Residual subjective daytime sleepiness under CPAP treatment in initially somnolent apnea patients: a pilot study using data mining methods.

BACKGROUND AND PURPOSE: Despite correct treatment with positive airway pressure (PAP), obstructive sleep apnea (OSA) patients sometimes remain subjectively somnolent. The reliability of the Epworth Sleepiness Scale (ESS) has been established for healthy subjects and patients under stable conditions; the ESS may eventually vary among treated OSA patients, biasing the results of a cross-sectional analysis of persisting sleepiness. The objective of this study was to depict the evolution of subjective vigilance under treatment using an index of ESS variability (DeltaESS). METHODS: In 80 OSA patients (apnea-hypopnea index [AHI]=54+/-26/h), initially somnolent (ESS=15+/-3) and treated with auto-titrating PAP (APAP) (oxyhaemoglobin desaturation index 3% [ODIapap]=3.4+/-2.2/h; daily APAP use=5.3+/-1.5 h) during 434+/-73 days, ESS scores were regularly collected four times every 109+/-36 days. DESS was calculated and data mining methods (Segmentation and Decision Tree) were used to determine homogeneous groups according to the evolution of ESS scores. RESULTS: When assessed cross-sectionally, 14-25% of the subjects were recognized as somnolent, depending on the moment when ESS was administered. Using data mining methods, three groups were clearly identifiable: two without residual somnolence - group 1, n=38 (47%), with high DeltaESS=-2.9+/-0.8, baseline ESS=16.3+/-3.3, AHI=58.5+/-26.1/h, mean ESSapap=5.1+/-2.4 and group 2, n=31 (39%), with low DeltaESS=-1.1+/-0.5, baseline ESS=13.2+/-1.4, AHI=53+/-27.3/h, mean ESSapap=8.8+/-1.9; and one with persisting sleepiness; group 3, n=11 (14%), with low DeltaESS=-0.3+/-0.8, baseline ESS=16.3+/-3, AHI=38.7+/-10.8/h, mean ESSapap=14.1+/-1.9. Compliance to PAP was high and comparable in the three groups. Age and body mass index (BMI) did not differ. CONCLUSION: Data mining methods helped to identify 14% of subjects with persisting sleepiness. Validation needs to be done on a larger population in order to determine predictive rules.

Radiofrequency ablation for the treatment of mild to moderate obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Obstructive sleep apnea syndrome is due to pharyngeal obstructions, which can take place at the level of the soft palate. Temperature-controlled radiofrequency ablation has been introduced as being capable of reducing soft tissue volume and excessive compliance. The aim of the study was to evaluate prospectively the possible efficacy of temperature-controlled radiofrequency ablation applied to the soft palate in subjects with mild to moderate obstructive sleep apnea syndrome. STUDY DESIGN: Twenty-nine patients with a respiratory disturbance index between 10 and 30 events per hour, body mass index equal to or less than 30 kg/m2, and obstruction at the level of the soft palate were included in a pilot, prospective nonrandomized study. METHODS: Snoring and daytime sleepiness were evaluated subjectively. Treatment (maximum of three sessions) was discontinued when the bed partner was satisfied with the snoring level. A full night recording was performed at least 4 months after the last treatment. RESULTS: Mean snoring level decreased significantly from 8.6 +/- 1.3 to 3.3 +/- 2.5 on a visual analogue scale (0-10). Daytime sleepiness decreased nonsignificantly. Mean respiratory disturbance index decreased significantly from 19.0 +/- 6.1 events per hour to 9.8 +/- 8.6 events per hour. Mean lowest oxygen saturation value increased nonsignificantly from 85.3% +/- 4.1% to 86.4% +/- 4.4%. Of the patients, 65.5% were cured of their disease. CONCLUSIONS: Temperature-controlled radiofrequency ablation was effective in selected patients with mild to moderate obstructive sleep apnea syndrome. A full-night polysomnography is required after completion of treatment to rule out residual disease.

Does propulsion mechanism influence the long-term side effects of oral appliances in the treatment of sleep-disordered breathing?

BACKGROUND: Mandibular advancement appliances (MAAs) can be used to treat sleep-disordered breathing, and differences in their designs have been thought to influence the occurrence of secondary effects. With bibloc devices, the lateral attachments producing mandibular propulsion can be inserted to generate traction or compression. We evaluated the clinical impact of this difference by comparing the long-term secondary effects and compliance of two devices. METHODS: One hundred sixty-two records of patients fitted with a traction-based or compression-based MAA before January 2008 were reviewed retrospectively for physical examination findings and cephalometry. Patients were sent a postal survey and contacted by phone 2 weeks later. They were offered a follow-up medical visit with repeat cephalometry. Main outcomes were long-term (> 2 years) secondary effects, compliance, or satisfaction. RESULTS: Of the patients who attended the follow-up visit, 48 had worn the MAA for > 2 years (16 traction based and 32 compression based), and nine for < 6 months (used as control subjects). Mean follow-up times for the traction and compression groups were 3.7 ± 1.2 years and 3.6 ± 1.2 years, respectively. No difference was found between the MAAs for subjective and objective side effects, except for greater early pain to the masticatory muscles (P = .02) and residual tongue pain (P = .04) in the compression group. However, pain intensity was low and clinical relevance was uncertain. No difference was found for compliance, satisfaction, and objective or subjective efficacy. CONCLUSIONS: This study suggests that traction-based appliances are similar to compression-based devices with regard to secondary effects and compliance.

Neuropathology of sleep disorders: a review.

Sleep disorders are important manifestations of neurodegenerativediseases and sometimes are clinically evident well before the onset of other neurological manifestations. This review addresses theneuroanatomical basis and the mechanisms of sleep regulation in humans in relation to the neuropathology of entities associated with sleep disturbances in selected diseases, including Alzheimer disease, progressive supranuclear palsy, Lewy body disorders, multiple-system atrophy, and fatal familial insomnia. This includes abnormalities of circadian rhythm, insomnia, narcolepsy, rapid eye movements sleep behavior disorders, and excessive daytime sleepiness.

Complications/adverse effects of maxillomandibular advancement for the treatment of OSA in regard to outcome.

OBJECTIVE: To evaluate adverse effects/postoperative complications and surgical response rate of maxillomandibular advancement for the treatment of severe obstructive sleep apnea syndrome. STUDY DESIGN: Case series with chart review. SETTING: Otolaryngology Head and Neck Surgery Department in a teaching hospital. SUBJECTS AND METHODS: A total of 59 consecutive severe sleep apnea patients underwent maxillomandibular advancement. Systemic complications were evaluated from medical charts. Functional adverse effects and cosmetic consequences were evaluated by questionnaires. The treatment outcome was assessed by polysomnography. RESULTS: Fifty patients were evaluated. They had a mean age of 46.4 +/- 9.0 years. No serious postoperative complication was observed. The most frequent local complication was mental nerve sensory loss. Most patients reported cosmetic changes. The mean apnea-hypopnea index decreased from 65.5 +/- 26.7 per hour to 14.4 +/- 14.5 per hour (P < 0.0001). Light-sleep stages were also decreased (P < 0.0001), whereas deep-sleep stages were increased (P < 0.001). CONCLUSION: Maxillomandibular advancement can induce local adverse effects and cosmetic changes, but they seem to be considered as secondary to the patients according to the surgical outcome.