Treatment of obstructive sleep apnea with hypoglossal nerve stimulation in a patient with Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome is a group of hereditary connective tissue disorders caused by defects in collagen synthesis and structure that manifests as tissue fragility, hypermobility, and vascular abnormalities. Patients with Ehlers-Danlos syndrome are at a high risk of developing obstructive sleep apnea due to increased tissue laxity in the upper airway, in addition to nasal-maxillary cartilaginous defects, scoliosis, or other abnormalities. Here we present the case of a patient with Ehlers-Danlos syndrome who underwent successful treatment of obstructive sleep apnea using hypoglossal nerve stimulation after continuous positive airway pressure therapy failure, demonstrating that this can be a useful treatment modality in this population. CITATION: Miller SM, Miller MB. Treatment of obstructive sleep apnea with hypoglossal nerve stimulation in a patient with Ehlers-Danlos syndrome. J Clin Sleep Med. 2023;19(3):631-632.

Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review.

BACKGROUND: Continuous positive airway pressure (CPAP) is the gold standard of care in providing non-invasive positive pressure support to neonates in respiratory distress in high-resource settings. While safety has been demonstrated in low-resource settings, there is a lack of knowledge on the barriers and facilitators to proper implementation. OBJECTIVE: To identify and describe the barriers, facilitators, and priorities for future implementation of CPAP for neonates and infants in low-resource settings. METHODS: A systematic search (database inception to March 6, 2020) was performed on MEDLINE, Embase, Web of Science, CINAHL, Global Health, and the WHO Global Index Medicus using PRISMA-ScR guidelines. Original research articles pertaining to implementation of CPAP devices in low-resource settings, provider or parent perspectives and experiences with CPAP, cost-benefit analyses, and cost-effectiveness studies were included. Inductive content analysis was conducted. FINDINGS: 1385 article were screened and 54 studies across 19 countries met inclusion criteria. Six major themes emerged: device attributes, patient experiences, parent experiences, provider experiences, barriers, and facilitators. Nasal trauma was the most commonly reported complication. Barriers included unreliable electricity and lack of bioengineering support. Facilitators included training, mentorship and empowerment of healthcare providers. Device design, supply chain infrastructure, and training models were imperative to the adoption and sustainability of CPAP. CONCLUSION: Sustainable implementation of CPAP in low resource settings requires easy-to-use devices, ready access to consumables, and holistic, user-driven training. Further research is necessary on standardizing metrics, interventions that support optimal provider performance, and conditions needed for successful long-term health system integration.

Characterizing Decisional Conflict in Patients Presenting to Sleep Surgery Clinic and an Exploration of Resource Limitations.

OBJECTIVES: Numerous therapies exist for adult obstructive sleep apnea (OSA), creating potential for patient decisional conflict (DC) that impacts treatment adherence and post-treatment regret. We evaluated the prevalence of elevated DC in OSA patients presenting for positive airway pressure (PAP) alternative therapies and identified gaps in available resources about OSA therapies. STUDY DESIGN: Cross-sectional study. METHODS: A cross-sectional study was performed based on questionnaires completed by adult OSA patients presenting to an academic sleep surgery clinic from March to October 2020. Surveys examined sleep symptoms, sleep apnea treatment history, goals of therapy, and the SURE checklist, a validated 4-item DC screening scale. Additional qualitative data about OSA decision tool needs were queried with structured interviews in a smaller subset of patients. RESULTS: Among 100 respondents, 60 were open to multiple treatment options, whereas 22 were not interested in surgical treatment. Eighty-one respondents (81%) had elevated DC (SURE score < 4). High DC was not associated with CPAP history, OSA severity, or daytime sleepiness (Epworth Sleepiness Scale score ≥ 10). Elevated DC was related to uncertainty regarding optimal treatment choice in 54% of respondents (n = 54), and lack of knowledge regarding risks and benefits of each treatment option in 71% (n = 71). Common themes identified in 9 interviewed patients suggested helpful resources should ideally compare treatment modalities and educate on surgery details, efficacy, and recovery. CONCLUSIONS: The majority of OSA patients presenting to sleep surgery clinics have elevated decisional conflict influenced by limited knowledge about options and the risks and benefits of each therapy. There is a need for decision tools that can reduce decisional conflict and promote equitable knowledge about PAP alternative OSA treatments. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2384-2390, 2021.

Oral Glucose and Listening to Lullaby to Decrease Pain in Preterm Infants Supported with NCPAP: A Randomized Controlled Trial.

BACKGROUND: Preterm infants spend the early days of their lives in neonatal intensive care units, where they undergo many minor painful procedures. There are many nonpharmacologic methods that can effectively reduce the pain response of neonates who undergo routine procedures. AIMS: This study aimed to investigate whether oral glucose and listening to lullabies could bring pain relief during the removal and reinsertion of the tracheal tube and also oronasopharyngeal suctioning in premature infants to whom nasal continuous positive airway pressure was applied. DESIGN: A double-blind, randomized controlled trial. SETTING: This study was conducted in the neonatal intensive care unit in the tertiary setting between November 2012 and September 2013. PARTICIPANTS/SUBJECTS: A total of 106 preterm infants were divided into three groups, including 37 infants in the control group, 35 infants in the lullaby group, and 34 infants in the glucose group. METHODS: All preterm infants were randomly assigned to either the intervention groups or the control group. Pain responses were assessed using the Neonatal Infant Pain Scale and the Premature Infant Pain Profile. RESULTS: An assessment of the pain severity of the preterm infants after the intervention indicated that the preterm infants in the lullaby and glucose groups had lower pain, whereas the preterm infants in the control group experienced more pain (p < .05). CONCLUSION: The findings suggest that pain could be reduced significantly in preterm infants after the suggested intervention, although further studies are required to identify the benefits of lullabies or glucose in infants during other painful procedures.

Noninvasive ventilation and respiratory physical therapy reduce exercise-induced bronchospasm and pulmonary inflammation in children with asthma: randomized clinical trial.

BACKGROUND: Asthma is characterized by hyperresponsiveness of the airways, and exercise-induced bronchospasm (EIB) is a symptom that limits a large proportion of asthmatic patients, especially children. Continuous positive airway pressure (CPAP) leads to a reduction in the reactivity of the airways. The aim of this study was to evaluate the effect of outpatient treatment with CPAP and bilevel pressure combined with respiratory physical therapy for children and adolescents with asthma following bronchial hyperresponsiveness caused by an exercise bronchoprovocation test. METHODS: A randomized, controlled, blind, clinical trial was conducted involving 68 asthmatic children and adolescents aged 4 to 16 years divided into three groups: G1, treated with bilevel pressure (inspiratory positive airway pressure: 12 cm H2O; expiratory positive airway pressure: 8 cm H2O), G2, treated with CPAP (8 cm H2O) and G3, treated with respiratory muscle training (RMT), considered as the control group. All groups were treated at an outpatient clinic and submitted to 10 1-hour sessions, each of which also included respiratory exercises. Evaluations were performed before and after treatment and involved spirometry, an exercise bronchoprovocation test, respiratory pressures, fraction of nitric oxide (FeNO), the Asthma Control Questionnaire (ACQ6) and anthropometric variables. This study received approval from the local ethics committee (certificate number: 1487225/2016) and is registered with ClinicalTrials [ ClinicalTrials.gov identifier: NCT02939625]. RESULTS: A total of 64 patients concluded the protocol; the mean age of the patients was 10 years. All were in the ideal weight range and had adequate height ( z score: -2 to +2). The three groups demonstrated improved asthma control after the treatments, going from partial to complete control. A significant increase in maximal inspiratory pressure occurred in the three groups, with the greatest increase in the RMT group. A reduction in FeNO in the order of 17.4 parts per billion (effect size: 2.43) and a reduction in bronchial responsiveness on the exercise bronchoprovocation test occurred in the bilevel group. An improvement in FeNO on the order of 15.7 parts per billion (effect size: 2.46) and a reduction in bronchial responsiveness occurred in the CPAP group. No changes in lung function or responsiveness occurred in the RMT group. CONCLUSION: Positive pressure and respiratory exercises were effective in reducing pulmonary inflammation, exercise-innduced bronchoespasm (EIB), and increased the clinical control of asthma, as well as RMT, which also resulted in improved clinical control.

Is servoventilation in central sleep apnea syndrom still working?.

Last black box on adaptive servoventilation in central apnoea syndrome generate many connective problems concerning the alternative therapies. The authors are starting from two recent french articles on this same subject and are trying to see what is missing and what we have to do.

The role of behavioral sleep medicine in the assessment and treatment of sleep disordered breathing.

With the dramatic rise in obesity in the United States, comorbid medical issues, such as sleep apnea and other forms of sleep disordered breathing (SDB), are becoming increasingly prevalent. Individuals with SDB have impairments in social, cognitive, and emotional functioning and an overall reduction in quality of life. Continuous positive airway pressure (CPAP) is the first-line treatment for SDB. CPAP use is associated with improvements in psychosocial functioning when individuals use the machine regularly. Unfortunately, CPAP adherence rates are often low. Patients sometimes discontinue CPAP therapy due to undesirable side effects, such as anxiety, insomnia, and nasal discomfort, or inconvenience. The goal of this review is to highlight the growing role of behavioral sleep medicine in the assessment and treatment of SDB and psychosocial impairments comorbid with SDB. More than any other health specialty, psychologists with behavioral sleep medicine experience are in the best position to treat psychiatric symptoms exacerbated by SDB-related sleep disturbances. Behavioral sleep medicine specialists also possess the expertise to address psychological obstacles to CPAP use. The assimilation of behavioral sleep medicine specialists into sleep clinics is likely to improve the overall quality of care for patients with SDB.