Camilo Fernandez-Salvador

Tongue retaining devices for obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVE Tongue Retaining Devices (TRD) anteriorly displace the tongue with suction forces while patients sleep. TRD provide a non-surgical treatment option for patients with Obstructive Sleep Apnea (OSA). Our objective was to conduct a systematic review of the international literature for TRD outcomes as treatment for OSA. METHODS Three authors independently and systematically searched four databases (including PubMed/MEDLINE) through June 26, 2016. We followed guidelines set within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS Sixteen studies with 242 patients met criteria. The overall means±standard deviations (M±SD) for apnea-hypopnea index (AHI) decreased from 33.6±21.1/h to 15.8±16.0/h (53% reduction). Seven studies (81 patients) reported lowest oxygen saturation (LSAT), which improved from 79.8±17.5% to 83.9±8.6%. Four studies (93 patients) reported Epworth sleepiness scale (ESS), which decreased from 10.8±4.8 to 8.2±4.5, p <0.0001. Four studies (31 patients) reported Oxygen Desaturation Index (ODI) which decreased from 29.6±32.1 to 12.9±8.7, a 56.4% reduction. CONCLUSION Current international literature demonstrates that tongue retaining devices reduce apnea-hypopnea index by 53%, increase lowest oxygen saturation by 4.1 oxygen saturation points, decrease oxygen desaturation index by 56% and decrease Epworth sleepiness scale scores by 2.8 points. Tongue retaining devices provide a statistically effective alternative treatment option for obstructive sleep apnea.

Treatment of Snoring with a Nasopharyngeal Airway Tube.

Objective. To study the feasibility of a standard nasopharyngeal airway tube (NPAT) as treatment for snoring. Methods. An obese 35-year-old man, who is a chronic, heroic snorer, used NPATs while (1) the patients bedpartner scored the snoring and (2) the patient recorded himself with the smartphone snoring app “Quit Snoring.” Baseline snoring was 8–10/10 (10 = snoring that could be heard through a closed door and interrupted the bedpartners sleep to the point where they would sometimes have to sleep separately) and 60–200 snores/hr. Several standard NPATs were tested, consisting of soft polyvinyl chloride material raging between 24- and 36-French (Fr) tubes. Results. The 24 Fr tube did not abate snoring. The 26 Fr tube was able to abate the snoring sound most of the night (smartphone app: 11.4 snores/hr, bedpartner VAS = 2/10). The 28 and 30 Fr tubes abated the snoring sound the entire time worn (smartphone app: 0 snores, bedpartner VAS 0/10) but could not be tolerated more than 2.5 hours. The tube of 36 Fr size could not be inserted, despite several attempts bilaterally. Conclusion. Appropriately sized nasopharyngeal airway tubes may abate the snoring sound; however, as in this patient, they may be too painful and intolerable for daily use.

Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis

PurposeOropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy.MethodsPubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs.ResultsA total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time.ConclusionsThis systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

Neuromuscular function of the soft palate and uvula in snoring and obstructive sleep apnea: A systematic review

OBJECTIVE A collapsible upper airway is a common cause of obstructive sleep apnea. The exact pathophysiology leading to a more collapsible airway is not well understood. A progressive neuropathy of the soft palate and pharyngeal dilators may be associated with the progression of snoring to OSA. The purpose of this study is to systematically review the international literature investigating the neurophysiologic changes in the soft palate and uvula that contribute to progression from snoring to OSA. METHODS PubMed/MEDLINE and 4 other databases were systematically searched through July 4, 2017. Eligibility: (1) Patients: controls, snoring or OSA patients (2) Intervention: neuromuscular evaluation of the palate and/or uvula (3) Comparison: differences between controls, snoring and OSA patients (4) Outcomes: neuromuscular outcomes (5) Study design: Peer reviewed publications of any design. RESULTS 845 studies were screened, 76 were downloaded in full text form and thirty-one studies met criteria. Histological studies of the soft palate demonstrated diffuse inflammatory changes, muscular changes consistent with neuropathy, and neural aberrancies. Sensory testing studies provided heterogeneous outcomes though the majority favored neuronal dysfunction. Studies have consistently demonstrated that increasing severity of snoring and sleep apnea is associated with worsening sensory nerve function of the palate in association with atrophic histological changes to the nerves and muscle fibers of the soft palate and uvula. CONCLUSIONS Recent evidence highlighted in this systematic review implicates the role of neurogenic pathology underlying the loss of soft palate and/or uvular tone in the progression of snoring to sleep apnea.

The effect of tonsillectomy on obstructive sleep apnea: an overview of systematic reviews

Objective Tonsillectomy with adenoidectomy is a combination surgery that has been used to treat pediatric obstructive sleep apnea (OSA). For adults, tonsillectomy has also been reported as a primary treatment modality when the tissue is hypertrophied. The objective of this study is to provide an overview of published systematic reviews and meta-analyses of tonsillectomy with or without adenoidectomy as used in the treatment of OSA in children and adults. Data sources Nine databases, including PubMed/MEDLINE. Review methods Databases were searched from their inception through July 9, 2017. The PRISMA statement was followed. Results More than 20 recent systematic reviews and meta-analyses were identified regarding tonsillectomy as a treatment modality for OSA. There were four articles that addressed tonsillectomy’s overall success, efficacy, and complications in otherwise healthy pediatric patients. Three studies evaluated tonsillectomy in obese children, and two specifically examined children with Down syndrome. Only one systematic review and meta-analysis discussed tonsillectomy as a treatment for OSA in the adult population. Conclusion Tonsillectomy as an isolated treatment modality is rarely performed in pediatric patients with OSA; however, tonsillectomy is commonly performed in combination with adenoidectomy and the combination has demonstrated efficacy as the primary treatment option for most children. In the limited adult data, tonsillectomy alone for OSA has a surprising success rate; yet, more research is required to determine long-term improvement and need for further treatment.

Human craniofacial evolution: A cause for obstructive sleep apnea

In 1859, Charles Darwin revealed his theory of evolution by natural selection in his famous book “On the Origin of Species.” According to the theory, natural selection is the process by which organisms evolve over time to allow for better adaption to its environment in order to survive and have more offspring [1]. In Homo sapiens (humans), the notion of natural selection is observed in the way we perform our activities of daily living. In 2003, Davidson et al. [2] presented data supporting the concept that craniofacial structural and anatomical changes took place for the development of speech and language (Figure 1). Unfortunately, the undesired consequence of this evolution facilitated obstructive sleep apnea (OSA) in modern humans [2]. Klinorynchy is the posterior migration of the splanchnocranium (facial skeleton) under the neurocranium [2]. This shift shortens the maxilla, palate, ethmoids, and mandible in order to provide speech and language. These changes are seen in the evolution from Pan Troglodyte, a common chimpanzee, to the modern Homo sapien [2]. According to Crelin et al. [3], the anterior migration of the foramen magnum with pharyngeal collapse is part of the evolutionary change to facilitate speech but diminishes olfaction. Lieberman et al. [4] proposed that the change from an obtuse to an acute cranial base angulation seen in the modern Homo sapiens furthered the development of speech, resonance, and voice. In regards to tongue position, Negus et al. [5] described that the posterior migration of the tongue into the pharynx decreased the oral cavity size to improve speech and deglutition. In the animal kingdom, the mechanism known as the epiglottic–soft palate lock-up, the overlapping of the epiglottis and soft palate, is prevalent [2]. Interestingly, the mechanism is present in infant Homo sapiens, but disappears as the soft palate shortens and the larynx descends, in order to promote buccal speech [2]. Although these adapted anatomical features facilitate speech and the development of language, they also predispose humans to OSA. Although the central reason for these anatomical changes were to develop voice, speech, and language, it is also recognized that these advances contributed to development of binocular vision and bipedalism [2]. We hypothesize that a separate series of events could have occurred in the central nervous system, which led to speech and OSA. With the understanding of craniofacial evolution in humans, perhaps we can orthodontically or surgically modify the mandible, maxilla, palate, pharynx and/or tongue to maintain appropriate speech but reduce the severity of OSA.

Nasal cannula technique for ventilating during the administration of general anesthesia in neonates and pediatric patients

ABSTRACT Objective: Minor surgeries on the oral cavity, e.g., frenulectomies, are often performed under general mask anesthesia. The objective is to present the nasal cannula technique for ventilating step-by-step method for ventilating during general anesthesia for minor surgeries in neonates and pediatric patients. Technique: The nasal cannula technique for ventilating has been used in over 20 pediatric cases (neonates and toddlers), without the need to re-mask during the procedure and without complications or oxygen desaturations. After induction of general mask anesthesia, propofol with or without adjunctive ketamine is administered. The anesthesia mask is exchanged with a nasal cannula, using the largest sized prongs that accommodate the nares, and the nasal cannula is connected to the anesthesia circuit. This permits administration of inspired fractions of oxygen. Conclusion: The nasal cannula technique for ventilating provides a safe method for delivering general anesthesia and ventilating during minor surgeries for neonates and pediatric patients.

Soft palate fistula after radiofrequency ablation for primary snoring: a case report and literature review ☆

Ronco é uma queixa comum em pacientes que procuram cuidados médicos. O ronco pode perturbar o sono dos parceiros de cama ou daqueles que compartilham um quarto com um roncador. Embora aplicativos de smartphone para ronco tenham sido usados para determinar a intensidade e o número de roncos por hora,1 o parceiro de cama é, em última análise, o principal determinante do que é e não é um ronco perturbador. O ronco é geralmente causado pela vibração do palato mole contra as paredes faríngeas. Embora o ronco possa ocorrer exclusivamente durante a respiração nasal,2 ocorre mais comumente durante a respiração oral. Várias técnicas foram desenvolvidas para tratar o ronco, tais como a injeção roncoplástica, implantes de pilar, cirurgia de endurecimento palatino com cautério (CAPSO) e ablação por radiofrequência (ARF). A ablação por radiofrequência tem sido efetivamente usada em várias especialidades cirúrgicas. O mecanismo de ação da ARF é relacionado à

From nuclear submarines to graduate medical education: applying David Marquet’s intent-based leadership model

L. David Marquet, a decorated Navy Captain, transformed an underperforming submarine crew by empowering his subordinates to be leaders and reach their full potential. He called this intent-based leadership (IBL). What would happen if Marquet’s model were implemented in Graduate Medical Education (GME)?In this letter to the editor, we summarize the potential of the IBL model in graduate medical education as opposed to the traditional leader-follower method. IBL harnesses human productivity toward the shared goals of GME, which are patient care and trainee learning. This shift in mindset could lead both teachers and trainees to focus more on the real reason that we undertake GME and change behaviors for the better. We suggest that IBL can and should be adopted in GME and propose that both patients and providers will benefit from this action.

Recent Updates to Soft Palate Surgery for Treatment of Obstructive Sleep Apnea

Purpose of ReviewThis study aims to provide an update on surgical modalities targeted specifically at the soft palate as treatment for obstructive sleep apnea (OSA). OSA is an ever-changing field with advancements in not only medical management but also surgical interventions that continue to add to the plethora of treatment options. Though a multitude of surgical treatment modalities exist, the most commonly used technique involved remains the uvulopalatopharyngoplasty (UPPP).Recent FindingsWhile over 100 articles were initially identified, many were excluded due to combination of other surgical techniques. Fewer than 20 studies evaluated surgery on the soft palate alone. This manuscript summarizes the techniques presented over the past 3 years.SummaryThis review of the literature failed to identify any new developments improving consistency of efficacy of the surgical techniques directed towards the soft palate.