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A systematic review of the efficacy of oral appliance design in the management of obstructive sleep apnoea

May 8, 2011 by SleepDT Leave a Comment

Source

Discipline of Dental Public Health.

Abstract

Oral appliances (OAs) are increasingly advocated as a treatment option for obstructive sleep apnoea (OSA). However, it is unclear how their different design features influence treatment efficacy. The aim of this research was to systematically review the evidence on the efficacy of different OAs on polysomnographic indices of OSA. A MeSH and text word search were developed for Medline, Embase, Cinahl, and the Cochrane library. The initial search identified 1475 references, of which 116 related to studies comparing OAs with control appliances. Among those, 14 were randomized controlled trials (RCTs), which formed the basis of this review. The type of OA investigated in these trials was mandibular advancement devices (MADs), which were compared with either inactive appliances (six studies) or other types of MADs with different design features. Compared with inactive appliances, all MADs improved polysomnographic indices, suggesting that mandibular advancement is a crucial design feature of OA therapy for OSA. The evidence shows that there is no one MAD design that most effectively improves polysomnographic indices, but that efficacy depends on a number of factors including severity of OSA, materials and method of fabrication, type of MAD (monobloc/twin block), and the degree of protrusion (sagittal and vertical). These findings highlight the absence of a universal definition of treatment success. Future trials of MAD designs need to be assessed according to agreed success criteria in order to guide clinical practice as to which design of OAs may be the most effective in the treatment of OSA.

Eur J Orthod. 2011 Jan 13.

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Filed Under: Events, Home Sleep Testing, Home Video List, insomnia, Mynewsletter, Newsletter 0810, Newsletter1, Newsletter2, Newsletter3, Newsletter5, sleep apnea, sleep disorders, sleep labs, Vendors, Videos, Volume 2, Volume 3, Volume 4, Volume 5, Volume 6

Subjective efficacy of oral appliance design features in the management of obstructive sleep apnea: a systematic review

May 8, 2011 by SleepDT Leave a Comment

Ahrens A, McGrath C, Hägg U.

Source

Discipline of Dental Public Health, Faculty of Dentistry, University of Hong Kong, Hong Kong SAR.

Abstract

INTRODUCTION:

The purpose of this study was to review available evidence on the efficacy of various oral appliances on subjectively perceived symptoms of obstructive sleep apnea syndrome.

METHODS:

A search of 4 databases was carried out. Articles were initially selected based on their titles or abstracts. Full articles were then retrieved and further scrutinized according to predetermined criteria. Reference lists of selected articles were searched for any missed publications. The finally selected articles were methodologically evaluated.

RESULTS:

Of an initial 1475 references, 14 studies were randomized controlled trials, which formed the basis of this review. Mandibular advancement devices (MADs) were compared with either inactive appliances (6 studies) or MADs with different design features (8 studies). In comparison with inactive appliances, the majority of studies showed improved subjective outcomes with MADs, suggesting that mandibular advancement is a crucial design feature of oral appliance therapy for obstructive sleep apnea syndrome.

CONCLUSIONS:

There is no 1 MAD design that most effectively influences subjectively perceived treatment efficacy, but efficacy depends on many factors including materials and method used for fabrication, type of MAD (monoblock or Twin-block), and the degree of protrusion (sagittal and vertical). This review highlights the absence of universally agreed subjective assessment tools and health-related quality of life outcomes in the literature today. Future trials of MAD designs need to assess subjective efficacy with agreed standardized tools and health-related quality of life measures to guide clinical practicitioners about which design might be most effective in the treatment of obstructive sleep apnea syndrome with oral appliances.

Am J Orthod Dentofacial Orthop. 2010 Nov;138(5):559-76.

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Maternal snoring during pregnancy is associated with enhanced fetal erythropoiesis – a preliminary study

May 7, 2011 by SleepDT Leave a Comment

Tauman R, Many A, Deutsch V, Arvas S, Ascher-Landsberg J, Greenfeld M, Sivan Y.

Source

Pediatric Sleep Center, Dana Children’s Hospital, Tel Aviv Souraski Medical Center, Tel Aviv University, Israel.

Abstract

OBJECTIVE AND BACKGROUND:

Snoring is common among pregnant women and early reports suggest that it may bear a risk to the fetus. Increased fetal erythropoiesis manifested by elevated circulating nucleated red blood cells (nRBCs) has been found in complicated pregnancies involving fetal hypoxia. Both erythropoietin (EPO) and interleukin-6 (IL-6) mediate elevation of circulating nRBCs. The intermittent hypoxia and systemic inflammation elicited by sleep-disordered breathing (SDB) could affect fetal erythropoiesis during pregnancy. We hypothesized that maternal snoring will result in increased levels of fetal circulating nRBCs via increased concentrations of EPO, IL-6, or both.

METHODS:

Women of singleton uncomplicated full-term pregnancies were recruited during labor and completed a designated questionnaire. Umbilical cord blood was collected immediately after birth and analyzed for nRBCs, plasma EPO and plasma IL-6 concentrations. Newborn data were retrieved from medical records.

RESULTS:

One hundred and twenty-two women were recruited. Thirty-nine percent of women reported habitual snoring during pregnancy. Cord blood levels of circulating nRBCs, EPO and IL-6 were significantly elevated in habitual snorers compared with non-snorers (p=0.03, 0.005 and 0.01; respectively). No differences in maternal characteristics or newborn crude outcomes were found.

CONCLUSIONS:

Maternal snoring during pregnancy is associated with enhanced fetal erythropoiesis manifested by increased cord blood levels of nRBCs, EPO and IL-6. This provides preliminary evidence that maternal snoring is associated with subtle alterations in markers of fetal well being.

Sleep Med. 2011 May;12(5):518-22.

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Aerophagia and Gastroesophageal Reflux Disease in Patients using Continuous Positive Airway Pressure: A Preliminary Observation

April 30, 2011 by SleepDT Leave a Comment

Nathaniel F. Watson, M.D.¹ and Sue K. Mystkowski, M.D.²

¹Department of Neurology, University of Washington, Seattle, WA

²Department of Medicine, Division of Pulmonary and Critical Care, University of Washington, Seattle, WA

Address correspondence to: Nathaniel F. Watson, University of Washington Sleep Disorders Center at Harborview, Box 359803, 325 Ninth Avenue, Seattle, WA 98104-2499Phone: (206) 744-4337Fax: (206) 744-5657,; Email: nwatson@u.washington.edu

Received February 2008; Accepted May 2008.

Abstract

Study Objectives:

Aerophagia is a complication of continuous positive airway pressure (CPAP) therapy for sleep disordered breathing (SDB), whereupon air is forced into the stomach and bowel. Associated discomfort can result in CPAP discontinuation. We hypothesize that aerophagia is associated with gastroesophageal reflux disease (GERD) via mechanisms involving GERD related lower esophageal sphincter (LES) compromise.

Methods:

Twenty-two subjects with aerophagia and 22 controls, matched for age, gender, and body mass index, who were being treated with CPAP for SDB were compared in regard to clinical aspects of GERD, GERD associated habits, SDB severity as measured by polysomnography, and mean CPAP pressure.

Results:

More subjects with aerophagia had symptoms of GERD (77.3% vs. 36.4%; p < 0.01) and were on GERD related medications (45.5% vs. 18.2%, p < 0.05) than controls. Regarding polysomnography, mean oxygen saturation percentages were lower in the aerophagia group than controls (95.0% vs. 96.5%, p < 0.05). No other differences were observed, including mean CPAP pressures. No one in the aerophagia group (vs. 27.3% of the control group) was a current tobacco user (p < 0.01). There was no difference in caffeine or alcohol use between the 2 groups.

Conclusions:

These results imply aerophagia is associated with GERD symptoms and GERD related medication use. This finding suggests a relationship between GERD related LES pathophysiology and the development of aerophagia in patients with SDB treated with CPAP.

Citation:

J Clin Sleep Med 2008;4(5):434–438.

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Filed Under: CPAP, Events, Home Sleep Testing, Home Video List, insomnia, Mynewsletter, Newsletter 0810, Newsletter1, Newsletter2, Newsletter3, Newsletter5, polysomnography, sleep apnea, sleep disorders, sleep labs, sleep therapy, Vendors, Videos, Volume 2, Volume 3, Volume 4, Volume 5, Volume 6 Tagged With: polysomnography

Influence of tongue/mandible volume ratio on oropharyngeal airway in Japanese male patients with obstructive sleep apnea

April 29, 2011 by SleepDT Leave a Comment

Shigeta Y, Ogawa T, Ando E, Clark GT, Enciso R.

Source

Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan

Abstract

OBJECTIVES:

The objective of this study was to investigate the influence on the upper airway of the size ratio of tongue and mandible (T/M ratio) with 3D reconstructed models from computed tomography (CT) data.

STUDY DESIGN:

The subjects were 40 OSA male patients. The age of the patients ranged from 25 to 77 years, with an average age of 52.6 ± 12.5 years. The body mass index (BMI) of the patients ranged from 20.1 to 35.8 kg/m(2), with an average BMI of 25.4 ± 3.4 kg/m(2). All patients underwent a full-night polysomnography. The mean AHI for our subjects was 23.6 ± 18.3 events per hour. CT imaging examinations were carried out in each patient. The mandible and airway volume (between posterior nasal spine [PNS] and the tip of the epiglottis) were segmented based on Hounsfield units, automatically or semi-automatically, and their volume was calculated from the number of voxels. The tongue was carefully outlined, and the inside of the tongue was smeared on each of the axial, frontal, and sagittal planes with a semi-automatic segmentation tool. The tongue/mandible (T/M) ratio was calculated from the volume of the mandible and the tongue. In addition, we investigated simple correlations between our anatomical variables and BMI, age, and AHI.

RESULTS:

In this study, the mean tongue and mandible volume were 79.00 ± 1.06 cm(3) and 87.80 ± 1.21 cm(3), respectively. As BMI increases, tongue volume increases (P = .004) and airway volume decreases (P = .021). However, no significant correlation was found between severity of OSA (AHI) and other variables. On the other hand, there was a negative correlation between airway volume and T/M ratio (P = .046).

CONCLUSION:

As tongue volume increases with BMI, the posterior airway is affected, and thus is likely to be involved in the development of OSA; however, in this study there was no correlation between the severity of sleep apnea (AHI) and other variables in the study.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Feb;111(2):239-43.

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Filed Under: Dental, dental appliances, Events, Home Sleep Testing, insomnia, polysomnography, sleep apnea, sleep disorders, sleep labs Tagged With: pharyngometry, polysomnography

Comparative Effects of Two Oral Appliances on Upper Airway Structure in Obstructive Sleep Apnea

April 13, 2011 by SleepDT 2 Comments

“Good article just published in the latest edition of Sleep. It compares a MAS device with a TSD – the results are interesting where both appliances worked, at least in the responders, but the imaging showed some differences. This data reinforces the need for tongue position and management with OAT like The Moses appliance does”

Ashley

Kate Sutherland, PhD¹^,²; Sheryn A. Deane, MDSc³; Andrew S.L. Chan, MD, PhD¹^,²^,⁴; Richard J. Schwab, MD⁵; Andrew T. Ng, MD, PhD⁴; M. Ali Darendeliler, PhD³; Peter A. Cistulli, MD, PhD¹^,²^,⁴

¹Centre for Sleep Health and Research, Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia; ²Woolcock Institute of Medical Research, University of Sydney, NSW, Australia; ³Department of Orthodontics, Faculty of Dentistry, University of Sydney, Sydney Dental Hospital, NSW, Australia; ⁴Department of Respiratory and Sleep Medicine, St George Hospital, University of New South Wales, NSW, Australia; ⁵University of Pennsylvania, Philadelphia, PA

Oral appliances are increasingly being used for treatment of obstructive sleep apnea (OSA). Mandibular advancement splint (MAS) mechanically protrudes the mandible, while the tongue stabilizing device (TSD) protrudes and holds the tongue using suction. Although both appliances can significantly improve or ameliorate OSA, their comparative effects on upper airway structure have not been investigated.

Design:

Cohort study.

Setting:

Sleep Investigation Unit.

Patients:

39 patients undergoing oral appliance treatment for OSA.

Interventions:

OSA patients underwent magnetic resonance imaging (MRI) of the upper airway during wakefulness at baseline and with MAS and TSD in randomized order. Treatment efficacy was determined by polysomnography in a subset of 18 patients.

Measurements and Results:

Upper airway lumen and surrounding soft tissue structures were segmented using image analysis software. Upper airway dimensions and soft tissue centroid movements were determined. Both appliances altered upper airway geometry, associated with movement of the parapharyngeal fat pads away from the airway. TSD increased velopharyngeal lateral diameter to a greater extent (+0.35 ± 0.07 vs. +0.18 ± 0.05 cm; P < 0.001) and also increased antero-posterior diameter with anterior displacement of the tongue (0.68 ± 0.04 cm; P < 0.001) and soft palate (0.12 ± 0.03 cm; P < 0.001). MAS resulted in significant anterior displacement of the tongue base muscles (0.35 ± 0.04 cm). TSD responders (AHI reduction ≥ 50%) increased velopharyngeal volume more than non-responders (+2.65 ± 0.9 vs. –0.44 ± 0.8 cm³; P < 0.05). Airway structures did not differ between MAS responders and non-responders.

Conclusions:

These results indicate that the patterns and magnitude of changes in upper airway structure differ between appliances. Further studies are warranted to evaluate the clinical relevance of these changes, and whether they can be used to predict treatment outcome.

SLEEP2011;34(4):469-477.

Full text with images: http://www.journalsleep.org/ViewAbstract.aspx?pid=28089

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A Daytime, Abbreviated Cardio-Respiratory Sleep Study (CPT 95807-52) To Acclimate Insomnia Patients with Sleep Disordered Breathing to Positive Airway Pressure (PAP-NAP)

April 11, 2011 by SleepDT Leave a Comment

Barry Krakow, M.D.^1,2,3; Victor Ulibarri, B.S.^1,2; Dominic Melendrez, B.S.^1,2; Shara Kikta²; Laura Togami²; Patricia Haynes, Ph.D.⁴

¹Sleep & Human Health Institute, Albuquerque, NM; ²Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM; ³Los Alamos Medical Center Sleep Laboratory, Los Alamos, NM;⁴Department of Psychiatry, University of Arizona, Tucson, AZ

Study Objectives:

To assess the impact of a daytime sleep medical procedure–the PAP-NAP–on adherence to positive airway pressure (PAP) therapy among insomnia patients with sleep disordered breathing (SDB)

Methods:

The PAP-NAP is based on Current Procedural Terminology (CPT) codes and combines psychological and physiological treatments into one procedure, which increases contact time between SDB patients and polysomnography technologists to enhance PAP therapy adherence. Using a Sleep Dynamic Therapy framework, explicating SDB as a mind-body disorder, the PAP-NAP includes mask and pressure desensitization, emotion-focused therapy to overcome aversive emotional reactions, mental imagery to divert patient attention from mask or pressure sensations, and physiological exposure to PAP therapy during a 100-minute nap period. Patients treated with the PAPNAP test (n=”39)” were compared to an historical control group (n=”60)” of insomnia patients with SDB who did not receive the test.

Results:

All 99 insomnia patients were diagnosed with SDB (mean AHI 26.5 + 26.3, mean RDI 49.0 + 24.9), and all reported a history of psychiatric disorders or symptoms as well as resistance to PAP therapy. Among 39 patients completing the PAP-NAP, 90% completed overnight titrations, compared with 63% in the historical control group; 85% of the nap-tested group filled PAP therapy prescriptions for home use compared with 35% of controls; and 67% of the nap-tested group maintained regular use of PAP therapy compared with 23% of the control group. Using standards from the field of sleep medicine, the nap-tested group demonstrated objective adherence of 49% to 56% compared to 12% to 17% among controls. All studies were reimbursed using CPT 95807-52.

Conclusion:

In this pilot study, the PAP-NAP functioned as a brief, useful, reimbursable procedure to encourage adherence in insomnia patients with SDB in comparison to an historical control group that did not undergo the procedure.

http://www.aasmnet.org/jcsm/ViewAbstract.aspx?pid=27183

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Non Surgical Approach for Obstructive Sleep Apnea (OSA) In Children

February 24, 2011 by SleepDT 1 Comment

Following is a link to a slide set presented at the APPA conference. Presentation was assembled and presented by

Abdullah Al-Shamrani, M.D

FRCPCH (UK), SSCP, ABP, JBP

Fellowship Pediatric Respiratory & pediatric Sleep Medicine (Canada)

Consultant Paediatric Pulmonologist, KFMC

Abdullah Al-Shamrani, M.D FRCPCH (UK), SSCP, ABP, JBPFellowship Pediatric Respiratory & pediatric Sleep Medicine (Canada)Consultant Paediatric Pulmonologist, KFMC

Full Slide presentation http://appa-conference.com/Files/presentations2010/004001.pdf

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Filed Under: insomnia, sleep apnea, sleep disorders

US Army Medical Services Standards of Medical Fitness

February 24, 2011 by SleepDT 1 Comment

Standards of fitness for military service are very clear with respect to all manner of illnesses and conditions. Sleep apnea and sleep disordered breathing are no different. Following are excerpts from the army standards manual. A diagnosis of OSA can affect deployment, retirement and can even stand in the way of enlistment. The link to the entire manual follow the excepted passages.

“Medical Fitness Standards for Retention and Separation, Including Retirement

c. Sleep apnea. Obstructive sleep apnea or sleep-disordered breathing that causes daytime hypersomnolence or snoring that interferes with the sleep of others and that cannot be corrected with medical therapy, nasal continuous positive airway pressure (CPAP), surgery, or an oral appliance. The diagnosis must be based upon a nocturnal polysomnogram and the evaluation of a pulmonologist, neurologist, or a privileged provider with expertise in sleep medicine.

(1) A 12-month trial of therapy with nasal continuous positive air pressure may be attempted to assist with other therapeutic interventions, during which time the individual will be issued a temporary profile. Soldiers with severe sleep apnea and/or symptoms may be referred directly for an MEB. If nasal CPAP is required for longer than 12 months, the Soldiers should be profiled as a permanent P2.

(2) If symptoms of hypersomnolence or snoring can not be controlled with medical therapy, nasal CPAP, surgery or an oral appliance, the individual should be referred for a MEB. If the use of nasal CPAP or other therapies for sleep apnea result in interference with satisfactory performance of duty as substantiated by the individual’s commander or supervisor, the Soldier should be referred to a MEB”

(6) Sleep apnea. See paragraph 3-41c for profile guidance and for MEB processing criteria. The Soldier can be deployed if nasal continuous positive airway pressure (CPAP) is required and can be supported in the area of deployment. Criteria for the ability to use nasal CPAP in the area of deployment include the following: availability of a reliable power source; absence of environmental factors that would render electrical equipment inoperable or unreliable, and the availability of a reliable source of replacement supplies such as masks, harnesses, and filters. A Soldier that requires nasal CPAP should not be deployed if these factors cannot be assured and the absence of nasal CPAP would hinder the Soldier from performing his/her military duties

Complete Document http://armypubs.army.mil/epubs/pdf/r40_501.pdf

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Filed Under: insomnia, sleep apnea, sleep disorders

National Transportation Safety Board Washington, D.C. 20594 Safety Recommendation

February 22, 2011 by SleepDT Leave a Comment

“The National Transportation Safety Board (NTSB) has investigated a number of

accidents and incidents in all modes of passenger transportation involving operators with sleep

disorders. These accidents include the following highway accidents in which the NTSB

identified commercial drivers with obstructive sleep apnea (OSA).

On July 26, 2000, the driver of a tractor-trailer travelling on Interstate 40 near

Jackson, Tennessee, collided with a Tennessee Highway Patrol vehicle trailing construction

vehicles, killing the state trooper inside.

The tractor-trailer then travelled across the median and

collided with a Chevrolet Blazer heading in the opposite direction, seriously injuring the driver

of the Blazer. The tractor-trailer driver was 5 feet, 11 inches tall, weighed 358 pounds, and had

been diagnosed with and had undergone surgery for OSA, though he had not indicated either the

diagnosis or the surgery on examinations for medical certification. The NTSB found that the

driver’s (unreported) OSA, his untreated hypothyroidism, or complications from either or both

conditions predisposed him to impairment or incapacitation, including falling asleep at the wheel

while driving. The NTSB determined that the probable cause of the accident was the driver’s

incapacitation, owing to the failure of the medical certification process to detect and remove a

	Randy Clare Managing Editor of SleepScholar and RespiratoryScholar
	Dr. Steve Carstensen Pankey Institute for Advanced Dental Education, American Academy of Dental Sleep Medicine.
	Ruchir Patel MD Founder & Medical Director at the Insomnia and Sleep Institute of Arizona.
	Dr. John S. Viviano AADSM Diplomate and member of various sleep organizations. Has lectured internationally on the treatment of Sleep-Disordered Breathing and the use of Acoustic Reflection.
	Jeffroy Wyscarver President, DDME Online, Sleep Lab Technology and Services for the Dental Community.
	Claude Albertario RPSGT, speaker, author and mentor in the field of sleep diagnostics with 25 yrs of management experience in one of New York's premier sleep centers.
	Joseph Anderson Co-Founder and Director of Education for Priority Health Education and Priority Scoring.
	Todd Austin Managed sleep labs and has 15 experience in sleep diagnostics and therapeutic systems. .
	Marietta Bibbs Sleep specialist and manager of Sleep and Neurodiagnostics at Morton Plant Mease Healthcare.
	Bradley Eli DMD, MS Director, San Diego Headache and Facial Pain Center / Sleep Treatment and Research Institute
	Edward Grandi Executive Director of the American Sleep Apnea Association.
	Edward Michaelson MD Board Certified in Pulmonary Medicine, Internal Medicine and Sleep Medicine
	Ashley Truitt Founder & Director of Dental Sleep Medicine Worldwide, Co-Founder of TPT Dental.

Influence of tongue/mandible volume ratio on oropharyngeal airway in Japanese male patients with obstructive sleep apnea

Source

Abstract

OBJECTIVES:

STUDY DESIGN:

RESULTS:

CONCLUSION:

Non Surgical Approach for Obstructive Sleep Apnea (OSA) In Children

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