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.

The effect of velar collapse patterns on unilateral upper airway stimulation therapy.

PURPOSE: Hypoglossal nerve stimulation is a promising alternative therapy for patients with obstructive sleep apnea with continuous positive airway pressure intolerance or failure. Previous studies concluded that a velar complete concentric collapse might prohibit a good therapeutic outcome. However, certain patients have an upper velar anteroposterior collapse and a lower velar complete concentric collapse. The effect of this velar collapse pattern is unknown, preventing evidence-based decision-making for these patients. This study aimed to compare the results of upper airway stimulation therapy in these patients to patients with a pure anteroposterior velar collapse. METHODS: A retrospective single-center cohort study was performed. Patients were included who were implanted with an upper airway stimulation device and had a 1-year follow-up. RESULTS: Of 66 patients, 10 had an upper velar anteroposterior collapse and lower velar complete concentric collapse. Fifty-six patients had a complete or partial velar anteroposterior collapse. At follow-up, all respiratory outcomes were similarly changed between the two groups. The mean apnea and hypopnea index reduced equally (26.9 events/hour vs. 23.9 events/hour, 95% CI (-5.0, 11.0), p = 0.46). A similar decrease in the oxygen desaturation index of ≥ 4% was observed (12.0/hour versus 11.5/hour, 95% CI (-8.7, 9.7) p = 0.92) CONCLUSION: Patients with an upper velar anteroposterior collapse and a lower velar complete concentric collapse are suitable candidates for upper airway stimulation therapy. In these patients, the lower velum may represent a transition zone between the anteroposterior collapse of the upper velum and the lateral collapse of the oropharynx, instead of being a real concentric collapse.

Drug-induced sleep endoscopy while administering CPAP therapy in patients with CPAP failure.

STUDY OBJECTIVES: To study the pattern of upper airway collapse in patients with CPAP failure by performing DISE while administering CPAP therapy and to determine the reason for CPAP failure accordingly. METHODS: This observational retrospective study comprised 30 patients diagnosed with OSA and CPAP failure, who underwent DISE while administering CPAP therapy. During DISE, the upper airway was assessed with and without CPAP therapy using the VOTE classification. Additionally, a jaw thrust maneuver was performed, in order to mimic the effect of an additional mandibular advancement device (MAD) in combination with CPAP therapy. Consequently, the outcome of DISE was translated into a clinically relevant categorization. RESULTS: Eleven patients (37%) had a persistent anteroposterior (AP) collapse, including a collapse at velum, tongue base, or epiglottis level and multilevel collapse. Eight patients (27%) had a floppy epiglottis. Five patients (17%) had a persistent complete concentric collapse (CCC) and three patients had a persistent laryngeal collapse (10%). In three patients (10%), no airway collapse was found after CPAP administration. CONCLUSIONS: Based on the results of the reported study, in most cases, the potential cause of CPAP failure can be determined by this new diagnostic method. Consequently, suggestions can be made for additional therapy.

Out of hospital treatment of acute pulmonary embolism in patients with a low NT-proBNP level.

BACKGROUND: Low NT-proBNP levels are associated with an uncomplicated course in patients with pulmonary embolism (PE). The aim of this multicenter management study was to investigate the safety of home treatment of patients with PE with low (< 500 pg mL(-1)) NT-proBNP. METHODS AND RESULTS: Hemodynamically stable outpatients with acute PE and NT-proBNP level < 500 pg mL(-1) were included. Patients were discharged immediately from the emergency room or within a maximum of 24 h after admission. The primary study objective was the absence of mortality during the first 10 days of treatment. Secondary objectives were the incidence of re-admission due to PE or its treatment and the patient's satisfaction during the first 10 days of treatment as well as the incidence of serious adverse events during the 3-month follow-up period. Of 351 patients, 152 (43%) fulfilled the inclusion criteria and were treated as outpatients. No deaths, major bleedings or recurrent venous thromboembolism occurred in the first 10 days of treatment or in the follow-up period of 3 months in these patients. Seven patients required readmission in the first 10 days: three because of complaints that could be related to PE and four due to an illness unrelated to PE. The HADS-A anxiety score did not change significantly between day 0 and day 10. The PSQ-18 showed a high score for satisfaction with home treatment. CONCLUSION: Out of hospital treatment is safe in hemodynamically stable patients with PE with low (< 500 pg mL(-1)) NT-proBNP levels. Approximately 45% of patients with PE can be treated in an outpatient setting. Patients do not consider out of hospital treatment as inconvenient and have no increase in anxiety scores. CLINICAL TRIAL REGISTRATION INFORMATION: http://clinicaltrials.gov/ct2/show/NCT00455819.