Weight reduction and alcohol abuse in sleep apnea patients

Obstructive sleep apnea syndrome (OSAS) has an estimated prevalence of 2 percent in women and 4 percent in men. OSAS is characterized by repeated obstructive events of the pharyngeal upper airway during sleep. OSAS, which often causes excessive daytime sleepiness, is both an individual and a societal problem with large personal suffering and societal costs. The most common cause of OSAS is overweight and obesity, an increasing burden worldwide. In Sweden, 43 percent of the adults are estimated to be overweight. Other causes to OSAS are anatomical narrowness with large tonsils and tongue, alcohol, smoking, and supine sleeping position. The prevalence of alcohol overconsumption is estimated to 10 percent in Swedish adults. This thesis evaluates two aspects of OSAS; firstly, the prevalence of alcohol over-consumption, secondly the effects of dietary weight reduction in the obese OSAS patient. In PAPER I we evaluated the overuse of alcohol and benzodiazepines among 98 OSAS patients at our ENT-department, which has not previously been reported. We screened the patients with a local questionnaire, but also objectively with blood and urine tests. A new laboratory marker, Carbohydrate-Deficient-Transferrin (CDT), reflecting the alcohol consumption the last two weeks, was used, in combination with benzodiazepine metabolites in urine. The prevalence of positive CDT was 8.5 percent, which is approximately the same level as estimated in the general population. The prevalence of benzodiazepine use was 3.2 percent. Only 2 persons denied study participation. None of the patients who screened positive for CDT had indicated overuse of alcohol in the questionnaire, and none was willing to accept contact with an abuse-clinic. In PAPER II we performed a randomized pilot study between weight reduction and expectancy among 20 obese (Body Mass Index >30) OSAS males. There is a demand for randomized studies on weight reduction and the goal of the study was to evaluate our weight reduction program in obese OSAS patients. The diet consisted of 8 weeks low-calorie-diet (LCD) with a protein drink (Nutrilett®) in combination with weekly group meetings for support. The controls were asked to maintain their weight. Evaluations included changes in weight and Oxygen Desaturation Index (ODI4) measured with polygraphy. The results showed significant differences between the intervention and control group concerning changes in weight and ODI4. However, there was a large drop-out rate (45 %), which makes the results uncertain. On the other hand, this pilot study showed us how difficult it is to motivate obese OSAS patients to change their life-style. In PAPER III and IV we continued to evaluate the effects of weight reduction with LCD in obese OSAS with a non-randomized prospective intervention study. We improved our selection methods to included better motivated patients compared to in study 2. The LCD was followed by an additional behavioral modifying group therapy for 2 years, which aimed to change dietary and exercise habits. A group of 33 patients (24 males, 9 females) were included, out of who 23 used OSAS-device (19 Continuous Positive Airway Pressure (CPAP), 4 Mandibular Retaining Device (MRD)). The evaluations included weight, bioelectrical impedance, polysomnographic respiratory and sleep parameters, metabolic status, blood pressure, excessive daytime sleepiness and ratings of quality of life. Such extensive information has not been reported previously for this patient group. The weight reduction at 6 months was in mean 18 kilos in 30 patients, a more impressive result than after 2 years, when it was 11 kilos in 23 patients. However, after 2 years nocturnal respiration, arousals, metabolic status (blood insulin levels and dyslipidemia), as well as daytime sleepiness, were still significantly improved compared to baseline values. Quality of life ratings showed significant improvements for the subscales vitality and physical functioning . Further, there was a significant positive correlation between the reductions in weight and apneas. There were no gender differences, neither between patients with CPAP/ MRD-device compared to without. In conclusion, as we found clinically important improvements, we recommend treating well motivated obese OSAS patients with dietary weight reduction in group therapy

15-year efficacy of uvulopalatopharyngoplasty based on objective and subjective data

Conclusions: This follow-up showed a stable and significant decrease in median oxygen desaturation index 4% (ODI(4)) values over the years. Approximately two-thirds of the patients fulfilled the success criteria (ODI4 reduction of 50% and andlt;20) after 15 years. A majority had improved/cured excessive daytime sleepiness (EDS) and were satisfied. No increased mortality rate was seen. Objectives: To evaluate sleep apnoea recordings and symptoms in patients with obstructive sleep apnoea syndrome 15 years after uvulopalatopharyngoplasty (UPPP) compared to baseline and previous follow-ups. Methods: This was a non-randomized, prospective intervention study on 50 patients who underwent UPPP during 1985-88. Their initial median age was 49 years (range 38-71) and ODI4 was 26.5 (4-82). Results: In all, 13 patients had died; 26 patients underwent sleep apnoea recordings. Median ODI4 had decreased from 26.5 (range 4-82) to 8.5 (0-60), p andlt; 0.01, a mean reduction of 52%; 65% of patients achieved the success criteria. One-third was objectively categorized as non-snorers. Median body mass index was unchanged. The questionnaires were answered by 32 of 37 patients; 88% reported improved or cured EDS and 78% were satisfied. Pharyngeal disturbances ratings were low. The standardized mortality rate did not differ from the general Swedish population.Funding Agencies|Swedish Association of Sleep Medicine and Sleep Research||Acta Otolaryngologica Foundation|

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery.

ObjectiveThe primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS).Materials & methodsA descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries).ResultsParacetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy.ConclusionThe Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery

Postoperative morbidity after adenotonsillectomy versus adenopharyngoplasty in young children with obstructive sleep apnea : an RCT

PURPOSE: In our previous randomized controlled trial (RCT), comparing adenotonsillectomy (ATE) with adenopharyngoplasty (APP) in children with severe obstructive sleep apnea (OSA), there were no differences in respiratory sleep parameters or quality of life. The purpose of the present report was to evaluate postoperative morbidity from this RCT. METHODS: The study was a blinded RCT in 83 children (ATE = 47; APP = 36), 2-4 years of age, with an obstructive apnea-hypopnea index of ≥ 10. Pain was assessed from the first until the tenth day after surgery with a logbook that reported pain by child (FPS-R, Faces Pain Scale-Revised) and caregiver (visual analogue scale), analgesic use, return to normal diet, and weight change. Bleeding, infection, satisfaction with treatment, speech, and swallowing were assessed with a questionnaire and medical records 6 months after surgery. RESULTS: Sixty-four children (77%) returned the logbook and 65 (78%) answered the questionnaire. The median (interquartile range) day the children graded themselves as pain free (FPS-R = 0) was 7 (6-10) after ATE, compared with 9 (7 to > 10) after APP (p = 0.018). There were no other significant differences between the groups regarding any other pain-related outcomes, bleeding, infection, satisfaction, swallowing, or speech, but three children (11%) reported impaired speech after APP compared to none after ATE (p = 0.067). CONCLUSION: The results regarding postoperative morbidity were in favor of ATE and the results from our previous report showed no advantages of APP. Therefore, APP should not be recommended in young, otherwise healthy children with OSA

N.B.: When citing this work, cite the original article. Original Publication:

http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-72804 15-year efficacy of uvulopalatopharyngoplasty based on objective and subjective data Conclusions: This follow-up showed a stable and significant decrease in median oxygen desaturation index 4 % (ODI4) values over the years. Approximately two thirds of the patients fulfilled the success criteria (ODI4 reduction of 50 % and < 20) after 15 years. A majority had improved/cured excessive daytime sleepiness (EDS) and was satisfied. No increased mortality rate was seen. Objectives: To evaluate sleep apnoea recordings and symptoms in patients with obstructive sleep apnoea syndrome 15 years after uvulopalatopharyngoplasty (UPPP) compared to baseline, and previous follow-ups. Method: A non-randomized, prospective intervention study on 50 patients who underwent UPPP during 1985–88. Their initial median age was 49 (range 38–71) and ODI4 26.5 (4–82)

Adenotonsillotomy versus adenotonsillectomy in pediatric obstructive sleep apnea : A 5-year RCT

Objectives: Adenotonsillectomy (ATE) is a common treatment for pediatric obstructive sleep apnea (OSA). Intracapsular adenotonsillotomy (ATT) is associated with less postoperative morbidity. Our previous randomized controlled trial (RCT) compared ATE and ATT in otherwise healthy children with moderate to severe OSA. No differences in polysomnographic (PSG) and OSA-18 were found between the groups at one-year follow-up. This study presents the long-term results of the RCT. Methods: Non-obese children (n = 79, 2-6 years) who had undergone either ATE (n = 40) or ATT (n = 39) were offered PSG and OSA-18 questionnaire five-years after surgery. Primary outcome was the group difference in postoperative Obstructive Apnea/Hypopnea Index (OAHI). ATE was recommended to the ATT group if they had a relapse of OSA. Results: The follow-up was completed by 45 of 79 (57%) children; 28 (35%) drop-outs, and six of 39(15%) in the ATT group were excluded after ATE. After ATE(n = 17), OAHI decreased from mean 12.3(SD 8.0) to 0.6(0.7), and after ATT(n = 28) from 12.6(7.4) to 0.5(0.6), a mean difference in postoperative OAHI of 0.1(95% CI -0.3 - 0.5). Sensitivity analyses did not change the results. The median OSA-18 decreased in the ATE group from 57(interquartile range 47-79) to 27(22-36), and in the ATT group from 67(53-79) to 32(25-44), without group differences for postoperative values. Conclusion: The results of this five-year follow-up of otherwise healthy OSA-children showed a high drop-out rate, but indicates that ATT could be an effective treatment for pediatric OSA. However, ATT warrants follow-up due to the risk of recurrence, and further studies are needed

Correlations between objective and subjective outcomes after adenotonsillar surgery in children with OSA

Objectives To investigate whether the OSA-18 questionnaire and a postoperative patient-reported outcome measure (PROM) question correlated with polysomnography (PSG) data. Methods A prospective study of otherwise healthy young children with moderate to severe obstructive sleep apnea (OSA) to investigate if the obstructive apnea–hypopnea index (OAHI) before and 6–12 months after adenotonsil surgery correlated with the OSA-18 total symptom score (TSS) and the sleep disturbance subscale (SDS), as well as a PROM question on symptom improvement with responses on a 4-grade Likert scale. Results Of 201 children, 173 (86%) had complete data of OAHI and OSA-18 pre- and postoperatively. The mean age was 3.2 years (SD 1.0) and the mean OAHI was 15.9 (11.3). Significant correlations between changes in the OAHI and OSA-18 were found, both TSS (r = 0.29, p < .001) and SDS (r = 0.53, p < .001). A total of 136 (68%) patients responded to the PROM question, the majority of whose symptoms had disappeared (n = 102) or almost disappeared (n = 30). Four patients had unchanged symptoms, and none had worsening symptoms. A correlation was found between the PROM question and a change in the OAHI (r = 0.36, p < .001), as well as a change in the OSA-18 TSS (r = 0.24, p = .006) and the SDS (r = 0.34, p < .001). The specificity of the PROM question for prediction of a postoperative OAHI < 2 was 82%, and the sensitivity was 38%. Conclusion Changes in the OAHI significantly correlated with changes in the OSA-18, especially with the sleep disturbance scale, which could be an alternative for evaluation at follow-ups

Trends and changes in paediatric tonsil surgery in Sweden 1987-2013 : a population-based cohort study.

Objectives The objective of this study was to longitudinally describe the history of tonsil surgery in Swedish children and adolescents regarding incidence, indications for surgery, surgical methods and the age and gender distributions. Setting A retrospective longitudinal population-based cohort study based on register data from the Swedish National Patient Register (NPR) and population data from Statistics Sweden. Participants All Swedish children 1–<18 years registered in the NPR with a tonsil surgery procedure 1987–2013. Results 167 894 tonsil surgeries were registered in the NPR 1987–2013. An increase in the total incidence rate was observed, from 22/10 000 person years in 1987 to 47/10 000 in 2013. The most marked increase was noted in children 1–3 years of age, increasing from 17 to 73/10 000 person years over the period. The proportion children with obstructive/sleep disordered breathing (SDB) indications increased from 42.4% in 1987 to 73.6% in 2013. Partial tonsillectomy, tonsillotomy (TT), increased since 1996 and in 2013 55.1% of all tonsil procedures were TTs. Conclusions There have been considerable changes in clinical practice for tonsil surgery in Swedish children over the past few decades. Overall, a doubling in the total incidence rate was observed. This increase consisted mainly of an increase in surgical procedures due to obstructive/SDB indications, particularly among the youngest age group (1–3 years old). TT has gradually replaced tonsillectomy as the predominant method for tonsil surgery

A validation study of data in the National Tonsil Surgery Register in Sweden : High agreement with medical records ensures that data can be used to monitor clinical practices and outcomes

Background The ambition of the National Tonsil Surgery Register in Sweden (NTSRS) is to improve otorhinolaryngological care by monitoring trends in the clinical practices, complications, and outcomes of tonsil surgery. The NTSRS collects data from both surgeons and patients and provides the participating clinics with daily updated data on a publicly available website. On the website, national and local results can be compared and monitored. The use of NTSRS data necessitates that the data is valid, but the NTSRS has not yet been validated. With approximately half of the registered patients responding to the postoperative questionnaires, an analysis of responders and non-responders is also necessary. The aim of this study was to assess the criterion validity of NTSRS data. Another aim was to compare the characteristics and rates of complications between postoperative questionnaire responders and non-responders. Methods Data in the NTSRS were compared with data in electronic medical records. The 200 most recent surgeries, up to 31 Dec 2019, in each of 11 surgical units were included. Criterion validity was analysed in terms of observed agreement, Cohens kappa, Gwet’s AC1, and positive and negative agreement. The sign test was used to analyse systematic differences between the NTSRS and the medical records. Comparisons of rates between groups were made with Fisher’s exact test, the chi-square test, and Fisher’s non-parametric permutation test. Results A total of 1991 registrations were included in the study. All variables showed very high observed agreement ranging from 0.91 to 1.00, and all variables had AC1 values corresponding to almost perfect agreement. The analysis of questionnaire responders and non-responders showed no statistically significant differences regarding age, indication, or type of surgery. The proportion of women was higher in the responder group. The rate of reoperation due to bleeding was higher in the responder group, but there were no differences regarding other complications. Conclusions The results of this study show that data in the NTSRS have criterion validity. The NTSRS is thus well suited for monitoring the clinical practices and outcomes of tonsil surgery. The quality of the data also implies that the registry can be used in both clinical improvement projects and research.Funding: Linkoping University - Swedish Association of Local Authorities and Regions</p