Durability of treatment effects of the Sleep Position Trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial

Positional Treatment of Obstructive Sleep Apnea

Positional sleep apnea (POSA), a distinctive subtype of obstructive sleep apnea, underscores the critical influence of a patient's sleeping position on the severity of their condition. In the management of POSA, compliance with positional therapy (PT) is paramount, as it wields a profound impact on the treatment's efficacy and the overall alleviation of the disease. The advent of new-generation PT devices offers a promising alternative to conventional methods like the tennis ball technique, boasting higher compliance rates and substantial disease alleviation.

Efficacy of Oral Appliance for Mild, Moderate, and Severe Obstructive Sleep Apnea: A Meta-analysis

OBJECTIVE

Oral appliances (OA) are the recommended first-line option for mild-to-moderate obstructive sleep apnea (OSA)-hypopnea. However, there is a lack of evidence to compare the effectiveness of OA in different severities of OSA. The purpose of this study was to investigate the therapeutic effects of preferred OA (tongue retention devices [TRD] and mandibular advancement device [MAD]) in different severities of OSA.

DATA SOURCES

PubMed/MEDLINE, The Cochrane Library, and Web of Science.

REVIEW METHODS

Concentrating on the efficacy of OA, 2 authors searched 3 databases up to November 10, 2022, independently and systematically, following the requirements and steps of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Ultimately, 42 studies with 2265 patients met the criteria for inclusion in OA. Overall, the apnea-hypopnea index improved by 48% (5.6), 67% (14.92), and 62% (32.1) in mild, moderate, and severe OSA, respectively. Subgroup analysis showed a significant difference between MAD and TRD efficacy in mild OSA (58% vs 21%). However, no significant difference was seen between MAD and TRD efficacy in moderate (67% vs 66%) and severe OSA (66% vs 51%). There was no significant difference across groups in the Epworth Sleepiness Scale, oxygen desaturation index (ODI), and lowest oxygen saturation (LSAT).

CONCLUSION

Overall, both TRD and MAD are effective treatments for moderate and severe OSA. MAD is efficacious in mild OSA, while TRD requires further validation. Furthermore, mild-moderate and severe OSA received similar improvements in sleepiness, ODI, and LSAT. This study complements the evidence for the efficacy of OA.

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.

Large variability in definitions of sleep apnea indices used in clinical studies

STUDY OBJECTIVES

We explored the variability of sleep apnea indices and definitions of obstructive sleep apnea in clinical studies of continuous positive airway pressure.

METHODS

In a systematic review of the long-term clinical effects of continuous positive airway pressure, we noted variability across studies in how sleep apnea was defined. We, thus, sought to quantify the heterogeneity.

RESULTS

Across 57 comparative studies of long-term clinical outcomes of continuous positive airway pressure, only 40% fully and explicitly reported their definitions of apnea and hypopnea. Most studies defined apnea as 100% airflow cessation, but a minority used 90% or even down to 75% thresholds. Almost half of the studies defined hypopnea as ≥ 50% airflow cessation, but the majority used 30% or even 25% thresholds. Similarly, about half of the studies used a 4% desaturation threshold to define oxygen desaturation and about half used a 3% threshold, with 2 studies using both thresholds for different purposes. Randomized trials were no more consistent or better-reported than observational studies. Studies that cited published criteria generally reported definitions that were different from the cited criteria.

CONCLUSIONS

The criteria used to define sleep apnea indices (apnea, hypopnea, and oxygen desaturation) were highly variable, even among studies stating that definitions were based on the same standard criteria. It was often difficult to discern the actual criteria used. The great variability across studies and lack of transparency about their sleep study methods hampers the interpretability and utility of the studies and calls into question whether studies are generalizable from one setting to another.

CITATION

Balk EM, Adam GP, D'Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. J Clin Sleep Med. 2024;20(3):461-468.

Endorsement of "European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea" by World Sleep Society

Guidelines for management of sleep disorders from national or regional societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society's (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Task Force reviewed the European Respiratory Society's guideline on non-CPAP therapies for obstructive sleep apnea (OSA) with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. The task force and the WSS guidelines committee endorsed the European Respiratory Society's guideline with respect to the utilization of bariatric surgery, mandibular advancement devices, positioning devices, myofunctional therapy, hypoglossal neurostimulation, maxilo-mandibular surgery, and carbonic anhydrase inhibitors for the treatment of OSA. The task force and the WSS guidelines committee noted that there is substantial new evidence for the role of soft tissue, upper airway surgery, not included in the guidelines paper.

A review of supine position related obstructive sleep apnea: Classification, epidemiology, pathogenesis and treatment

Supine related obstructive sleep apnea (OSA) is the most common clinical and physiological phenotype of OSA. This condition is recognizable by patients, their families and through polysomnographic recordings. Commonly used definitions distinguish the presence of supine related OSA when respiratory events occur at twice the frequency when the patient lies in the supine compared to non-supine sleeping positions. Recent physiology studies have demonstrated that airway obstruction arises more commonly in the supine position particularly at the level of the soft palate and epiglottis. Increased airway collapsibility is reliability observed supine relative to lateral position. To a lesser extent, changes in control of breathing favour less stable ventilation when the supine sleeping posture is adopted. Many treatments have been developed and trialled to help patients avoid sleeping on their back. The last 10 years has seen the emergence of vibrotactile warning devices that are worn on the patients' neck or chest. High quality randomized controlled trial data is accumulating on the efficacy and common pitfalls of the application of these treatments.

Effects of mandibular advancement devices on upper airway dimensions in obstructive sleep apnea: responders versus non-responders

STUDY OBJECTIVES

To compare the effects of mandibular advancement device (MAD) therapy on upper airway dimensions between responders and non-responders with mild to moderate obstructive sleep apnea (OSA).

METHODS

Thirty-one participants (21 men and 10 women) with a mean ± SD apnea-hypopnea index (AHI) of 16.6 ± 6.7 events/h, and aged 48.5 ± 13.9 years, were included in this study. Polysomnographic recordings and cone beam computed tomography (CBCT) scans in supine position were performed for every participant at baseline and at 3-month follow-up with their MAD in situ. Responders were defined as having ≥ 50% reduction in baseline AHI with a residual AHI < 10 events/h. The primary outcome variable was the minimal cross-sectional area of the upper airway (CSAmin).

RESULTS

No significant differences were found between responders (n = 15) and non-responders (n = 16) in age, gender distribution, body mass index, and neck circumference (P = 0.06-0.93), nor in AHI and CSAmin (P = 0.40 and 0.65, respectively) at baseline. The changes of the CSAmin with MAD in situ in the responder group were not significantly different compared to those in the non-responder group (P = 0.06).

CONCLUSION

Within the limitations of this study, we conclude that the changes of the upper airway dimensions induced by MADs are not significantly different between responders and non-responders with mild to moderate OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724865. https://clinicaltrials.gov/ct2/show/NCT02724865.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Comparisons of the effects of two types of titratable mandibular advancement devices on respiratory parameters and upper airway dimensions in patients with obstructive sleep apnea: a randomized controlled trial

OBJECTIVES

To compare the effects of two types of titratable mandibular advancement devices (MADs), namely MAD-H (allowing limited vertical opening) and MAD-S (allowing free vertical opening), on respiratory parameters and upper airway dimensions in patients with mild to moderate obstructive sleep apnea (OSA).

MATERIALS AND METHODS

Patients with mild to moderate OSA (5 ≤ apnea-hypopnea index (AHI) < 30 /h) were randomly assigned to two parallel MAD groups. All MADs were subjectively titrated according to a standardized protocol during a 3-month follow-up. Every patient underwent two polysomnographic recordings, and two cone beam computed tomography scans in supine position: one at baseline and another one after 3 months with the MAD in situ. The primary outcome variables were the AHI in supine position (AHI-supine) and the minimal cross-sectional area of the upper airway in supine position (CSAmin-supine).

RESULTS

A total of 49 patients were recruited, and 31 patients (21 men and 10 women) with a mean (± SD) age of 48.5 (± 13.9) years and a mean AHI of 16.6 (± 6.7) /h completed the study. In the per-protocol analysis, there was no significant difference between MAD-H (n = 16) and MAD-S (n = 15) in their effects on AHI-supine (P = 0.14) and CSAmin-supine (P = 0.59). Similar results were found in the intention-to-treat analysis (P = 0.47 and 0.57, respectively).

CONCLUSIONS

Within the limitations of this study, we conclude that there is no significant difference in the effects of an MAD allowing limited vertical opening and an MAD allowing free vertical opening on respiratory parameters and upper airway dimensions in patients with mild to moderate OSA.

CLINICAL RELEVANCE

MADs allowing limited vertical opening and allowing free vertical opening have similar effects on respiratory parameters and upper airway dimensions in patients with mild to moderate OSA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02724865. https://clinicaltrials.gov/ct2/show/NCT02724865.

Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: A multi-arm, parallel-group randomized controlled trial

OBJECTIVES

We explored whether a new combination of eye mask sleep position therapy (SPT) and oral appliance therapy (OAT) was more effective at treating positional obstructive sleep apnea (POSA) than was the use of either device alone.

METHODS

In this randomized controlled trial, 60 POSA subjects diagnosed by standard polysomnography (PSG) were divided into three groups (ratio 1:1:1): SPT, OAT, and SPT combined with OAT (SOT). Participants underwent hospital-based follow-ups during months 1 and 6 after beginning treatment. The primary outcome was the decline in the apnea hypopnea index (AHI) at month 6. The secondary outcomes were changes in oxygen-derived parameters and the curative effect at month 6.

RESULTS

After 6 months of treatment, PSG showed that SPT, OAT, and SOT all improved the AHI and oxygen-derived parameters. The AHI decline was significantly better in the SOT group than in the OAT or SPT group (71.58% [50.56-84.84%] for SOT, 44.42% [21.23-67.52%] for OAT, and 33.24% [19.03-54.62%] for SPT at 6 months) (P = 0.018 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). In terms of oxygen-derived parameters, only the sleep apnea-specific hypoxic burden (SASHB) improved more in the SOT group (76.89% [57.43-85.91%]) than in the other groups (44.73% [32.38-72.69%] for OAT and 41.82% [15.40-65.24%] for SPT, P = 0.002 and P < 0.001 for the comparisons of SOT with OAT and SOT with SPT, respectively). The efficacies of SPT, OAT, and SOT were 36.84%, 50%, and 80% at 6 months; the SOT group evidenced the highest value (rate ratio [95% confidence interval] 1.78 (1.05-3.03), P = 0.048 and 2.17 (1.16-4.07), P = 0.010, for the comparisons of SOT with OAT and SOT with SPT, respectively).

CONCLUSION

The combination of SPT and OAT was better than either treatment alone and may represent a good option for the treatment of POSA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn/showproj.aspx?proj=42,852; No. ChiCTR1900025584.

The effect of wearable-delivered sleep interventions on sleep outcomes among adults: A systematic review and meta-analysis of randomized controlled trials

The aims of the review were to (i) evaluate the effectiveness of wearable-delivered sleep interventions on sleep outcomes among adults, and (ii) explore the effect of factors affecting total sleep time. Eight databases were searched to identify relevant studies in English from inception until December 23, 2021. The Cochrane Risk of Bias tool version 2.0 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria were used to assess the risk of bias and certainty of the evidence, respectively. Twenty randomized controlled trials (RCTs) were included, involving 1608 adults across nine countries. Wearable-delivered sleep interventions elicited significant improvement of 1.96 events/h for the oxygen desaturation index and 3.13 events/h for the respiratory distress index. Meta-analyses found that wearable-delivered sleep interventions significantly decreased sleep disturbance (Hedges' g [g] = -0.37, 95% confidence interval [CI]: -0.59, -0.15) and sleep-related impairment (g = -1.06, 95% CI: -1.99, -0.13) versus the comparators. The wearable-delivered sleep interventions may complement usual care to improve sleep outcomes. More rigorous RCTs with a long-term assessment in a wide range of populations are warranted.

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

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

OSA-patients who refuse/don't adhere to CPAP can profit from established/emerging treatment options. High scientific evidence is lacking. Patients’ values/preference may weigh heavy in the decision for non-CPAP options, while health inequity is a concern.https://bit.ly/3o0tJeP

Dropout and adherence of obstructive sleep apnoea patients to mandibular advancement device therapy: A systematic review of randomised controlled trials with meta-analysis and meta-regression

BACKGROUND

Mandibular advancement devices (MADs) are used as an alternative to continuous positive airways pressure to treat obstructive sleep apnoea (OSA) patients, but to date, specific data on the adherence to MAD therapy are lacking.

OBJECTIVES

The aim of the present systematic review was to investigate the dropout rate and adherence of OSA patients to different custom-made (CM) and non-custom-made (NCM) MAD therapies.

SEARCH METHODS

An electronic search was performed in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, LILACS and Web of Science.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the compliance to customised and not customised MADs in the treatment of adult OSA patients were included.

DATA COLLECTION AND ANALYSIS

The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias by the Cochrane Collaboration's tool for assessing risk of bias in RCT. The dropout rate of each study was computed and the adherence to MAD therapy in terms of hours per night and nights per week was extracted from each study.

RESULTS

Thirty-two RCTs were included. The risk of bias resulted low in most of the studies. The GRADE scores indicated that the quality of evidence was from very low to moderate. The meta-analyses showed that the mean dropout rate did not significantly differ between CM and NCM MADs: The overall mean dropout rate was 0.171 [0.128-0.213] with a mean follow-up of 4.1 months. The hours per night adherence was significantly higher for CM MADs (6.418 [6.033-6.803]) compared to NCM MADs (5.107 [4.324-5.890]. The meta-regression showed that the dropout rate increases significantly during time (p < .05).

CONCLUSIONS

There is a very low to moderate quality of evidence that the dropout rate of MAD therapy is similar among CM and NCM MADs, that the dropout rate increases significantly during time and that CM MADs have higher hours per night adherence compared with NCM MAD.

REGISTRATION

The study protocol was registered on PROSPERO (n. CRD42020199866).

Impact of oral appliance therapy on quality of life (QoL) in patients with obstructive sleep apnea - a systematic review and meta-analysis

PURPOSE

Treatment of patients with obstructive sleep apnea (OSA) using mandibular advancement appliances enhances the airway and may be an alternative to continuous positive airway pressure (CPAP) in individuals with reduced adherence to CPAP therapy. The effectiveness as well as improved patient compliance associated with these appliances may improve the quality of life in patients with OSA. The aim of this systematic review of studies was to determine the improvement in quality of life amongst patients with OSA who were treated with an oral appliance.

METHODS

The research study was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42021193386). A search was carried out using the search engines Google Scholar, PubMed, Ovid, Cochrane Trial Registry, and LILACS. Patients with OSA treated with oral appliance therapy to advance the mandible were studied. Twenty-five studies were identified through the literature search and all had varying control groups for assessment of quality of life. Seventeen studies were included for the quantitative synthesis.

RESULTS

QoL, evaluated by the Functional Outcomes of Sleep Questionnaire (FOSQ), significantly improved in patients treated with oral appliance therapy. There was a mean difference of 1.8 points between the baseline scores and the scores following treatment with an oral appliance.

CONCLUSION

Overall, a significant improvement in the QoL was observed with the Functional Outcomes of Sleep Questionnaire, following oral appliance therapy.

Persistent OSA in obese children: does body position matter?

STUDY OBJECTIVES

The objective of this study was to determine if positional therapy is a viable treatment alternative for obese children with persistent obstructive sleep apnea (OSA).

METHODS

A retrospective review was performed of children who underwent an adenotonsillectomy for OSA from 2014 to 2017. Children were included if they had a body mass index ≥ 95th percentile and underwent a postoperative polysomnogram. Subjects fell into one of three categories: mixed sleep (the presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Cure was defined as an OSA/apnea-hypopnea index of < 1 events/h. Paired t tests were used to assess the differences, and a linear model adjusting for obesity class, age at procedure, and sex was performed to assess the differences between nonsupine and supine sleep.

RESULTS

There were 154 children who met the inclusion criteria. Using a paired t test, supine sleep position had a significantly higher average OSA/apnea-hypopnea index (7.9 events) compared with nonsupine (OSA/apnea-hypopnea index of 4.1); P value was < .01 for the 60 children with mixed sleep. Forty-three children had predominantly nonsupine sleep and 33 predominantly supine sleep, and a McNemar's test comparing these children showed that those sleeping in the nonsupine position were significantly more likely to be cured than those in the supine position (P < .001).

CONCLUSIONS

Sleep physicians and otolaryngologists should be cognizant of positional treatment when consulting with families and note that the postoperative polysomnography may be inaccurate if it does not include supine sleep. Positional therapy as a potential treatment option for obese children with persistent OSA after adenotonsillectomy warrants further investigation.

Efficacy and long-term follow-up of positional therapy by vibrotactile neck-based device in the management of positional OSA

STUDY OBJECTIVES

Different therapeutic strategies have been investigated for the treatment of positional obstructive sleep apnea, but more evidence is needed about efficacy and compliance. The objective of this study was to describe the efficacy of vibrotactile neck-based treatment in patients with positional obstructive sleep apnea with different degrees of obstructive sleep apnea severity who were followed for 6 months.

METHODS

This is a retrospective study including 162 patients with positional obstructive sleep apnea undergoing vibrotactile neck-based positional therapy. We compared polysomnographic data obtained at baseline and during positional therapy after 1 month. We performed a subgroup analysis based on obstructive sleep apnea severity. Furthermore, we analyzed follow-up data in 84/162 (51.8%) patients with particular focus on discontinuation and complications related to the device.

RESULTS

We observed a significant difference between mean baseline obstructive apnea-hypopnea index (OAHI; 21.9 ± 9.9 events/h) and during positional therapy (12 ± 9.2 events/h; P < .01). Moreover, 87/162 (54.9%) patients showed a reduced baseline OAHI of at least 50% and 38/162 (23.4%) achieved complete disease control (OAHI < 5 events/h). At subgroup analysis, at least 50% reduction from baseline OAHI was observed in 56.8% of patients with mild, 55% with moderate, and 47.4% with severe OAHI, whereas complete control of disease was achieved in 50% of patients with mild, 22.5% with moderate, and 7.9% with severe OAHI. At a 6-month follow-up, only 35/84 patients (41.6%) were regularly using the device, with a mean of 5.9 ± 1.2 days per week.

CONCLUSIONS

Our results on the efficacy and long-term adherence to vibrotactile neck-based positional therapy showed that positional therapy can be an efficient first-line treatment option for mild positional obstructive sleep apnea and in selected cases of moderate disease. Long-term compliance is limited because of complications and low satisfaction in some patients.

Standardized framework to report on the role of sleeping position in sleep apnea patients

PURPOSE

Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea.

METHODS

We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these 5 main recommendations.

RESULTS

In this paper, we present the rationale behind this construct and present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patients should be reported separately for PP and NPP.

CONCLUSION

Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.

Criteria for oral appliance and/or supine avoidance therapy selection based on outcome optimization and cost-effectiveness

AIM

Produce empirical support for further enhancements to a therapy selection protocol for obstructive sleep apnea (OSA) patients intolerant of positive airway pressure.

METHODS

A retrospective analysis was conducted in 101 men and 69 women patients. Two-night home sleep apnea studies were conducted at baseline and with a trial oral appliance. Twenty-minutes in-position sleep was required to compute supine and non-supine apnea-hypopnea indexes (AHI). Data analyses were applied after stratification by sex and response to oral appliance therapy (OAT), and the results used for to calculate incremental cost-effectiveness ratios (ICER).

RESULTS

Compared with men, women had significantly lower pre-treatment supine and non-supine AHI values (p < .05). OAT non-responders had higher non-supine AHIs, resulting in less positional-OSA and more cases with severe OSA (p < .05). Across the cohort, 21% had positional-OSA with a pre-treatment non-supine AHI < 5 events/h. In those who met this criterion, supine avoidance therapy (SAT) could have reduced the AHI values more than OAT by an average of 33% (p < .0001). The ICER for SAT instead of OAT in this group was negative, a condition that only occurs when one therapy is both less expensive and more effective than the other. A greater proportion of non-responders had post-OAT overall AHI ≥ 10 events/h with residual positional-OSA compared with responders (p < .0001). Combination therapy could reduce the AHI values by an average of 68%, resulting in ICER estimates five-times less than the reimbursement decision-making threshold.

CONCLUSIONS AND LIMITATIONS

Based on pre-treatment non-supine AHI values, SAT would provide a superior first-line treatment outcome as compared to OAT in 21% of patients diagnosed with OSA. SAT would also provide a cost-effective adjuvant to OAT in an additional 15% of cases. The benefit of SAT could not be determined in one-fifth of the cohort who slept exclusively supine.

Positional Therapy for Positional Obstructive Sleep Apnea

Positional therapy appears to be an attractive strategy for many patients with positional obstructive sleep apnea (OSA). However, under the American Academy of Sleep Medicine OSA guidelines, positional therapy is considered as only an alternative therapy, because previous research has demonstrated poor treatment tolerance and adherence. Recent technological advances have renewed interest in positional therapy, with the invention of new sophisticated vibratory positional therapy devices. These devices have shown great promise with efficacy, markedly improved patient tolerance, and long-term adherence. We review the literature on positional therapy and explore the most current evidence on the new positional therapy devices.

Polysomnographic phenotyping of obstructive sleep apnea and its implications in mortality in Korea

Conventionally, apnea–hypopnea index (AHI) is used to define and categorize the severity of obstructive sleep apnea. However, routine polysomnography (PSG) includes multiple parameters for assessing the severity of obstructive sleep apnea. The goal of this study is to identify and categorize obstructive sleep apnea phenotypes using unsupervised learning methods from routine PSG data. We identified four clusters from 4,603 patients by using 29 PSG variable and arranged according to their mean AHI. Cluster 1, spontaneous arousal (mean AHI = 8.52/h); cluster 2, poor sleep and periodic limb movements (mean AHI = 12.16/h); cluster 3, hypopnea (mean AHI = 38.60/h); and cluster 4, hypoxia (mean AHI = 69.66/h). Conventional obstructive sleep apnea classification based on apnea–hypopnea index severity showed no significant difference in cardiovascular or cerebrovascular mortality (Log rank P = 0.331), while 4 clusters showed an overall significant difference (Log rank P = 0.009). The risk of cardiovascular or cerebrovascular mortality was significantly increased in cluster 2 (hazard ratio = 6.460, 95% confidence interval 1.734–24.073) and cluster 4 (hazard ratio = 4.844, 95% confidence interval 1.300–18.047) compared to cluster 1, which demonstrated the lowest mortality. After adjustment for age, sex, body mass index, and underlying medical condition, only cluster 4 showed significantly increased risk of mortality compared to cluster 1 (hazard ratio = 7.580, 95% confidence interval 2.104–34.620). Phenotyping based on numerous PSG parameters gives additional information on patients’ risk evaluation. Physicians should be aware of PSG features for further understanding the pathophysiology and personalized treatment.

Telehealth, Telemedicine, and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.

Sleep endoscopy findings in children in supine versus left lateral position

OBJECTIVE

To describe how drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea (OSA) change with lateral positioning.

METHODS

Children undergoing DISE for OSA in 2018-19 at a tertiary care children's hospital were positioned first supine and then in left lateral (LL) and findings were compared.

RESULTS

63 children were included, 30 (47.6%) female and 33 (52.4%) male, mean age 4.64 years, and a mean Z-score 0.70. Mean pre-op Apnea Hypopnea Index (AHI) was 6.41 and REM AHI was 15.04. In supine position, 20 had obstruction at the palate (31.7%), 39 (61.9%) had obstruction at each of the base of tongue and the larynx, 17 (27.0%) had obstruction at the tonsils. In LL position, 11 (17.5%) were obstructed at the palate, 21 (33.3%) at the tonsils, 8 (12.7%) at the base of tongue and 7 (11.1%) at the larynx. Larynx and base of tongue were most likely to improve in LL position, as 54% of patients obstructed in supine position were open in LL position. Overall 38 (60.3%) patients improved on LL, 18 (28.6%) had no change, and 7 (11.1%) worsened. 30 (47.6%) patients improved in 1 site while 12 (19.0%) improved in more than 1 site. 16 (25.4%) patients worsened in 1 site and 9 (56.3%) of these had improvement in another site.

CONCLUSION

A significant number of patients improved airway patency, particularly at the base of tongue/larynx, during DISE when placed in LL position as compared to standard supine positioning.

A stepwise titration protocol for oral appliance therapy in positional obstructive sleep apnea patients: proof of concept

Purpose

In patients with positional obstructive sleep apnea (POSA), oral appliance therapy (OAT) is among the first-line treatments. The aim of this study was to evaluate the effects of a new standardized stepwise titration protocol for OAT in a group of patients with POSA.

Methods

This was an observational intervention trial. Patients who were previously randomized to the OAT intervention arm of a comparison study comprised the subjects for this study. These patients, who had mild to moderate POSA, were assessed after 3 and 12 months for treatment efficacy, objective adherence by temperature microsensor, and side effects. The titration of OAT was performed using a standardized stepwise titration protocol including advancement levels of 60%, 75%, and 90% of the maximum mandibular protrusion. The optimal advancement level per individual was based on a weighted compromise between efficacy and side effects.

Results

In total, 36 patients were included and all completed the titration protocol after 3 months. At baseline, the OAT was set at 60% of the maximal mandibular protrusion position. At a 3-month evaluation, the advancement remained at 60% in 16 patients (44%) and reached 75% advancement in 20 patients (56%). Mean apnea-hypopnea index decreased from 12.9 events per hour (9.1–16.7) to 6.9 (3.7–10.3) (P < 0.001), and median objective adherence was 97.4 (61.4–100.00) after 3 months. The 12-month analysis showed consistent results and good OAT tolerance. Six patients (16.7%) terminated OAT and one patient (2.8%) was lost to follow-up.

Conclusions

This standardized stepwise titration protocol for OAT showed good efficacy, good OAT tolerance, and good objective adherence in patients with mild to moderate POSA. Therefore, the protocol is recommended in research projects to improve standardization of methods between studies and in clinical practice for its practical feasibility.

Electronic supplementary material

The online version of this article (10.1007/s11325-020-02045-w) contains supplementary material, which is available to authorized users.

Positional Sleep Apnea Among Regional and Remote Australian Population and Simulated Positional Treatment Effects

PURPOSE

To assess the prevalence of positional sleep apnea (POSA) and its predictors in patients diagnosed to have obstructive sleep apnea (OSA) in the regional and remote population of the Northern Territory of Australia over a two-year study period (2018 and 2019).

PATIENTS AND METHODS

Of the total 1463 adult patients who underwent a diagnostic polysomnography (PSG), 946 patients were eligible to be included in the study, of them, 810 consecutive patients with OSA (Apnea-Hypopnea Index (AHI) ≥ 5) who slept >4 h and had ≥30 min sleep in both supine and lateral positions were assessed. Patients were considered to have POSA if supine AHI to lateral AHI ratio ≥2. The likely comparative impact of use of continuous positive airway therapy (CPAP) or positional therapy (PT) on disease severity was evaluated using model simulation.

RESULTS

A total of 495/810 (61%) patients had POSA, the majority were males (68% vs 60%, p=0.013) and non-Indigenous Australians (93% vs 87%, p=0.004). POSA patients were younger (mean difference 2.23 years (95% CI 0.27, 4.19)), less obese (BMI mean difference 3.06 (95% CI 2.11, 4.01)), demonstrated less severe OSA (p < 0.001) and a greater proportion reported alcohol consumption (72% vs 62%, p=0.001) as compared to those with non-POSA. Using the simulation model, if patients with POSA use PT two-thirds (323/495, 65%) would obtain significant improvement of their OSA severity, with one in five (92/495, 19%) displaying complete resolution. Comparing this to simulated CPAP therapy, where the majority (444/495, 90%) will show significant improvement, and one-third (162/495, 33%) will display complete resolution.

CONCLUSION

POSA needs to be routinely recognised and positional therapy integrated in practice especially in the remote regions and in the developing world when effective methods are in place to monitor positional therapy.

Obstructive Sleep Apnea: Do Positional Patients Become Nonpositional Patients With Time?

OBJECTIVES

Obstructive sleep apnea (OSA) patients with breathing abnormalities only or mainly in the supine posture are designated positional patients (PPs), whereas nonpositional patients (NPPs) have many breathing abnormalities in both lateral and supine postures. Positional therapy (PT), the avoidance of the supine posture during sleep, is the obvious treatment for PPs. The stability over time of being PP and leading factors that are involved in converting a PP to an NPP are addressed.

METHODS

We analyzed polysomnographic (PSG) recordings of 81 consecutive adult patients with OSA who were judged to be PPs at the first PSG evaluation, and their follow-up PSGs were obtained after an average period of 6.6 years.

RESULTS

The follow-up PSGs indicated that 57 PPs (70.4%) remained PPs, whereas 24 (29.6 %) converted to NPPs. Among PPs and NPPs, body mass index (P ≤ 0.05), overall Apnea-Hypopnea Index (AHI, P ≤ 0.087), and lateral AHI (P ≤ 0.046) increased and minimum SpO₂ during rapid eye movement (REM) sleep (P ≤ 0.028) decreased significantly during the follow-up. However, among patients who became NPPs, the changes in these parameters were significantly (P ≤ 0.05) more pronounced compared to the patients who remained PPs.

CONCLUSION

After an average of 6.6 years, 70.4% of PPs remained PPs. Therefore, if adherence for PT is good, they could continue to benefit from this therapy. For those who turned to NPPs, PT will not be the optimal treatment anymore; thus, these patients should be frequently monitored. Furthermore, an early treatment of PPs with PT would be highly beneficial to prevent worsening of their OSA.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:2263-2268, 2020.

Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.

Prevalence and characteristics of positional obstructive sleep apnea (POSA) in patients with severe OSA

PURPOSE

We assessed the prevalence of positional patients (PPs) and the main predictors of positional dependency in severe obstructive sleep apnea (OSA). A simulated effect of positional therapy (PT) vs. continuous positive airway pressure (CPAP) was also assessed.

METHODS

Polysomnographic recordings of 292 consecutive patients with severe OSA (Apnea-Hypopnea Index (AHI) ≥ 30) who slept > 4 h and had ≥ 30 min sleep in both supine and lateral positions were assessed. PPs were defined to have a supine AHI/lateral AHI ratio ≥ two and non-positional patients (NPPs) a supine AHI/lateral AHI ratio < two.

RESULTS

A total of 35.3% of the severe OSA patients were PPs. They were less obese and had less severe OSA (p < 0.001) compared with NPPs. The percentage of total apnea-hypopnea time from total sleep time (AHT%) was the most significant predictor for positional dependency. By sleeping in the lateral posture (i.e. after simulated PT), 78 (75.7%) PPs obtained significant improvement of their OSA severity and 9 (8.7%) of them became "non-OSA". Moreover, if CPAP was used only for 50% of total sleep time, 53 patients (18.2%) gained more benefit from avoiding the supine posture than from CPAP therapy.

CONCLUSIONS

More than a third of the studied severe OSA patients were PPs. These patients could achieve a significant decrease in the number and severity of apneas and hypopneas by adopting the lateral posture, suggesting that PT may be a valuable therapy for a significant portion of these severe OSA patients who for whatever reason are not being treated by CPAP.

TRIAL REGISTRY

ClinicalTrials.gov Identifier: NCT03232658.

NightBalance Sleep Position Treatment Device Versus Auto-Adjusting Positive Airway Pressure for Treatment of Positional Obstructive Sleep Apnea

STUDY OBJECTIVES

Compare treatment efficacy and objective adherence between the NightBalance sleep position treatment (SPT) device and auto-adjusting positive airway pressure (APAP) in patients with exclusive positional obstructive sleep apnea (ePOSA) defined as a supine apnea-hypopnea index (sAHI) ≥ 2 times the nonsupine AHI (nsAHI) and a nsAHI < 10 events/h.

METHODS

This prospective multicenter randomized crossover trial enrolled treatment naive participants with ePOSA (AHI ≥ 15 events/h and nsAHI < 10 events/h) or (AHI > 10 and < 15 events/h with daytime sleepiness and nsAH < 5 events/h). Polysomnography and objective adherence determination (device data) were performed at the end of each 6-week treatment. Patient device preference was determined at the end of the study.

RESULTS

A total of 117 participants were randomized (58 SPT first, 59 APAP first). Of these, 112 started treatment with the second device (adherence cohort) and 110 completed the study (AHI cohort). The AHI on SPT was higher (mean ± standard deviation, 7.29 ± 6.8 versus 3.71 ± 5.1 events/h, P < .001). The mean AHI difference (SPT-APAP) was 3.58 events/h with a one sided 95% confidence interval upper bound of 4.96 events/h (< the prestudy noninferiority margin of 5 events/h). The average nightly adherence (all nights) was greater on SPT (345.3 ± 111.22 versus 286.98 ± 128.9 minutes, P < .0001). Participants found the SPT to be more comfortable and easier to use and 53% reported a preference for SPT assuming both devices were equally effective.

CONCLUSIONS

Treatment with SPT resulted in non-inferior treatment efficacy and greater adherence compared to APAP in ePOSA suggesting that SPT is an effective treatment for this group.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: The POSAtive Study: Study for the Treatment of Positional Obstructive Sleep Apnea; Identifier: NCT03061071; URL: https://clinicaltrials.gov/ct2/show/NCT03061071.

A comparison between auto-scored apnea-hypopnea index and oxygen desaturation index in the characterization of positional obstructive sleep apnea

OBJECTIVE

Evaluate the concordance between overall and positional oxygen desaturation indices (ODI) and apnea-hypopnea indices (AHI) according to two different definitions for positional obstructive sleep apnea (POSA).

METHODS

A total of 184 in-home polysomnograms were edited to simulate Level III home sleep apnea tests (HSAT) with the auto-scored AHI and ODI based on recording time. POSA was determined using 132 records with an AHI≥5 and at least 20 mins of recording time in both supine and non-supine positions. POSA was defined independently for the AHI and ODI based on ratios of overall/non-supine event/h ≥1.4 (O/NS) and supine/non-supine event/h≥2.0 (S/NS).

RESULTS

Correlation between the AHI and ODI was 0.97 overall, 0.94 for supine, and 0.96 for non-supine recording times (all p<0.001). For most records, differences between the AHI and ODI were small, with only 14% of the records having a AHI-ODI difference exceeding >5/hr, and 6% exceeding >10 events/hr. The positive and negative percent agreements were uniformly good to excellent across varying clinical POSA cutoffs; percent agreements (positive, negative) were: AHI≥5=0.99, 0.78; AHI≥10=0.96, 0.89; and AHI≥15=0.96, 0.89. Cohen's Kappa scores also showed substantial agreement for overall as well as supine and non-supine positions across varying clinical cutoffs of the AHI. Frequency of POSA was reproducibly uniform between 59% and 61% for both POSA criteria. When the O/NS and S/NS definitions conflicted in POSA characterization, O/NS was superior for identifying patients who might exhibit a greater response to supine restriction positional therapy.

CONCLUSIONS

Auto-scored positional oximetry is a clinically viable alternative to an auto-scored Level III HSAT AHI in the characterization of POSA based on a 3% desaturation.

Positional Therapy for Positional Obstructive Sleep Apnea

Positional therapy appears to be an attractive strategy for many patients with positional obstructive sleep apnea (OSA). However, under the American Academy of Sleep Medicine OSA guidelines, positional therapy is considered as only an alternative therapy, because previous research has demonstrated poor treatment tolerance and adherence. Recent technological advances have renewed interest in positional therapy, with the invention of new sophisticated vibratory positional therapy devices. These devices have shown great promise with efficacy, markedly improved patient tolerance, and long-term adherence. We review the literature on positional therapy and explore the most current evidence on the new positional therapy devices.

Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level.

Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but thresholds for and effectiveness of intervention are unclear. Clinicians should use shared decision making for screening and treatment decisions.http://ow.ly/N0oN30noWnx

Treatment of sleep-disordered breathing with positional therapy: long-term results

PURPOSE

The aim of the present study was to assess the efficacy of a sleep position trainer (SPT) in patients with an established diagnosis of positional obstructive sleep apnea and to evaluate the adherence after 1-year follow-up.

METHODS

Polysomnography (PSG) was performed at baseline and after 1 year of SPT use. Patients received questionnaires to assess treatment satisfaction and subjective adherence. Data on objective adherence and number of vibrations initiated by the SPT were collected from the SPT device.

RESULTS

Nine out of 58 patients stopped using the SPT during the first year of treatment (16%). Thirty-four middle-aged and overweight patients underwent a PSG after 1 year of SPT use (male/female ratio, 28/6; overall apnea/hypopnea index (AHI), 16/h). A significant reduction in overall AHI to 6/h was observed using treatment (p < 0.001). The median percentage of supine sleep decreased significantly to 1% with SPT (p < 0.001). The mean objective SPT use in 28 patients was 7.3 ± 0.9 h/night and 69 ± 26% of the nights. Furthermore, 75% of the patients reported a better sleep quality since the start of SPT treatment.

CONCLUSIONS

Long-term treatment with the SPT was found to be effective in reducing overall AHI. Time spent sleeping in supine position was reduced to almost zero in the continuing users. Patient satisfaction was high when using the SPT.

Split-night polysomnography at Fundación Santa Fe de Bogotá

Introduction: The obstructive sleep apnea-hypopnea syndrome (OSAHS) is usually established using polysomnography (PSG). Most patients diagnosed with this condition receive treatment with continuous positive airway pressure (CPAP). The conventional approach requires performing a full-night PSG and CPAP titration over a two-night stay in a sleep laboratory, which is costly and may present scheduling difficulties. However, the combined use of polysomnography and CPAP titration in a single night, procedure known as split-night polysomnography (SNPSG), is less-expensive and is a time saving strategy for diagnosis and treatment.Objectives: To characterize the SNPSG studies conducted in the sleep laboratory of the Hospital Universitario Santa Fe de Bogotá (HUFSFB) and assess their performance in the diagnosis and treatment of OSAHS.Materials and methods: Retrospective, observational and longitudinal study performed on a sample of 221 patients.Results: 208 (94.1%) SNPSG studies were compatible with OSAHS. Most cases (54.7%) had a hypopnea apnea index (AHI) ≥30. Adequate CPAP titration was achieved in 78% of patients who had severe AHI (p=0.00).Conclusions: OSAHS was diagnosed and an adequate CPAP titration was achieved in most of the SNPSG studies of the analyzed sample.

Subjective effects of the sleep position trainer on snoring outcomes in position-dependent non-apneic snorers

Purpose

To evaluate the effect of a new-generation positional device, the sleep position trainer (SPT), in non-apneic position-dependent snorers.

Methods

Non-apneic position-dependent snorers with an apnea–hypopnea index (AHI) < 5 events/h were included between February 2015 and September 2016. After inclusion, study subjects used the SPT at home for 6 weeks. The Snore Outcome Survey (SOS) was filled out by the subjects at baseline and after 6 weeks, and at the same time, the Spouse/Bed Partner Survey (SBPS) was filled out by their bed partners.

Results

A total of 36 participants were included and 30 completed the study. SOS score improved significantly after 6 weeks from 35.0 ± 13.5 to 55.3 ± 18.6, p < 0.001. SBPS score also improved significantly after 6 weeks from 24.7 ± 16.0 versus 54.5 ± 25.2, p < 0.001. The severity of snoring assessed with a numeric visual analogue scale (VAS) by the bed partner decreased significantly from a median of 8.0 with an interquartile range (IQR) of [7.0–8.5] to 7.0 [3.8–8.0] after 6 weeks (p = 0.004).

Conclusions

Results of this study indicate that positional therapy with the SPT improved several snoring-related outcome measures in non-apneic position-dependent snorers. The results of this non-controlled study demonstrate that this SPT could be considered as an alternative therapeutic option to improve sleep-related health status of snorers and their bed partners.