clinical practice.

Discussion and conclusions

According to the present review, there is insufficient evidence to either confirm or deny the effectiveness of oral appliances for treating pediatric OSA due to significant methodological limitations, such as small sample sizes, inadequate control groups, short study durations, and a lack of long-term follow-up. Additionally, this condition cannot be diagnosed solely based on craniofacial morphology, but an interdisciplinary evaluation is strictly required. In addition, orthopedic treatment may be considered only as an adjunct therapy for children with craniofacial anomalies increasing the risk for OSA, and the combination of multiple therapeutic approaches may be necessary to achieve effective treatment outcomes.

Maxilla management in "phase II" skeletal surgery for obstructive sleep apnea

This study investigates the management of patients with obstructive sleep apnea (OSA) who have previously undergone palatal surgery and subsequently undergo maxillomandibular advancement (MMA). The research entails a retrospective analysis of phase II MMA cases from 2017 to 2022. Data encompassing demographics, clinical profiles, pre- and post-operative polysomnographic and radiological findings, surgical techniques, and complications were collected. Out of the 14 patients studied, conservative vestibular approaches were applied universally, with four cases necessitating the sectioning of descending palatine arteries. Results indicate an average maxillary sagittal advancement of 10.07 mm, a mean counterclockwise rotation of the maxillary occlusal plane at 9.35°, and a decline in apnea-hypopnea index from 45.5 to 4.5 events per hour. Surgical success and cure rates were 93.3% and 40%, respectively, with no major complications observed throughout the 45-month follow-up. This study underscores the safe and efficacious application of MMA in OSA patients with prior palatal surgery, offering valuable insights into their management.

Deciphering loop gain complexity: a primer for understanding a pathophysiological trait of obstructive sleep apnea patients

Loop Gain (LG), a concept borrowed from engineering used to describe the stability of electrical circuits under negative feedback, has emerged as a crucial pathophysiological trait in sleep respiratory disorders. In simple terms, LG measures how the respiratory control system reacts to changes in breathing. A high LG suggests that minor disturbances in breathing prompt exaggerated responses, potentially leading to instability and oscillations in respiratory patterns. Conversely, a low LG implies that the system responds more gently to disturbances, resulting in stable and well-regulated breathing. However, understanding the concept of loop gain presents challenges due to its dynamic nature across various sleep respiratory disorders, sleep stages, positions, and interactions with other pathophysiological traits. Recent efforts have aimed to identify a non-invasive method for assessing LG, with some evidence suggesting that information regarding pathophysiological traits can be extracted from polysomnography. There exists a clinical imperative for physician to unravel the intricacies of LG when managing Obstructive Sleep Apnea (OSA) patients, because LG abnormalities delineate a distinct pathophysiological phenotype of OSA. Specifically, certain patients exhibit a high LG as the primary factor driving sleep apnea, influencing treatment outcomes. For instance, individuals with high LG may respond differently to therapies such as continuous positive airway pressure (CPAP) or oral appliances compared to those with normal LG, or they can be treated with specific drugs or combination therapies. Thus, understanding LG becomes paramount for precise assessment of OSA patients and is fundamental for optimizing a personalized and effective treatment approach.

A comparative analysis of unsupervised machine-learning methods in PSG-related phenotyping

Obstructive sleep apnea is a heterogeneous sleep disorder with varying phenotypes. Several studies have already performed cluster analyses to discover various obstructive sleep apnea phenotypic clusters. However, the selection of the clustering method might affect the outputs. Consequently, it is unclear whether similar obstructive sleep apnea clusters can be reproduced using different clustering methods. In this study, we applied four well-known clustering methods: Agglomerative Hierarchical Clustering; K-means; Fuzzy C-means; and Gaussian Mixture Model to a population of 865 suspected obstructive sleep apnea patients. By creating five clusters with each method, we examined the effect of clustering methods on forming obstructive sleep apnea clusters and the differences in their physiological characteristics. We utilized a visualization technique to indicate the cluster formations, Cohen's kappa statistics to find the similarity and agreement between clustering methods, and performance evaluation to compare the clustering performance. As a result, two out of five clusters were distinctly different with all four methods, while three other clusters exhibited overlapping features across all methods. In terms of agreement, Fuzzy C-means and K-means had the strongest (κ = 0.87), and Agglomerative hierarchical clustering and Gaussian Mixture Model had the weakest agreement (κ = 0.51) between each other. The K-means showed the best clustering performance, followed by the Fuzzy C-means in most evaluation criteria. Moreover, Fuzzy C-means showed the greatest potential in handling overlapping clusters compared with other methods. In conclusion, we revealed a direct impact of clustering method selection on the formation and physiological characteristics of obstructive sleep apnea clusters. In addition, we highlighted the capability of soft clustering methods, particularly Fuzzy C-means, in the application of obstructive sleep apnea phenotyping.

Sleep and periodontal health

Sleep is fundamental for health and well-being. An adequate amount and quality of sleep is a cardinal component of a healthy lifestyle at the basis of the prevention of many non-communicable chronic diseases. Recent evidence suggests that sleep disorders, particularly obstructive sleep apnea, represent an emerging risk factor for periodontal health. This review article provides a critical appraisal of the existing literature concerning the association between sleep duration, sleep quality, sleep disorders in general, and obstructive sleep apnea with periodontal diseases, including gingivitis and periodontitis. The putative mechanisms underlying these associations are described as well as the potential clinical implications for diagnosis and treatment.

Therapeutic Potential of Glucagon-like Peptide-1 Receptor Agonists in Obstructive Sleep Apnea Syndrome Management: A Narrative Review

Background: Obstructive Sleep Apnea (OSA) is a prevalent disorder characterized by repetitive upper airway obstructions during sleep, leading to intermittent hypoxia and sleep fragmentation. Current treatments, particularly Continuous Positive Airway Pressure (CPAP), face adherence challenges, necessitating novel therapeutic approaches. Methods: This review explores the potential of Glucagon-like Peptide-1 receptor agonists (GLP-1RA), commonly used for type 2 diabetes and obesity, in managing OSA. GLP-1RA promotes weight loss, enhances insulin sensitivity, and exhibits anti-inflammatory and neuroprotective properties, potentially addressing key pathophysiological aspects of OSA. Results: Emerging evidence suggests that these agents may reduce OSA severity by decreasing upper airway fat deposition and improving respiratory control. Clinical trials have demonstrated significant reductions in the Apnea-Hypopnea Index (AHI) and improvements in sleep quality with GLP-1 therapy. Conclusions: Future research should focus on elucidating the mechanisms underlying GLP-1 effects on OSAS, optimizing combination therapies, and identifying patient subgroups that may benefit the most. Integrating GLP-1RA into OSAS management could revolutionize treatment by addressing both the metabolic and respiratory components of the disorder, ultimately enhancing patient outcomes.

Baseline Characteristics Associated with Hypoglossal Nerve Stimulation Treatment Outcomes in Patients with Obstructive Sleep Apnea: A Systematic Review

Hypoglossal nerve stimulation (HGNS) has emerged as an effective treatment for obstructive sleep apnea (OSA). Identifying baseline characteristics that prospectively could predict treatment outcomes even better is crucial for optimizing patient selection and improving therapeutic success in the future. A systematic review was conducted following PRISMA guidelines. Literature searches in Medline, Web of Science, and Cochrane databases identified studies assessing baseline characteristics associated with HGNS treatment outcomes. Inclusion criteria focused on studies with adult patients diagnosed with OSA, treated with HGNS, and assessed using full-night efficacy sleep studies. Risk of bias was evaluated using the NICE tool. Twenty-six studies met the inclusion criteria. Commonly reported baseline characteristics with predictive potential included BMI, site of collapse, and various pathophysiological endotypes. Most studies used the original Sher criteria to define treatment response, though variations were noted. Results suggested that lower BMI, absence of complete concentric collapse at the palatal level, and specific pathophysiological traits were associated with better HGNS outcomes. This review identified several baseline characteristics associated with HGNS outcomes, which may guide future patient selection. Importantly, patients were already preselected for HGNS. Standardizing response criteria is recommended to enhance the evaluation and effectiveness of HGNS therapy in OSA patients.

Mask side-effects are related to gender in long-term CPAP: results from the InterfaceVent real-life study

BACKGROUND

Over the past three decades, our understanding of sleep apnea in women has advanced, revealing disparities in pathophysiology, diagnosis, and treatment compared to men. However, no real-life study to date has explored the relationship between mask-related side effects (MRSEs) and gender in the context of long-term CPAP.

METHODS

The InterfaceVent-CPAP study is a prospective real-life cross-sectional study conducted in an apneic adult cohort undergoing at least 3 months of CPAP with unrestricted mask-access (34 different masks, no gender specific mask series). MRSE were assessed by the patient using visual analog scales (VAS). CPAP-non-adherence was defined as a mean CPAP-usage of less than 4 h per day. The primary objective of this ancillary study was to investigate the impact of gender on the prevalence of MRSEs reported by the patient. Secondary analyses assessed the impact of MRSEs on CPAP-usage and CPAP-non-adherence depending on the gender.

RESULTS

A total of 1484 patients treated for a median duration of 4.4 years (IQ25-75: 2.0-9.7) were included in the cohort, with women accounting for 27.8%. The prevalence of patient-reported mask injury, defined as a VAS score ≥ 5 (p = 0.021), was higher in women than in men (9.6% versus 5.3%). For nasal pillow masks, the median MRSE VAS score for dry mouth was higher in women (p = 0.039). For oronasal masks, the median MRSE VAS score for runny nose was higher in men (p = 0.039). Multivariable regression analyses revealed that, for both women and men, dry mouth was independently and negatively associated with CPAP-usage, and positively associated with CPAP-non-adherence.

CONCLUSION

In real-life patients treated with long-term CPAP, there are gender differences in patient reported MRSEs. In the context of personalized medicine, these results suggest that the design of future masks should consider these gender differences if masks specifically for women are developed. However, only dry mouth, a side effect not related to mask design, impacts CPAP-usage and non-adherence.

TRIAL REGISTRATION

INTERFACEVENT IS REGISTERED WITH CLINICALTRIALS.GOV (NCT03013283).FIRST REGISTRATION DATE IS 2016-12-23.

Combination of acute intermittent hypoxia and intermittent transcutaneous electrical stimulation in obstructive sleep apnea: a randomized controlled crossover trial

Intermittent hypoxia (IH) and intermittent transcutaneous electrical stimulation (ITES) might benefit patients with obstructive sleep apnea (OSA). However, the therapeutic value of combined IH and ITES in OSA is unknown. In this prospective, randomized, controlled crossover study, normoxia (air exposure for 50 min before sleep and sham stimulation for 6 h during sleep), IH (5 repeats of 5 min 10-12 % O2 alternating with 5 min air for 50 min, and sham stimulation for 6 h), ITES (air exposure for 50 min and 6 repeats of 30 min transcutaneous electrical stimulation alternating with 30 min of sham stimulation for 6 h), and IH&ITES (10-12 % O2 alternating with air for 50 min and transcutaneous electrical stimulation alternating with sham stimulation for 6 h) were administered to patients with OSA over four single-night sessions. The primary endpoint was difference in OSA severity between the interventions according to apnea-hypopnea index (AHI) and oxygen desaturation index (ODI). The efficacy was response to IH, ITES, IH&ITES defined as a ≥50 % reduction in AHI compared with normoxia. Twenty participants (17 male, 3 female) completed the trial. The median (IQR) AHI decreased from 14.5 (10.8, 17.5) events/h with normoxia to 6.9 (3.9, 14.8) events/h with IH (p=0.020), 5.7 (3.4, 9.1) events/h with ITES (p=0.001), and 3.5 (1.8, 6.4) events/h with IH&ITES (p=0.001). AHI was significantly different between IH and IH&ITES (p=0.042) but not between ITES and IH&ITES (p=0.850). For mild-moderate OSA (n=17), IH, ITES, and IH&ITES had a significant effect on AHI (p=0.013, p=0.001, p=0.001, respectively) compared with normoxia, but there were no differences in post hoc pairwise comparisons between intervention groups. No serious adverse events were observed. In conclusion, IH, ITES, and IH&ITES significantly reduced OSA severity. IH&ITES showed better efficacy in mild-moderate OSA than IH and was comparable to ITES. Our data do not support recommending IH&ITES over ITES for OSA.

Role of Nasal Surgery in Adult Obstructive Sleep Apnea: A Systematic Review

Objective  To perform a systematic review to determine if isolated nasal surgery has any impact on subjective or objective parameters in adult obstructive sleep apnea (OSA) patients. Materials and Methods  From December 2022 to March 2023, we conducted a search on the PubMed, Cochrane, Scopus, and Web of Science databases. Two independent investigators performed a study selection according to the established criteria, as well as data collection, including the study design, the subjective and objective parameters addressed, the type of intervention, and the outcomes, considering the methodological quality and risk of bias. Results  In total, 25 studies met the selection criteria, and they showed that there is a significant improvement in sleep quality, sleepiness, nasal resistance, and snoring after isolated nasal surgery. Still, there is no relevant modification of other polysomnographic parameters. It also reduces the required titration pressures of continuous positive airway pressure (CPAP) and increases the duration of its use. Conclusion  Isolated nasal surgery is not a primary treatment for OSA. Still, it improves the subjective parameters and can lead to CPAP therapy success by enhancing its effectiveness and long-term compliance.

Diagnostic and Therapeutic Indications of Different Types of Mandibular Advancement Design for Patients with Obstructive Sleep Apnea Syndrome: Indications from Literature Review and Case Descriptions

BACKGROUND

Mandibular advancement devices (MADs) are considered a primary alternative treatment for adults with moderate to severe obstructive sleep apnea (OSA) who are unable to tolerate or do not respond to continuous positive airway pressure (CPAP) therapy, supported by substantial scientific evidence. While a range of designs and materials for MADs are commercially available, there is a lack of clear diagnostic guidelines to assist clinicians in selecting the most appropriate device based on a multidisciplinary evaluation of OSA patients. This narrative review seeks to outline the key characteristics of MADs that clinicians should evaluate during both the diagnostic and treatment phases for patients with OSA.

METHODS

An extensive search of academic databases was conducted to gather relevant studies that address therapeutic and diagnostic recommendations for the design and titration of MADs. The search was carried out across EMBASE, Scopus, PubMed, and Web of Science up to May 2024. From a total of 1445 identified citations, 1103 remained after duplicate removal. Based on the inclusion criteria, the full text of 202 articles was retrieved, and 70 studies were ultimately included in this review. The extracted data were organized to generate clinical insights, aimed at guiding orthodontists in optimizing diagnostic and decision-making processes for treating OSA patients with MADs.

RESULTS

The analysis led to the identification of key clinical questions that can assist orthodontists in enhancing their approach and choosing the appropriate appliance basing on the diagnosis and clinical dento-orofacial characteristics.

CONCLUSIONS

Bibloc appliances could be preferred over mono-bloc devices due to the possibility of arranging the mandibular advancement according to the patient's clinical condition and orofacial symptoms. Provisional devices could be used as screening tools to verify the patient's adherence to the therapy. Regardless of the MAD design, type and programmed advancement, it must be under-lined that the rule of the orthodontist/dental specialist is secondary to the other sleep-medicine specialists (ORL, pulmonologist) and must be related to (1) a preliminary assessment of MAD usage (dental anatomical conditions), (2) testing a diagnostic MAD usable during a sleep examination (PSG or DISE), (3) final treatment with a definitive MAD.

Personalized Treatment for Obstructive Sleep Apnea: Beyond CPAP

Obstructive sleep apnea (OSA) is a sleep disorder characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep. Continuous positive airway pressure (CPAP) is a method used as a first-line treatment for obstructive sleep apnea (OSA). However, intolerance and resistance to CPAP can limit its long-term effectiveness. Alternative treatments are available, such as Mandibular Advancement Devices (MADs), positional therapy, upper airway surgery, and maxillomandibular osteotomy. However, often less efficient in reducing the apnea-hypopnea index, the higher tolerance of and compliance to alternative treatment has resulted in the adequate treatment of OSA in CPAP-intolerant patients. This paper describes the protocol of a prospective single-center cohort study including adult patients with moderate to severe OSA (15 events/h ≤ apnea-hypopnea index (AHI) < 65 events/h) that failed to comply with CPAP therapy. Selected patients will be invited to the clinic to explore alternative treatment options where DISE will be a first step in further identifying upper airway collapse during sleep. By exploring alternative treatment options in CPAP-intolerant patients and systematically documenting their treatment paths, an algorithm can be defined to better guide patients towards personalized treatment for OSA. The follow-up is aimed at 5 years with an inclusion of 170 patients per year, including a drop-out rate of 15%. By leveraging a real-world database, this study aims to bridge the gap between research and clinical practice, facilitating the development of evidence-based guidelines and personalized treatment algorithms for CPAP-intolerant patients.

Surgical failure guided by DISE in patients with obstructive sleep apnea: a systematic review and meta-analysis

OBJECTIVES

The failure rate and risk factors of upper airway surgery with drug induced sleep endoscopy (DISE) remain unknown in the treatment of obstructive sleep apnea (OSA). This review aims to analyze the failure rate of upper airway surgery with DISE and identify obstruction sites for surgical failure.

METHODS

A systematic review was conducted using PubMed, Embase, Web of Science, and Google Scholar until May 20th, 2023. We included studies that used DISE to assess obstructive sites before upper airway surgery and reported surgical failure rates and outcomes in patients with OSA.

RESULTS

25 studies with a total of 1522 patients were included in the systematic review and meta-analysis. Upper airway surgery guided by DISE had a relatively low failure rate of 37% (95% CI 0.31-0.44) in the random effects model (I2 = 85.97%, P < 0.001). According to the velum, oropharynx, tongue base, and epiglottis (VOTE) scoring system, major risk factors for surgical failure included circumferential collapse at the velum, lateral wall collapse and small tonsils at the oropharynx, anterior-posterior lingual collapse and complete collapse at the tongue base. High body mass index and large preoperative apnea hypopnea index were also risk factors for OSA surgical failure.

CONCLUSIONS

Upper airway surgery guided by DISE in patients with OSA had a low failure rate of 37%. DISE can identify obstruction sites associated with surgical failure and guide single-level and multi-level surgeries.

Hypoglossal Nerve Stimulation Therapy in a Belgian Cohort of Obstructive Sleep Apnea Patients

Hypoglossal nerve stimulation (HGNS) has emerged as a widespread and innovative treatment option for selected moderate-to-severe obstructive sleep apnea (OSA) patients who cannot be treated effectively with traditional treatment modalities. In this observational cohort study, the objective and subjective outcomes of Belgian OSA patients treated with HGNS therapy were analyzed at 6 and 12 months post-implantation. Thirty-nine patients implanted with a respiration-synchronized HGNS device at the Antwerp University Hospital w ere included in this study. Patients underwent baseline in-laboratory polysomnography and a follow-up sleep study 6 and 12 months post-implantation. Questionnaires on patient experience and daytime sleepiness were filled out and data on objective therapy usage were collected. All 39 patients completed the 6-month follow-up and 21 patients (54%) completed the 12-month follow-up. Median AHI decreased from 33.8 [26.1;45.0] to 10.2 [4.8;16.4] at the 6-month follow-up, and to 9.6 [4.1;16.4] at the 12-month follow-up (p < 0.001). The surgical success rate, according to the Sher20 criteria, was 80% and 76% at the 6- and 12-month follow-ups, respectively. Median ESS improved from 12.0 [7.0;18.0] at baseline to 6.0 [2.5;11.0] at 6 months (p < 0.001) and to 6.5 [2.8;11.5] at 12 months (p = 0.012). Objective therapy usage was 7.4 [6.6;8.0] and 7.0 [5.9:8.2] h/night at the 6- and 12-month follow-ups, respectively. A high overall clinical effectiveness of HGNS therapy, as shown by a mean disease alleviation of 58%, was demonstrated at 12 months post-implantation. Overall, HGNS therapy using respiration-synchronized neurostimulation of the XII cranial nerve resulted in a significant improvement in both objective and subjective OSA outcomes, with a high level of patient satisfaction and high treatment adherence.

Obstructive sleep apnoea/hypopnoea syndrome: a feasibility study to review NICE guidelines

Introduction Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a sleep-related respiratory condition, leading to repeated temporary cessation of breathing. OSAHS affects approximately eight million people in the UK and can contribute to many comorbidities. Recently, there has been updated National Institute for Health and Care Excellence (NICE) guidelines for the management of OSAHS in the UK.Aims To assess the current care pathway for OSAHS patients in St George's Hospital (SGH) and if the hospital was complying with current NICE guidelines.Methods A retrospective case note analysis of 50 adult patients who have attended SGH for OSAHS in 2022 was undertaken to review their care pathway. Patient notes were reviewed to determine if key criteria of NICE guidelines were followed.Results The OSA clinic follows some of the NICE guidelines and had this recorded in the notes for 40% of the standards/criteria reviewed (10 out of 25 standards were met and recorded).Discussion This service evaluation reveals patients have multiple appointments and have varying treatment compliance. Further discussions are required with the sleep clinicians to determine an efficient pathway for patients who require consideration for alternative therapies for OSA and understanding the funding flows.Conclusions There is a need to raise awareness of these guidelines and improve record-keeping of lifestyle advice given and monitoring treatment efficacy, as the NICE guidelines were not yet being routinely followed.

Revolutionizing Sleep Health: The Emergence and Impact of Personalized Sleep Medicine

Personalized sleep medicine represents a transformative shift in healthcare, emphasizing individualized approaches to optimizing sleep health, considering the bidirectional relationship between sleep and health. This field moves beyond conventional methods, tailoring care to the unique physiological and psychological needs of individuals to improve sleep quality and manage disorders. Key to this approach is the consideration of diverse factors like genetic predispositions, lifestyle habits, environmental factors, and underlying health conditions. This enables more accurate diagnoses, targeted treatments, and proactive management. Technological advancements play a pivotal role in this field: wearable devices, mobile health applications, and advanced diagnostic tools collect detailed sleep data for continuous monitoring and analysis. The integration of machine learning and artificial intelligence enhances data interpretation, offering personalized treatment plans based on individual sleep profiles. Moreover, research on circadian rhythms and sleep physiology is advancing our understanding of sleep's impact on overall health. The next generation of wearable technology will integrate more seamlessly with IoT and smart home systems, facilitating holistic sleep environment management. Telemedicine and virtual healthcare platforms will increase accessibility to specialized care, especially in remote areas. Advancements will also focus on integrating various data sources for comprehensive assessments and treatments. Genomic and molecular research could lead to breakthroughs in understanding individual sleep disorders, informing highly personalized treatment plans. Sophisticated methods for sleep stage estimation, including machine learning techniques, are improving diagnostic precision. Computational models, particularly for conditions like obstructive sleep apnea, are enabling patient-specific treatment strategies. The future of personalized sleep medicine will likely involve cross-disciplinary collaborations, integrating cognitive behavioral therapy and mental health interventions. Public awareness and education about personalized sleep approaches, alongside updated regulatory frameworks for data security and privacy, are essential. Longitudinal studies will provide insights into evolving sleep patterns, further refining treatment approaches. In conclusion, personalized sleep medicine is revolutionizing sleep disorder treatment, leveraging individual characteristics and advanced technologies for improved diagnosis, treatment, and management. This shift towards individualized care marks a significant advancement in healthcare, enhancing life quality for those with sleep disorders.

Oral appliance therapy for snoring and obstructive sleep apnoea: a Practical Guide for Clinical Care

Obstructive sleep apnoea (OSA) is a disorder associated with multiple cardiovascular, metabolic and neurocognitive comorbidities which impact the health and quality of life of patients. Dentists trained in dental sleep medicine have a significant role as part of a collaborative multidisciplinary team led by specialist sleep physicians in the overall management of OSA. Based on the recommendations of the medical team and the patient's preference, dentists have a pertinent role in the provision of oral appliance (OA) therapy for OSA. This narrative review provides a practical guide for OA therapy for snoring and OSA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-Term Adherence to Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnoea Set Up in a Complete Remote Pathway: A Single-Centre Service Evaluation Project

Background: Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnoea (OSA). Maintaining adherence to CPAP in the long term is a clinical problem, and numerous factors have been identified that impact adherence. Although fully remote diagnostic and CPAP services were frequently utilised during the COVID-19 pandemic for patients with OSA, long-term adherence data have not been published. The aim of this service evaluation project was to describe the long-term adherence to CPAP. We also analysed factors that are associated with it. Methods: two-hundred and eighty patients diagnosed with OSA and set up on CPAP remotely during the first wave of the COVID-19 pandemic as part of routine clinical practice were analysed. Results: One-hundred and seven patients (38%) were fully adherent to CPAP at 24 months, determined by at least 4 h of usage on at least 70% of the days. Of the factors analysed, body mass index, disease severity, driving status and the presence of depression were related to long-term adherence (all p < 0.05). Conclusions: with the likelihood of future pandemics similar to COVID-19, our data provide evidence that fully remote pathways for management of patients with OSA can be designed and be sustainable with good long-term adherence.

A randomized controlled crossover trial of acute intermittent and continuous hypoxia exposure in mild-moderate obstructive sleep apnea: A feasibility study

In a prospective, randomized, controlled crossover study, we explored the effects of acute intermittent hypoxia and acute continuous hypoxia on patients with mild-moderate obstructive sleep apnea. Over three single-night sessions, subjects were alternately exposed to normoxia, acute continuous hypoxia and acute intermittent hypoxia before sleep. The apnea-hypopnea index and oxygen desaturation index were used to diagnose obstructive sleep apnea and evaluate efficacy. A responder was defined as a participant with a ≥ 50% reduction in apnea-hypopnea index between normoxia and hypoxia exposure. Sixteen participants with mild-moderate obstructive sleep apnea completed the study. Compared with normoxia, the mean apnea-hypopnea index decreased by 8.9 events per hr (95% confidence interval, 4.2-13.6, p = 0.001) with acute intermittent hypoxia and by 4.1 events per hr (95% confidence interval, 0.5-8.8, p = 0.082) with acute continuous hypoxia, equating to a mean decrease in apnea-hypopnea index of 4.8 events per hr (95% confidence interval, 0.1-9.5, p = 0.046) with acute intermittent hypoxia compared with acute continuous hypoxia. Compared with normoxia, the mean oxygen desaturation index decreased by 9.8 events per hr (95% confidence interval, 4.4-15.1, p = 0.001) with acute intermittent hypoxia but did not significantly decrease with acute continuous hypoxia; the mean oxygen desaturation index decreased by 7.2 events per hr (95% confidence interval, 1.8-12.6, p = 0.010) with acute intermittent hypoxia compared with acute continuous hypoxia. Of the 16 participants, 11 responded to acute intermittent hypoxia and four responded to acute continuous hypoxia (p = 0.032), of whom eight of 11 cases and all four cases had oxygen desaturation indexes <5 events per hr, respectively (p = 0.273). All participants tolerated acute intermittent hypoxia and there were no obvious adverse events during acute intermittent hypoxia exposure. In conclusion, acute intermittent hypoxia exposure improved apnea-hypopnea index and oxygen desaturation index in patients with mild-moderate obstructive sleep apnea, suggesting that further prospective validation of intermittent hypoxia exposure in patients with obstructive sleep apnea is needed to establish its clinical feasibility as a therapeutic modality.

Effect of mandibular advancement appliance use on oral and periodontal health in patients with OSA: a systematic review

STUDY OBJECTIVES

Use of a mandibular advancement appliance (MAA) is an effective treatment option for mild-to-moderate obstructive sleep apnea (OSA). MAA is well-tolerated but undesirable effects may be observed over time. The present systematic review aimed to assess the effect of MAA use on oral and periodontal health in patients with OSA.

METHODS

MEDLINE (PubMed), Cochrane, and Scopus were searched for randomized and non-randomized controlled trials (RCTs, NRCTs), cohorts, and case-control studies reporting on side effects of MAA treatment in OSA patients during a follow-up of at least 6 months.

RESULTS

From a total of 169 articles screened, 28 were selected. The most frequently reported MAA-related effects on oral health were: hypersalivation (weighted mean prevalence, 33.3%), occlusal changes (30.2%), muscle pain (22.9%), tooth discomfort or pain (20.2%), and xerostomia (18.3%). No MAA-related periodontal effect was reported. The periodontal status prior to MAA treatment was rarely assessed and described, but 5 studies (17.8%) stated that periodontitis was an exclusion criterion for MAA. Only one retrospective study specifically evaluated periodontal parameters and reported no significant changes in periodontally healthy patients with OSA using MAA for over 7 years.

CONCLUSION

MAA use is associated with a number of clinical consequences on oral health, but there is no evidence to conclude whether or not MAA affects periodontal health in patients with OSA. This aspect appears to be under-evaluated and should be further investigated in relation to the type of MAA, the duration of treatment, and prior history of periodontitis.

Economic evaluation of telemonitoring as a follow-up approach for patients with obstructive sleep apnea syndrome starting treatment with continuous positive airway pressure

Telemonitoring of obstructive sleep apnea patients is increasingly being adopted though its cost-effectiveness evidence base is scanty. This study investigated whether telemonitoring is a cost-effective strategy compared with the standard follow-up in patients with obstructive sleep apnea who are starting continuous positive airway pressure treatment. In total, 167 obstructive sleep apnea patients were randomised into telemonitoring (n = 79) or standard follow-up (n = 88), initiated continuous positive airway pressure treatment, and were followed up for 6 months. The frequencies of healthcare contacts, related costs (in USD 2021 prices), treatment effect and compliance were compared between the follow-up approaches using generalised linear models. The cost effectiveness analysis was conducted from a healthcare perspective and the results presented as cost per avoided extra clinic visit. Additionally, patient satisfaction between the two approaches was explored. The analysis showed no baseline differences. At follow-up, there was no significant difference in treatment compliance, and the mean residual apnea-hypoapnea index. There was no difference in total visits, adjusted incidence rate ratio 0.87 (0.72-1.06). Participants in the telemonitoring arm made eight times more telephone visits, 8.10 (5.04-13.84), and about 73% fewer physical healthcare visits 0.27 (0.20-0.36). This translated into significantly lower total costs for the telemonitoring approach compared with standard follow-up, -192 USD (-346 to -41). The form of follow-up seemed to have no impact on the extent of patient satisfaction. These results demonstrate the telemonitoring of patients with obstructive sleep apnea initiating continuous positive airway pressure treatment as a cost saving strategy and can be argued as a potential worthy investment.

Effect of different anti-cardiovascular disease treatments on the severity of obstructive sleep apnea

Obstructive sleep apnea (OSA) and cardiovascular co-morbidities have a mutually reinforcing effect, but existing studies have focussed only on the improvement of the associated co-morbidities by treatment for OSA. To provide fresh guidelines for the treatment of OSA from a co-morbidity standpoint, we conducted a systematic search of Web of Science, PubMed, EMBASE, and the Cochrane Library for articles published from inception up to 2 May 2023. Fourteen original studies of patients with OSA with cardiovascular co-morbidities and who received related treatment were included in the analysis. We found that diuretic treatment can reduce the apnea-hypopnea index in patients with OSA and hypertension (-19.41/h, p = 1.0 × 10-5 ), aldosterone-angiotensin inhibitors also have a 9.19/h reduction (p = 0.003), while the effect of renal sympathetic denervation is insignificant (-2.32/h, p = 0.19). The short-term treatment (<4 weeks) did not show an improvement (-2.72/h, p = 0.16), while long-term treatment (>4 weeks) produced surprising outcomes (-12.78/h, p = 0.002). Patients with milder disease (baseline AHI < 35/h) had insignificant improvements (-1.05/h, p = 0.46), whereas those with more severe disease (baseline AHI > 35/h) could achieve satisfactory outcomes (-14.74/h, p < 0.00001). In addition, it also showed some improvement in the oxygen desaturation index and blood oxygen. Our results support the additional benefit of antihypertensive treatment for OSA symptoms, and the efficacy can be affected by different therapy, treatment duration, and severity levels. It could be useful in developing clinical therapy, educating patients, and exploring interaction mechanisms. The proposal was registered with PROSPERO (CRD42022351206).

Diagnosis and management of obstructive sleep apnoea in adults

Obstructive sleep apnoea is the most common form of sleep-disordered breathing. It is characterised by recurrent occlusion of the airway during sleep. Ensuing apnoeas terminate in arousal from sleep and lead to non-restorative sleep, excessive daytime sleepiness and adverse cardiovascular and neurocognitive effects. A sleep study should be offered to patients reporting witnessed apnoeas or symptoms related to non-restorative sleep. It should also be considered in the presence of predisposing factors for obstructive sleep apnoea (e.g. obesity, tonsillar hypertrophy, retrognathia, refractory hypertension). Treatment should aim to improve symptoms and reduce cardiovascular and neurocognitive risk. The treatment approach should consider the symptom burden, severity, anatomical factors, and patient preference. Positive airway pressure is the most effective treatment option, although intolerance and non-adherence are common. Other options include positional therapy, oral appliances and upper airway surgery. Weight loss and optimisation of cardiovascular disease risk should be considered in selected patients.

Indications for Dental Specialists for Treating Obstructive Sleep Apnea with Mandibular Advancement Devices: A Narrative Review

Obstructive sleep apnea (OSA) syndrome is characterized by repeated airway collapse during sleep. It determines cardiovascular, pulmonary, and neurocognitive consequences and is associated with several daytime and nighttime symptoms that influence the patient's quality of life. The contribution of the dental specialist in the clinical management of OSA patients entails participating in the screening process as diagnostic sentinels and providing adequate treatment using mandibular advancement devices (MADs). Since the treatment of OSA requires a multidisciplinary approach, including different medical specialists, dentists should have a comprehensive understanding of medical and dental factors that influence the strategy and effectiveness of OSA treatment with MAD. Such expertise is crucial in determining the appropriate treatment indications and helps clinicians establish a consolidated position within the multidisciplinary OSA team. In this regard, this review summarizes the evidence of the clinical indications for MAD treatment and provides the dental specialist with helpful information about medical, functional, and other relevant factors that should be considered during diagnosis, treatment plan, and follow-up stages. Information retrieved was organized and discussed, generating specific domains/queries oriented to the clinical management of OSA patients from the clinical perspective of dental specialists.

Advance in the pharmacological and comorbidities management of heart failure with preserved ejection fraction: evidence from clinical trials

The prevalence of heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of the total heart failure population, and with the aging of the population and the increasing prevalence of hypertension, obesity, and type 2 diabetes (T2DM), the incidence of HFpEF continues to rise and has become the most common subtype of heart failure. Compared with heart failure with reduced ejection fraction, HFpEF has a more complex pathophysiology and is more often associated with hypertension, T2DM, obesity, atrial fibrillation, renal insufficiency, pulmonary hypertension, obstructive sleep apnea, and other comorbidities. HFpEF has generally been considered a syndrome with high phenotypic heterogeneity, and no effective treatments have been shown to reduce mortality to date. Diuretics and comorbidity management are traditional treatments for HFpEF; however, they are mostly empirical due to a lack of clinical evidence in the setting of HFpEF. With the EMPEROR-Preserved and DELIVER results, sodium-glucose cotransporter 2 inhibitors become the first evidence-based therapies to reduce rehospitalization for heart failure. Subgroup analyses of the PARAGON-HF, TOPCAT, and CHARM-Preserved trials suggest that angiotensin receptor-neprilysin inhibitors, spironolactone, and angiotensin II receptor blockers may be beneficial in patients at the lower end of the ejection fraction spectrum. Other potential pharmacotherapies represented by non-steroidal mineralocorticoid receptor antagonists finerenone and antifibrotic agent pirfenidone also hold promise for the treatment of HFpEF. This article intends to review the clinical evidence on current pharmacotherapies of HFpEF, as well as the comorbidities management of atrial fibrillation, hypertension, T2DM, obesity, pulmonary hypertension, renal insufficiency, obstructive sleep apnea, and iron deficiency, to optimize the clinical management of HFpEF.

The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study

STUDY OBJECTIVES

To prospectively validate drug-induced sleep endoscopy with mandibular advancement maneuvers as a prediction tool for treatment success of oral appliance treatment (OAT).

METHODS

Seventy-seven patients diagnosed with moderate obstructive sleep apnea were included and underwent drug-induced sleep endoscopy. The upper airway collapse was assessed using the VOTE classification. Additionally, three mandibular advancement maneuvers were performed to predict treatment success of OAT. If the maneuver was negative, the level and degree and configuration of the persistent collapse was described according to the VOTE classification. All patients were treated with OAT and completed a follow-up sleep study with OAT in situ without regard to their anticipated response to treatment.

RESULTS

Sixty-four patients completed 6-month follow up. A positive jaw thrust maneuver proved to be significantly associated with favorable OAT response, whereas the chin lift maneuver and the vertical chin lift maneuver were not. Additionally, a persistent lateral oropharyngeal collapse when performing any mandibular advancement maneuver was significantly associated with unfavorable OAT response.

CONCLUSIONS

The current findings suggest that a jaw thrust maneuver should be preferred over the chin lift maneuver for predicting OAT response. Patients with a positive jaw thrust maneuver should be counseled toward favorable OAT response, whereas those with persistent lateral oropharyngeal collapse should be advised about the likelihood of unfavorable OAT response. A negative jaw thrust maneuver did not prove to be a significant predictor for unfavorable response to OAT. Consequently, uncertainties arise regarding the justification of performing drug-induced sleep endoscopy solely for predicting the efficacy of OAT. However, the results of the current study could be influenced by heterogeneity in the assessment of respiratory parameters, variability in the performance of the mandibular advancement maneuvers, and the instability of bolus technique sedation.

CLINICAL TRIAL REGISTRATION

Registry: Netherlands Trial Register; Name: Drug-induced Sleep Endoscopy: a prediction tool for success rate of oral appliance treatment; Identifier: NL8425; URL: https://www.onderzoekmetmensen.nl/en/trial/20741.

CITATION

Veugen CCAFM, Kant E, Kelder JC, Schipper A, Stokroos RJ, Copper MP. The predictive value of mandibular advancement maneuvers during drug-induced sleep endoscopy for treatment success of oral appliance treatment in obstructive sleep apnea: a prospective study. J Clin Sleep Med. 2024;20(3): 353-361.

Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring

Obstructive sleep apnea is a highly prevalent sleep-related breathing disorder, resulting in a disturbed breathing pattern, changes in blood gases, abnormal autonomic regulation, metabolic fluctuation, poor neurocognitive performance, and increased cardiovascular risk. With broad inter-individual differences recognised in risk factors, clinical symptoms, gene expression, physiological characteristics, and health outcomes, various obstructive sleep apnea subtypes have been identified. Therapeutic efficacy and its impact on outcomes, particularly for cardiovascular consequences, may also vary depending on these features in obstructive sleep apnea. A number of interventions such as positive airway pressure therapies, oral appliance, surgical treatment, and pharmaceutical options are available in clinical practice. Selecting an effective obstructive sleep apnea treatment and therapy is a challenging medical decision due to obstructive sleep apnea heterogeneity and numerous treatment modalities. Thus, an objective marker for clinical evaluation is warranted to estimate the treatment response in patients with obstructive sleep apnea. Currently, while the Apnea-Hypopnea Index is used for severity assessment of obstructive sleep apnea and still considered a major guide to diagnosis and managements of obstructive sleep apnea, the Apnea-Hypopnea Index is not a robust marker of symptoms, function, or outcome improvement. Abnormal cardiac autonomic modulation can provide additional insight to better understand obstructive sleep apnea phenotyping. Heart rate variability is a reliable neurocardiac tool to assess altered autonomic function and can also provide cardiovascular information in obstructive sleep apnea. Beyond the Apnea-Hypopnea Index, this review aims to discuss the role of heart rate variability as an indicator and predictor of therapeutic efficacy to different modalities in order to optimise tailored treatment for obstructive sleep apnea.