Linda B. L. Benoist

Correction to: Durability of treatment effects of the sleep position trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial

The article “Durability of treatment effects of the Sleep Position Trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial”, by M. H. T. de Ruiter et al., was originally published online in SpringerLink on 15 September 2017 without open access.

Organization and logistics of drug-induced sleep endoscopy in a training hospital

Drug-induced sleep endoscopy (DISE) is a rapidly growing method to evaluate airway collapse in patients receiving non-CPAP therapies for sleep-disordered breathing (SDB). The growing number of DISEs has consequences for the organization of clinical protocols. In this paper we present our recent experiences with DISE, performed by an ENT resident, with sedation given by a nurse anesthetist, in an outpatient endoscopy setting, while the staff member/sleep surgeon discusses the findings and the recommended treatment proposal on the same day.

Comparison of upper airway collapse patterns and its clinical significance: drug-induced sleep endoscopy in patients without obstructive sleep apnea, positional and non-positional obstructive sleep apnea

PurposeTo compare patient characteristics, upper airway (UA) collapse patterns and treatment outcome in obstructive sleep apnea (OSA) patients, including non-positional OSA patients (NPP) and positional OSA patients (PP), and non-OSA.MethodsCohort study of patients screened for OSA in 2012. Polysomnography was performed and UA was evaluated using the VOTE classification during drug-induced sleep endoscopy (DISE). Treatment outcome of MAD and UA surgery was evaluated.ResultsEight hundred sixty patients were included. Higher BMI, larger neck circumference, and greater age were independent significant predictors for OSA. DISE was performed in 543 patients: 119 non-OSA and 424 OSA patients of whom 257 PP and 167 NPP patients. PP were younger, had smaller neck circumference, lower BMI and apnea-hypopnea index (AHI) than NPP. Collapse at velum (p < 0.001) and oropharynx (p < 0.001) significantly increased the odds for having OSA. Tongue base and epiglottis collapse were, on group level, not determinative for OSA or non-OSA. Complete concentric collapse (CCC) was observed less frequently in PP (31.5%) as compared to NPP (46.1%). After UA surgery, OSA often was cured or improved to less severe positional OSA. Lower efficacy of UA surgery was observed in PP as compared to NPP. No differences were observed in MAD treatment outcome.ConclusionsCurrent study provides insight in patients screened for OSA: collapse at velum and oropharynx significantly determined presence of OSA and CCC occurred less frequently in PP compared to NPP. In addition, residual positional dependency is common after UA surgery. More trials are needed to gain insight in pathophysiology and treatment outcome.

Novel Positional Devices for the Treatment of Positional Obstructive Sleep Apnea, and How This Relates to Sleep Surgery

If untreated, obstructive sleep apnea (OSA) develops as a gradual progressive disease. In the early stage of the disease most patients with OSA are positional. The archetypical patient might progress from simple positional snoring via positional early-stage mild disease to less positional moderate and finally nonpositional severe OSA. At first, the apnea-hypopnea index (AHI) is high only in the supine position, and later is high in all sleeping positions. The phenomenon is reversible. After partial effective treatment, patients with severe OSA can reverse to less severe positional OSA or, in other words, the AHI drops more in the lateral position than in supine position. This has been shown for palatal surgery, multilevel surgery, bimaxillary osteotomies, and bariatric surgery. The absence or presence of positional dependency has a great influence on sleep surgery. First, the results of sleep surgery might be worse in positional patients. Second, the addition of positional therapy to sleep surgery might improve the overall outcome and, as such, enhance the indication of sleep surgery as an alternative to continuous positive airway pressure and mandibular advancement device treatment.

Subjective effects of the sleep position trainer on snoring outcomes in position-dependent non-apneic snorers

PurposeTo evaluate the effect of a new-generation positional device, the sleep position trainer (SPT), in non-apneic position-dependent snorers.MethodsNon-apneic position-dependent snorers with an apnea–hypopnea index (AHI) < 5 events/h were included between February 2015 and September 2016. After inclusion, study subjects used the SPT at home for 6 weeks. The Snore Outcome Survey (SOS) was filled out by the subjects at baseline and after 6 weeks, and at the same time, the Spouse/Bed Partner Survey (SBPS) was filled out by their bed partners.ResultsA total of 36 participants were included and 30 completed the study. SOS score improved significantly after 6 weeks from 35.0 ± 13.5 to 55.3 ± 18.6, p < 0.001. SBPS score also improved significantly after 6 weeks from 24.7 ± 16.0 versus 54.5 ± 25.2, p < 0.001. The severity of snoring assessed with a numeric visual analogue scale (VAS) by the bed partner decreased significantly from a median of 8.0 with an interquartile range (IQR) of [7.0–8.5] to 7.0 [3.8–8.0] after 6 weeks (p = 0.004).ConclusionsResults of this study indicate that positional therapy with the SPT improved several snoring-related outcome measures in non-apneic position-dependent snorers. The results of this non-controlled study demonstrate that this SPT could be considered as an alternative therapeutic option to improve sleep-related health status of snorers and their bed partners.

Advances in the Diagnosis of Obstructive Sleep Apnea: Drug-Induced Sleep Endoscopy

Drug-induced sleep endoscopy was introduced in 1991 and has recently evolved into a pivotal instrument for patients in whom obstructive sleep apnea surgery is considered. Here, we discuss the indications, contraindications, technique, anesthesia, scoring systems, validity, and insights of the literature.

Residual POSA After Maxillomandibular Advancement in Patients with Severe OSA

In patients with severe or extreme OSA and CPAP failure, maxillomandibular advancement (MMA) can be considered. Because of its considerable morbidity, MMA is mostly reserved for severe to extreme cases, often after less aggressive surgeries have failed. The success rates of MMA are very high: between 80 and 90 %. A new finding is that MMA failure can be due to the fact that after surgery the AHI in supine sleep position remains much higher as compared to the non-supine AHI: in other words, non-positional OSA has reversed into less severe POSA. Postoperative residual POSA can be in theory a good indication for additional positional therapy. In this chapter we will discuss our theoretical considerations on this phenomenon of residual POSA after MMA surgery.

Influence of Sleep Position on the Transition of Mild to Moderate and Severe OSA

Various chapters have shown that positional OSA patients are younger and have a lower BMI, neck circumference, and AHI compared to non-positional OSA patients. In this chapter, several theories about the influences of sleep position on the transition of mild to moderate and severe OSA will be discussed.

Influence of Sleep Position on Snoring

Snoring is an acoustic phenomenon that affects approximately 20–40 % of the general population [1]. It is caused by vibration of tissue structures in the upper airway during sleep [2, 3]. Non-apneic snoring has been shown to be associated with clinical conditions such as depression and excessive daytime sleepiness in adults and may also have clinical implications in the development of hypertension, ischemic heart disease, and cerebrovascular diseases [1, 4]. In this chapter, the prevalence of position dependency in non-apneic snorers and the influence of various factors such as BMI, neck circumference, age, gender, and sleep efficiency on sleeping position will be discussed.

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.