Effects of respiratory exercises in sleep bruxism and associated obstructive sleep apnea: a double-blind, placebo-controlled randomized clinical trial.

PURPOSE: The aim of this study is to assess the effects of respiratory exercises (inspiratory and expiratory) in individuals with sleep bruxism (SB) and associated obstructive sleep apnea (OSA). METHODS: This is a double-blind, placebo-controlled randomized clinical trial including individuals with SB and associated respiratory events in OSA. Respiratory physical therapy was performed using inspiratory (Threshold® IMT), expiratory (Threshold® PEP) muscle training, and compared with a placebo group. A total of 30 daily respiratory cycles (inspiration and expiration) were performed five times a week for 12 weeks. Individuals were reassessed at two times, at baseline (T1) and after 12 weeks of training (T2) by means of the Pittsburgh Sleep Quality Index and Polysomnography. RESULTS: Awakening was significantly different (p ≤ 0.05) between the inspiratory group and placebo 12 weeks after respiratory physical therapy. The number of contractions of the masseter muscle differed between the inspiratory, expiratory, and placebo groups (p ≤ 0.05). CONCLUSION: Respiratory physical therapy for OSA improved awaking levels in 80 and 67% of the number of masseter muscle contractions, when compared to placebo. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (No. RBR-9F6JKM).

Distribution of LPRD in OSAHS Patients: Is There a Correlation?

Objective: Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) and Laryngopharyngeal Reflux Disease (LPRD) are interrelated medical conditions affecting the respiratory system. This article aimed to investigate the potential correlation between the two. Methods: This cross-sectional study was carried out on a total of 52 participants diagnosed with both OSAHS and LPRD. Clinical data of baseline demographics of year, sex, BMI, including clinical indicators such as AHI (Apnea Hypopnea Index), OSAHS severity grading, RFS (Reflux Finding Score), RSI (Reflux Symptom Index), and 24-hour pH level were collected. Statistical analysis was then conducted to evaluate the correlation between OSAHS and LPRD. Results: Among the 52 patients, the the average age was 43.3±11.6 years with a mean 24.7±2.9 kg/m2 BMI level. The mean duration of OSAHS was 4.1±1.7 years with mean 38.7±12 AHI scores and 30.8% mild OSAHS, 51.9% moderate OSAHS, and 17.3% severe OSAHS. Mean LPRD duration was 3.2±1.5 years with a mean 15.9±4.9 RFS score, mean 28.0±6.8 RSI score, and mean 3.9±0.8 24-hour pH level. There was a strong positive correlation between AHI scores and both the RFS score (r>0.9, P < .01) and RSI score (r>0.9, P < .01). While a strong negative correlation between AHI scores and 24-hour pH level was observed (r < -0.8, P < .01). And there was a strong positive correlation between OSAHS severity levels and both the RSF score (r>0.8, P < .01) and RSI score (r>0.79, P < .01). While a significant negative correlation between OSAHS severity and 24-hour pH level was detected (r < -0.7, P < .01). Conclusions: The findings of this cross-sectional study demonstrate a strong positive correlation between the severity of OSAHS, as indicated by AHI scores, and the severity of LPRD, as measured by RFS and RSI scores. A negative correlation was also observed between AHI scores and 24-hour pH level, indicating a connection between these two medical conditions.

Exploring the link between vitamin D deficiency and obstructive sleep apnea: A comprehensive review.

Despite the high prevalence and significant health burden of obstructive sleep apnea (OSA), its underlying pathophysiology remains incompletely understood. This comprehensive review explores the emerging connection between vitamin D deficiency and OSA, discusses potential mechanisms underlying this association, and explores the therapeutic implications of these findings. Recent research has consistently highlighted the high incidence of vitamin D deficiency among patients with OSA, which often occurs independently of geographical location. This suggests that factors beyond lack of sunlight exposure may be involved. This review also discusses how reduced vitamin D may be associated with more severe manifestations of OSA. In addition, it explores the potentiality of using vitamin D supplements as a therapeutic strategy for OSA, noting that some studies have found improvements in sleep quality and a reduction in OSA severity. Potential mechanisms are proposed, including the role of vitamin D deficiency in promoting inflammation, oxidative stress, hypoxia, impairing immune function, muscle function, and gene polymorphism of vitamin D receptors, all of which could contribute to the pathogenesis of obstructive sleep apnea. The paper underscores the need for future research to validate these observations, to determine optimal vitamin D supplementation dosage and duration, to explore potential side effects and risks, and to investigate potential interactions with other treatments.

Impact of Functional Conservation Surgery on Sleep Respiration of Patients with Glottic Cancer.

Objective: Laryngeal cancer is a common tumor in the head and neck, and surgery is one of the main treatment methods for laryngeal cancer. Laryngeal cancer surgery destroys the laryngeal cartilage scaffold, leading to structural changes in the laryngeal cavity and affecting respiratory compliance during sleep. However, less attention has been paid to the impact of changes in laryngeal structure on sleep breathing conditions. This article conducts a prospective study on the effects of preserving laryngeal function in cancer glottic surgery on sleep and respiratory status in patients, in order to understand the preoperative and postoperative OSAHS(obstructive sleep apnea-hypopnea syndrome) of glottic cancer patients , as well as the impact of surgery on OSAHS of patients. Provide a reference for improving the sleep quality of postoperative patients with laryngeal cancer. Methods: 47 patients with glottic cancer who underwent laryngeal function preservation surgeries were studied. They are divided into 28 cases of T1 and T2, who underwent vertical lateral frontal partial laryngectomy (VLFPL), and 19 cases of T3 and T4 who underwent vertical lateral frontal subtotal laryngectomy (VLFSL). All patients' sleep breathing statuses were recorded using a portable sleep breathing monitor one week before surgery and two months after the removal of the tracheal cannula. Analyze the proportion of OSAHS in the 47 patients before and after surgery and compare the obstructive sleep apnea scores of these patients using the Wilcoxon rank sum test of paired grade data. The paired data t-test was used to analyze the apnea-hypopnea index (AHI), apnea index (AI), hypopnea index (HI), minimum blood oxygen saturation (LSaO2), and mean blood oxygen saturation (MSaO2) of all study subjects, patients undergoing VLFPL and VLFSL. Results: 1. Among the 47 patients with glottic cancer, 42.6% (20 / 47) were in line with OSAHS before the operation, and 57.4% (27 / 47) were in line with OSAHS after the operation. 47 patients showed an increasing trend in the OSAHS scores (no, mild, moderate, and severe) after surgery compared to the before-surgery scores, and the difference was statistically significant (P < 0.05). 2. Among the 47 study subjects, AHI and HI increased after surgery compared to preoperative, while LSaO2 and MSaO2 decreased after surgery compared to preoperative (P < .05); There was no statistically significant difference between postoperative and preoperative AI (P > .05). Among 28 patients undergoing VLFPL, LSaO2 decreased after surgery compared to before surgery (P < .05) and there was no statistically significant difference in AHI, AI, MSaO2, and HI after surgery compared to before surgery (P > .05). Among 19 patients undergoing VLFSL, AHI, and HI increased after surgery, while LSaO2 and MSaO2 decreased after surgery (P < .05) and there was no statistically significant difference in postoperative AI compared to preoperative (P > .05). Conclusion: The prevalence of OSAHS in patients with glottic cancer before and after surgery was higher than that in the general population. The effect of functional preservation surgery on sleep breathing in patients with glottic cancer is related to the degree of destruction of the thyroid cartilage scaffold and the scope of surgery. Surgery mainly increases the degree of OSAHS by aggravating patients' hypoventilation rather than apnea.

Feasibility of oropharyngeal and respiratory muscle training in individuals with OSA and spinal cord injury or disease: A pilot study.

OBJECTIVES: To examine the feasibility of individuals with spinal cord injury or disease (SCI/D) to perform combined oropharyngeal and respiratory muscle training (RMT) and determine its impact on their respiratory function. METHODS: A prospective study at a single Veterans Affairs (VA) Medical Center. Inclusion criteria included: 1) Veterans with chronic SCI/D (>6 months postinjury and American Spinal Injury Association (ASIA) classification A-D) and 2) evidence of OSA by apnea-hypopnea index (AHI ≥5 events/h). Eligible participants were randomly assigned to either an experimental (exercise) group that involved performing daily inspiratory, expiratory (using POWERbreathe and Expiratory Muscle Strength Trainer 150 devices, respectively), and tongue strengthening exercises or a control (sham) group that involved using a sham device, for a 3-month period. Spirometry, maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP), polysomnography, and sleep questionnaires were assessed at baseline and at 3 months. RESULTS: Twenty-four individuals were randomized (12 participants in each arm). A total of eight (67%) participants completed the exercise arm, and ten (83%) participants completed the sham arm. MIP was significantly increased (p < 0.05) in the exercise group compared with the baseline. CONCLUSIONS: Combined oropharyngeal and RMT are feasible for individuals with SCI/D. Future studies are needed to determine the clinical efficacy of these respiratory muscle exercises.

Right Versus Left Cuff Position for Upper Airway Stimulation.

OBJECTIVE: Upper airway stimulation (UAS) is a treatment option for obstructive sleep apnea in which electrical stimulation is applied to the hypoglossal nerve. Nerve branches that control tongue protrusion are located inferiorly. Due to positioning, left-sided implants are typically placed with an inferiorly oriented electrode cuff (L-down) as opposed to superiorly on the right (R-up). In this study, we assess the impact of left- versus right-sided UAS on patient outcomes. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary Academic Medical Center. METHODS: Patients who underwent UAS implantation between 2016 and 2021 with an L-down or R-up oriented cuff as confirmed by X-ray were included. Data were collected retrospectively. Most recent sleep study variables were used for analysis. RESULTS: A total of 190 patients met the inclusion criteria. The average age was 61.0 ± 11.0 years, with 55 (28.9%) females. L-down orientation was present in 21 (11.1%) patients vs 169 (88.9%) R-up. Indications for L-down included hunting/shooting (n = 15), prior radiation/surgery (n = 4), central port (n = 1), and brachial plexus injury (n = 1). Adherence was higher among L-down patients (47.1 vs 41.0 hours use/week, P = .037) in univariate analysis, with a similar time to adherence data collection (4.4 vs 4.2 months, P = .612), though this finding was not maintained in the multivariate regression analysis. Decrease in apnea-hypopnea index (21.3 vs 22.8, P = .734), treatment success (76.5% vs 84.0%, P = .665), functional threshold (1.5 vs 1.6, P = .550), therapeutic amplitude (2.3 vs 2.4, P = .882), and decrease in Epworth Sleepiness Scale (4.9 vs 2.6, P = .060) were not significantly different between cohorts. CONCLUSION: This study is the first to examine the orientation of the UAS electrode cuff concerning the electrodes' natural position and the potential effect on postoperative outcomes. Our study found no significantly different treatment outcomes between the L-down versus R-up cohort, with the exception of device adherence, which was significantly higher in the L-down group on univariate analysis though not on multivariate analysis. Future studies with larger patient cohorts are needed to further investigate this potential relationship between treatment outcomes and electrode cuff orientation.

Efficacy of oropharyngeal exercises as an adjuvant therapy for obstructive sleep apnea: A randomized controlled trial.

PURPOSE: Some patients with mild-to-moderate obstructive sleep apnea (OSA) undergoing mandibular advancement device (MAD) therapy may exhibit residual sleep-breathing abnormalities. These cases require adjunctive treatment to further reduce the remaining airway inadequacy, which may affect the health and quality of life. This clinical trial was conducted since the oropharyngeal exercise, which aims to enhance the muscular function of the upper airway, combined with MAD, is unknown. We assessed the possible improvements in respiratory event parameters and lip and tongue physiological properties in patients with OSA who received oropharyngeal exercises for 2 months as an adjunct to MAD therapy. METHODS: Twenty-three participants with OSA who had been using MAD but still had residual apnea-hypopnea were randomly allocated to either the oropharyngeal exercise (OE group; N=12) or the sham exercise group (N=11). Lip and tongue strength, endurance, daytime sleepiness, respiratory event index (REI), and the lowest oxygen saturation (SpO2 nadir) were determined. RESULTS: Within and between the treatment groups, no significant improvement in the REI or SpO2 nadir was found. In both groups, there was a significant reduction in the Epworth Sleepiness Scale at 2 months (OE, P = 0.02; control, P = 0.02). In the OE group, lip endurance (P = 0.03), anterior tongue strength (P = 0.02), and endurance (P = 0.02) increased after 2-month of exercise, but only anterior tongue endurance increased significantly compared with the sham control (P = 0.01). CONCLUSIONS: This study found that adjunctive OE to MAD showed no additive effect in treating patients with moderate OSA who had a mild residual apnea-hypopnea index following MAD treatment. However, the exercises successfully enhanced lip and anterior tongue endurance, as well as anterior tongue strength.

Challenging Case: A Multidisciplinary Approach to Demystifying Chronic Sleep Impairment in an Infant with a Complex Medical and Behavioral Profile.

CASE: X is a 22-month-old White male infant with a complex medical history, including diagnoses of FBXO11 mutation, hypotonia, restrictive lung disease and mild intermittent asthma, laryngotracheomalacia, obstructive sleep apnea (OSA), feeding difficulties with a history of aspiration, gastroesophageal reflux disease (GERD), and developmental delays. X's medical presentation has resulted in multiple prior medical admissions for respiratory failure due to acute illnesses, procedures and treatments including gastrojejunostomy (GJ) tube dependence, supraglottoplasty to reshape tissues of the upper larynx, and the use of biphasic positive airway pressure (BiPAP) at night and room air during the day when he is at baseline. In addition, he has nocturnal events characterized by significant agitation, screaming, crying, body stiffening and limb movements with pauses in breathing, mouth breathing, restless sleep, and difficulty waking in the morning with concomitant daytime fatigue despite above treatments for OSA. There is no history of congenital heart disease or sudden unexplained death. Family history is noncontributory because parents are negative for the FBXO11 variant.X's sleep disruption has led to significant sleep deficits for both X and his caregivers, who spend much of the night strategizing on how to console him. X has undergone several sleep studies, starting when X was aged 4 months, at several children's hospitals across the nation to determine the cause of his chronic sleep disturbance, which yielded limited information and treatment success. As an infant, X received a medical workup and was subsequently treated with a proton pump inhibitor (PPI) for reflux. At 12 months, he was diagnosed with disordered sleep with myoclonic jerks and started on melatonin and gabapentin for involuntary movements. At 13 months, gabapentin was weaned back because of intolerance, and at 15 months, nortriptyline and clonidine were started because of worsening symptoms to target potential neuropathic pain. While most of his symptoms were at night, he had occasional daytime screaming episodes, particularly when experiencing illness. Gabapentin and clonidine were stopped because nortriptyline seemed most effective.At 17 months, the results from a sleep study led to a diagnosis of night terrors, and several clinicians agreed that X's sleep disruption was behavioral in nature. At this time, an infant mental health consultant met with a sleep psychologist on the family's behalf to support family in considering systematic desensitization therapy to increase tolerance to wearing his BiPAP mask, as well as other behavioral and sleep hygiene strategies, which were tried on several occasions and again, resulted in limited improvement in functioning.At 19 months, X's multidisciplinary team reconsidered a night terror diagnosis after a failed trial of clonazepam and pursued a differential diagnosis of periodic limb movement disorder (PLMD). X trialed gabapentin again, but this time only a nighttime dose, per sleep medicine and psychiatry recommendation. While this brought some temporary relief from nighttime distress, despite increasing to the highest dose for age and weight (15 mg/kg/dose), this became less effective, and he was weaned off at 22 months. He had been on iron supplementation since age 6 months and received an iron infusion at 22 months because of persistently low ferritin levels and PLMD in sleep.At 24 months, X was briefly trialed on levetiracetam. While no evidence for seizures on EEG was present, this medication was chosen for involuntary movements and genetic risk for seizures. However, this medication was not useful. At 25 months, an evaluation with a movement disorder physiatrist resulted in a diagnosis of nocturnal paroxysmal dystonia, and he was started on baclofen, which has provided some, but not complete relief to nighttime symptoms. Parents are reporting he has more "good nights" than "bad nights," but "bad nights" come in stretches of a few days in length with no known trigger or relief.Most recently, X was evaluated by general genetics. Whole exome sequencing (WES) was pursued which revealed a pathogenic de novo variant in FBXO11 and provides a likely cause for his neurodevelopmental phenotype. However, he has some features not explained by FBX011; thus, reanalysis of his WES was performed and revealed a de novo variant of uncertain significance in RAF1. Because pathogenic variants in RAF1 have been associated with dilated cardiomyopathy and Noonan spectrum disorder, it was recommended that X be followed periodically in a cardiac genetics clinic. Family is well connected into the FBXO11 community, including supportive Facebook groups. Parents have shared that they do not feel X's breathing issues and pain fit with the phenotype of other children with FBXO11 mutations.X is also enrolled in a medical child care program to facilitate development and social-emotional functioning and receives learning, speech, occupational, physical, and feeding therapy while in attendance. Despite periods of absence due to contracting numerous viral illnesses over the past several months, X continues to make progress across developmental therapies and happily engages when at the program.What additional diagnostic tests and treatment should be considered to better understand X's medical and behavioral presentation? What are the implications of chronic sleep deprivation and stress on the behavior and development of infant with X's profile? What are important psychosocial considerations because it relates to children with medical complexity (CMC), particularly for X and his family to support caregiver, family, and X's quality of life and overall well-being?

Effects of soft tissue mobilisation on subacute adherent linear scars: a single-group intervention study.

OBJECTIVE: Scar adherence due to a pathological healing process can cause physical and psychological disturbance. Soft tissue mobilisation (STM) techniques are widely used to treat and prevent scar adherence, but little is known on their effects. We aimed to analyse the effect of STM in patients with subacute post-surgical scar adhesions affecting the extremities. METHOD: A single-group quasi-experimental study was conducted on consecutive patients undergoing post-surgery limb rehabilitation. Patients with a baseline Adhesion Severity (AS) index of <0.5 at the worst scar point, as measured by the Adheremeter, were eligible. All patients who completed a minimum of five manual treatment sessions were included. The primary outcome was the AS index and the secondary outcome was the Italian version of the Patient and Observer Scar Assessment Scales (POSAS-I). RESULTS: A cohort of 19 patients underwent an average of eight STM sessions over a period of one month. The AS index value increased from a median of 0.12 at baseline (interquartile range (IQR): 0.05-0.25) to 0.41 post-treatment (IQR: 0.26-0.63; median change: 0.24; IQR: 0.16-0.40; p<0.001). A large effect size was observed for both AS and Observer Scar Assessment Scale (OSAS-I) (Cohen r=0.6), with a large probability of superiority (PS) (87% and 86%, respectively). A moderate effect was observed for the Patient Scar Assessment Scale (PSAS-I) (Cohen=0.4; PS=71%). Pre-post treatment changes exceeded the minimal detectable changes for the AS and OSAS-I in 68% of subjects, and for PSAS-I in 21% of subjects. CONCLUSION: STM manual techniques may produce a large effect on the mobility of adherent subacute post-surgical scars.

Pediatric Down Syndrome Upper Airway Stimulation: Patient Selection and Post-Implantation Optimization.

OBJECTIVE: The Food and Drug Administration recently approved upper airway stimulation (UAS) for children with Down Syndrome and persistent obstructive sleep apnea who meet certain inclusion and exclusion criteria. Although there is a robust experience with this therapy in the adult population, established protocols used in adults are not directly transferrable to a complex pediatric population. This review aims to combine the protocols from several institutions for patient selection and postimplantation optimization, including a protocol for Drug-Induced Sleep Endoscopy in children with Down Syndrome, preactivation threshold measurements, device titration, and follow-up sleep studies. STUDY DESIGN: Expert panel development of best Practice algorithm. SETTING: Multi-institutional investigator review. METHODS: An expert panel was assembled of pediatric otolaryngologists with extensive experience in hypoglossal nerve stimulation in children with Down Syndrome. Thirty statements were created during an initial drafting session. A modified Delphi method was used assess consensus among the panel. RESULTS: After 2 rounds of Delphi surveys, 29 statements met criteria for consensus. One statement did not meet consensus. The statements were grouped into several categories to facilitate presentation. CONCLUSIONS: A standardized approach to UAS for children with Down Syndrome must take into account the unique challenges inherent to treating a complex pediatric population with a high rate of sensory processing disorders. This expert panel has met consensus on several statements that will guide clinicians as this novel therapy is adopted.

Hypoglossal Nerve Stimulation and Cardiovascular Outcomes for Patients With Obstructive Sleep Apnea: A Randomized Clinical Trial.

Importance: Sham-controlled trials are needed to characterize the effect of hypoglossal nerve stimulation (HGNS) therapy on cardiovascular end points in patients with moderate-severe obstructive sleep apnea (OSA). Objective: To determine the effect of therapeutic levels of HGNS, compared to sham levels, on blood pressure, sympathetic activity, and vascular function. Design, Setting, and Participants: This double-blind, sham-controlled, randomized crossover therapy trial was conducted from 2018 to 2022 at 3 separate academic medical centers. Adult patients with OSA who already had an HGNS device implanted and were adherent and clinically optimized to HGNS therapy were included. Participants who had fallen asleep while driving within 1 year prior to HGNS implantation were excluded from the trial. Data analysis was performed from January to September 2022. Interventions: Participants underwent a 4-week period of active HGNS therapy and a 4-week period of sham HGNS therapy in a randomized order. Each 4-week period concluded with collection of 24-hour ambulatory blood pressure monitoring (ABPM), pre-ejection period (PEP), and flow-mediated dilation (FMD) values. Main Outcomes and Measures: The change in mean 24-hour systolic blood pressure was the primary outcome, with other ABPM end points exploratory, and PEP and FMD were cosecondary end points. Results: Participants (n = 60) were older (mean [SD] age, 67.3 [9.9] years), overweight (mean [SD] body mass index, calculated as weight in kilograms divided by height in meters squared, 28.7 [4.6]), predominantly male (38 [63%]), and had severe OSA at baseline (mean [SD] apnea-hypopnea index, 33.1 [14.9] events/h). There were no differences observed between active and sham therapy in 24-hour systolic blood pressure (mean change on active therapy, -0.18 [95% CI, -2.21 to 1.84] mm Hg), PEP (mean change on active therapy, 0.11 [95% CI, -5.43 to 5.66] milliseconds), or FMD (mean change on active therapy, -0.17% [95% CI, -1.88% to 1.54%]). Larger differences between active and sham therapy were observed in a per-protocol analysis set (n = 20) defined as experiencing at least a 50% reduction in apnea-hypopnea index between sham and active treatment. Conclusions and Relevance: In this sham-controlled HGNS randomized clinical trial, mean 24-hour systolic blood pressure and other cardiovascular measures were not significantly different between sham and active HGNS therapy. Several methodologic lessons can be gleaned to inform future HGNS randomized clinical trials. Trial Registration: ClinicalTrials.gov Identifier: NCT03359096.

Retrospective review of acute post-tracheostomy complications and contributing risk factors.

OBJECTIVE: Tracheostomy is performed for various indications ranging from prolonged ventilation to airway obstruction. Many factors may play a role in the incidence of complications in the immediate post-operative period including patient-related factors. Chronic obstructive pulmonary disease and asthma are some of the most common pulmonary pathologies in the United States. The relationship between obstructive pulmonary diseases and acute post-tracheostomy complications has been incompletely studied. DESIGN: A retrospective chart review was designed in order to answer these objectives. Medical records were reviewed for the technique used, complications, and contributing patient factors. Post-operative complications were defined as any tracheostomy-related adverse event occurring within 14 days. SETTING: The study took place at an academic comprehensive cancer. PARTICIPANTS: Inclusion criteria included patients from January 2017 through December 2018 who underwent a tracheostomy. Exclusion criteria included presence of stomaplasty, total laryngectomy, and tracheostomies performed at outside hospitals. MAIN OUTCOME MEASURES: Patient factors examined included demographics, comorbidities, and body mass index with the primary outcome measured being the rate of tracheostomy complications. RESULTS: The most common indication for tracheostomy among the 321 patients that met inclusion criteria was airway obstruction or a head and neck cancer surgical procedure. Obstructive sleep apnea was associated with acute complications in bivariate analysis (29.4% complications, p = .003). Chronic obstructive pulmonary disease and asthma were not associated with acute complications in bivariate analysis (11.6% complications, p = .302). Among the secondary outcomes measured, radiation was associated with early complications occurring in post-operative days 0-6 (1.1%, p = .029). CONCLUSION: Patients with obstructive sleep apnea may have a higher risk of acute post-tracheostomy complications that might be due to the patient population at risk for obstructive sleep apnea. Patients with obstructive pulmonary pathologies such as asthma or chronic obstructive pulmonary disorder did not have an elevated risk of complications which is clinically significant when considering the utility of ventilation and tracheostomy in the management of acute respiratory failure secondary to these conditions.

Snoring Patterns During Hypoglossal Nerve Stimulation Therapy Up-Titration.

Longitudinal snoring changes can be captured using a mobile phone application. During hypoglossal nerve stimulator (HNS) therapy up-titration, increasing stimulation voltage was associated with reduced snoring frequency and intensity in this case series of six patients. Laryngoscope, 134:987-992, 2024.

Impact of Insomnia on Hypoglossal Nerve Stimulation Outcomes in the ADHERE Registry.

OBJECTIVE: We aimed to determine the preoperative prevalence of insomnia in the Adherence and Outcomes of Upper Airway Stimulation for OSA International Registry (ADHERE) and to examine serial sleep-related data longitudinally, in particular the Insomnia Severity Index (ISI), to compare outcomes between patients with no/subthreshold insomnia (ISI < 15) and moderate/severe insomnia (ISI ≥ 15) at baseline. METHODS: We analyzed observational data from ADHERE between March 2020 and September 2022. Baseline demographic and mental health (MH) data, apnea hypopnea index (AHI), ISI, and ESS (Epworth Sleepiness Scale) were recorded. At post-titration (PT) and final visits, AHI, ISI, ESS and nightly usage were compared between baseline ISI < 15 and ISI ≥ 15 subgroups. RESULTS: A baseline ISI was obtained in 928 patients (62% with ISI ≥ 15). Of the 578 and 141 patients reaching the 12- and 24-month time periods to complete PT and final visits, 292 (50.5%) and 91 (64.5%) completed the ISI, respectively. Baseline MH conditions were higher with ISI ≥ 15 than ISI < 15 (p < 0.001). AHI reduction and adherence did not differ between patients with baseline ISI ≥ 15 and ISI < 15. Patients with ISI ≥ 15 experienced greater improvement in ESS than ISI < 15 at post-titration and final visits (p = 0.014, 0.025). All patients had improved nocturnal, daytime, and overall ISI scores at follow-up visits (p < 0.001), especially for those with baseline ISI ≥ 15 compared with ISI < 15 (p < 0.05). CONCLUSION: HGNS therapy efficacy and adherence were similar between ISI severity subgroups at follow-up visits. Insomnia and sleepiness scores improved in all patients with HGNS therapy and to a greater degree in patients with baseline moderate/severe insomnia. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:471-479, 2024.

Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis.

OBJECTIVE: Orofacial myofunctional therapy (OMT) is an alternative form of treatment of obstructive sleep apnea (OSA), that incorporates various exercises to optimize tongue placement and increase oropharyngeal tone. The objective of this systematic review and meta-analysis is to determine the efficacy of OMT in OSA patients. DATA SOURCES: PubMed/Medline, EMBASE, Cochrane, Web of Science. REVIEW METHODS: Using PRISMA guidelines, a directed search strategy was performed for randomized control trials (RCTs) published prior to March 24, 2023, featuring 10+ patients with OSA undergoing mono-therapeutic OMT. The primary outcome of interest was apnea-hypopnea index (AHI). Secondary outcomes included subjective sleepiness, sleep-related quality-of-life, and snoring frequency. RESULTS: Of the 1244 abstracts that were identified, 7 RCTs involving 310 patients met inclusion criteria. Adult OMT patients had a statistically significant improvement in AHI (MD -10.2; 95% CI, -15.6, -4.8, p < 0.05), subjective sleepiness (Epworth Sleepiness Scale; MD -5.66; 95% CI, -6.82, -4.5, p < 0.05), sleep-related quality-of-life (Pittsburgh Sleep Quality Index; MD -3.00; 95% CI, -4.52, -1.49, p < 0.05), and minimum oxygen saturation (MD 2.71; 95% CI, 0.23, 5.18, p < 0.05) when compared with sham OMT or no therapy. Within the single RCT featuring pediatric OMT patients, patients had poor compliance (<50%) and did not show any improvements in AHI, minimum oxygen saturation, or snoring frequency. CONCLUSION: OMT may provide a reasonable alternative for OSA patients who cannot tolerate CPAP or other more established treatment options. OMT benefits appear limited in children due to poor compliance. More studies are required to evaluate compliance and the long-term effects of OMT on OSA outcomes. LEVEL OF EVIDENCE: 1 Laryngoscope, 134:480-495, 2024.

Bright light therapy for CPAP-resistant OSA symptoms.

STUDY OBJECTIVES: Sleep fragmentation and daytime sleepiness often persist in patients with sleep apnea despite correctly administered continuous positive airway pressure (CPAP). Our proof-of-concept study tested the acceptability and efficacy of morning bright light therapy (BLT) to improve sleep, circadian rhythms, and CPAP-resistant daytime symptoms in patients with sleep apnea. METHODS: In this within-subject crossover study, 14 individuals completed 4 weeks of BLT and sham BLT in randomized order. Outcomes included actigraphy-based objective sleep measures, sleepiness, depressive symptoms, and sleep-related functional impairment, analyzed with multilevel models. RESULTS: Patients experienced greater reductions in wake after sleep onset and increased amplitude of rest-activity rhythms in a shorter photoperiod with BLT compared with sham. Patients also reported reductions in self-reported sleepiness and depressive symptoms with BLT compared with sham only during the early stages of treatment and shorter photoperiod. CONCLUSIONS: These results suggest the potential for novel applications for existing chronotherapeutic interventions for improving symptoms and quality of life for those patients who experience residual symptoms with current available treatments. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Bright Light Therapy for Residual Daytime Symptoms Associated With Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT04299009; Identifier: NCT04299009. CITATION: Soreca I, Arnold N, Dombrovski AY. Bright light therapy for CPAP-resistant OSA symptoms. J Clin Sleep Med. 2024;20(2):211-219.

Mitigating Infection Risk in Upper Airway Stimulation.

OBJECTIVE: This study aims to define the incidence of infection with upper airway stimulation (UAS) devices requiring explantation in a single academic center and identify factors that may influence the risk of infection. METHODS: A database of patients who underwent UAS at a single tertiary referral academic center from 2017 to 2021 was retrospectively reviewed to identify patients who developed surgical site infections, with and without subsequent explantation. Additional data for cases complicated by infection was extracted from the electronic medical record (EMR) and included: demographic information, medical history, complications and management, and overall outcomes. In March 2021, 2 modifications to infection control protocols were implemented: double skin preparation with Betadine and chlorhexidine, and MRSA decolonization. Statistical analysis was performed to compare infectious risk before and after these protocol changes. RESULTS: In the study period, 215 patients underwent UAS in the specified time period and 3 cases (1.4%) of postoperative infections were identified, all of which required explantation. The infection rate did not significantly change after modifications to the surgical prep protocol (P = .52). CONCLUSIONS: While no significant difference in infection risk was noted after modifying infection control protocols, additional longer-term study is warranted to elucidate effective infection reduction strategies.

Treatment of a floppy epiglottis with upper airway stimulation therapy.

PURPOSE: To evaluate the efficacy of upper airway stimulation therapy in patients with a floppy epiglottis who have experienced continuous positive airway pressure failure or intolerance. METHODS: A retrospective single-center cohort study was conducted. Patients who received an Inspire Upper Airway Stimulation system and had a 1-year follow-up were included. Baseline and one-year in-laboratory polysomnography examinations were performed. Patient characteristics, Epworth Sleepiness Scale scores and upper airway stimulation device settings were collected. RESULTS: A total of 75 patients were included, of whom 10 had a floppy epiglottis. Patients with a floppy epiglottis had a significant therapeutic response to upper airway stimulation therapy, similar to patients without a floppy epiglottis. According to the Sher's success criteria, 90% of patients with a floppy epiglottis and 68% of patients without a floppy epiglottis were responders to therapy (p = 0.149). In the floppy epiglottis group, the apnea-hypopnea index decreased from 35.1 ± 5.5 events/hour to 11.2 ± 11.3 events/hour (95% CI (15.0, 32.9), p < 0.001), similarly in the non-floppy epiglottis group, the decline was from 36.4 ± 8.3 events/hour to 14.4 ± 9.5 events/hour (95% CI (18.6, 25.2), p < 0.001, between groups p = 0.659). Comparable reductions were observed for the other respiratory parameters. CONCLUSION: Treatment of patients with obstructive sleep apnea and a floppy epiglottis can be challenging. Continuous positive airway pressure may aggravate the epiglottis collapse. Upper airway stimulation therapy can be considered an effective alternative treatment option for patients with a floppy epiglottis who have encountered either continuous positive airway pressure failure or intolerance.