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Ratneswaran D, Cheng M, Nasser E, Madula R, Pengo M, Hope K, Schwarz EI, Luo Y, Kaltsakas G, Polkey MI, Moxham J, Steier J. Domiciliary transcutaneous electrical stimulation in patients with obstructive sleep apnoea and limited adherence to continuous positive airway pressure therapy: a single-centre, open-label, randomised, controlled phase III trial. EClinicalMedicine 2023; 62:102112. [PMID: 37654667 PMCID: PMC10466238 DOI: 10.1016/j.eclinm.2023.102112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 09/02/2023] Open
Abstract
Background Hypoglossal nerve stimulation (HNS) for obstructive sleep apnoea (OSA) is a novel way to manage the condition. We hypothesised that in patients with OSA and limited adherence to continuous positive airway pressure (CPAP) therapy, domiciliary transcutaneous electrical stimulation (TESLA) would control sleep apnoea and provide health benefits. Methods We undertook a single-centre, open-label, randomised, controlled phase III trial in patients with OSA (apnoea-hypopnoea-index [AHI] 5-35 h-1), a BMI of 18.5-32 kg∗m-2, and a documented lack of adherence to CPAP therapy (<4 h∗night-1) at Guy's & St Thomas' NHS Foundation Trust (hospital), UK. Patients were randomly assigned (1:1) using minimisation (gender and OSA severity) to receive TESLA or usual care (CPAP) for at least 3 months; sleep study analysis was provided without knowledge of the assignment arm. The primary outcome was change in AHI at 3-months. The primary outcome and safety were analysed in the intention-to-treat population. Data are reported as median (interquartile range), unless otherwise explained. This trial is registered at ClinicalTrials.gov, NCT03160456. Findings Between 6 June 2018 and 7 February 2023, 56 participants were enrolled and randomly assigned (29 patients in the intervention group and 27 in the usual care group). Patients were followed up for a median of 3.0 months (IQR 3.0; 10.0). The groups were similar in terms of age (55.8 (48.2; 66.0) vs 59.3 (47.8; 64.4) years), gender (male:female, 19:10 vs 18:9) and BMI (28.7 (26.4; 31.9) vs 28.4 (24.4; 31.9) kg∗m-2). The unadjusted group difference in the Δ AHI was -11.5 (95% CI -20.7; -2.3) h-1 (p = 0.016). Adjusted for the baseline value, the difference was Δ AHI -7.0 (-15.7; 1.8) h-1 (p = 0.12), in favour of the intervention. Minor adverse events were found in one of the participants who developed mild headaches related to the intervention. Interpretation Domiciliary TESLA can be used safely and effectively in OSA patients with poor adherence to CPAP, with favourable impact on sleepiness and sleep fragmentation. Despite pandemic-related limitations of the amended protocol this trial provides the evidence that TESLA improves clinically meaningful outcomes over the observed follow up period, and the transcutaneous approach is likely to offer an affordable alternative for responders to electrical stimulation in clinical practice. Funding British Lung Foundation, United Kingdom Clinical Research Collaboration-registered King's Clinical Trials Unit at King's Health Partners.
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Affiliation(s)
- Deeban Ratneswaran
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Michael Cheng
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Ebrahim Nasser
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
| | - Rajiv Madula
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Martino Pengo
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
- Istituto Auxologico Italiano IRCCS, University of Milan, Milan, Italy
| | - Kath Hope
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
- Hope2Sleep Patient Charity, Hull, UK
| | - Esther I. Schwarz
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
- Department of Pulmonology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Yuanming Luo
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Georgios Kaltsakas
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Michael I. Polkey
- Royal Brompton & Harefield Campus, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - John Moxham
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
| | - Joerg Steier
- Faculty of Life Sciences and Medicine, King’s College London, Centre for Human & Applied Physiological Sciences, London, UK
- Lane Fox Unit/Sleep Disorders Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
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Gruenberg E, Cooper J, Zamora T, Stepnowsky C, Vahabzadeh-Hagh AM, Malhotra A, Nokes B. Beyond CPAP: modifying upper airway output for the treatment of OSA. Front Neurol 2023; 14:1202271. [PMID: 37545734 PMCID: PMC10403235 DOI: 10.3389/fneur.2023.1202271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
Obstructive Sleep Apnea (OSA) is exceedingly common but often under-treated. Continuous positive airway pressure (CPAP) has long been considered the gold standard of OSA therapy. Limitations to CPAP therapy include adherence and availability. The 2021 global CPAP shortage highlighted the need to tailor patient treatments beyond CPAP alone. Common CPAP alternative approaches include positional therapy, mandibular advancement devices, and upper airway surgery. Upper airway training consists of a variety of therapies, including exercise regimens, external neuromuscular electrical stimulation, and woodwind instruments. More invasive approaches include hypoglossal nerve stimulation devices. This review will focus on the approaches for modifying upper airway muscle behavior as a therapeutic modality in OSA.
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Affiliation(s)
- Eli Gruenberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Jessica Cooper
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Tania Zamora
- Health Services Research and Development, Veteran's Affairs (VA) San Diego Healthcare System, San Diego, CA, United States
| | - Carl Stepnowsky
- Health Services Research and Development, Veteran's Affairs (VA) San Diego Healthcare System, San Diego, CA, United States
| | - Andrew M. Vahabzadeh-Hagh
- Department of Otolaryngology—Head and Neck Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Brandon Nokes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, United States
- Sleep Section at the Veteran's Affairs (VA) San Diego Healthcare System, San Diego, CA, United States
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Wu X, Zhao D, Hu W, Zheng Z, Zha S, Zhang Q, Hu K. Randomised, controlled crossover trial of intermittent and continuous transcutaneous electrical stimulation of the genioglossus muscle for obstructive sleep apnoea. Thorax 2023; 78:713-720. [PMID: 36690924 DOI: 10.1136/thorax-2021-218277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 08/13/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Continuous transcutaneous electrical stimulation (CTES) of the genioglossus muscle may benefit patients with obstructive sleep apnoea (OSA). However, the therapeutic value of intermittent transcutaneous electrical stimulation (ITES) for OSA is unclear. METHODS This was a randomised, controlled, crossover study to compare the effects of ITES and CTES of the genioglossus muscle. Over three single-night sessions, participants were alternately subjected to three genioglossus stimulation modalities during sleep (sham, CTES and ITES). The apnoea-hypopnoea index (AHI) and oxygen desaturation index (ODI) were used for OSA diagnosis and to evaluate efficacy. A responder was defined as an individual with a ≥50% reduction in AHI together with <10 AHI events per hour and/or an ODI reduction of ≥25% between sham stimulation and electrical stimulation nights. RESULTS Fifteen men with OSA completed the study. Compared with sham, the median AHI with ITES decreased by 13.3 events/hour (95% CI 3.1 to 23.5, p=0.030) and by 7.3 events/hour (95% CI -3.9 to 18.5, p=0.825) with CTES. The median ODI was reduced by 9.25 events/hour (95% CI 0.5 to 18.0) with ITES and 3.3 events/hour (95% CI -5.6 to 12.2) with CTES; however, there was no significant difference between groups. Furthermore, ITES outperformed CTES with respect to longest apnoea duration (median (95% CI), 9.5 (0.0 to 19.0), p=0.011)) and the highest sleep efficiency (12.2 (2.7 to 21.7), p=0.009). Of the 15 participants, 8 responded to ITES and 3 responded to CTES (p=0.058), of whom all eight cases and two out of three cases had ODIs <5 events/hour, respectively. All participants tolerated ITES well. CONCLUSIONS ITES improved upper airway obstruction in patients with OSA, suggesting that further prospective validation of the intermittent approach is warranted. TRIAL REGISTRATION NUMBER ChiCTR2100050138.
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Affiliation(s)
- Xiaofeng Wu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Dong Zhao
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Weihua Hu
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhishui Zheng
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Shiqian Zha
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qingfeng Zhang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Ke Hu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
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Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
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Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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Nasser E, Ratneswaran D, Alsharifi A, Williams AJ, Steier J. Transcutaneous electrical stimulation in obstructive sleep apnoea: current developments and concepts of the TESLA-home programme. Curr Opin Pulm Med 2022; 28:529-536. [PMID: 35993267 DOI: 10.1097/mcp.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Obstructive sleep apnoea (OSA) is a highly prevalent condition affecting about 1 billion people worldwide. The first line therapy for most patients with OSA is continuous positive airway pressure (CPAP) therapy. However, there are significant limitations with long-term adherence to CPAP therapy, which may be as low as 30-60%. RECENT FINDING Electrical stimulation of the hypoglossal nerve has been studied in recent years. It achieves upper airway patency by causing a contraction of the genioglossus muscle, the strongest dilator of the upper airway, and by maintaining its neuromuscular tone in the asleep patient with OSA. Electrical stimulation can be delivered invasively, hypoglossal nerve stimulation (HNS), and noninvasively, transcutaneous electrical stimulation in OSA (TESLA). However, randomised controlled trials, the STAR and the TESLA trial, have provided promising results on efficacy and safety of the methods. SUMMARY Patient and public involvement underlines the interest in TESLA and HNS and highlights the need to provide non-CPAP therapeutic options to those who may find it difficult to cope with first line therapies. The relatively low costs and the favourable safety profile of the TESLA approach provide the chance to offer this treatment to patients with OSA following further development of the evidence.
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Affiliation(s)
- Ebrahim Nasser
- Lane Fox Unit, Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Deeban Ratneswaran
- Lane Fox Unit, Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Adrian J Williams
- Lane Fox Unit, Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust
| | - Joerg Steier
- Lane Fox Unit, Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Randerath W, de Lange J, Hedner J, Ho JPT, Marklund M, Schiza S, Steier J, Verbraecken J. Current and Novel Treatment Options for OSA. ERJ Open Res 2022; 8:00126-2022. [PMID: 35769417 PMCID: PMC9234427 DOI: 10.1183/23120541.00126-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/24/2022] [Indexed: 12/03/2022] Open
Abstract
Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy. The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd
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Arachchige MA, Steier J. Beyond Usual Care: A Multidisciplinary Approach Towards the Treatment of Obstructive Sleep Apnoea. Front Cardiovasc Med 2022; 8:747495. [PMID: 35071340 PMCID: PMC8767108 DOI: 10.3389/fcvm.2021.747495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/14/2021] [Indexed: 01/16/2023] Open
Abstract
Obstructive Sleep Apnoea (OSA) is common and characterised by repeated apnoeas and hypopnoeas while asleep due to collapse of the upper airway. OSA can have a significant impact on physical and mental health and, when left untreated, is associated with increased risk of developing cardiovascular ill health. Besides cardiorespiratory implications excessive daytime sleepiness, morning headaches, limited memory function and lack of concentration are some further symptoms caused by OSA. Continuous Positive Airway Pressure (CPAP) therapy is the evidence-based treatment to maintain upper airway patency in patients with moderate to severe OSA. Proper adherence to CPAP therapy successfully abolishes nocturnal apnoeas and hypopnoeas, and diminishes consequences of uncontrolled OSA, such as treatment resistant hypertension. However, long term adherence to CPAP remains an unresolved limitation of this method. Although alternatives to CPAP therapy may be less efficacious, there is a variety of non-CPAP treatments that includes conventional lifestyle advice, postural advice, the use of mandibular advancement devices (MADs), surgical treatment options, such as uvulopalatopharyngoplasty, tonsillectomy, or maxillomandibular advancement, and the use of electrical stimulation of the upper airway dilator muscles. Hypoglossal Nerve Stimulation is available as an invasive (HNS) and a transcutaneous (TESLA) approach. For the management of “difficult-to-treat” patients with OSA, particularly in those in whom first line therapy proved to be unsuccessful, a multidisciplinary team approach may be helpful to incorporate the available options of non-CPAP therapy and provide appropriate choices. Symptom control, patient-related outcome measures and long-term cardiovascular health should be prioritised when choosing long-term therapies to treat OSA. The inclusion of patients in the choice of successful management options of their condition will facilitate better long-term adherence. Advancing clinical trials in the field will further help to resolve the relative lack of evidence for effective non-CPAP methods.
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Affiliation(s)
| | - Joerg Steier
- CHAPS, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.,Lane Fox Unit/Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Abstract
Epidemiological studies show a steady rise in the prevalence of obstructive sleep apnea (OSA). Untreated OSA is responsible for numerous chronic health conditions, motor vehicle, and workplace-related accidents leading to substantial economic burden both to the individual and society. Multiple causes for OSA and a wide range of consequences has made its diagnosis and treatment difficult. Obstructive sleep apnea may be caused by anatomical variation, increased collapsibility of the upper airway, low sleep arousal threshold, and exaggerated response to desaturation. Lifestyle changes, anatomical corrective surgeries, and oral appliances have been used but patient compliance is poor as it interferes in the daily routine. Neuromodulation is a promising functional modifying option that addresses the cause of obstructive sleep apnea at multiple levels.
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Affiliation(s)
- Vikas Naik
- Department of Neurosurgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Ninad Khandekar
- Department of Medicine, Government Medical College, Nagpur, Maharashtra, India
| | - Milind Deogaonkar
- Department of Functional Neurosurgery, West Virginia University Health Sciences, WV, USA
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Rodríguez Hermosa JL, Calle M, Guerassimova I, Fernández B, Montero VJ, Álvarez-Sala JL. Noninvasive electrical stimulation of oropharyngeal muscles in obstructive sleep apnea. Expert Rev Respir Med 2021; 15:1447-1460. [PMID: 34038311 DOI: 10.1080/17476348.2021.1935244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Continuous positive airway pressure (CPAP) therapy remains the standard treatment for obstructive sleep apnea. However, its proven effect is useless if the patient does not tolerate the treatment. The electrical stimulation approach has been investigated for several decades now and it seems that the implantable devices for invasive electrical stimulation of hypoglossal nerve are viewed as effective with some of them already approved for human use.Areas covered: in this review, we intent to summarize the existing records of noninvasive stimulation in sleep apnea to make the scientific community aware of the details before deciding on its future. We believe that this is a battle still to fight and more could be done bearing in mind the safety of this method.Expertopinion: noninvasive electrical stimulation has been left behind based on few, small and inconsistent studies using different stimulation parameters. These studies are difficult to compare and to draw conclusions.Electrical stimulation is a field for research in the treatment of obstructive sleep apnea, with many aspects still to be discovered, and which may become a therapeutic alternative to the use of CPAP in certain patients.
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Affiliation(s)
- Juan Luis Rodríguez Hermosa
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Myriam Calle
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | - Ina Guerassimova
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
| | | | - Víctor Javier Montero
- Torytrans SL, Innovative and technological-based company, Almagro, Ciudad Real, Spain
| | - José Luis Álvarez-Sala
- Pneumology Department. Hospital Clínico San Carlos. School of Medicine, Complutense University, Madrid, Spain
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Kotecha B, Wong PY, Zhang H, Hassaan A. A novel intraoral neuromuscular stimulation device for treating sleep-disordered breathing. Sleep Breath 2021; 25:2083-2090. [PMID: 33772397 PMCID: PMC8590646 DOI: 10.1007/s11325-021-02355-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/06/2021] [Accepted: 03/19/2021] [Indexed: 11/25/2022]
Abstract
Purpose To ascertain the usefulness of a novel intraoral neuromuscular stimulation device in treating patients with primary snoring and mild obstructive sleep apnoea (OSA). This device uses daytime awake neuromuscular electrical stimulation (NMES) as an application to induce toning of the tongue muscles. Methods A prospective cohort study of 70 patients with sleep-disordered breathing was conducted. Objective snoring and respiratory parameters were recorded with 2 consecutive night WatchPat sleep studies before and after treatment. The device was used for 20 min once daily for a 6-week period. Secondary outcome measures using visual analogue scale reporting of snoring by patient and Epworth Sleepiness Score (ESS) were recorded. Quality of life parameters were also noted. Results Objective reduction of snoring was noted on the sleep studies in 95% of participants, with an average snoring time reduction of 48%. Subjectively, the visual analogue scale reported by partners’ similarly demonstrated reduction in 95% of the patients with an average reduction of 40%. In a subset of 38 patients with mild OSA, AHI reduced from 9.8 to 4.7/h (52% reduction), ODI 7.8 to 4.3/h (45% reduction), and ESS from 9.0 to 5.1. Adverse effects encountered were minimal. Conclusion This prospective cohort study demonstrates a notable improvement in both objective and subjective parameters of snoring and mild OSA in both simple snorers and patients with mild OSA. This device offers a safe and novel approach to reduce snoring and mild OSA by utilising intraoral neuromuscular electrical stimulation. This could be a preferred option for patients as it alleviates the need of using an oral device during sleep. Trial registration clinicaltrials.gov identifier NCT03829956
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Affiliation(s)
- Bhik Kotecha
- Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Rom Valley Way, Romford, Essex, RM7 0AG UK
| | - Phui Yee Wong
- Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Rom Valley Way, Romford, Essex, RM7 0AG UK
| | - Henry Zhang
- Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Rom Valley Way, Romford, Essex, RM7 0AG UK
| | - Amro Hassaan
- Queen’s Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, Rom Valley Way, Romford, Essex, RM7 0AG UK
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Al-Sherif M, He B, Schwarz EI, Cheng M, Said AF, AbdelWahab NH, Refat N, Luo Y, Ratneswaran D, Steier J. Ultrasound assessment of upper airway dilator muscle contraction during transcutaneous electrical stimulation in patients with obstructive sleep apnoea. J Thorac Dis 2020; 12:S139-S152. [PMID: 33214919 PMCID: PMC7642638 DOI: 10.21037/jtd-cus-2020-001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Electrical current can be used to stimulate upper airway dilator muscles to treat obstructive sleep apnoea (OSA). Ultrasound devices are widely available and may be used to detect contraction of the upper airway dilator muscles assessing the functionality of electrical stimulation (ES) used for this treatment. Methods In a physiological sub-study of a randomised controlled trial, patients with OSA underwent ultrasound examination to assess contraction of the upper airway dilator muscles in response to transcutaneous ES. Ultrasound scans were scored according to the picture quality (poor = '0', acceptable = '1' and good = '2'). Tongue base thickness was assessed in mid-sagittal and coronal planes with (D2, A2) and without ES (D1, A1), while awake and seated. The primary outcome was to determine the increase in tongue thickness during ES in both views (D2 - D1 = ΔD), as well as any increase in the cross-sectional area (CSA) in the coronal view (A2 - A1 = ΔA). Data were presented as mean and standard deviation (SD). Results Fourteen patients [eight male, age 57.5 (9.8) years, body mass index (BMI) 29.5 (2.8) kg/m2] with OSA [Apnea-Hypopnea Index (AHI) 19.5 (10.6) × hour-1] were studied. Quality of the ultrasound scans was acceptable or good with 1.5 (0.5) points. In the mid-sagittal plane, ΔD was +0.17 (0.07) cm in midline and +0.21 (0.09) cm in the widest diameter, a percentual change of 12.2% (4%) and 12.8% (5.2%) (P<0.001, respectively). In the coronal plane, ΔD was +0.17 (0.04) cm, an increase of 12.3% (4.6%) (P<0.001, respectively), ΔA in the CSA increased by +18.9% (3.0%) with stimulation (P<0.001). There was a negative correlation between age and ΔA (r= -0.6, P=0.03), but no significant associations were found with gender, BMI, neck circumference, Epworth Sleepiness Scale (ESS), AHI, skin and subcutaneous tissue in the submental area. Conclusions Ultrasound can visualise upper airway dilator muscle contraction during transcutaneous ES in awake patients with OSA. Contraction is best detected in the CSA of the tongue base in the coronal plane.
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Affiliation(s)
- Miral Al-Sherif
- Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Centre of Human and Applied Physiological Sciences (CHAPS), Faculty of Life Sciences and Medicine, King's College London, London, UK.,Department of Respiratory Medicine, Minia University, Minia, Egypt
| | - Baiting He
- Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Centre of Human and Applied Physiological Sciences (CHAPS), Faculty of Life Sciences and Medicine, King's College London, London, UK.,Key National Laboratory for Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Esther Irene Schwarz
- Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Department of Pulmonology and Sleep Disorders Centre, University Hospital Zurich, Zurich, Switzerland
| | - Michael Cheng
- Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Centre of Human and Applied Physiological Sciences (CHAPS), Faculty of Life Sciences and Medicine, King's College London, London, UK.,Department of Respiratory Medicine University of Sydney, Sydney, Australia
| | - Azza Farag Said
- Department of Respiratory Medicine, Minia University, Minia, Egypt
| | | | - Nezar Refat
- Department of Respiratory Medicine, Minia University, Minia, Egypt
| | - Yuanming Luo
- Centre of Human and Applied Physiological Sciences (CHAPS), Faculty of Life Sciences and Medicine, King's College London, London, UK.,Key National Laboratory for Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Deeban Ratneswaran
- Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Centre of Human and Applied Physiological Sciences (CHAPS), Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Joerg Steier
- Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.,Centre of Human and Applied Physiological Sciences (CHAPS), Faculty of Life Sciences and Medicine, King's College London, London, UK
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12
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Ratneswaran D, Guni A, Pengo MF, Al-Sherif M, He B, Cheng MC, Steier J, Schwarz EI. Electrical stimulation as a therapeutic approach in obstructive sleep apnea - a meta-analysis. Sleep Breath 2020; 25:207-218. [PMID: 32388780 DOI: 10.1007/s11325-020-02069-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/23/2020] [Accepted: 03/19/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Electrical stimulation of the upper airway dilator muscles is an emerging treatment for obstructive sleep apnea (OSA). Invasive hypoglossal nerve stimulation (HNS) has been accepted as treatment alternative to continuous positive airway pressure (CPAP) for selected patients, while transcutaneous electrical stimulation (TES) of the upper airway is being investigated as non-invasive alternative. METHODS A meta-analysis (CRD42017074674) on the effects of both HNS and TES on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) in OSA was conducted including published evidence up to May 2018. Random-effects models were used. Heterogeneity and between-study variance were assessed by I2 and τ2, respectively. RESULTS Of 41 identified clinical trials, 20 interventional trials (n = 895) could be pooled in a meta-analysis (15 HNS [n = 808], 5 TES [n = 87]). Middle-aged (mean ± SD 56.9 ± 5.5 years) and overweight (body mass index 29.1 ± 1.5 kg/m2) patients with severe OSA (AHI 37.5 ± 7.0/h) were followed-up for 6.9 ± 4.0 months (HNS) and 0.2 ± 0.4 months (TES), respectively. The AHI improved by - 24.9 h-1 [95%CI - 28.5, - 21.2] in HNS (χ2 79%, I2 82%) and by - 16.5 h-1 [95%CI - 25.1, - 7.8] in TES (χ2 7%, I2 43%; both p < 0.001). The ESS was reduced by - 5.0 (95%CI - 5.9, - 4.1) (p < 0.001). CONCLUSION Both invasive and transcutaneous electrical stimulation reduce OSA severity by a clinically relevant margin. HNS results in a clinically relevant improvement of symptoms. While HNS represents an invasive treatment for selected patients with moderate to severe OSA, TES should be further investigated as potential non-invasive approach for OSA.
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Affiliation(s)
- Deeban Ratneswaran
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.
| | - Ahmad Guni
- Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Martino F Pengo
- Department of Cardiovascular, Sleep Disorder Centre, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Miral Al-Sherif
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Baiting He
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK
| | - Michael Cf Cheng
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK
| | - Joerg Steier
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Esther I Schwarz
- Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK. .,Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, 8091, Zurich, Switzerland.
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13
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Byun YJ, Yan F, Nguyen SA, Lentsch EJ. Transcutaneous Electrical Stimulation Therapy in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2020; 163:645-653. [PMID: 32366179 DOI: 10.1177/0194599820917631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with obstructive sleep apnea (OSA). DATA SOURCES Primary studies were identified though PubMed, Scopus, OVID, and Cochrane Library. REVIEW METHODS Systematic review was conducted by querying databases for articles published through July 2019. The search identified randomized controlled trial, randomized comparison, or observational studies pertaining to TENS treatment for OSA. Meta-analysis was performed on pre- and posttreatment apnea-hypopnea index (AHI), mean oxygen saturation (SaO2), lowest oxygen saturation (LSAT), and arousal index (AI). RESULTS Literature search identified 10 studies that reported sufficient outcome measures to be considered for analysis. A total of 198 patients were identified with a mean age of 50.9 years with a male to female ratio of 1.6:1. Average body mass index (BMI) of the cohort was 29.8 kg/m2. Treatment with TENS demonstrated reduction in AHI by 12.9 points (95% confidence interval, -22.3 to -3.43; P = .008). The mean differences in SaO2, LSAT, and AI did not reach statistical significance. CONCLUSION The TENS treatment of upper airway dilator muscles resulted in reduction of AHI in patients with OSA. However, its effects on SaO2, LSAT, and AI were equivocal. Its impact on patients' quality of life could not be assessed due to heterogeneity in outcome measures. Future randomized controlled trials with generalizable standardized outcome measures are needed to assess the efficacy and compliance of TENS.
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Affiliation(s)
- Young Jae Byun
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Flora Yan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric J Lentsch
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Abstract
IMPORTANCE Obstructive sleep apnea (OSA) affects 17% of women and 34% of men in the US and has a similar prevalence in other countries. This review provides an update on the diagnosis and treatment of OSA. OBSERVATIONS The most common presenting symptom of OSA is excessive sleepiness, although this symptom is reported by as few as 15% to 50% of people with OSA in the general population. OSA is associated with a 2- to 3-fold increased risk of cardiovascular and metabolic disease. In many patients, OSA can be diagnosed with home sleep apnea testing, which has a sensitivity of approximately 80%. Effective treatments include weight loss and exercise, positive airway pressure, oral appliances that hold the jaw forward during sleep, and surgical modification of the pharyngeal soft tissues or facial skeleton to enlarge the upper airway. Hypoglossal nerve stimulation is effective in select patients with a body mass index less than 32. There are currently no effective pharmacological therapies. Treatment with positive airway pressure lowers blood pressure, especially in patients with resistant hypertension; however, randomized clinical trials of OSA treatment have not demonstrated significant benefit on rates of cardiovascular or cerebrovascular events. CONCLUSIONS AND RELEVANCE OSA is common and the prevalence is increasing with the increased prevalence of obesity. Daytime sleepiness is among the most common symptoms, but many patients with OSA are asymptomatic. Patients with OSA who are asymptomatic, or whose symptoms are minimally bothersome and pose no apparent risk to driving safety, can be treated with behavioral measures, such as weight loss and exercise. Interventions such as positive airway pressure are recommended for those with excessive sleepiness and resistant hypertension. Managing asymptomatic OSA to reduce cardiovascular and cerebrovascular events is not currently supported by high-quality evidence.
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Affiliation(s)
- Daniel J Gottlieb
- Medical Service, VA Boston Healthcare System, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Naresh M Punjabi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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15
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Pengo M, Schwarz EI, Steier J. Electrical stimulation in obstructive sleep apnoea: the less invasive the better? Eur Respir J 2020; 55:55/2/1902013. [DOI: 10.1183/13993003.02013-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/17/2019] [Indexed: 11/05/2022]
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Baptista PM, Costantino A, Moffa A, Rinaldi V, Casale M. Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: Patient Selection and New Perspectives. Nat Sci Sleep 2020; 12:151-159. [PMID: 32104122 PMCID: PMC7026121 DOI: 10.2147/nss.s221542] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Hypoglossal nerve stimulation (HNS) is an increasingly widespread OSA treatment. It is a non-anatomical modifying surgery able to achieve an adequate objective and subjective result with a reasonable complication rate. HNS exploits the neurostimulation to reduce upper airway collapsibility providing a multilevel upper airway improvement within a single procedure. Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome. All patient candidates for HNS undergo a standard comprehensive sleep medicine assessment and upper airway surgical examination. Several features should be assessed preoperatively in order to predict patients' response to HNS treatment. In particular, the assessment of OSA severity, BMI > 32 Kg/m2, collapse pattern during drug-induced sleep endoscopy (DISE), and many other parameters, is central for a good patient selection and customization of OSA treatment. HNS is indeed one of the most promising tools in the widespread context of personalized sleep medicine. HNS is an adjustable medical device that could be titrated in order to improve HNS effectiveness, maintaining patient comfort. Moreover, HNS provides the opportunity for patients to play an active role in their own care, with a potential improvement in therapy adherence and efficacy. This review summarizes the current evidence in patient selection for HNS, highlighting the reasons behind the optimistic future of this OSA treatment in the context of personalized medicine.
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Affiliation(s)
- Peter M Baptista
- Department of ORL, Clínica Universidad de Navarra, Pamplona, Spain
| | - Andrea Costantino
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Antonio Moffa
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy.,Department of Otolaryngology, University of Foggia, Foggia, Italy
| | - Vittorio Rinaldi
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
| | - Manuele Casale
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
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