Developments in diagnosis and treatment of obstructive sleep apnea

Identificatie van fenotypen en endotypen draagt bij tot een beter begrip van de complexe pathofysiologie en heterogene klinische presentatie van obstructieve slaapapneu (OSA). Het algemene doel van dit proefschrift was om de toegevoegde waarde te bepalen van potentiële voorspellers; risicofactoren geassocieerd met OSA en factoren die het behandelresultaat beïnvloeden. Middels het vaststellen van voorspellers kan de specificiteit en sensitiviteit van diagnostiek worden verhoogd. Daarnaast kunnen deze voorspellers richting geven tijdens de keuze uit de verschillende behandelopties, wat vervolgens zou kunnen leiden tot toename van het behandelsucces. De onderzochte fenotypen zijn: snurkgeluiden, gebitsparameters en positieafhankelijkheid. Snurkgeluiden voorspellen niet de aanwezigheid van een obstructie op elk niveau van de bovenste luchtweg zoals gevonden tijdens een slaapendoscopie. Gebitsparameters dragen niet bij aan de OSA screening of de voorspelling van het behandelsucces middels een mandibulair repositie apparaat (MRA). Positieafhankelijk OSA voorspelt niet of een patiënt al dan niet een geschikte kandidaat is voor een MRA behandeling. Ook is de voorspellende waarde van specifieke manoeuvres en hulpmiddelen tijdens een slaapendoscopie onderzocht. De nieuwe generatie MRA voorspelt zijn eigen behandelsucces en, door de gevonden gelijkenis met de standaard MRA, ook dat van een standaard op maat gemaakte MRA. De ernst van OSA vóór de behandeling middels nervus hypoglossus stimulatie (NHS) en follow-up middels dagtitraties hebben beiden geen (negatieve) invloed op het resultaat van de NHS-behandeling. Hierdoor kan de indicatie voor HNS worden verruimd en de logistiek voor follow-up worden vereenvoudigd met betere werkomstandigheden voor somnotechnologen zonder de kwaliteit van de titratie in gevaar te brengen

Developments in diagnosis and treatment of obstructive sleep apnea

Identificatie van fenotypen en endotypen draagt bij tot een beter begrip van de complexe pathofysiologie en heterogene klinische presentatie van obstructieve slaapapneu (OSA). Het algemene doel van dit proefschrift was om de toegevoegde waarde te bepalen van potentiële voorspellers; risicofactoren geassocieerd met OSA en factoren die het behandelresultaat beïnvloeden. Middels het vaststellen van voorspellers kan de specificiteit en sensitiviteit van diagnostiek worden verhoogd. Daarnaast kunnen deze voorspellers richting geven tijdens de keuze uit de verschillende behandelopties, wat vervolgens zou kunnen leiden tot toename van het behandelsucces. De onderzochte fenotypen zijn: snurkgeluiden, gebitsparameters en positieafhankelijkheid. Snurkgeluiden voorspellen niet de aanwezigheid van een obstructie op elk niveau van de bovenste luchtweg zoals gevonden tijdens een slaapendoscopie. Gebitsparameters dragen niet bij aan de OSA screening of de voorspelling van het behandelsucces middels een mandibulair repositie apparaat (MRA). Positieafhankelijk OSA voorspelt niet of een patiënt al dan niet een geschikte kandidaat is voor een MRA behandeling. Ook is de voorspellende waarde van specifieke manoeuvres en hulpmiddelen tijdens een slaapendoscopie onderzocht. De nieuwe generatie MRA voorspelt zijn eigen behandelsucces en, door de gevonden gelijkenis met de standaard MRA, ook dat van een standaard op maat gemaakte MRA. De ernst van OSA vóór de behandeling middels nervus hypoglossus stimulatie (NHS) en follow-up middels dagtitraties hebben beiden geen (negatieve) invloed op het resultaat van de NHS-behandeling. Hierdoor kan de indicatie voor HNS worden verruimd en de logistiek voor follow-up worden vereenvoudigd met betere werkomstandigheden voor somnotechnologen zonder de kwaliteit van de titratie in gevaar te brengen

The predictive value of drug-induced sleep endoscopy for treatment success with a mandibular advancement device or positional therapy for patients with obstructive sleep apnea

© 2021, The Author(s), under exclusive licence to Springer Nature Switzerland AG.Purpose: As drug-induced sleep endoscopy (DISE) can provide additional diagnostic information on collapse patterns of the upper-airway, it is widely used in patients with obstructive sleep apnea (OSA). Although more controversial, DISE may also predict the success of treatment with a mandibular advancement device (MAD) and/or positional therapy (PT). In 2018, we proposed a prediction model to investigate the predictive value of passive maneuvers during DISE — such as jaw thrust and changes in body position — on upper-airway patency. Based on the outcomes of various studies, we then adjusted our DISE protocol to better mimic the effect of a MAD, PT, or a combination of both. The aim of this study was to verify whether or not our adjustments would increase the value of DISE as a selection tool. Methods: This single-center retrospective cohort study involved a consecutive series of patients with OSA. Patients were included if a DISE had been performed in supine and non-supine sleeping position and with and without a boil-and-bite MAD in situ between December 2018 and February 2020. The VOTE scoring system was used to evaluate the obstruction at four levels of the upper-airway. Results: Among 94 patients included. the median apnea–hypopnea index (AHI) was 16.2 (events/h). As a temporary MAD during DISE reduced obstruction by 54% and jaw thrust by 57%, both mimicked the effect of the custom-made MADs referred to in the literature, which reduces the AHI by 60%. Head-and-trunk rotation reduced obstruction by 55% and thus mimicked the effect of PT, which is known to reduce the AHI by 50%. Conclusion: A jaw thrust, a temporary MAD, and head-and-trunk rotation during DISE all seem to mimic the treatment effects of MAD and PT. These findings may be of added value when choosing OSA treatment. To prove the predictive value of these maneuvers during DISE, a prospective study should be performed

Position-dependent obstructive sleep apnea and its influence on treatment success of mandibular advancement devices

© 2021, The Author(s), under exclusive licence to Springer Nature Switzerland AG.Purpose: Depending on the severity of pre-treatment obstructive sleep apnea (OSA) and the criteria used to define treatment success, the efficacy of mandibular advancement devices (MADs) ranges from 30 to 69%. Identifying suitable candidates is the key to increasing the efficacy of a MAD. Positive predictors include a low body mass index, a low apnea–hypopnea index (AHI), and low age. Another consideration is whether or not a patient’s OSA is position dependent. To evaluate the effect of such dependency on MAD treatment success, we studied the following: treatment success across the patient’s total AHI and in the supine and non-supine sleeping positions; the influence of pre-treatment position dependency on MAD treatment success; and the effect of MAD treatment on post-treatment shifts in position dependency. Methods: This is a single-center retrospective study of patients with OSA. Patients were diagnosed through an overnight polysomnography and treated with a MAD between February 2015 and January 2018. They were defined as being positional if the AHI in supine sleeping position was at least twice as high as in the non-supine position. Results: Complete treatment success was achieved in 32% of study population (n = 96) and partial success in 54%. Complete treatment success was significantly higher (p = 0.004) when a patient was sleeping in the non-supine position. Treatment success did not differ significantly between patients who were position dependent and those who were not. When treated with a MAD, patients did not spend significantly more time in supine position. Neither did we find any post-treatment shifts in position dependency. Conclusion: A MAD is an effective treatment modality that may significantly reduce the total AHI, supine, and non-supine AHI. Since position dependency has no impact on MAD treatment success, it does not determine whether or not a patient is a suitable candidate for MAD treatment

Daytime polysomnography to perform titration for upper airway stimulation in patients with obstructive sleep apnea

© 2021, The Author(s), under exclusive licence to Springer Nature Switzerland AG.Purpose: Upper airway stimulation (UAS) is an innovative treatment for patients with obstructive sleep apnea (OSA). UAS titrations are performed 3 months after activation of the device to optimize its effectiveness. In general, these titrations are performed during an in-laboratory overnight polysomnography (PSG). However, overnight titrations are expensive and can be logistically challenging because they are labor-intensive which causes shortage of sleep technicians available for night shifts. In addition, recently, overnight PSGs were postponed and canceled due to the COVID-19 pandemic. We aimed to assess the feasibility of a daytime PSG to perform titration of UAS therapy as an alternative for a conventional overnight PSG. Methods: We performed a prospective single-center observational cohort study. Patients were included when planned for UAS titration; this was approximately 6 months after UAS activation. Data on sleep architecture, patient experience, and respiratory outcomes were collected to evaluate the feasibility. An overnight follow-up PSG 12 months after implantation was used to compare sleep architecture and therapy response. Results: Of 23 patients, four were excluded from analysis because of technical issues during PSG. Even though patients slept significantly shorter during the daytime PSG, this was enough time to complete the titration successfully with 30-min sleep in final therapeutic settings in 84% of the patients. Patients (94%) had a positive experience with the daytime titration. Respiratory outcomes were significantly reduced during titration and were maintained at the 12-month follow-up. Conclusion: Daytime titrations are a valuable alternative for conventional overnight titrations. Our findings suggest the implementation of daytime titrations as standard of care. This will contribute to easier logistics and better work circumstances for sleep technicians without jeopardizing titration quality

The effect of postoperative CPAP use on anastomotic and staple line leakage after bariatric surgery

© 2020, Springer Nature Switzerland AG.Purpose: Almost two-thirds of the population undergoing bariatric surgery (BS) suffers from obstructive sleep apnea (OSA). Continuous positive airway pressure (CPAP) is the standard treatment for moderate to severe OSA and is recommended in patients undergoing BS perioperatively. A severe and dreaded complication after BS is anastomotic leakage. There is theoretical concern that perioperative CPAP use may result in increased distension of the gastrointestinal tract and increase the risk of developing an anastomotic leakage. The aim of this study was to evaluate the effect of postoperative CPAP use on the risk of developing anastomotic leakages after BS. Methods: Retrospectively, all patients from a single bariatric center who underwent BS from November 2007 to August 2019 were included. Presence and severity of OSA were determined using poly(somno)graphy. To evaluate the effect of postoperative CPAP use on anastomotic leakage, a multivariable logistic regression analysis was performed. Results: A total of 4052 patients were included, with OSA being diagnosed in 62%. Overall, 970 patients (24%) used CPAP after BS. Anastomotic leakage occurred in 64 (1.6%) patients after BS. Leakage rate was 1.3% in non-CPAP group versus 2.5% in CPAP group (p = 0.01). CPAP use was associated with anastomotic leakage; however, after adjustment, CPAP use was not an independent predictor (OR = 1.40, 95% CI 0.60–3.28, p = 0.44). Conclusion: There is no independent relation between postoperative CPAP use and anastomotic leakage after BS. Only revision surgery was an independent predictor of anastomotic leakage