Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome

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.

Maternal positional therapy for fetal growth and customised birth weight centile benefit in a Bayesian reanalysis of a double-blind, sham-controlled, randomised clinical trial

OBJECTIVES

To update the Ghana PrenaBelt Trial's (GPT) primary outcome data with the latest fetal growth standard and reanalyse it. To estimate the posterior probability, under various clinically relevant prior probabilities, of maternal nightly positional therapy (PT) throughout the third-trimester having a beneficial effect on customised birth weight centile (CBWC) using Bayesian analyses.

DESIGN

A reanalysis of a double-blind, sham-controlled, randomised clinical trial.

SETTING

A single, tertiary-level centre in Accra, Ghana.

PARTICIPANTS

Two-hundred participants entered, 181 completed and 167 were included in the final analysis. Participants were Ghanaian, healthy, aged 18-35 years, with low-risk, singleton pregnancies in their third-trimester, with Body Mass Index<35 kg/m2 at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep.

INTERVENTIONS

Participants were randomised to receive treatment with either a PT or sham-PT device.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the CBWC using the latest Perinatal Institute, Gestation-Related Optimal Weight calculator. Using Bayesian methods, posterior probabilities of achieving a greater than 0%, 5% and 10% benefit in CBWC with PT were estimated. There was no secondary outcome.

RESULTS

The median (IQR) CBWC was 42% (15-71) and 28% (9-52) in the PT and sham-PT groups, respectively (difference 8.4%; 95% CI -0.30 to 18.2; p=0.06). For achieving a >0%, >5% and >10% gain in CBWC with PT, the posterior probabilities were highly probable, probable and unlikely, respectively, given a range of prior probabilities reflecting varying degrees of pre-existing enthusiasm and scepticism.

CONCLUSIONS

Maternal nightly PT throughout the third-trimester did not have a statistically significant effect on CBWC on a frequentist analysis using the latest fetal growth standard. However, from a Bayesian analysis, clinicians can infer that PT is likely to benefit fetal growth but with a modest effect size.

TRIAL REGISTRATION NUMBER

NCT02379728.

Efficacy of vibrotactile positional therapy devices on patients with positional obstructive sleep apnoea: a systematic review and meta-analysis

INTRODUCTION

Vibrotactile positional therapy (PT) devices are a new treatment modality for positional obstructive sleep apnoea (POSA). This review aimed to determine the effect of vibrotactile PT on the Apnoea Hypopnoea Index (AHI) and the percentage of time spent in the supine position (%Tsupine) in patients with POSA, compared with baseline. Secondary aims were to investigate the effect on daytime sleepiness, quality of life and sleep quality.

METHODS

A systematic review and meta-analysis was performed of randomised controlled trials (RCTs) and cohort studies that investigated the effect of vibrotactile PT in POSA patients. Searches were performed via MEDLINE, CENTRAL and Embase up to 29 October 2022.

RESULTS

1119 studies were identified, 18 studies met the inclusion criteria (10 RCTs, 8 cohort studies). The use of vibrotactile PT significantly reduced the AHI at follow-up compared with baseline (mean difference (95% CI) -9.19 events/hour (-11.68 to -6.70); p<0.00001). The mean %Tsupine was also significantly reduced (mean difference (95% CI) -32.79% (-38.75% to -26.83%); p<0.00001). The percentage changes in the AHI and %Tsupine were 43% and 70%, respectively. Secondary outcomes were daytime sleepiness, quality of life and sleep indices. These showed minimal change, although follow-up was short.

CONCLUSION

Vibrotactile PT devices are effective in treating POSA; reducing both AHI and %Tsupine. The effect on sleep quality, daytime sleepiness and disease-specific quality of life was minimal. However, there were limited data and follow-up was often brief, meaning that further research is needed to determine the effect of vibrotactile PT on patient-centred outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020188617.

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.

Patient compliance and satisfaction with a new forehead device for positional obstructive sleep apnoea treatment: a post hoc analysis of a randomised controlled trial

BACKGROUND

The influence of body position in obstructive sleep apnoea patients is well known. A positional therapy device placed at the forehead has proven to be effective in reducing the severity of positional obstructive sleep apnoea (POSA) symptoms. The aim of the study was to evaluate patients' therapy compliance and satisfaction in the short term and mid-term.

METHODS

A post hoc analysis of a randomised controlled trial was conducted using an inactive device (ID) or an active device (AD) for 3 months. The primary outcomes were device usage and the percentage of patients with good compliance (defined as device use for more than 4 hours per night and more than 70% of nights per week). Secondary outcomes included time spent with head in the supine position, patient satisfaction and side effects.

RESULTS

The median duration of using the device was 6.9 hours in the ID group and 6.7 hours in the AD group (p=0.309), and the durations were similar throughout the follow-up period and from the first day of use. The percentage of patients with good compliance was similar and greater than 60% in both groups. The median time spent with head in the supine position was significantly lower in the AD group (2.9%) than in the ID group (12.4%) since the first day of treatment. Both groups showed satisfaction scores values above 8.5 (out of 10) in all items, while side effects were scarcely reported.

CONCLUSION

High device compliance was achieved in POSA patients, both in terms of device usage time and percentage of days used. Patients were highly satisfied, and the device effectively reduced the time spent with the head in the supine position from the first day of use.

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.

Non-CPAP therapy for obstructive sleep apnoea

Treatment of obstructive sleep apnoea in adults is evolving, from a "one treatment fits all" to a more individualised approach. The spectrum of treatment options is broad and heterogeneous, including conservative, technological and pharmaceutical modalities. This raises the questions of which patients these modalities might be useful for, and if there are specific criteria for single or combined treatment. The most commonly used non-CPAP treatment is a mandibular advancement device. Furthermore, it appears from the available evidence that upper airway surgery, bariatric surgery, and maxillomandibular advancement can be effective in particular patient groups and should be indicated more readily in clinical practice. Technically, a tracheotomy is the most effective surgical treatment, but is not socially acceptable and is associated with major side-effects. Other treatment options are emerging, like positional therapy, hypoglossal nerve stimulation, and myofunctional exercises. Drug therapy is also promising when pathophysiological traits are considered. The range of currently available treatment options will be discussed in this review, with emphasis on the selection of appropriate patients, therapeutic efficacy and compliance, and reference to recent guidelines. In the selection process, routine application of drug-induced sleep endoscopy to assess the site(s) of collapse during sleep can increase the success rate of both surgical interventions and oral appliance therapy.

Educational aims

To outline recommendations concerning the proper management of obstructive sleep apnoea (OSA) patients that cannot be treated adequately with continuous positive airway pressure (CPAP) due to intolerance, poor adherence or compliance, or CPAP refusal.To provide information about the selection of appropriate patients for alternative non-CPAP treatment options.To better understand the different aspects of OSA treatment with noninvasive approaches, such as oral appliances, positional therapy, drug treatment and myofunctional therapy, including indications, contraindications, and expected short- and long-term results.To discuss the different surgical options for the treatment of OSA and to provide information on the important issue of proper patient selection for surgery, as most OSA surgical outcomes are associated with the pre-operative assessment of the level(s) of upper airway collapse.

Current and Novel Treatment Options for OSA

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

Quantitative effects of head rotation angle on apnea hypopnea index in positional obstructive sleep apnea – a preliminary case series

Objectives

Quantify the effects of head rotation and head incline on obstructive sleep apnea (OSA) severity.

Design

Single-arm, intervention study.

Setting

Pulmonary specialty clinic.

Case presentation

Ten adults diagnosed with positional OSA ranging from 32 to 64 years of age 6 females, 4 males reporting persistent daytime sleepiness and health issues with consistent use of CPAP.

Intervention

Standard polysomnography with a head angle sensor attached to the forehead and coaching to fall asleep with head at various rotation and incline angles and torso in supine and non-supine positions.

Measurements

OSA severity was scored according to American Academy of Sleep Medicine guidelines. Apnea hypopnea index (AHI) and peripheral capillary oxygen (SpO2) saturation were measured during each sleep epoch of unique head rotation, head incline, and torso position.

Results

Two participants (1 with no apneas and 1 with central sleep apnea) were excluded. Among the remaining 8 participants, average reduction in peak AHI was 66% (range 18–88%) with head rotation ≤ 20° above the horizon compared with > 20° above the horizon. The average of peak AHI values with head rotation ≤ 20° was significantly lower than with head rotation > 20° (20.0 vs 45.3, P = 0.002). Minimum SpO2 was significantly higher for head rotation ≤ 20° compared with > 20° (mean: 90.6% vs 84.3%, P = 0.03). In the torso supine position, average peak AHI was significantly lower with head rotation ≤ 20° compared with > 20° (7.1 vs 52.1, P < 0.001). In the torso non-supine position, lower average peak AHI with head rotation ≤ 20° was not statistically significant (22.3 vs 38.4, P = 0.09).

Conclusion

These results support further exploration of maintaining head position ≤ 20° above the horizon to minimize AHI and oxygen desaturation in OSA patients.

Trial registration

Apnea Hypopnea Index Severity Versus Head Position During Sleep.

ClinicalTrials.gov Identifier: NCT04086407 September 11, 2019 Registered retrospectively.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is a disease that results from loss of upper airway muscle tone leading to upper airway collapse during sleep in anatomically susceptible persons, leading to recurrent periods of hypoventilation, hypoxia, and arousals from sleep. Significant clinical consequences of the disorder cover a wide spectrum and include daytime hypersomnolence, neurocognitive dysfunction, cardiovascular disease, metabolic dysfunction, respiratory failure, and pulmonary hypertension. With escalating rates of obesity a major risk factor for OSA, the public health burden from OSA and its sequalae are expected to increase, as well. In this chapter, we review the mechanisms responsible for the development of OSA and associated neurocognitive and cardiometabolic comorbidities. Emphasis is placed on the neural control of the striated muscles that control the pharyngeal passages, especially regulation of hypoglossal motoneuron activity throughout the sleep/wake cycle, the neurocognitive complications of OSA, and the therapeutic options available to treat OSA including recent pharmacotherapeutic developments.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

The positional characteristics of patients with obstructive sleep apnea: a single institute retrospective study in Japan

Obstructive sleep apnea (OSA) causes sleep-disordered breathing (SDB) due to upper airway obstruction. The severity of OSA changes with position during sleep. Patients with marked significant improvement in apnea-hypopnea index (AHI) level by sleep position change are defined as ''positional patients'' (PP), while those without improvement are defined as ''non-positional patients'' (NPP). We aimed to verify their clinical characteristics. Between May 2008 and May 2020, 237 patients with OSA were registered retrospectively and classified into two groups: PP (n = 158) and NPP (n = 79). The differences in clinical background and full-night polysomnography (PSG) between the two groups were observed. A logistic regression analysis was conducted to identify the risk factors for severe AHI (≥ 30 events/h) in the PP group. Moreover, confounding factor-adjusted sub-analysis by a propensity score matching method was performed, and the PSG results were compared between the two groups. The PP group was older than the NPP group. Furthermore, the PP group had lower body mass index (BMI) and AHI levels compared with the NPP group. The independent risk factors for severe AHI in the PP group were BMI and being in the supine position during sleep. The PP group had a significantly milder nocturnal hypoxemia despite having no significant difference in AHI levels between the two groups. The characteristics of PP were old age, low BMI, and low AHI associated with milder nocturnal hypoxemia. Moreover, they were less likely to worsen with nocturnal hypoxemia compared with NPP having similar severity.

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

Alternatives to continuous positive airway pressure treatment in sleep apnoeas and hypopnoeas syndrome related to myofunctional and postural reeducation therapy: protocol for a systematic review

INTRODUCTION

The main treatment for sleep apnoeas and hypopnoeas syndrome (SAHS) is continuous positive airway pressure (CPAP). However, patients sometimes do not adhere to the treatment protocol. Supplementary and complementary therapies have appeared as alternatives. Some of the therapies which are especially important are those related to myofunctional (MFT) and postural therapy (PT), as all of them are non-invasive, and their application is simpler than that of CPAP. We aim to present a protocol for a systematic review and meta-analysis for investigating new SAHS treatments, including the protocols and frequency of use and the effects they have on patient signs, symptoms and quality of life.

METHODS AND ANALYSIS

The literature search will be conducted using the Cochrane, Web of Science, Medline (via PubMed) and Scopus databases, from January 2020 to December 2020. All types of studies written in English and Spanish that investigate the use of alternative SAHS treatments related to MFT, or more importantly, the combination of MFT and PRT, will be selected. To evaluate their quality, the Critical Appraisal Checklist for Analytical Cross-Sectional will be applied. The primary factor valued in the studies will be the inclusion of MFT and PT reeducation in the treatment. Subgroup analyses will be carried out evaluating the specific type of treatments chosen and the improvements or deteriorations in the level of health and quality of life in the patients. Finally, several patient-related outcomes, namely sleep quality, quality of life and sleep Apnoeas and Hypoapnoeas Index, will be examined.

ETHICS AND DISSEMINATION

In this case, ethical approval is not necessary. The data used in the review will be exclusively obtained from published studies, implying there are no privacy concerns. The information obtained will be relevant to understand if the new treatments applied in SAHS are effective, and if postural and MFT therapy used together can be considered an appropriate approach to treat this disease.The results will be published in a peer-reviewed journal.

SleepPos App: An Automated Smartphone Application for Angle Based High Resolution Sleep Position Monitoring and Treatment

Poor sleep quality or disturbed sleep is associated with multiple health conditions. Sleep position affects the severity and occurrence of these complications, and positional therapy is one of the less invasive treatments to deal with them. Sleep positions can be self-reported, which is unreliable, or determined by using specific devices, such as polysomnography, polygraphy or cameras, that can be expensive and difficult to employ at home. The aim of this study is to determine how smartphones could be used to monitor and treat sleep position at home. We divided our research into three tasks: (1) develop an Android smartphone application (‘SleepPos’ app) which monitors angle-based high-resolution sleep position and allows to simultaneously apply positional treatment; (2) test the smartphone application at home coupled with a pulse oximeter; and (3) explore the potential of this tool to detect the positional occurrence of desaturation events. The results show how the ‘SleepPos’ app successfully determined the sleep position and revealed positional patterns of occurrence of desaturation events. The ‘SleepPos’ app also succeeded in applying positional therapy and preventing the subjects from sleeping in the supine sleep position. This study demonstrates how smartphones are capable of reliably monitoring high-resolution sleep position and provide useful clinical information about the positional occurrence of desaturation events.

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.

Positional obstructive sleep apnea within a large multicenter French cohort: prevalence, characteristics, and treatment outcomes

STUDY OBJECTIVES

To assess, in a large cohort of patients with obstructive sleep apnea, the factors that are independently associated with positional obstructive sleep apnea (POSA) and exclusive POSA (e-POSA) and determine their prevalence. The secondary objective was to evaluate the outcome of positive airway pressure (PAP) therapy for patients with POSA and e-POSA.

METHODS

This retrospective study included 6,437 patients with typical mild-to-severe OSA from the Pays de la Loire sleep cohort. Patients with POSA and e-POSA were compared to those with non-POSA for clinical and polysomnographic characteristics. In a subgroup of patients (n = 3,000) included in a PAP follow-up analysis, we determined whether POSA and e-POSA phenotypes were associated with treatment outcomes at 6 months.

RESULTS

POSA and e-POSA had a prevalence of 53.5% and 20.1%, respectively, and were independently associated with time in supine position, male sex, younger age, lower apnea-hypopnea index and lower body mass index. After adjustment for confounding factors, patients with POSA and e-POSA had a significantly lower likelihood of treatment adherence (PAP daily use ≥ 4 h) at 6 months and were at higher risk of PAP treatment withdrawal compared to those with non-POSA.

CONCLUSIONS

The prevalence and independent predictors of POSA and e-POSA were determined in this large clinical population. Patients with POSA and e-POSA have lower PAP therapy adherence, and this choice of treatment may not be optimal. Thus, there is a need to offer these patients an alternative therapy.

New forehead device in positional obstructive sleep apnoea: a randomised clinical trial

RATIONALE

Approximately 60% of the patients with obstructive sleep apnoea suffer from a positional effect, and approximately 25% of these patients present events only in the supine position.

OBJECTIVE

To validate a new positional vibrating device and evaluate its efficacy in reducing the Apnoea-Hypopnoea Index and the total sleep time in the supine position without disturbing sleep.

METHODS

A total of 128 patients were recruited for this multicentre, prospective, parallel, randomised controlled trial and were distributed in three arms (general recommendations, inactive and active device). Full overnight polysomnography was performed at baseline and at 12 weeks. Anthropometric variables and sleep and quality of life questionnaires were collected at 4, 8 and 12 weeks.

RESULTS

The Apnoea-Hypopnoea Index decreased from 30.6 per hour to 20.4 per hour (p<0.001) in the active device (AD) group. In this group the reduction was 2.3-fold and 3.3-fold than the ones in the general recommendations (GR) and inactive device (ID) groups, respectively (p=0.014). Sleep time in supine position decreased 17.7%±26.3% in GR group (p<0.001), 13.0%±22.4% with ID group (p<0.001) and 21.0%±25.6% in the AD group (p<0.001). Furthermore, total sleep time increased significantly only in the AD group (22.1±57.5 min, p=0.016), with an increased percentage of time in the N3 (deep sleep) and N3+REM (rapid eye movement) stages, without sleep fragmentation.

CONCLUSION

The device was effective in reducing the Apnoea-Hypopnoea Index and time spent in the supine position also in improving sleep architecture. Therefore, the device could be a good option for the management of patients with positional obstructive sleep apnoea.

TRIAL REGISTRATION DETAILS

The trial was registered at www.clinicaltrials.gov (NCT03336515).

Evaluation and Management of Adults with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common and underdiagnosed medical condition characterized by recurrent sleep-dependent pauses and reductions in airflow. While a narrow, collapsible oropharynx plays a central role in the pathophysiology of OSAS, there are other equally important nonanatomic factors including sleep-stage dependent muscle tone, arousal threshold, and loop gain that drive obstructive apneas and hypopneas. Through mechanisms of intermittent hypoxemia, arousal-related sleep fragmentation, and intrathoracic pressure changes, OSAS impacts multiple organ systems. Risk factors for OSAS include obesity, male sex, age, specific craniofacial features, and ethnicity. The prevalence of OSAS is rising due to increasing obesity rates and improved sensitivity in the tools used for diagnosis. Validated questionnaires have an important but limited role in the identification of patients that would benefit from formal testing for OSA. While an in-laboratory polysomnography remains the gold standard for diagnosis, the widespread availability and accuracy of home sleep apnea testing modalities increase access and ease of OSAS diagnosis for many patients. In adults, the most common treatment involves the application of positive airway pressure (PAP), but compliance continues to be a challenge. Alternative treatments including mandibular advancement device, hypoglossal nerve stimulator, positional therapies, and surgical options coupled with weight loss and exercise offer possibilities of an individualized personal approach to OSAS. Treatment of symptomatic patients with OSAS has been found to be beneficial with regard to sleep-related quality of life, sleepiness, and motor vehicle accidents. The benefit of treating asymptomatic OSA patients, particularly with regard to cardiovascular outcomes, is controversial and more data are needed.

Influence of head flexion and rotation on obstructive sleep apnea severity during supine sleep

Head posture influences the collapsibility of the passive upper airway during anaesthesia. However, little is known about the impact of head posture during sleep. The objective of this study was to develop and validate an instrument to measure head posture during supine sleep and to apply this instrument to investigate the influence of head posture on obstructive sleep apnea (OSA) severity. A customized instrument to quantify head flexion and rotation during supine sleep was developed and validated in a benchtop experiment. Twenty-eight participants with suspected OSA were successfully studied using diagnostic polysomnography with the addition of the customized instrument. Head posture in supine sleep was discretized into four categories by two variables: head flexed or not (flexion >15°); and head rotated or not (rotation >45°). Sleep time in each posture and the posture-specific apnea-hypopnea index (AHI) were quantified. Linear mixed-effect modelling was applied to determine the influence of flexion and rotation on supine OSA severity. Twenty-four participants had ≥15 min of supine sleep in at least one head-posture category. Only one participant had ≥15 min of supine sleep time with the head extended. Head flexion was associated with a 12.9 events/h increase in the AHI (95% CI: 3.7-22.1, p = .007). Head rotation was associated with an 11.0 events/h decrease in the AHI (95% CI: 0.3-21.6, p = .04). Despite substantial interparticipant variability, head flexion worsened OSA severity, and head rotation improved OSA severity. Interventions to promote rotation and restrict flexion may have therapeutic benefit in selected 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.

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.

The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea

Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.

Comparing treatment effects of a convenient vibratory positional device to CPAP in positional OSA: a crossover randomised controlled trial

OBJECTIVES

Up to 77% of patients with obstructive sleep apnoea (OSA) have positional OSA (POSA) but traditional positional therapy (PT) methods have failed as they were poorly tolerated. New convenient vibratory PT devices have been invented but while recent studies suggest high treatment efficacy and adherence, there are no published data comparing these devices directly with continuous positive airway pressure (CPAP). Our objective is to evaluate if a convenient vibratory PT device is non-inferior to CPAP in POSA treatment.

METHODS

In this crossover randomised controlled trial, we enrolled patients with POSA with significant daytime sleepiness (Epworth Sleepiness Scale (ESS)≥10). POSA diagnosis was based on: (1) total Apnoea/Hypopnoea Index (AHI)>10/hour and non-supine AHI<10/hour (2) supine AHI≥2 × non-supine AHI. Patients used their initial allocated devices (PT or CPAP) for 8 weeks before crossing to the alternative intervention after a 1 week washout. The primary aim is to measure changes in ESS between the two treatments. Secondary outcomes include sleep study parameters and patient treatment preference (ClinicalTrials.gov: NCT03125512).

RESULTS

40 patients completed the trial between April 2017 and December 2018. Difference in ESS after 8 weeks of device use (PT minus CPAP) was 2.0 (95% CI 0.68 to 3.32), exceeding our predetermined non-inferiority margin of 1.5. AHI on CPAP was lower than with PT (4.0±3.2 vs 13.0±13.8 events/hour, respectively, p=0.001), although both were lower than at baseline. Time spent supine was significantly lower with PT than CPAP (p<0.001). 60% of patients preferred CPAP, 20% preferred PT, while 20% preferred neither device.

CONCLUSIONS

The non-inferiority ESS endpoint for PT compared with CPAP was not met and the results were inconclusive. Future trials with larger sample sizes or in less symptomatic patients are warranted to provide further insight into the role of these new vibratory PT devices.

The effects of body position on the distribution of obstructive, mixed and central sleep apnoea

Background

Obstructive sleep apnoea is commonly aggravated by the supine body position. The impact of body position on the severity of mixed and central sleep apnoeas is understudied.

Objectives

To evaluate the impact of body position on obstructive, mixed and central apnoea indices in subjects presenting with this triform of sleep apnoea during a single polysomnogram.

Methods

We retrospectively analysed 26 polysomnograms where obstructive, mixed and central apnoeas each occurred at a rate >5/hr. Comparisons between lateral and supine body positions were made for obstructive apnoea index (OAI), mixed apnoea index (MAI), central apnoea index (CAI), apnoea-hypopnoea index (AHI) and obstructive apnoea-hypopnoea index (OAHI).

Results

Mean (SD) apnoea indices were significantly lower in lateral v. supine positions, respectively: MAI 15.06 (18.34) v. 32.09 (17.05); p<0.001, CAI 11.82 (11.77) v. 23.82 (14.18); p<0.001, AHI 79.46 (31.17) v. 99.47 (26.33); p<0.001, OAHI 67.87 (28.25) v. 76.00 (23.21); p=0.039. Unexpectedly, the converse was seen for OAI when comparing the lateral v. supine position: 53.10 (30.64) v. 43.58 (25.83); p=0.009, respectively.

Conclusion

It may be beneficial for subjects with a combination of obstructive, mixed, and central apnoeas to avoid the supine body position. In this triform phenotype, mixed apnoeas are neither purely obstructive nor purely centrally mediated. Furthermore, obstructive, mixed, and central apnoeas may be different representations of a single respiratory abnormality.

Positional obstructive sleep apnoea: challenging findings in consecutive patients treated with a vibrating position trainer

OBJECTIVES

Last years, vibrating devices were introduced to treat positional sleep apnoea (POSA). However, few data exist on determinants of effectiveness and adherence in clinical settings. Methods: The NightBalance Sleep Position Trainer (SPT) analyses the patient's position during the first 2 nights, starts to build up vibrations during the following 7 and is 100% performant from night 10 on; and, reports on %supine, usage time, number of (responses on) vibrations. The device was started for a 28-day try-out period in a clinical cohort of 51 consecutive patients with POSA. SPT-stored data were studied on different time points: first 2 nights without vibrations (baseline), first 2 nights on SPT 100% performance (short term) and 2 later nights after having used the full performant device for 14 days (long term). Results: Only 27 patients used the device throughout the long-term period. The baseline %supine was lower than during polysomnography: 22.9 ± 16.2 versus 40.7 ± 20.0% (p = 0.0005). Apnoea-hypopnoea index calculation taking into account the %supine on SPT revealed that 2/27 patients would not have obstructive sleep apnoea at home. The baseline %supine dropped (p < 0.0001) on short term without further change on long term. Ten patients could be considered cured and demonstrated higher response on vibrations. Only 29 patients could be considered as adherent, and they demonstrated higher response on vibrations and less side effects; only 13 wanted to purchase the SPT. Conclusion: On polysomnography, the %supine is overestimated. The efficacy and low adherence are influenced by differences in response to vibrations. The training effect is already presented on short term.

[Non-surgical treatment of the sleep related breathing disorders in adults]

The treatment of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) must allow for the suppression of symptoms and also prevent its immediate and long-term consequences. The evaluation of the effectiveness of treatments is now based on a normal apnea/hypopnea index, a normal oxygen saturation and the disappearance of sleep fragmentation. Clinical and biological follow-up of co-morbidities must be ensured. Compliance with treatment, a major element of success, must be monitored. Continuous Positive Airway Pressure (CPAP) is still the most effective and widely used treatment. However, mandibular advancement orthosis is now recommended as a first-line treatment in moderate forms in the absence of severe cardiovascular comorbidities (CV) and remains a therapeutic alternative in the event of refusal or intolerance to CPAP. Nutritional management in cases of obesity and a physical activity program must be systematically offered. A reduction in nocturnal breathing disorders can also be achieved by using a device in the event of positional OSAHS, or by limiting fluid movements. The contribution of myofunctional therapy is currently being evaluated. Very recently, a study testing the efficiency of pharmacological treatment on the severity of OSAHS and the reactivity of geniogloss appears to be promising. The evaluation of these different treatments and their combination should make it possible to evolve towards a personalised management adapted to each patient.

Polysomnography and sleep position, a Heisenberg phenomenon? : A large-scale series

BACKGROUND

The severity of position-dependent obstructive sleep apnea (POSA) depends on the nonsupine and supine apnea-hypopnea index (AHI) as well as the time spent in supine position. The latter in particular is susceptible to variation. Several small-scale studies suggest that wearing polysomnography (PSG) apparatus leads to an increase in supine sleeping position.

OBJECTIVES

The aim of this study was to evaluate the effect of wearing PSG apparatus on sleeping position and on OSA severity.

MATERIAL AND METHODS

A large-scale, retrospective study was performed, including a consecutive series of POSA and non-apneic snoring patients who were prescribed positional therapy (Sleep Position Trainer [SPT]). The effect of wearing PSG apparatus on sleeping position was evaluated by comparing body position during the PSG night and inactive (diagnostic) phase of SPT.

RESULTS

The mean percentage of total recording time (TRT) in supine position was 43.1% during the PSG night phase compared with 28.6% of TRT during the inactive (diagnostic) phase of SPT; i.e., a significant decrease of 33.6% (p < 0.001). When adjusting the AHI using TRT in different sleeping positions measured with the SPT, the median AHI decreased from 13.3/h (9.0-20.4) to 10.3/h (6.8-16.2); p < 0.001. When using the adjusted AHI, 33% (N = 66) of all patients had a change in OSA severity.

CONCLUSIONS

The results of this study indicate that wearing PSG apparatus leads to an increase in the percentage of supine sleeping position causing an overestimation of OSA severity, especially in patients with POSA. This can have significant impact on both clinical and scientific practice.

Positional sleep disordered breathing in patients with arrhythmia. Should we advise our patients to avoid supine position during sleep?

BACKGROUND

Sleep disordered breathing [SDB] is a well-known problem in patients with cardiovascular diseases. Around 50% of pts. with SDB present positional sleep disordered breathing [PSDB].

AIMS

The aim of this study was the investigation of the frequency of PSDB in patients with different forms of arrhythmias.

METHODS

We analyzed the presence of SDB in 53 pts. with diagnosed atrial fibrillation (paroxysmal or persistent), 88 pts. before ablation of ventricular ectopy and 110 pts. that had Holter monitoring due to the symptoms suggesting arrhythmia.

RESULTS

Finally, we could collect all the data in 243 pts. - 150 men 93 women. AHI < 15 was recorded in 136 (56%) pts., AHI > 15 in 107 (44%) pts. Moderate sleep disordered breathing was diagnosed in 59 (24%) pts. (AHI 15-30), severe sleep disordered breathing (AHI > 30) was recognized in 48 (20%) pts. In all of the analyzed groups, AHI in supine position was significantly higher than in nonsupine position. PSDB was recorded in 55% of pts. with AHI > 15 and in 29% of pts. (n = 14) with AHI > 30. Percentage of time in supine position was an independent factor related with the presence of at least moderate or severe sleep disordered breathing.

CONCLUSION

1. Moderate or severe SDB is recorded in 44% of pts. with arrhythmias, almost 50% of them have positional SDB. 2. Percent of time of sleeping in supine position has an important independent impact on the presence of SDB. 3. Big studies should be conducted to verify if avoidance of sleeping in supine position may improve clinical outcome.

CONDENSED ABSTRACT

Sleep disordered breathing SDB is a frequent problem of pts. with cardiovascular diseases. It may influence the prognosis. Moderate or severe SDB is recorded in 44% of pts. with arrhythmias, almost 50% of them have positional SDB. Percent of time of sleeping in supine position has an important independent impact on the presence of SDB. 3. Big studies should be conducted to verify if avoidance of sleeping in supine position may improve clinical outcome. What is new?

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.

The Ghana PrenaBelt trial: a double-blind, sham-controlled, randomised clinical trial to evaluate the effect of maternal positional therapy during third-trimester sleep on birth weight

OBJECTIVE

To evaluate the effect, on birth weight and birth weight centile, of use of the PrenaBelt, a maternal positional therapy device, during sleep in the home setting throughout the third trimester of pregnancy.

DESIGN

A double-blind, sham-controlled, randomised clinical trial.

SETTING

Conducted from September 2015 to May 2016, at a single, tertiary-level centre in Accra, Ghana.

PARTICIPANTS

Two-hundred participants entered the study. One-hundred-eighty-one participants completed the study. Participants were women, 18 to 35 years of age, with low-risk, singleton, pregnancies in their third-trimester, with body mass index <35 kg/m² at the first antenatal appointment for the index pregnancy and without known foetal abnormalities, pregnancy complications or medical conditions complicating sleep.

INTERVENTIONS

Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either the PrenaBelt or sham-PrenaBelt. Participants were instructed to wear their assigned device to sleep every night for the remainder of their pregnancy (approximately 12 weeks in total) and were provided a sleep diary to track their use. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants and the outcomes assessor were blinded to allocation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were birth weight and birth weight centile. Secondary outcomes included adherence to using the assigned device nightly, sleeping position, pregnancy outcomes and feedback from participants and maternity personnel.

RESULTS

One-hundred-sixty-seven participants were included in the primary analysis. The adherence to using the assigned device nightly was 56%. The mean ±SD birth weight in the PrenaBelt group (n=83) was 3191g±483 and in the sham-PrenaBelt group (n=84) was 3081g±484 (difference 110 g, 95% CI -38 to 258, p=0.14). The median (IQR) customised birth weight centile in the PrenaBelt group was 43% (18 to 67) and in the sham-PrenaBelt group was 31% (14 to 58) (difference 7%, 95% CI -2 to 17, p=0.11).

CONCLUSIONS

The PrenaBelt did not have a statistically significant effect on birth weight or birth weight centile in comparison to the sham-PrenaBelt.

TRIAL REGISTRATION NUMBER

NCT02379728.

Positional therapy for obstructive sleep apnoea

BACKGROUND

The modalities of therapy for obstructive sleep apnoea (OSA) include behavioural and lifestyle modifications, positional therapy, oral appliances, surgery and continuous positive airway pressure therapy (CPAP). Though CPAP has proven efficacy in treating OSA, adherence with CPAP therapy is suboptimal. Positional therapy (to keep people sleeping on their side) is less invasive and therefore expected to have better adherence. This review considered the efficacy of positional therapy compared to CPAP as well as positional therapy against no positional therapy. Devices designed for positional therapy include lumbar or abdominal binders, semi-rigid backpacks, full-length pillows, a tennis ball attached to the back of nightwear, and electrical sensors with alarms that indicate change in position.

OBJECTIVES

To compare the efficacy of positional therapy versus CPAP and positional therapy versus inactive control (sham intervention or no positional therapy intervention) in people with OSA.

SEARCH METHODS

We identified studies from the Cochrane Airways' Specialised Register (including CENTRAL, MEDLINE, Embase, CINAHL, AHMED and PsycINFO), ClinicalTrials.gov, and the World Health Organization trials portal (ICTRP). It also contains results derived from handsearching of respiratory journals and abstract books of major annual meetings. We searched all databases from their inception to September 2018, with no restrictions on language of publication or publication type.

SELECTION CRITERIA

We included randomised controlled trials comparing positional therapy with CPAP and positional therapy with inactive control.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted the data. We used a random-effects model in the meta-analysis to estimate mean differences and confidence intervals. We assessed certainty of evidence using the GRADE approach.

MAIN RESULTS

We included eight studies. The studies randomised 323 participants into two types of interventions. The comparison between positional therapy and CPAP included 72 participants, while the comparison between positional therapy and inactive control included 251 participants. Three studies used supine vibration alarm devices, while five studies used physical positioning like specially designed pillows or semirigid backpacks.Positional therapy versus CPAPThe three studies included for this comparison were randomised cross-over trials. Two studies found that there was no difference in Epworth Sleepiness Scale (ESS) scores between CPAP and positional therapy. Two studies showed that CPAP produced a greater reduction in Apnoea-Hypopnoea Index (AHI) with a mean difference (MD) of 6.4 events per hour (95% CI 3.00 to 9.79; low-certainty evidence) compared to positional therapy. Subjective adherence, evaluated in one study, was found to be significantly greater with positional therapy (MD 2.5 hours per night, 95% CI 1.41 to 3.59; moderate-certainty evidence).In terms of secondary outcomes, one study each reported quality-of-life indices and quality-of-sleep indices with no significant difference between the two groups. One study reported cognitive outcomes using multiple parameters and found no difference between the groups. There were insufficient data to comment on other secondary outcomes like respiratory disturbance index (RDI), and frequency and duration of nocturnal desaturation. None of the studies clearly reported adverse effects.Positional therapy versus inactive controlThree studies of positional therapy versus no intervention were randomised cross-over trials, while two studies were parallel-arm studies. Data from two studies showed that positional therapy significantly improved ESS scores (MD -1.58, 95% CI -2.89 to -0.29; moderate-certainty evidence). Positional therapy showed a reduction in AHI compared with control (MD -7.38 events per hour, 95% CI -10.06 to -4.7; low-certainty evidence). One study reported adherence. The number of participants who continued to use the device at two months was no different between the two groups (odds ratio (OR) 0.80, 95% CI 0.33 to 1.94; low-certainty evidence). The same study reported adverse effects, the most common being pain in the back and chest, and sleep disturbance but there was no significant difference between the two groups in terms of device discontinuation (OR 1.25, 95% CI 0.5 to 3.03; low-certainty evidence). One study each reported quality-of-life indices and quality-of-sleep indices, with no significant difference between the two groups. One study reported cognitive outcome, and found no difference between the groups. There was insufficient evidence to comment on other secondary outcomes (RDI, frequency and duration of nocturnal desaturation).

AUTHORS' CONCLUSIONS

The review found that CPAP has a greater effect on improving AHI compared with positional therapy in positional OSA, while positional therapy was better than inactive control for improving ESS and AHI. Positional therapy may have better adherence than CPAP. There were no significant differences for other clinically relevant outcomes such as quality of life or cognitive function. All the studies were of short duration. We are unable to comment on the long-term effects of the therapies. This is important, as most of the quality-of-life outcomes will be evident only when the therapies are given over a longer period of time. The certainty of evidence was low to moderate.

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.

From CPAP to tailored therapy for obstructive sleep Apnoea

Obstructive Sleep Apnoea (OSA) is a common sleep disorder that is associated with daytime symptoms and a range of comorbidity and mortality. Continuous Positive Airway Pressure (CPAP) therapy is highly efficacious at preventing OSA when in use and has long been the standard treatment for newly diagnosed patients. However, CPAP therapy has well recognised limitations in real world effectiveness due to issues with patient acceptance and suboptimal usage. There is a clear need to enhance OSA treatment strategies and options. Although there are a range of alternative treatments (e.g. weight loss, oral appliances, positional devices, surgery, and emerging therapies such as sedatives and oxygen), generally there are individual differences in efficacy and often OSA will not be completely eliminated. There is increasing recognition that OSA is a heterogeneous disorder in terms of risk factors, clinical presentation, pathophysiology and comorbidity. Better characterisation of OSA heterogeneity will enable tailored approaches to therapy to ensure treatment effectiveness. Tools to elucidate individual anatomical and pathophysiological phenotypes in clinical practice are receiving attention. Additionally, recognising patient preferences, treatment enhancement strategies and broader assessment of treatment effectiveness are part of tailoring therapy at the individual level. This review provides a narrative of current treatment approaches and limitations and the future potential for individual tailoring to enhance treatment effectiveness.

Modifying maternal sleep position in the third trimester of pregnancy with positional therapy: a randomised pilot trial

OBJECTIVE

To evaluate whether the percentage of time spent supine during sleep in the third trimester of pregnancy could be reduced using a positional therapy device (PrenaBelt) compared with a sham device.

DESIGN

A double-blind, randomised, sham-controlled, cross-over pilot trial.

SETTING

Conducted between March 2016 and January 2017, at a single, tertiary-level centre in Canada.

PARTICIPANTS

23 participants entered the study. 20 participants completed the study. Participants were low-risk, singleton, third-trimester pregnant women aged 18 years and older with body mass index <35 kg/m² at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep.

INTERVENTIONS

A two-night, polysomnography study in a sleep laboratory. Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either a PrenaBelt or a sham-PrenaBelt on the first night and were crossed over to the alternate device on the second night. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants, the recruiter and personnel involved in setting up, conducting, scoring and interpreting the polysomnogram were blinded to allocation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the percentage of time spent supine during sleep. Secondary outcomes included maternal sleep architecture, respiration, self-reported sleep position and feedback.

RESULTS

The median percentage of sleep time supine was reduced from 16.4% on the sham night to 3.5% on the PrenaBelt night (pseudomedian=5.8, p=0.03). We were unable to demonstrate differences in sleep architecture or respiration. Participants underestimated the time they spent sleeping supine by 7.0%, and six (30%) participants indicated they would make changes to the PrenaBelt. There were no harms in this study.

CONCLUSIONS

This study demonstrates that the percentage of sleep time supine during late pregnancy can be significantly reduced via positional therapy.

TRIAL REGISTRATION NUMBER

NCT02377817; Results.

A narrative review of interventions for improving sleep and reducing circadian disruption in medical inpatients

Sleep and circadian disruptions are frequently observed in patients across hospital wards. This is alarming, since impaired nocturnal sleep and disruption of a normal circadian rhythm can compromise health and disturb processes involved in recovery from illness (eg, immune functions). With this in mind, the present narrative review discusses how patient characteristics (sleep disorders, anxiety, stress, chronotype, and disease), hospital routines (pain management, timing of medication, nocturnal vital sign monitoring, and physical inactivity), and hospital environment (light and noise) may all contribute to sleep disturbances and circadian misalignment in patients. We also propose hospital-based strategies that may help reduce sleep and circadian disruptions in patients admitted to the hospital.

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

PURPOSE

The Sleep Position Trainer (SPT) is a new option for treating patients with positional obstructive sleep apnea (POSA). This study investigated long-term efficacy, adherence, and quality of life during use of the SPT device compared with oral appliance therapy (OAT) in patients with POSA.

METHODS

This prospective, multicenter trial randomized patients with mild to moderate POSA (apnea-hypopnea index [AHI] 5-30/h) to SPT or OAT. Polysomnography was performed at baseline and after 3 and 12 months' follow-up. The primary endpoint was OSA severity; adherence, quality of life, and adverse events were also assessed.

RESULTS

Ninety-nine patients were randomized and 58 completed the study (29 in each group). Median AHI in the SPT group decreased from 13.2/h at baseline to 7.1/h after 12 months (P < 0.001); corresponding values in the OAT group were 13.4/h and 5.0/h (P < 0.001), with no significant between-group difference (P = 1.000). Improvements throughout the study were maintained at 12 months. Long-term median adherence was also similar in the two treatment groups; the proportion of patients who used their device for ≥ 4 h for 5 days in a week was 100% in the SPT group and 97.0% in the OAT group (P = 0.598).

CONCLUSIONS

The efficacy of SPT therapy was maintained over 12 months and was comparable to that of OAT in patients with mild to moderate POSA. Adherence was relatively high, and similar in the two groups.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT02045576).

Evaluation of a Trial Period With a Sleep Position Trainer in Patients With Positional Sleep Apnea

STUDY OBJECTIVES

To assess the overall clinical effectiveness of a sleep position trainer (SPT) in patients with positional obstructive sleep apnea (POSA) and to evaluate how many patients were willing to continue treatment after a 1-month trial period.

METHODS

Patients in whom POSA was diagnosed underwent a 1-month trial period with the SPT. Home sleep apnea tests were used to measure baseline data and data following the trial period with the SPT.

RESULTS

The 79 patients who completed the study protocol were 81% male, had a mean age of 52 ± 12 years, and a median baseline respiratory event index (REI) of 11 (8, 16) events/h. A significant reduction in overall REI to 5 (3, 10) events/h was observed with the SPT as compared to baseline (P < .001). The median percentage of sleep time in the supine position decreased significantly from 27 (20, 48) to 7 (2, 20) with the SPT (P < .001). Adherence was found to be 95 ± 8%. Of the 44 patients who decided to continue treatment, 27 were categorized as responders (having a decrease in REI of at least 50%) and 17 were non-responders. The most important reasons for not purchasing the SPT were poor objective results, intolerance to the vibrations, cost of the device, persistent daytime sleepiness, or patient preference for other treatment options.

CONCLUSIONS

Treatment with the SPT came with high adherence rates and was effective in reducing REI and supine sleep position. The trial period is in the patients' best interest, as it may prevent those who will not benefit from positional training from purchasing an SPT.

Can positional therapy be simple, effective and well tolerated all together? A prospective study on treatment response and compliance in positional sleep apnea with a positioning pillow

PURPOSE

Until now, there is no clear consensus on optimal care for mild sleep-related breathing disorders (SRBD) in general or for positional obstructive sleep apnea (POSA) in particular. Most proposed treatment options are either invasive and/or expensive. Positional therapy (PT) may therefore present as a valuable first-line intervention in POSA.

METHODS

Twenty-eight patients presenting with POSA were enrolled in a prospective cohort study. The protocol consisted of three nights of polysomnography (PSG) in an academic sleep lab. Inclusion was based on the first PSG. During a consecutive PSG, PT was provided by means of a sleep-positioning pillow (Posiform®). The third PSG was performed after 1 month of PT. Sleepiness, fatigue, and sleep quality were assessed with the Epworth Sleepiness Scale (ESS), the fatigue severity scale (FSS), the Pittsburgh Sleep Quality Index (PSQI), and the Function Outcomes of Sleep Questionnaire (FOSQ) at baseline, and after 1 and at 6 months of PT alongside satisfaction and compliance ratings.

RESULTS

Significant immediate treatment effects after one night and sustained after 1 month were observed by significant reductions of sleep in supine position (p < .001), sleep fragmentation (p < .05), apnea-hypopnea (p < .001), respiratory disturbance (p < .001), and oxygen desaturation (p < .001) indices. PSQI (p < .001), ESS (p < .005), and FOSQ (p < .001) also showed significant and persistent improvements.

CONCLUSIONS

Combined effects on sleep-related respiration and clinical symptoms were observed after PT initiation as well as after 1 month using the sleep-positioning pillow. Furthermore, reported compliance and overall satisfaction appeared to be highly concordant both at 1 month and 6 months follow-up.

Post-Stroke Sleep-Disordered Breathing-Pathophysiology and Therapy Options

Sleep-disordered breathing (SDB), encompassing both obstructive and central sleep apnea, is prevalent in at least 50% of stroke patients. Small studies have shown vast improvements in post-stroke functional recovery outcomes after the treatment of SDB by continuous positive airway pressure. However, compliance to this therapy is very poor in this complex patient group. There are alternative therapy options for SDB that may be more amenable for use in at least some post-stroke patients, including mandibular advancement, supine avoidance, and oxygen therapy. There are few studies, however, that demonstrate efficacy and compliance with these alternative therapies currently. Furthermore, novel SDB-phenotyping approaches may help to provide important clinical information to direct therapy selection in individual patients. Prior to realizing individualized therapy, we need a better understanding of the pathophysiology of SDB in post-stroke patients, including the role of inherent phenotypic traits, as well as the contribution of stroke size and location. This review summarizes the available literature on SDB pathophysiology and treatment in post-stroke patients, identifies gaps in the literature, and sets out areas for further research.

User Compliance and Behavioral Adaptation Associated With Supine Avoidance Therapy

This study investigates behavioral adaptation to vibrotactile position-avoidance therapy during sleep in patients with obstructive sleep apnea (n =135) across 15 to 52 weeks. The overall compliance, based on nights used ≥ 4 hr, was 71%. Overall regular use, that is, ≥ 4 hr/night over 70% of nights, was 88%. Poor early compliance strongly predicted poor long-term treatment adherence, with 92% of those noncompliant across the first 12 weeks of therapy remaining noncompliant. Conversely, 21% of those with compliant utilization in the short term became noncompliant in the long term. It appears that patients do not habituate to the stimulus during sleep, nor was there a training effect associated with long-term use.