Noncontinuous Positive Airway Pressure Therapies for Obstructive Sleep Apnea Veronica Brito, MD1

1 Division of Pulmonary, Critical Care, and Sleep Medicine, Scott and

White Healthcare, Texas A&M Health Science Center, Temple, Texas Semin Respir Crit Care Med 2014;35:613–620.

Abstract Keywords

► obstructive sleep apnea ► oral appliances ► mandibular advancement device ► surgery ► uvulopalatopharyngoplasty ► tongue ► tonsils ► nasal surgery

Address for correspondence Shirley F. Jones, MD, Division of Pulmonary, Critical Care and Sleep Medicine, Scott and White Healthcare, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76502 (e-mail: [email protected]; [email protected]).

While continuous positive airway pressure is the first-line treatment for obstructive sleep apnea, many patients find this form of therapy undesirable leading to treatment nonadherence. Both mandibular advancement devices and surgical therapy offer alternative solutions for such patients. This article serves to compare the types of surgical interventions and mandibular advancement devices available, their mechanisms of action, and expected side effects. Emphasis is made on the limitations and challenges in the interpretation of the available literature due to the varying definitions of curative success. The effects of mandibular advancement devices and surgical therapy on the apnea–hypopnea index and oxygen saturation are reviewed. Patientcentered outcomes of sleepiness, quality of life, treatment preference, adherence, and their effects on disease-related outcomes of hypertension are summarized. When available, comparative effectiveness trials between these therapies versus continuous positive airway pressure are emphasized. Patient selection criteria, practice parameters, and treatment limitations are discussed.

Obstructive sleep apnea (OSA) affects 2 to 4% of the general population and is characterized by a repetitive collapse of the upper airway leading to a partial reduction or complete absence of the airflow.1 The respiratory events may be associated with hypoxemia and arousals from sleep. The diagnosis of OSA is based on clinical examination and polysomnography, and therapy is instituted in patients with an apnea–hypopnea index (AHI) of  15 events per hour or with an AHI of  5 events per hour in the presence of excessive daytime sleepiness, insomnia, hypertension, coronary artery disease, or stroke. While the pathophysiology of OSA is multifactorial, the anatomical site of obstructive events is located between the hard palate and the larynx, also termed the upper airway. Effects of obesity generate change to the caliber of the upper airway by affecting the composition of muscle and fat in the uvula, tongue, and pharyngeal walls.2,3 Continuous positive airway pressure (CPAP) acts as a pneumatic splint to increase the diameter of the upper airway by decreasing the thickness of the lateral pharyngeal walls and is a first-line therapy for mild, moderate, and severe

Issue Theme Clinical Consequences and Management of Sleep Disordered Breathing; Guest Editors, Ravi Aysola, MD, Teofilo L. Lee-Chiong, Jr., MD

forms of OSA.4 Unfortunately, CPAP compliance is less than optimal despite that use of CPAP is associated with positive outcomes such as reduction in excessive daytime sleepiness, motor vehicle accidents, and improvements in cardiovascular outcomes and blood pressure.5–8 While several alternative therapies exist, the most well studied and utilized are oral appliances and surgery. Currently, oral appliances are recommended for patients with mild-to-moderate degrees of OSA or in patients who have failed or refuse CPAP. Surgical therapy is reserved for those who fail medical treatment. This review will highlight the available evidence on the use of oral appliance and surgery emphasizing efficacy, comparative effectiveness, patient selection criteria, limitations, and future research.

Oral Appliances Practical Considerations and Mechanism of Action The term oral appliances include both tongue retaining devices and mandibular advancement devices (MADs).

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1390047. ISSN 1069-3424.

Downloaded by: University of Queensland. Copyrighted material.

Shirley F. Jones, MD1

Non-CPAP Therapies for OSA

Jones, Brito

Tongue-retaining devices protrude the tongue via the negative pressure created once the tongue is inserted into the bulb of the device. Current practice parameters recommend the use of oral appliances for patients with mild-to-moderate OSA and in patients who have failed, refuse or are not appropriate candidates for CPAP.9 The Standards of Practice Committee of the American Academy of Sleep Medicine published an initial review of oral appliances and found few studies utilizing tongue-retaining devices hence they will not be discussed in this review. The wealth of the medical literature examines the use of MADs. MADs enlarge and stabilize the upper airway by protrusion of the mandible, enlarging the volume of the velopharynx by the MADs effects on the lateral dimension and advancement of the tongue.10 A minimum of six teeth on the maxillary and mandibular arches are required for device anchoring. A variety of MADs exists on the market today, and can be classified as prefabricated versus custom-made and fixed versus adjustable. The MAD can also be a one “monobloc” or two piece “duobloc” device. Prefabricated MADs include the “boil and bite” type whereas a custom-made MAD is made using dental impressions in a laboratory. Fixed MADs protrude the mandible at a set degree, usually 50 to 80% of the maximal protrusion. Once set, no further adjustments can be made. The advantages of fixed MADs include the reduced cost and time to treatment as well as ease of fit. In comparison, adjustable MADs allow for the patient or operator to adjust the amount of protrusion via a screw-like mechanism or its equivalence. This factor is important because there is a dose-dependent effect of mandibular protrusion on oxygen saturation, pharyngeal collapse, and improvement in AHI.11,12 Each 2 mm advancement in mandibular protrusion leads to a 20% improvement in frequency and severity of oxygen desaturations.11 The downsides of an adjustable device include expense, additional visits for adjustment, and the time needed to allow for device tolerance after each adjustment, which may lead to delays in optimal efficacy. Other proprietary differences between MADs include construction materials and amount of vertical opening. Side effects of MAD can be separated into minor and temporary effects and moderate-to-severe and continuous side effects. The latter may result in discontinuance of MADs. All side effects are reported widely. Minor and temporary side effects are observed in 6 to 86% of the patients with more severe side effects observed in 0 to 75% of the patients.13 Temporomandibular joint (TMJ) pain tends to occur after initiation of MAD but improves over the long term. In a study of 51 patients randomized to MAD versus CPAP, the frequency of TMJ pain was 24% in subjects randomized to MAD within the first 2 months of use. However, the frequency of TMJ pain significantly reduced to 8% by 1 year.14 A 2-year follow-up data shows that use of MADs results in decrease in overbite and overjet; however changes are small.14 ►Table 1 lists the commonly reported side effects.

Efficacy Studies (MAD vs. Placebo) Randomized controlled cross-over studies have examined the effect of MADs on clinical endpoints of AHI, oxygen saturation, and symptoms, including excessive daytime sleepiness Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014

Table 1 Side effects of mandibular advance devices Minor and temporary side effects Temporomandibular joint pain Myofascial pain Dental pain Salivation Jaw stiffness Muscle tenderness Temporomandibular joint sounds Dry mouth Gum irritation Occlusal changes Moderate-to-severe and continuous side effects Temporomandibular joint pain Myofascial pain Tooth pain Gum pain Dry mouth

and quality of life. The major caveat to interpretation of these studies is the definition of success used. When success is defined on less stringent criteria such as an AHI reduction of 50%, a greater degree of success is reported. In a randomized controlled cross-over study of 24 patients with mild-tosevere OSA, complete response was defined as the resolution of symptoms plus reduction of AHI to < 5 events per hour. Using these criteria, a complete response was observed in 37.5% of the subjects.15 Treatment failure was defined as ongoing clinical symptoms and/or a < 50% reduction in AHI. Using this definition, the study found an equal number of treatment failures.15 This study found a significant reduction in the AHI of 53% and an improvement in minimum oxygen saturation from 87 to 91% with MAD.15 Gotsopoulos et al reported similar rates of complete responders and treatment failures at 36 and 37%, respectively, in a randomized controlled trial of MAD versus placebo. Minimum oxygen saturation improved from 86 to 89% with MADs.16 In this study, the respiratory disturbance index (RDI) was reported in contrast to the AHI in the Mehta et al study, but the mean RDI improved from 27 to 12 events per hour.15,16 Barnes et al reported a higher rate of complete success of 49% but used a less stringent definition of success (AHI < 10 events per hour) and reported that MADs decreased the AHI from mean 21.3 to 14 events per hour and increased the minimum oxygen saturation from 86.7 to 87.8%.17 In all three studies mean subjective sleepiness using the Epworth Sleepiness Scale improved with MAD, however significant improvements were also observed with the control device, indicating a placebo effect.15–17 Objective sleepiness as measured by the multiple sleep latency test improved by 1.2 minutes with the MAD as compared with placebo.16 MADs improved the Functional Outcomes of Sleep Questionnaire score, a tool

Downloaded by: University of Queensland. Copyrighted material.


to assess the impact of disorders of hypersomnia on daily life and a faster performance on a test of vigilance/psychomotor speed as compared with placebo.18,19 In summary, MADs are more efficacious than placebo to reduce the AHI, improve oxygen saturation indices; however, one should be cautious when interpreting the available literature as the degree of success depends upon the definition used.

Comparative Effectiveness Trials (MADs vs. CPAP) An increasing number of studies have been done examining the effects of MADs versus CPAP on efficacy points of AHI, nadir oxygen saturation, health-related outcomes, daytime sleepiness, quality of life, cognitive performance, blood pressure, patient preference, and adherence. In multiple studies, CPAP consistently achieves lower AHI as compared with MADs. The mean AHI with CPAP was less than five in all but one study.20 Meanwhile the mean success rate of MADs to achieve an AHI < 5 was 48% (range, 29–71%) with mean failure rates of 35% as defined as posttreatment AHI  50% (range, 6–63%).21 The large range of failure and success rates are likely due in part to the different devices used in these studies and the study-related inclusion criteria. In the largest study to date comparing MADs to CPAP in 108 patients, the mean AHI after treatment with CPAP was 4.5 events per hour as compared with 11.1 with MAD.22 In addition, twice as many patients had complete resolution of OSA (defined as treatment AHI < 5 events per hour) with CPAP over MAD.22 Posttreatment CPAP was also associated with higher minimum oxygen saturation compared with MADs.22 Both a Cochrane review and a meta-analysis of MADs versus CPAP found that both the treatments improve daytime sleepiness equally.23,24 Quality of life measures using the sleep apnea quality of life, Functional Outcomes of Sleep Questionnaire, and cognitive performance did not differ between CPAP and MADs.24 In a recent meta-analysis of MADs and their effect on blood pressure, seven studies that enrolled a total of 399 subjects with primarily mild-to-moderate OSA showed that MADs improved systolic blood pressure, diastolic blood pressure, and mean arterial pressure modestly with decreases of 2.7, 2.7, and 2.4 mm Hg in the short term.25 However, this study included only two randomized controlled trials. In a separate study, Phillips et al reported noninferiority of MADs compared with CPAP on effect of 24-hour mean arterial pressure. While presence of hypertension was not an inclusion criteria for enrollment in this trial, the greatest improvements in 24-hour mean arterial pressure were in those subjects who were hypertensive at baseline.22 In comparison, the effect of CPAP on blood pressure also yields similar albeit modest changes in blood pressure. In a meta-analysis of 818 participants encompassing 16 randomized controlled trials, the mean net change in systolic, diastolic, and mean arterial pressure was 2.46, 1.83, and 2.22 mm Hg.26 The effects of MADs on blood pressure needs additional investigation in the form of randomized controlled trials with larger numbers of participants carried over a longer duration of time. If effects of treatment on blood pressure outcomes are dependent upon hours of use then patient preference

Jones, Brito

become very important. While patient preference has been evaluated in multiple studies, the results appear to be mixed. In a study of 114 subjects with mild-to-moderate OSA, 44% of the subjects and 40% of their partners preferred CPAP compared with 30% of the subjects and 36% of their partners who preferred MADs. Furthermore, over half of subjects and partners felt that CPAP worked best.17 Meanwhile, Engleman et al found no difference in patient preference, a finding confirmed by Li et al in a meta-analysis of 14 comparative trials.20,23 This is in contrast to studies performed by Ferguson et al which show patient preference and satisfaction favoring MADs over CPAP.27,28 With some patients refusing CPAP altogether and rates of noncompliance between 29 and 83%, many argue that the compliance achieved with MADs compared with CPAP would offset its less optimal efficacy.29 Comparative studies examining treatment adherence either support MADs or are equivalent. One should recognize that until recently, objective monitoring of MADs has not been utilized and that adherence data relied upon subjective reporting, possibly inflating the hours of usage compared with the objective monitoring using CPAP data cards. Currently, there is an increasing interest and utilization of a microsensor thermometer capable of measuring MADs adherence objectively with one study showing subjective use of MADs is overestimated by 30 minutes.30 Nevertheless, subjective compliance with MADs was 6.5 hours compared with 5.2 hours with CPAP in a study of 108 subjects with mild-tosevere OSA followed for 1 month.22 A 2-year follow-up study of MADs versus CPAP demonstrated that at 2 years, compliance rates were similar used per night.31 Interestingly, a higher but nonsignificant number of dropouts occurred in those using MADs in this study.31 Perhaps this was due to the waning success of the MADs overtime to reduce the AHI. At 2month follow-up, 76.5% of those receiving MADs were successfully treated, an effect that had dissipated by the 2nd year in which 52.9% of the subjects using MADs were still successfully treated. This is in contrast to 82.7 and 67.3% in the subjects using CPAP.31 In summary, it appears that comparison studies between MADs and CPAP demonstrate that while the success of MADs to reduce the AHI and improve minimum oxygen saturation is inferior to CPAP, this does not appear to make a difference on daytime sleepiness and quality of life. Perhaps the improvement in health outcomes is related to the increased time of use with MADs. The effect of MADs on blood pressure requires additional study and patient preference is an important factor when formulating treatment plans and goals.

Comparative Effectiveness Trials (MADs vs. MADs) There are unfortunately few head-to-head trials between different MADs, hence limiting their generalizability. There does not appear to be any increase in side effects between fixed and adjustable MADs.32 However, adjustable device are more successful in reducing the AHI to < 5 events per hour compared with fixed devices in a retrospective study of 805 patients.33 Both monobloc and duobloc MADs significantly reduce the AHI but the posttreatment AHI with monobloc devices was lower.34,35 While thermoplastic devices are less Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014


Downloaded by: University of Queensland. Copyrighted material.

Non-CPAP Therapies for OSA

Non-CPAP Therapies for OSA

Jones, Brito

expensive as compared with custom-made devices, the success rates of thermoplastic devices are significantly less than custom-made devices with lower adherence rates at 1 and 6 months.36,37 Proprietary differences in custom-made devices may contribute to attrition.38 At the time, more comparative effectiveness research is needed. No single MADs is recommended over others based on the available literature. The American Academy of Sleep Medicine recommends that after final adjustments have been made to the MAD, patients should undergo a follow-up polysomnogram with the MAD in place. These guidelines also recommend routine follow-up with dentistry every 6 months during the 1st year and then annually thereafter to monitor adherence, side effects, and efficacy of treatment.9

Determining Treatment Success

tolerate and comply.29 Surgical options, therefore are considered as therapies or adjuncts to improve tolerance of CPAP or oral appliance. The expectation that surgical therapies for OSA would lead to a permanent resolution or at least improvement of sleepdisordered breathing has been challenged. The 2010 practice parameters for surgical modifications of the upper airway for OSA in adults, a statement from the American Academy of Sleep Medicine recommends systematic and methodical investigations to improve the quality of evidence, assess additional outcome measures, and select the patients who are more likely to benefit from a particular procedure.43 In recent years, studies have shown the possible rationale for the paucity of concordance between the data for surgical studies, due to the presence of anatomical and physiological variations in patients with OSA.44,45

Current practice parameters recommend that MADs are to be used in patients with mild-to-moderate OSA who prefer MADs over CPAP.9 This recommendation is based on multiple studies that show success rates of 57 to 81% in this mild-tomoderate OSA patients as compared with success rates of 14 to 61% in severe OSA patients.13 In addition to milder forms of OSA, patients with positional-dependent OSA who have a lower body mass index and less oropharyngeal crowding are more likely to have a favorable response to MADs.12,39 Currently, there is no single accepted method to predict treatment success but patient variables, such as neck circumference, body mass index, Mallampati score, the AHI, cephalometry, nasal endoscopy, and the development of MAD titration methods allowing mandibular protrusion adjustments during a polysomnogram have been used.15,39,40

The efficacy of surgical procedures for the therapy of OSA varies according to the metrics used. Cure can be defined using different AHI thresholds, different metrics can be used on AHI reduction (absolute reduction or percent reduction from baseline), and other parameters considering quality of life, such as presence of snoring, alertness level, and sleep quality can be used as measurements of efficacy. Patient selection also varies, and patients with various degrees of severity, or other characteristics such as body mass index can be accounted. Many reports lack data on polysomnography findings postoperatively. For these reasons, success following OSA surgery can produce conflicting outcomes.46


Surgical Procedures and Outcomes Data

Overall MADs are effective in the treatment of OSA; however, in comparison with CPAP, MADs are not as effective at reducing the AHI or improving the oxygen saturation; however MADs achieve similar patient-centered outcomes to those of CPAP. Additional research is needed to evaluate disease-related outcomes of hypertension and cardiovascular comorbidities along with comparative effectiveness studies between different MADs and developing methods of predicting treatment success.

Listed below are a series of surgical interventions, which have been described for the therapy of OSA.

Surgery for Obstructive Sleep Apnea Surgical treatment for OSA has been described before positive pressure application. In 1965, Valero and Alroy described successful therapy for a patient with hypersomnia and chronic respiratory failure with tracheostomy.41 Nonsurgical therapy for OSA with positive pressure application was first described in 1981 and is considered the preferred approach receiving guideline recommendation as first-line therapy for patients without contraindications.42 Other noninvasive therapies, such as oral appliances, are also recommended in a particular subset of patients. The applicability of positive airway pressure therapy, oral appliances, and other medicalmanagement modalities are limited by the patient’s ability to Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014

Efficacy Studies

Uvulopalatopharyngoplasty and Tonsillar Procedures Uvulopalatopharyngoplasty (UPPP) consists of trimming and reorientation of the posterior and anterior tonsillar pillars and excising the uvula and posterior portion of the palate, creating a larger retropalatal airway. Tonsils and adenoids can be surgically removed without removal of other palatal structures. The peritonsillar space between the tonsil capsule and muscular wall is dissected, removing the tonsil. The adenoids are often removed as well during the same procedure. It should be considered as an approach to therapy in thin, young adults with hypertrophied tonsils. UPPP and other oropharyngeal procedures outcomes vary. According to a recent meta-analysis, UPPP as a sole procedure, with or without tonsillectomy does not reliably normalize the AHI when treating moderate-to-severe OSA. A meta-analysis has shown that patients who initially had moderate-to-severe OSA had a residual AHI of 29.8 events per hour.47 In highly selected patients, UPPP may be considered as an adjunct to CPAP or oral appliances. Common side effects of UPPP include postoperative bleeding, and complications associated with velopharyngeal insufficiency, difficulty in swallowing, and

Downloaded by: University of Queensland. Copyrighted material.


nasal regurgitation, taste disturbances, and voice changes.47 New studies show a decreasing rate of complication, but the overall risk of death following UPPP is 0.2%.48

Laser-Assisted Palatoplasty This procedure consists of placing bilateral vertical incisions or trenches directly along both sides of the uvula, followed by laser ablation of the uvula. It has been shown to effectively reduce snoring, but there are no meaningful effects when treating OSA.49–51

Palatal Implants Implantable malleable plastic rods are placed into the soft palate under local anesthesia.

Maxillomandibular Advancement Maxillomandibular advancements (MMAs) are generally performed with the creation of a LeFort 1 osteotomy to the maxilla and a bilateral splint sagittal osteotomy to the mandible. The airway is enlarged by the increase in the retrolingual airway and some advancement of the retropalatal airway. This procedure not only has been demonstrated to be efficacious, but can also be considered cosmetically desirable. It has been studied in a “stepwise approach,” following soft tissue surgeries (i.e., MMA following UPPP) or a primary procedure, occasionally with genioglossal advancement and or hyoid repositioning and myotomy used also as an adjunct.52 Recent series suggest that this procedure can be highly effective in decreasing the AHI.53,54 Other reported improvement parameters are mean systolic and diastolic blood pressures, hypersomnolence, and cognitive performance measurements by vigilance tests, Epworth sleepiness scale, and other quality-of-life parameters.53 Cephalometric and 3dMD (3dMD, Atlanta, GA) reconstruction of the facial skeleton show significant improvement of the entire upper airway, particularly at the retropalatal and retroglossal levels.45 This procedure leads to obvious changes in the craniofacial features, and can also produce significant neurosensory deficits such as surgical area anesthesia, minor malocclusion, superficial wound infection, and TMJ disorder. There were no reported cases of pharyngeal dysfunction, postoperative hemorrhage or death.53 Primary MMA has been shown to be as effective in reducing the AHI as UPPP/MMA.54

Surgical Procedures Involving the Tongue Procedures altering the anatomy of the tongue have been used to treat OSA, particularly when associated with surgery in other anatomical points: tongue suspension devices, radiofrequency ablation of the base of the tongue, genioglossus advancement, minimally invasive submucosal lingual excision, lingual tonsillectomy, and robotic glossectomy. Coblation technology refers to radiofrequency associated with saline resulting in a localized plasma field that ablates a column of tissue to produce multiple channels of ablated tissue through anatomically safe areas of the tongue.55 Genioglossus advancement can be achieved by different techniques. Genial tubercle advancement is achieved by pulling the genioglossus anteriorly after a rectangular osteotomy (8–10 mm  20 mm) and rotated 30 to

Jones, Brito

90 degrees. The cancellous bone and outer cortex are removed, and the inner cortex is fixated to the lower mandibular border with a single screw.45 Hyoid suspension can also be performed concomitantly. Tongue surgery for OSA is generally performed in a multilevel approach context, and is combined with other palatal procedures. When compared, UPPP þ radiofrequency tongue ablation versus UPPP alone, the former has lower success. UPPP þ RFA has better outcomes in a particular subgroup of Friedman classification stage III (lower palate position on oral examination).56 The efficacy of tongue procedures is generally reported as an adjunct to other procedures. Recent series of patients who underwent Z-palatopharyngoplasty (ZPPP) showed improvement of sleep-disordered breathing in patients with severe OSA 3 months after the procedure, with a reduction in mean AHI from 50.6  16.6 to 26.5  23.5 events per hour, and increase in nadir oxygen saturation from 70.4  9.9 to 80.1  11.3.57 Multilevel temperature– controlled radiofrequency tissue ablation may be an option therefore for patients with less severe disease and when performed in conjunction with other palatal procedures.

Nasal Surgeries Rhinoplasty, turbinoplasty, septoplasty, and polypectomy are surgical procedures performed in patients with sleep apnea. They are generally indicated in patients with daytime symptoms of nasal obstruction, and can be used in attempt to improve CPAP compliance. In spite of decline in nasal resistance after surgery, sleepdisordered breathing and snoring do not substantially decrease with the procedure.58 Another study evaluating the impact of nasal surgeries on OSA also failed to show significant improvement in statistically significant difference in AHI or CPAP pressure requirements in spite of improvement of nasal obstructive symptoms.59

Tracheostomy By creating an opening in the trachea and placing an indwelling tube or stoma for ventilation, the upper airway is bypassed, which can correct upper airway obstruction. This procedure is deforming, requires ongoing care, and lifestyle modification. Careful selection of patients is indicated. It should be reserved only for urgent situations, or in patients to whom other options are not available, have failed, or are refused.43 When the airway is bypassed with tracheostomy, significant improvement in AHI is noted with the mean AHI decreasing from 92.0  34.8 to 17.3  20.5 events per hour. Central apneas may occur following tracheostomy, but the central AHI demonstrated near normalization to a mean of 2.1  3.5 events per hour after 14 weeks. Subjective sleepiness also improves posttracheostomy.60

Patient Selection Prinsell has suggested guidelines for OSA surgery. Surgical prerequisites include clinically significant OSA (AHI > 15 events per hour or AHI > 5 events per hour with nadir oxygen saturation less than 90% and excessive daytime sleepiness). The patient should have failed conservative treatments Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014


Downloaded by: University of Queensland. Copyrighted material.

Non-CPAP Therapies for OSA

Non-CPAP Therapies for OSA

Jones, Brito

Table 2 Surgical therapies and patients selection Tracheostomy

This operation should be considered only when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency

Maxillomandibular advancement

This operation is indicated for surgical treatment of severe OSA in patients who cannot tolerate or who are unwilling to adhere to PAP therapy, or in whom oral appliance, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable


UPPP as a single procedure with or without tonsillectomy does not reliably normalize AHI. When treating moderate-to-severe OSA. Patients should initially be offered oral appliance or PAP therapy

Multilevel or stepwise surgery

These are acceptable in patients with narrowing of multiple sites in the upper airway, particularly if they failed UPPP

Radiofrequency ablation

It can be considered as a treatment in patients with mild-to-moderate OSA who cannot tolerate or who are unwilling to adhere to PAP therapy, or in whom oral appliance, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable

Palatal implants

They can be considered as a treatment in patients with mild OSA who cannot tolerate or who are unwilling to adhere to PAP therapy, or in whom oral appliance, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable

Laser-assisted uvulopalatoplasty

It is not routinely recommended as the treatment for OSA syndrome

Abbreviations: AHI, apnea–hypopnea index; OSA, obstructive sleep apnea; PAP, positive airway pressure; UPPP, uvulopalatopharyngoplasty.

(i.e., CPAP), due to intolerance, lack of success or not applicable to the patient. The patient also has to be medically and psychologically stable, and willing to proceed with surgery. Other prerequisites were listed according to site or segmental area distinctly identified, with appropriate procedures for appropriate sites, and if the recommended or desired approach is staged, the first procedure should be to treat the most severe or critical site. When there are multiple sites involved, and they are not readily distinguishable, extrapharyngeal skeletal advancement procedures are performed first to enlarge and stabilize the airway, to minimize risk of edema or to allow this approach to be the single-stage definitive therapy. Intrapharyngeal soft tissues should be done subsequently, if still indicated.61 After extensive review of the literature, a task force from the American Academy of Sleep Medicine has published practice parameters for surgical modifications of the upper airway for the treatment of OSA. Patients are selected for surgery when the desired outcomes include resolution of the clinical signs and symptoms of OSA, in conjunction with normalization of sleep quality and AHI, and oxyhemoglobin desaturation. Follow-up is recommended with not only objective measurements of the presence and severity of sleepdisordered breathing, but should also be assessed clinically for resolution of symptoms and should be followed long term to detect recurrence of disease. The following recommendations are listed in ►Table 2.

Conclusion While CPAP remains the most efficacious therapy for all severities of OSA, its acceptance for many patients is challenging, leaving a significant portion of patients untreated Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014

and vulnerable to the consequences of OSA. MAD are recommended for patients with mild to moderate degrees of OSA or in patients who have failed or refuse CPAP. Surgical therapy is reserved for those who fail medical treatment. The success rates of both therapies depend on the metrics used. Multiple studies support that CPAP achieves greater reduction in the AHI compared to MADs, however both performed similarly in patient-centered outcomes of sleepiness and quality of life. Multiple different surgical procedures have been attempted for the treatment of obstructive sleep apnea and snoring. There is lack of uniformity on results of different surgical procedures involving the oropharynx and nasopharynx, mostly due to different patient characteristics on these reports, and different outcomes measured. This is a factor for less widespread recommendation for the application of these procedures on the treatment of OSA. Although tracheostomy can be considered a curative procedure, since in essence it bypasses the upper airway, it should be reserved for emergency situations and as a last resort, when other options cannot be considered. Maxillomandibular advancement surgery appears to carry a higher success rate of cure of symptoms of obstructive sleep apnea and AHI reduction, and should be considered on selected patients with micro or retrognathia, preferably those patients who are not obese.

References 1 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The

occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328(17):1230–1235 2 Stauffer JL, Buick MK, Bixler EO, et al. Morphology of the uvula in obstructive sleep apnea. Am Rev Respir Dis 1989;140(3): 724–728 3 Schwab RJ, Pasirstein M, Pierson R, et al. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med 2003;168(5):522–530

Downloaded by: University of Queensland. Copyrighted material.


Jones, Brito

4 Schwab RJ, Pack AI, Gupta KB, et al. Upper airway and soft tissue

22 Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes

structural changes induced by CPAP in normal subjects. Am J Respir Crit Care Med 1996;154(4 Pt 1):1106–1116 McDaid C, Durée KH, Griffin SC, et al. A systematic review of continuous positive airway pressure for obstructive sleep apnoeahypopnoea syndrome. Sleep Med Rev 2009;13(6):427–436 Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005;365(9464): 1046–1053 George CF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP. Thorax 2001;56(7): 508–512 Barbé F, Durán-Cantolla J, Capote F, et al; Spanish Sleep and Breathing Group. Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Am J Respir Crit Care Med 2010;181(7):718–726 Kushida CA, Morgenthaler TI, Littner MR, et al; American Academy of Sleep. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep 2006;29(2):240–243 Chan AS, Sutherland K, Schwab RJ, et al. The effect of mandibular advancement on upper airway structure in obstructive sleep apnoea. Thorax 2010;65(8):726–732 Kato J, Isono S, Tanaka A, et al. Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing. Chest 2000; 117(4):1065–1072 Walker-Engström ML, Ringqvist I, Vestling O, Wilhelmsson B, Tegelberg A. A prospective randomized study comparing two different degrees of mandibular advancement with a dental appliance in treatment of severe obstructive sleep apnea. Sleep Breath 2003;7(3):119–130 Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 2006;29(2):244–262 Doff MH, Veldhuis SK, Hoekema A, et al. Long-term oral appliance therapy in obstructive sleep apnea syndrome: a controlled study on temporomandibular side effects. Clin Oral Investig 2012;16(3): 689–697 Mehta A, Qian J, Petocz P, Darendeliler MA, Cistulli PA. A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. Am J Respir Crit Care Med 2001;163(6): 1457–1461 Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial. Am J Respir Crit Care Med 2002;166(5): 743–748 Barnes M, McEvoy RD, Banks S, et al. Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 2004;170(6):656–664 Blanco J, Zamarrón C, Abeleira Pazos MT, Lamela C, Suarez Quintanilla D. Prospective evaluation of an oral appliance in the treatment of obstructive sleep apnea syndrome. Sleep Breath 2005;9(1):20–25 Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med 2005; 1(4):374–380 Engleman HM, McDonald JP, Graham D, et al. Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med 2002;166(6):855–859 Sutherland K, Vanderveken OM, Tsuda H, et al. Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 2014;10(2):215–227

of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med 2013;187(8):879–887 Li W, Xiao L, Hu J. The comparison of CPAP and oral appliances in treatment of patients with OSA: a systematic review and metaanalysis. Respir Care 2013;58(7):1184–1195 Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev 2006;(1): CD004435 Iftikhar IH, Hays ER, Iverson MA, Magalang UJ, Maas AK. Effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med 2013;9(2): 165–174 Bazzano LA, Khan Z, Reynolds K, He J. Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea. Hypertension 2007;50(2):417–423 Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest 1996;109(5):1269–1275 Ferguson KA, Ono T, Lowe AA, al-Majed S, Love LL, Fleetham JA. A short-term controlled trial of an adjustable oral appliance for the treatment of mild to moderate obstructive sleep apnoea. Thorax 1997;52(4):362–368 Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 2008;5(2):173–178 Dieltjens M, Braem MJ, Vroegop AV, et al. Objectively measured vs self-reported compliance during oral appliance therapy for sleepdisordered breathing. Chest 2013;144(5):1495–1502 Doff MH, Hoekema A, Wijkstra PJ, et al. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep 2013;36(9):1289–1296 Fritsch KM, Iseli A, Russi EW, Bloch KE. Side effects of mandibular advancement devices for sleep apnea treatment. Am J Respir Crit Care Med 2001;164(5):813–818 Lettieri CJ, Paolino N, Eliasson AH, Shah AA, Holley AB. Comparison of adjustable and fixed oral appliances for the treatment of obstructive sleep apnea. J Clin Sleep Med 2011;7(5):439–445 Zhou J, Liu YH. A randomised titrated crossover study comparing two oral appliances in the treatment for mild to moderate obstructive sleep apnoea/hypopnoea syndrome. J Oral Rehabil 2012;39(12):914–922 Bloch KE, Iseli A, Zhang JN, et al. A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment. Am J Respir Crit Care Med 2000;162(1):246–251 Vanderveken OM, Devolder A, Marklund M, et al. Comparison of a custom-made and a thermoplastic oral appliance for the treatment of mild sleep apnea. Am J Respir Crit Care Med 2008;178(2): 197–202 Friedman M, Hamilton C, Samuelson CG, et al. Compliance and efficacy of titratable thermoplastic versus custom mandibular advancement devices. Otolaryngol Head Neck Surg 2012;147(2): 379–386 Ghazal A, Sorichter S, Jonas I, Rose EC. A randomized prospective long-term study of two oral appliances for sleep apnoea treatment. J Sleep Res 2009;18(3):321–328 Tsuiki S, Ito E, Isono S, et al. Oropharyngeal crowding and obesity as predictors of oral appliance treatment response to moderate obstructive sleep apnea. Chest 2013;144(2):558–563 Remmers J, Charkhandeh S, Grosse J, et al. Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. Sleep 2013;36(10):1517–1525, 1525A Valero A, Alroy G. Hypoventilation in Acquired Micrognathia. Arch Intern Med 1965;115:307–310





































Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014


Downloaded by: University of Queensland. Copyrighted material.

Non-CPAP Therapies for OSA

Non-CPAP Therapies for OSA

Jones, Brito

42 Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstruc-

53 Prinsell JR. Primary and secondary telegnathic maxillomandibular

tive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981;1(8225):862–865 Aurora RN, Casey KR, Kristo D, et al; American Academy of Sleep Medicine. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep 2010; 33(10):1408–1413 Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med 2013;188(8): 996–1004 Camacho M, Jacobson RL, Schendel SA. Surgical Treatment of Obstructive Sleep Apnea. Sleep Med Clin 2013;8(4):495–503 Hobson JC, Robinson S, Antic NA, et al. What is “success” following surgery for obstructive sleep apnea? The effect of different polysomnographic scoring systems. Laryngoscope 2012;122(8): 1878–1881 Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep 2010;33(10):1396–1407 Kezirian EJ, Weaver EM, Yueh B, et al. Incidence of serious complications after uvulopalatopharyngoplasty. Laryngoscope 2004;114(3):450–453 Maheshwar AA, Gomez KG, Obilanade M, Evans RA. Efficacy of laser palatoplasty: four-year results. Int J Clin Pract 2002;56(7):501–503 Ferguson KA, Heighway K, Ruby RR. A randomized trial of laserassisted uvulopalatoplasty in the treatment of mild obstructive sleep apnea. Am J Respir Crit Care Med 2003;167(1):15–19 Larrosa F, Hernandez L, Morello A, Ballester E, Quinto L, Montserrat JM. Laser-assisted uvulopalatoplasty for snoring: does it meet the expectations? Eur Respir J 2004;24(1):66–70 Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac Surg 1993;51(7):742–747, discussion 748–749

advancement, with or without adjunctive procedures, for obstructive sleep apnea in adults: a literature review and treatment recommendations. J Oral Maxillofac Surg 2012;70(7):1659–1677 Boyd SB, Walters AS, Song Y, Wang L. Comparative effectiveness of maxillomandibular advancement and uvulopalatopharyngoplasty for the treatment of moderate to severe obstructive sleep apnea. J Oral Maxillofac Surg 2013;71(4):743–751 MacKay SG, Carney AS, Woods C, et al. Modified uvulopalatopharyngoplasty and coblation channeling of the tongue for obstructive sleep apnea: a multi-centre Australian trial. J Clin Sleep Med 2013; 9(2):117–124 Friedman M, Ibrahim H, Lee G, Joseph NJ. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2003;129(6):611–621 Lin HC, Friedman M, Chang HW, Yalamanchali S. Z-palatopharyngoplasty Combined with Endoscopic Coblator Open Tongue Base Resection for Severe Obstructive Sleep Apnea/Hypopnea Syndrome. Otolaryngol Head Neck Surg 2014;150(6): 1078–1085 Virkkula P, Bachour A, Hytönen M, et al. Snoring is not relieved by nasal surgery despite improvement in nasal resistance. Chest 2006;129(1):81–87 Sufioğlu M, Ozmen OA, Kasapoglu F, et al. The efficacy of nasal surgery in obstructive sleep apnea syndrome: a prospective clinical study. Eur Arch Otorhinolaryngol 2012;269(2): 487–494 Camacho M, Certal V, Brietzke SE, Holty JE, Guilleminault C, Capasso R. Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope 2014;124(3):803–811 Prinsell JR. Maxillomandibular Advancement (MMA) in a SiteSpecific Treatment Approach for Obstructive Sleep Apnea: A Surgical Algorithm. Sleep Breath 2000;4(4):147–154



45 46



49 50



Seminars in Respiratory and Critical Care Medicine

Vol. 35

No. 5/2014









Downloaded by: University of Queensland. Copyrighted material.


Noncontinuous positive airway pressure therapies for obstructive sleep apnea.

While continuous positive airway pressure is the first-line treatment for obstructive sleep apnea, many patients find this form of therapy undesirable...
140KB Sizes 1 Downloads 11 Views