Review of oral appliances for treatment of sleep-disordered breathing

Between 1982 and 2006, there were 89 distinct publications dealing with oral appliance therapy involving a total of 3,027 patients, which reported results of sleep studies performed with and without the appliance. These studies, which constitute a very heterogeneous group in terms of methodology and patient population, are reviewed and the results summarized. This review focused on the following outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea index or respiratory disturbance index), ability of oral appliances to reduce snoring, effect of oral appliances on daytime function, comparison of oral appliances with other treatments (continuous positive airway pressure and surgery), side effects, dental changes (overbite and overjet), and long-term compliance. We found that the success rate, defined as the ability of the oral appliances to reduce apnea/hypopnea index to less than 10, is 54%. The response rate, defined as at least 50% reduction in the initial apnea/hypopnea index (although it still remained above 10), is 21%. When only the results of randomized, crossover, placebo-controlled studies are considered, the success and response rates are 50% and 14%, respectively. Snoring was reduced by 45%. In the studies comparing oral appliances to continuous positive airway pressure (CPAP) or to uvulopalatopharyngoplasty (UPPP), an appliance reduced initial AHI by 42%, CPAP reduced it by 75%, and UPPP by 30%. The majority of patients prefer using oral appliance than CPAP. Use of oral appliances improves daytime function somewhat; the Epworth sleepiness score (ESS) dropped from 11.2 to 7.8 in 854 patients. A summary of the follow-up compliance data shows that at 30 months, 56–68% of patients continue to use oral appliance. Side effects are relatively minor but frequent. The most common ones are excessive salivation and teeth discomfort. Efficacy and side effects depend on the type of appliance, degree of protrusion, vertical opening, and other settings. We conclude that oral appliances, although not as effective as CPAP in reducing sleep apnea, snoring, and improving daytime function, have a definite role in the treatment of snoring and sleep apnea

Persistent Cough in Nonsmokers

OBJECTIVE: The purpose of this study was to test the hypothesis that, using Irwin's protocol, the majority of nonsmokers with persistent cough can be diagnosed and treated successfully

Persistent Cough in Nonsmokers

OBJECTIVE: The purpose of this study was to test thehypothesis that, using Irwin's protocol, the majority ofnonsmokers with persistent cough can be diagnosed andtreated successfully.DESIGN: Retrospective review of patients referred for theinvestigation of chronic cough.SETTING: Referral out-patient practice of a hospital-basedpulmonary physician.PATIBNTS: There were 228 patients who satisfied the followingentry criteria for inclusion in the data analysis:cough longer than four weeks; nonsmoker; normal chestradiograph; and completion of the required investigations.A total of 198 patients completed the required investigationsand returned for the final follow-up visit.INTERVENTIONS: Diagnostic tests included chest radiographs,pulmonary function tests, radiographs of the sinuses,barium swallow and fibreoptic bronchoscopy.MAIN OUTCOME MEASURES: Status of cough at the timeof final follow-up visit, classified according to four levels:resolved, improved, unchanged or worse.RESULTS: The diagnosis was established in 91 % of patients.The most common diagnoses (alone or in combination)were postnasal drip (26% ), asthma (25% ), gastroesophagealreflux (24%), postinfectious cough (21 %), andcough due to angiotensin-converting enzyme inhibitors(6%); none had an occult malignancy and one patient hadendobronchial tuberculosis. The initial diagnostic impressionwas best in patients with postinfectious cough (100%)and worst in patients with asthma (25%). The outcome ofspecific therapy was successful in 91 % of patients.CONCLUSIONS: In the majority of nonsmoking adultscough can be diagnosed and treated successfully. mostcauses are relatively 'benign' and the initial clinical impressionmay be quite misleading, particularly in cough-variantasthma.Peer Reviewe

Pleuroparenchymal lung disease secondary to nonoccupational exposure to vermiculite

An unusual case of pleuroparenchymal lung disease caused by the inhalation of vermiculite dust, presumably containing asbestos fibers is described. The uniqueness of the case lies in the very indirect nature of exposure – the wife of a factory owner, rather than a worker exposed to asbestos, whose factory manufactured vermiculite. The present case illustrates the importance of taking careful occupational histories of all household members when presented with a patient whose chest radiograph exhibits features consistent with asbestos exposure

Pleuroparenchymal Lung Disease Secondary to Nonoccupational Exposure to Vermiculite

An unusual case of pleuroparenchymal lung disease caused by the inhalation of vermiculite dust, presumably containing asbestos fibers is described. The uniqueness of the case lies in the very indirect nature of exposure – the wife of a factory owner, rather than a worker exposed to asbestos, whose factory manufactured vermiculite. The present case illustrates the importance of taking careful occupational histories of all household members when presented with a patient whose chest radiograph exhibits features consistent with asbestos exposure.Peer Reviewe

Acidification of distal esophagus and sleep-related breathing disturbances

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldSTUDY OBJECTIVES: To investigate whether distal esophageal acidification occurs during sleep in patients suspected of sleep-disordered breathing, and whether such acidification is related to respiratory abnormalities. DESIGN AND PATIENTS: Fourteen middle-aged, snoring men all complaining of daytime sleepiness and suspected of having obstructive sleep apnea. SETTING: Sleep laboratory, Pulmonary Department, Landspitali University Hospital, Reykjavik, Iceland. MEASUREMENTS AND RESULTS: Each patient underwent full nocturnal polysomnography testing, which included continuous monitoring of esophageal pressure (Pes) and pH. We identified all pH events, which were defined as a reduction in esophageal pH of >/= 1.0. During each pH event, the respiratory recordings where examined for the presence of apneas or hypopneas, and Pes was recorded. The data were analyzed to determine the possible relationships between pH events and respiratory events, and between changes in pH and changes in Pes. We found that there were more respiratory events than pH events. The mean (+/- SD) number of apneas and hypopneas per hour of sleep was 33 +/- 22, whereas the mean number of pH events per hour of sleep was 7 +/- 6. Overall, 81% of all pH events were associated with respiratory events. Correlation analysis did not reveal any significant relationship between pH events and the magnitude of Pes or apnea-hypopnea index. CONCLUSIONS: Episodes of esophageal acidification are common in patients with sleep apnea, and are usually associated with respiratory and pressure events. However, changes in pH were independent of the magnitude of the Pes

Management of idiopathic pulmonary fibrosis: selected case reports

In 2011, revised international guidelines were issued jointly by the American Thoracic Society, the European Respiratory Society, the Japanese Respiratory Society and the Latin American Thoracic Association, which provide a valuable framework for the diagnosis and management of idiopathic pulmonary fibrosis (IPF). However, due to the complexity of IPF, these guidelines may not comprehensively account for the management of individual IPF patients in clinical practice. We describe three patient cases that were presented and discussed during the 2013 AIR: Advancing IPF Research meeting in Nice, France. These cases highlight the heterogeneity in the presentation, history and clinical course of IPF, together with expert insights regarding the diagnosis and management of IPF in the real-life setting