Anneclaire V. Vroegop

Drug‐induced sleep endoscopy in sleep‐disordered breathing: Report on 1,249 cases

To describe upper airway (UA) collapse patterns during drug‐induced sleep endoscopy (DISE) in a large cohort of patients with sleep‐disordered breathing (SDB) and to assess associations with anthropometric and polysomnographic parameters.

Evaluation of Drug-Induced Sleep Endoscopy as a Patient Selection Tool for Implanted Upper Airway Stimulation for Obstructive Sleep Apnea

STUDY OBJECTIVES To study the possible predictive value of drug-induced sleep endoscopy (DISE) in assessing therapeutic response to implanted upper airway stimulation (UAS) for obstructive sleep apnea (OSA). METHODS During DISE, artificial sleep is induced by midazolam and/or propofol, and the pharyngeal collapse patterns are visualized using a flexible fiberoptic nasopharyngoscope. The level (palate, oropharynx, tongue base, hypopharynx/epiglottis), the direction (anteroposterior, concentric, lateral), and the degree of collapse (none, partial, or complete) were scored in a standard fashion. RESULTS We report on the correlation between DISE results and therapy response in 21 OSA patients (apnea-hypopnea index [AHI] 38.5 ± 11.8/h; body mass index [BMI] 28 ± 2 kg/m(2), age 55 ± 11 y, 20 male/1 female) who underwent DISE before implantation of a UAS system. Statistical analysis revealed a significantly better outcome with UAS in patients (n = 16) without palatal complete concentric collapse (CCC), reducing AHI from 37.6 ± 11.4/h at baseline to 11.1 ± 12.0/h with UAS (p < 0.001). No statistical difference was noted in AHI or BMI at baseline between the patients with and without palatal CCC. In addition, no predictive value was found for the other DISE collapse patterns documented. CONCLUSIONS The absence of palatal CCC during DISE may predict therapeutic success with implanted UAS therapy. DISE can be recommended as a patient selection tool for implanted UAS to treat OSA.

Sleep endoscopy with simulation bite for prediction of oral appliance treatment outcome

The aim of this study was to assess the value of drug‐induced sleep endoscopy (DISE) using a custom‐made simulation bite in maximal comfortable protrusion (MCP) of the mandible, in the prediction of treatment outcome for obstructive sleep apnea (OSA) with a mandibular advancement device (MAD). Two hundred patients (74% male; age 46 ± 9 years; apnea–hypopnea index [AHI] 19 ± 13 h−1 sleep; body mass index [BMI] 27 ± 4 kg m−2) with sleep‐disordered breathing underwent DISE with a simulation bite in MCP. One hundred and thirty‐five patients with an established diagnosis of OSA commenced MAD treatment. The associations between the findings during DISE with simulation bite and treatment outcome were evaluated. Treatment response was defined as a reduction in AHI following MAD treatment of ≥ 50% compared to baseline. Overall MAD treatment response in the studied population was 69%. The results of this study demonstrated a statistically significant association between a positive effect of the simulation bite on the upper airway patency during DISE and treatment response with MAD (P < 0.01). The results of this study suggest that the use of a simulation bite in maximal comfortable protrusion (MCP) of the mandible, as used during DISE in patients with OSA, tends to be effective in predicting treatment response of MAD treatment.

A promising concept of combination therapy for positional obstructive sleep apnea

PurposeThe objective of this randomized controlled trial was to assess the additional effect of a chest-worn sleep position trainer (SPT) in patients with residual supine-dependent obstructive sleep apnea (sdOSA) under mandibular advancement device (MAD) therapy.MethodsBaseline and follow-up polysomnography with MAD were performed. Twenty patients with sdOSA under MAD therapy underwent two consecutive randomized polysomnographies: one with SPT and one with combination of SPT + MAD. Data are presented as median (quartile 1, quartile 3).ResultsThe SPT reduced the time spent in supine sleeping position compared to baseline and MAD therapy. Both MAD and SPT were individually effective in reducing the overall apnea/hypopnea index (AHI) significantly when compared to baseline from 20.8 (15.1; 33.6)/h at baseline to 11.0 (6.7; 13.8)/h and to 11.1 (3.5; 17.7)/h with MAD or SPT, respectively. The combination of SPT + MAD further reduced the overall AHI to 5.7 (3.6; 7.4), which was significantly lower than with MAD alone (p < 0.001) and SPT alone (p < 0.008), respectively.ConclusionsThe results of this study indicate that combination of SPT + MAD leads to a higher therapeutic efficacy in patients with sdOSA under MAD therapy when compared to one of the treatment modalities alone.

Objectively measured vs. self-reported compliance during oral appliance therapy for sleep-disordered breathing

BACKGROUND Assessment of the overall therapeutic effectiveness of oral appliance therapy can only be realized through objectively measured compliance. The aims of this study were to assess objectively measured compliance during oral appliance therapy at 1-year follow-up and to compare these data with self-reported use. METHODS Fifty-one eligible patients were enrolled in this 1-year prospective clinical study (men, 61%; mean age, 49 ± 10 years; apnea-hypopnea index, 18.0 ± 11.9 events/h sleep; BMI, 26.6 ± 4.1 kg/m²). Objective compliance during oral appliance therapy at 1-year follow-up was assessed with a microsensor thermometer. Subjective compliance was assessed by self-report. Patients with a mean objectively measured use of ≥ 4 h/night on 70% of nights monitored were considered regular users. The mean disease alleviation was calculated as a measure of overall therapeutic effectiveness. RESULTS High agreement between objective and subjective compliance data at 1-year follow-up was reported (intraclass correlation coefficient, 0.8; 95% CI, 0.5-0.9), showing a mean subjective overestimation of 30 min (95% CI, -3.1 to 1.9; P = .02). The discontinuation rate at 1-year follow-up was 9.8%. The objective mean use rate was 6.4 ± 1.7 h/night at 1-year follow-up in continuing users, with a regular use rate of 83%. The mean disease alleviation was 54.9%. CONCLUSIONS This study is the first to our knowledge to report the 1-year results of objectively measured compliance during oral appliance therapy. In addition, a high agreement between objective and subjective compliance data were reported, with a mean subjective overestimation of 30 min. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01284881; URL: www.clinicaltrials.gov.

Effects of vertical opening on pharyngeal dimensions in patients with obstructive sleep apnoea

BACKGROUND It is still subject to controversy if an increased vertical opening (VO) is beneficial in oral appliance therapy for the treatment of obstructive sleep apnoea. Each oral appliance has a given thickness causing VO. Therefore, evaluation of the effects of the amount of VO on pharyngeal dimensions is mandatory. METHODS The effects of VO on the cross-sectional area of the upper airway at the level of the tongue base during sleep endoscopy were scored and categorised. RESULTS The figures demonstrate the possible effects of VO on pharyngeal collapse relative to the baseline cross-sectional area and the maximal comfortable protrusion of the mandible. Thirty-two patients (80%) showed an adverse effect of VO (Fig. 1), one patient (2.5%) had a positive effect (Fig. 2), and seven patients (17.5%) demonstrated an indifferent effect (Fig. 3). CONCLUSION Based on literature, the effect of VO on pharyngeal collapse is unclear and the therapeutic impact of VO is not determined. The results of the present study indicate that the effect of VO on the degree of pharyngeal collapse as assessed during sleep endoscopy tends to be adverse, causing an increase in collapsibility in the majority of patients.

Long-term self-reported treatment effects and experience of radiofrequency-induced thermotherapy of the inferior turbinates performed under local anesthesia: a retrospective analysis

Nasal obstruction due to inferior turbinate hypertrophy is a common complaint. Radiofrequency-induced thermotherapy of the inferior turbinates (RFITT) under local anesthesia is now a widely used treatment, however reports of assessment of the long-term self-reported benefits and patient satisfaction of the treatment are scarce. This study focuses on the self-reported long-term effects of treatment and experience of RFITT. A questionnaire was sent to 441 patients who underwent RFITT in our clinic to treat symptoms of impaired nasal passage due to enlarged inferior turbinates. All patients had enlarged inferior turbinates on nasal examination. Patients were included if RFITT was done under local anaesthesia, was performed more than a year before the questionnaire was forwarded and on the indication-significant nasal obstruction because of enlarged inferior turbinates. Improvement of nasal breathing (by means of a Visual Analog Scale, VAS), changes in use of nasal spray (VAS), usage of pain medication, patient friendliness of the treatment, complaints reported after treatment, permanent effect of treatment during day and night time and willingness to recommend treatment to others were analyzed. No significant post-operative complications were observed. There was a significant reduction in use of nasal spray and the majority of patients interviewed reported long-term positive effects of RFITT during the daytime. This study shows that RFITT performed under local anesthesia is a valuable, minimally invasive, patient-friendly and well-tolerated treatment in patients with impaired nasal passage due to inferior turbinate hypertrophy.

European position paper on drug-induced sleep endoscopy: 2017 Update

The first edition of the European position paper (EPP) on drug‐induced sleep endoscopy (DISE) was published in 2014 with the aim to standardise the procedure, to provide an in‐depth insight into the main aspects of this technique and to have a basis for future research. Since 2014, new studies have been published concerning new sedative agents or new insights into the pattern/levels of the obstruction depending on the depth of sedation. Therefore, an enlarged group of European experts in the field of sleep breathing disorders (SBD), including the most of the first DISE EPP main authors, has decided to publish an update of the European position paper on DISE, in order to include new evidence and to find a common language useful for reporting the findings of this endoscopic evaluation in adult population affected by SBD.

Correlation Between Calculated/Predicted and Actual AHI After Positional Therapy

Prediction of treatment outcome is crucial for all OSA treatment modalities, as this may prevent unnecessary costs and “trial and error” treatment choices. This is an important item of the clinical reality involving OSA patients. With this in mind, the crucial question that still remains unanswered is: Can the effect of positional therapy be predicted from the (baseline) sleep study? What treatment outcome is to be expected in which patient? What is the predictive value of the baseline non-supine AHI? This item is subject to different theories and hypotheses and will be discussed in the following paragraphs.

Prevalence and Effect of Supine-Dependent Obstructive Sleep Apnea on Oral Appliance Therapy

Oral appliance (OA) therapy is a noninvasive treatment option for patients with obstructive sleep apnea (OSA). The most common type of OA therapy prescribed for the treatment of OSA is an oral appliance worn intraorally at night in order to reduce upper airway collapse by protruding the mandible (OAm). In this chapter, we will focus on the effect of supine-dependent OSA (sdOSA) on treatment outcome during OAm therapy, the prevalence of sdOSA before and under OAm therapy, and the effect of combination of an OAm and positional therapy. Retrospective analyses of clinical, physiological, and polysomnographic variables were performed in literature in order to identify predictors of treatment success with OA therapy. Six studies assessed a significant association between the efficacy of OAm therapy and the presence of sdOSA, whereas the results of two other studies couldn’t confirm this finding. In order to evaluate the treatment effect of OAm therapy among patients with or without sdOSA, it can be important to determine the prevalence of sdOSA in the patient population starting OAm therapy. In this restricted patient group, the prevalence of sdOSA at baseline ranged from 27 to 80 %. In addition, up to one third of patients undergoing OAm therapy have sdOSA under OAm therapy. Those patients could probably benefit from additional therapy with a supine-avoidance device. Two studies assessed the efficacy of OA therapy combined with positional therapy showing promising results for this specific combination therapy.