Madeline Ravesloot

One hundred consecutive patients undergoing drug-induced sleep endoscopy: Results and evaluation†‡

Polysomnography (PSG) is mandatory in the diagnostic workup of obstructive sleep apnea (OSA); drug‐induced sleep endoscopy (DISE) is a valid addition. DISE is a dynamic, safe, easy‐to‐perform technique that visualizes the anatomic sites of snoring or apneas and guides the making of a tailor‐made treatment plan in individual cases. The aim of this prospective study was to document the results of 100 consecutive DISE procedures and investigate associations between PSG and DISE findings.

Surgery for obstructive sleep apnea: Sleep endoscopy determinants of outcome

Although drug‐induced sleep endoscopy is often employed to determine the site of obstruction in patients with obstructive sleep apnea (OSA) who will undergo upper airway surgery, it remains unknown whether its findings are associated with surgical outcome. This study tested the hypothesis that drug‐induced sleep endoscopy variables can predict the outcome of upper airway surgery in OSA patients.

Evaluation of a new simple treatment for positional sleep apnoea patients

Obstructive sleep apnoea syndrome is a common clinical problem. Positional sleep apnoea syndrome, defined as having a supine apnoea–hypopnoea index of twice or more compared to the apnoea–hypopnoea index in the other positions, occurs in 56% of obstructive sleep apnoea patients. A limited number of studies focus on decreasing the severity of sleep apnoea by influencing sleep position. In these studies an object was strapped to the back (tennis balls, squash balls, special vests), preventing patients from sleeping in the supine position. Frequently, this was not successful due to arousals while turning from one lateral position to the other, thereby disturbing sleep architecture and sleep quality. We developed a new neck‐worn device which influences sleep position by offering a vibration when in supine position, without significantly reducing total sleep time. Thirty patients with positional sleep apnoea were included in this study. No side effects were reported. The mean apnoea–hypopnoea index dropped from 27.7 ± 2.4 to 12.8 ± 2.2. Seven patients developed an overall apnoea–hypopnoea index below 5 when using the device in ON modus. We expect that positional therapy with such a device can be applied as a single treatment in many patients with mild to moderate position‐dependent obstructive sleep apnoea, while in patients with a more severe obstructive sleep apnoea such a device could be used in combination with other treatment modalities.

Treatment adherence should be taken into account when reporting treatment outcomes in obstructive sleep apnea

INTRODUCTION Treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) or intraoral devices is regarded as successful if a reduction in the apnea-hypopnea index (AHI) below 5 is achieved while the devices are used. It is, however, common knowledge that a majority of patients are not adherent to the treatment during 100% of the total sleep time under everyday, nonlaboratory conditions. In line with the theory that limited adherence leads to periods of sleep without effective treatment, studies have shown a positive relationship between hours of CPAP use and a favorable outcome. The effectiveness of conservative treatment regarding the reduction of AHI depends both on its impact on airway obstruction and compliance. Presently, the second aspect is often overlooked. Currently, when reporting on treatment effectiveness of conservative treatment, the reduction in AHI while using CPAP in laboratory situations is documented. An artificial compliance of 100% is assumed. Therefore, we propose that treatment adherence should be taken into account when reporting outcomes of treatment of OSA with regard to the AHI and comparing effects of different treatment options. EVIDENCE FOR CHANGE In a double-blind, placebo-controlled, cross-over trial, patients with OSA were randomly assigned to therapeutic or sham CPAP treatment for a period of 3 months, with a washout period of 1 month in between. A statistically significant greater mean reduction in systolic and diastolic blood pressure (BP), glycated hemoglobin, triglycerides, and low-density lipoprotein and total cholesterol was observed in a subgroup of patients who used CPAP 5 hours. Similar results were found in a prospective long-term follow-up study and a randomized controlled trial. A significant decrease in the 24-hour mean arterial pressure was achieved in patients who used CPAP >5.3 hours/day, and a statistically significant decrease in systolic BP was observed in patients who use CPAP 5.6 hours/night. Hours of CPAP use was an independent predictor of reduction in BP. In a retrospective cohort study, the 5-year cumulative survival rate was significantly higher in patients with sleep apnea and hypertension who used CPAP 6 hours/night. Weaver et al. reported a linear-dose relationship between hours of CPAP use and improvement in daytime sleepiness after 3 months of therapy in a recent follow-up cohort study of patients with severe OSA. This current evidence demonstrates that clinical outcome is dependent on compliance to treatment in a dose-dependent manner.

Efficacy of the New Generation of Devices for Positional Therapy for Patients With Positional Obstructive Sleep Apnea: A Systematic Review of the Literature and Meta-Analysis

STUDY OBJECTIVES In approximately 56% to 75% of patients with obstructive sleep apnea (OSA), the frequency and duration of apneas are influenced by body position. This is referred to as position-dependent OSA or POSA. Patients with POSA can be treated with a small device attached to either the neck or chest. These devices-a new generation of devices for positional therapy (PT)-provide a subtle vibrating stimulus that prevents patients adopting the supine position. The objectives of this study were to determine whether PT is effective in improving sleep study variables and sleepiness, and to assess compliance. METHODS A systematic review and meta-analysis. RESULTS Three prospective cohort studies and four randomized controlled trials were included in this review. Combined data for studies reporting on the effect of PT show that there was a mean difference of 11.3 events/h (54% reduction) in apnea-hypopnea index and 33.6% (84% reduction) in percentage total sleeping time in the supine position. The standardized mean difference for both parameters demonstrated a large magnitude of effect (> 0.8 in both cases). CONCLUSIONS There is strong evidence that the new generation of devices for PT are effective in reducing the apnea-hypopnea index during short-term follow-up. These devices are simple-to-use for patients and clinicians and are reversible. Under study conditions with short-term follow-up, compliance is high; however, long-term compliance cannot be assessed because of lack of reliable data. Additional long-term, high-quality studies are needed to confirm the role of PT as a single or as a combination treatment modality for OSA patients and to assess long-term compliance.

Reliable Calculation of the Efficacy of Nonsurgical and Surgical Treatment of Obstructive Sleep Apnea

Objective: The effectiveness of CPAP compliance criteria can be questioned, just as the effectiveness of surgical success criteria has often been questioned. The aim of the study was to measure the effectiveness of compliant CPAP use. Method: Using mathematical function formulas, the effect on the AHI of various treatment modalities and their respective compliance and success criteria were calculated. Results: The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to smaller than 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP). Conclusion: Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI.

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.

‘A good shepherd, but with obstructive sleep apnoea syndrome’: traditional uvulectomy case series and literature review

BACKGROUND In the West, removal of the uvula is predominantly undertaken as part of palatal surgery, in cases of obstructive sleep apnoea. In the developing world, such as the Middle East and Africa, uvulectomy is a more common practice. The uvula is removed for curative or preventive purposes, or as part of ritual practice. Due to immigration from developing to developed world countries, and to Western doctors working abroad, such doctors are increasingly being confronted with unfamiliar traditional healing practices, within a medical context. METHODS The Medline and Embase online databases were systematically searched for literature on traditional uvulectomy. We present a review of this literature. We also present the first report, to our best knowledge, of obstructive sleep apnoea as a late complication of traditional uvulectomy. DISCUSSION Traditional uvulectomy may be complicated by post-operative haemorrhage and local infections, among many other problems. We report cases of obstructive sleep apnoea and snoring caused by palatal stenosis resulting from traditional uvulectomy during childhood.

Persistent moderate or severe obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass: which patients?

BACKGROUND Patients with severe obesity and obstructive sleep apnea (OSA) might decide to undergo bariatric surgery to improve this disease or, more specifically, to become independent of continuous positive airway pressure (CPAP) therapy, which is generally indicated in case of moderate and severe OSA. Knowledge of this topic is important for patient education on expectations of surgical outcome. OBJECTIVES To evaluate the prevalence and phenotypes of patients with persistent moderate to severe OSA after bariatric surgery. SETTING Obesity Center Amsterdam, Amsterdam, the Netherlands. METHODS Patients who underwent a laparoscopic Roux-en-Y gastric bypass, had a preoperative apnea-hypopnea index (AHI)≥15/hr, and of whom a follow-up AHI/hr was available were included. RESULTS Out of 437 patients, 205 underwent pre- and postoperative polysomnography; 232 (53.1%) were lost to follow-up. Median AHI was 32.3/hr (range, 15-138) and mean body mass index was 46 (standard deviation 7.2) kg/m2. A postoperative AHI<15/hr was achieved in 152 patients (74.1%), whereas 53 (25.9%) still had moderate or severe disease 8.6 (standard deviation 4.8) months postoperatively. Predictive factors for persistent moderate to severe disease were age≥50 years, preoperative AHI≥30/hr, excess weight loss (EWL)<60%, and hypertension (area under the curve: .772). CONCLUSION After bariatric surgery, around three quarters of the moderate to severe OSA patients had no or mild OSA, whereas one quarter (25.9%) still had moderate to severe OSA. Age≥50 years, preoperative AHI≥30/hr, EWL<60%, and hypertension were predictive factors for this persistent postoperative AHI≥15/hr.

Positional Therapy in Obstructive Sleep Apnea

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