Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device

Treatment of moderate to severe obstructive sleep apnea poses clinical challenges in persons with intolerance or inadequate response to traditional treatment modalities, including positive airway pressure and mandibular advancement devices. Hypoglossal nerve stimulation is a new treatment option, but few management guidelines exist when it is intolerable or ineffective. Combining several treatment modalities has been an effective strategy for improving symptoms, tolerance, and efficacy. We describe a patient intolerant to positive airway pressure therapy who had continued sleepiness, morning headaches, and snoring with a mandibular advancement device. He underwent hypoglossal nerve stimulation implantation but was intolerant of the voltages required to adequately control his obstructive sleep apnea. Multimodal management with hypoglossal nerve stimulation, mandibular advancement device, and positional therapy was successfully implemented to improve sleepiness, nocturnal symptoms, and the apnea-hypopnea index. This case highlights the personalization and adaptability of combination therapy to suit patient needs while effectively controlling obstructive sleep apnea.

CITATION

Lowery MM, Rundo JV, Walia HK, Shah V. Personalized multimodal management for severe obstructive sleep apnea in a patient intolerant of positive airway pressure with hypoglossal nerve stimulator and mandibular advancement device. J Clin Sleep Med. 2023;19(2):403-408.

OMS residents’ obstructive sleep apnea‐related education, knowledge, and professional behavior: A national survey

OBJECTIVES

Oral and maxillofacial surgeons (OMS) treat adult and pediatric patients with obstructive sleep apnea (OSA). Objective 1 assessed sleep apnea-related education, knowledge, and professional behavior of OMS residents in the United States. Objective 2 was to compare the responses of junior versus senior residents and residents in single- versus dual-degree programs.

METHODS

OMS residents in the United States received a recruitment email with a link to an anonymous online survey; 81 residents responded. The survey included 20 questions to assess respondents' OSA-related education, knowledge, attitudes, and professional behavior.

RESULTS

Respondents generally agreed that they had received OSA-related didactic-based education (5-point scale with "5" = agree strongly: mean = 3.62) and clinical training (mean = 3.75). Clinical and classroom educational gaps were identified in relation to treatment with oral appliances and hypoglossal nerve stimulation. The residents scored on average 10.38 out of 18 (58%) possible correct answer points for the knowledge questions. Findings about pediatric OSA suggest that only 43.8% of residents understand diagnostic criteria for pediatric OSA, with only 26.6% screening pediatric patients for OSA. A case analysis showed that only 1.5% of residents correctly identified an apnea-hypopnea index of 17 as moderate sleep apnea.

CONCLUSION(S)

This survey found knowledge gaps in several areas that can be improved upon. It identifies deficiency in objective knowledge about OSA among OMS residents and a specific lack of clinical training and confidence with hypoglossal nerve stimulation and management of pediatric patients with OSA. Junior and senior residents and single- and dual-degree residents showed no statistically significant differences in any category except senior residents in regard to surgical management of OSA, particularly with maxillomandibular advancement.

Impact of Body Mass Index and Discomfort on Upper Airway Stimulation: ADHERE Registry 2020 Update

OBJECTIVES/HYPOTHESIS

To provide the ADHERE registry Upper Airway Stimulation (UAS) outcomes update, including analyses grouped by body mass index (BMI) and therapy discomfort.

STUDY DESIGN

Prospective observational study.

METHODS

ADHERE captures UAS outcomes including apnea-hypopnea index (AHI), Epworth sleepiness scale (ESS), therapy usage, patient satisfaction, clinician assessment, and safety over a 1-year period. BMI ≤32 kg/m² (BMI₃₂ ) and 32 < BMI ≤35 kg/m² (BMI₃₅ ) group outcomes were examined.

RESULTS

One thousand eight hundred forty-nine patients enrolled in ADHERE, 1,019 reached final visit, 843 completed the visit. Significant changes in AHI (-20.9, P < .0001) and ESS (- 4.4, P < .0001) were demonstrated. Mean therapy usage was 5.6 ± 2.2 hr/day. Significant therapy use difference was present in patients with reported discomfort versus no discomfort (4.9 ± 2.5 vs. 5.7 ± 2.1 hr/day, P = .01). Patients with discomfort had higher final visit mean AHI versus without discomfort (18.9 ± 18.5 vs. 13.5 ± 13.7 events/hr, P = .01). Changes in AHI and ESS were not significantly different. Serious adverse events reported in 2.3% of patients. Device revision rate was 1.9%. Surgical success was less likely in BMI₃₅ versus BMI₃₂ patients (59.8% vs. 72.2%, P = .02). There was a significant therapy use difference: 5.8 ± 2.0 hr/day in BMI₃₂ versus 5.2 ± 2.2 hr/day in BMI₃₅ (P = .028).

CONCLUSIONS

Data from ADHERE demonstrate high efficacy rates for UAS. Although surgical response rate differs between BMI₃₂ and BMI₃₅ patient groups, the AHI and ESS reduction is similar. Discomfort affects therapy adherence and efficacy. Thus, proper therapy settings adjustment to ensure comfort is imperative to improve outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2616-2624, 2021.

Hypoglossal Nerve Stimulation Usage by Therapy Nonresponders

OBJECTIVE

The purpose of this study is to examine differences in therapy usage and outcomes of therapy between responder (R) and nonresponder (NR) groups in an international, multicenter prospective registry of patients undergoing hypoglossal nerve stimulation for obstructive sleep apnea (OSA).

STUDY DESIGN

Database analysis (level III).

SETTING

International, multicenter registry.

METHODS

The studied registry prospectively collects data pre- and postimplantation, including sleep parameters, Epworth score, patient experience, and safety questions, over the course of 12 months. Patients are defined as a "responder" based on Sher criteria, which require a final apnea-hypopnea index (AHI) of ≤20 and a final AHI reduction of >50% at their 12-month follow-up.

RESULTS

Overall, there were 497 (69%) R and 220 (31%) NR. Most patients in both groups experienced improvement in quality of life following implantation (96% of R; 77% of NR) with reductions in oxygen desaturation index and Epworth score. At final follow-up, the R group demonstrated significantly better adherence to recommended therapy (>4 hours/night) (P = .001), average hours of nightly use (P = .001), final Epworth scores (P = .001), and degree of subjective improvement (P < .001).

CONCLUSION

Patients classified as NR to upper airway stimulation continue to use therapy with improvement in percent time of sleep with O₂ <90%, reduction in daytime sleepiness, and improvement in quality of life. Therefore, ongoing usage of the device should be encouraged in NR patients who note improvement while integrating additional strategies to lower the long-term effects of OSA.

Obstructive Sleep Apnea: Non-positive Airway Pressure Treatments

Undiagnosed and untreated obstructive sleep apnea (OSA) is associated with health comorbidities and negatively affects quality of life. Alternative treatments should be considered in patients who are unable to tolerate or benefit from positive airway pressure treatment. When properly indicated, positional devices, oral appliances, airway surgery, and hypoglossal nerve stimulation have been shown to be effective in treating OSA. Hypoglossal nerve stimulation is a successful second-line treatment with low associated morbidity and complication rate.

Post-implant care pathway: lessons learned and recommendations after 5 years of clinical implementation of hypoglossal nerve stimulation therapy

Hypoglossal nerve stimulation (HNS) therapy is now an established and widely-available obstructive sleep apnea (OSA) treatment alternative for continuous positive airway pressure (CPAP)-intolerant patients. Additionally, the HNS body of literature is robust with strong data on safety, efficacy, and durability-from the 5-year STAR Trial outcomes, to post-approval studies of independent institutions, to the multicenter ADHERE registry which recently reported outcomes on over 1,000 patients and is poised to enroll 5,000 HNS patients total. Nevertheless, now with thousands of implanted patients across hundreds of certified centers, and that number growing rapidly, the post-implant management of the HNS patient represents the next critical frontier. Post-implant patient management (therapy titration, troubleshooting, adjustments, and adherence monitoring) across a longitudinal care model is key to ensuring long-term therapy success and optimizing patient outcomes and health benefits. As with CPAP, patient education and close clinical monitoring are often essential to successful long-term management. Although many HNS patients are clear responders with excellent comfort and adherence as well as effective improvement in symptomatic and objective outcome measures, and even a smaller subset is clear non-responders, there is a growing body of patients somewhere in the middle: good outcomes but not great; partial but incomplete response. These are the patients in whom a standardized best-practice approach to treatment monitoring and targeted therapy modifications is likely critical to optimizing long-term outcomes.

Use of overnight pulse oximetry and a type 3 sleep study to titrate hypoglossal nerve stimulation therapy

NONE

This is a case series of 3 patients with moderate-severe OSA who were PAP-intolerant and underwent implantation of the hypoglossal nerve stimulator. All patients recorded baseline overnight pulse oximetry without the hypoglossal nerve stimulator and at least 1 night at each hypoglossal nerve stimulator setting as they up-titrated the device at home. Because of the impact of the novel coronavirus on sleep laboratories, all patients proceeded directly to type 3 sleep studies performed at a single setting determined by a combination of self-reported improvement and pulse oximetry data.

Development of a Clinical Pathway and Technical Aspects of Upper Airway Stimulation Therapy for Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease with high morbidity and related mortality. Narrowing and collapse of the pharyngeal airway during sleep characterize the disease, resulting in a decrease (hypopnea) or a complete cessation (apnea) of oronasal airflow. Upper airway stimulation (UAS), using electrical neurostimulation of the hypoglossal nerve (n. XII) synchronized with ventilation, is a novel, evolving treatment option. UAS was found to be an effective treatment in CPAP-intolerant patients. The treatment success is partly due to the strict selection of the patients, based on previous findings. Furthermore, post-operative follow-up is needed in order to maintain or improve treatment outcome. Therefore, a clinical pathway, which provides structure and standardization, is crucial. In this paper, the aim is to discuss the technical aspects of UAS therapy and to describe a clinical pathway to organize the care process of UAS for OSA in a structured and standardized way.

Upper Airway Stimulation for Obstructive Sleep Apnea: Patient-Reported Outcomes after 48 Months of Follow-up

Objective To assess patient-based outcomes of participants in a large cohort study-the STAR trial (Stimulation Therapy for Apnea Reduction)-48 months after implantation with an upper airway stimulation system for moderate to severe obstructive sleep apnea. Study Design A multicenter prospective cohort study. Setting Industry-supported multicenter academic and clinical setting. Subjects Participants (n = 91) at 48 months from a cohort of 126 implanted participants. Methods A total of 126 participants received an implanted upper airway stimulation system in a prospective phase III trial. Patient-reported outcomes at 48 months, including Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), and snoring level, were compared with preimplantation baseline. Results A total of 91 subjects completed the 48-month visit. Daytime sleepiness as measured by ESS was significantly reduced ( P = .01), and sleep-related quality of life as measured by FOSQ significantly improved ( P = .01) when compared with baseline. Soft to no snoring was reported by 85% of bed partners. Two patients required additional surgery without complication for lead malfunction. Conclusion Upper airway stimulation maintained a sustained benefit on patient-reported outcomes (ESS, FOSQ, snoring) at 48 months in select patients with moderate to severe obstructive sleep apnea.

Annual review of selected scientific literature: Report of the committee on scientific investigation of the American Academy of Restorative Dentistry

STATEMENT OF PROBLEM

It is clear the contemporary dentist is confronted with a blizzard of information regarding materials and techniques from journal articles, advertisements, newsletters, the internet, and continuing education events. While some of that information is sound and helpful, much of it is misleading at best.

PURPOSE

This review identifies and discusses the most important scientific findings regarding outcomes of dental treatment to assist the practitioner in making evidence-based choices. This review was conducted to assist the busy dentist in keeping abreast of the latest scientific information regarding the clinical practice of dentistry.

MATERIAL AND METHODS

Each of the authors, who are considered experts in their disciplines, was asked to peruse the scientific literature published in 2015 in their discipline and review the articles for important information that may have an impact on treatment decisions. Comments on experimental methodology, statistical evaluation, and overall validity of the conclusions are included in many of the reviews.

RESULTS

The reviews are not meant to stand alone but are intended to inform the interested reader about what has been discovered in the past year. The readers are then invited to go to the source if they wish more detail.

CONCLUSIONS

Analysis of the scientific literature published in 2015 is divided into 7 sections, dental materials, periodontics, prosthodontics, occlusion and temporomandibular disorders, sleep-disordered breathing, cariology, and implant dentistry.

Novel Surgical Approaches for the Treatment of Obstructive Sleep Apnea

Novel approaches to upper airway anatomic phenotyping, more reconstructive upper airway surgical techniques, and new implantable hypoglossal neurostimulation technology have very favorable potential to improve symptoms and quality-of-life measures, to reduce obstructive sleep apnea (OSA) disease severity and associated cardiovascular risk, and to serve as an adjunct to continuous positive airway pressure, oral appliances, and other forms of OSA medical therapy. Successful surgical therapy depends critically on accurate diagnosis, skillful knowledge and examination of the upper airway anatomy, proper procedure selection, and proficient technical application.