Assessment and rehabilitation of tongue motor skills with myofunctional therapy in obstructive sleep apnea: a systematic review and meta-analysis.

STUDY OBJECTIVES: The first objective of this study was to compare tongue motor skills between patients with obstructive sleep apnea (OSA) and healthy participants. Second, the effect of oropharyngeal myofunctional therapy (MFT) on the tongue muscular qualities of patients with OSA was evaluated. METHODS: Searches were conducted in 5 electronic databases up to July 2023. Risk of bias was assessed via the Joanna Briggs Institute appraisal checklist for cross-sectional studies (aim number 1) and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials (aim number 2). Pooled standardized mean differences and 95% confidence intervals were calculated using a random-effects model. RESULTS: Thirteen studies including 520 adults and one study including 92 children addressed aim number 1. Compared to healthy adults, individuals with OSA had no significant difference in tongue protrusion strength (9 studies, n = 366; standardized mean difference [95% confidence interval], -0.00 [-0.45, 0.44]) or endurance (5 studies, n = 125; 0.31 [-0.26, 0.88]) but presented a lower tongue elevation strength (6 studies, n = 243; 1.00 [0.47, 1.53]) and elevation endurance (3 studies, n = 98; 0.52 [0.11, 0.94]). In children, tongue elevation strength was lower but elevation endurance was higher in those with OSA than in healthy children. Two randomized controlled trials (28 adults, 54 children) addressed aim number 2 and were of poor methodological quality. In these studies, myofunctional therapy improved tongue motor skills in patients with OSA. CONCLUSIONS: Tongue elevation motor skills are decreased in adults with OSA, whereas tongue protrusion motor skills seem preserved. Very few data are available in children. There are also too few data about the impact of myofunctional therapy on tongue motor skills. CITATION: Poncin W, Willemsens A, Gely L, Contal O. Assessment and rehabilitation of tongue motor skills with myofunctional therapy in obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(9):1535-1549.

Impact of Unintentional Air Leaks on Automatic Positive Airway Pressure Device Performance in Simulated Sleep Apnea Events.

BACKGROUND: Positive airway pressure (PAP) is the accepted standard treatment for obstructive sleep apnea. In the last decades, automatic PAP (APAP) adjustment modes have been increasingly used. Pressure auto adjustment offers better comfort to the patient and represents a valuable help for the clinician to provide optimal treatment. However, device performance differs among manufacturers. Furthermore, the success of the therapy relies greatly on unintentional air leak level for many reasons, hence the importance to investigate the performance of the most common devices. The aim of this study was to compare the performance of 3 APAP devices from the most common manufacturers in specific conditions (ie, obstructive sleep apnea, central sleep apnea, hypopnea), with and without unintentional air leak. METHODS: This was a bench test study. Performance tests were conducted on a breathing simulator using a Starling resistor, representing the upper airways, and an adjustable unintentional air leak valve. Three APAP devices (AirSense 10, DreamStation, and Prisma 20A) were tested in different scenarios. RESULTS: Without unintentional air leak, performance of the 3 devices was similar to existing literature. However, performance was altered with the addition of unintentional air leak in some scenario. The AirSense 10 was not able to respond correctly to obstructive apnea (intraclass correlation coefficient [ICC] 0.021, P = .61) and hypopnea (ICC 0.059, P = .26). Prisma 20A lowest performance was seen during simulated obstructive apnea (ICC 0.708, P < .001). DreamStation lowest performance was seen during simulated hypopnea events (ICC 0.755, P < .001). CONCLUSIONS: All 3 APAP devices reacted differently to the added unintentional air leak. Performance was altered with some devices, which could affect the therapy success in patients with sleep apnea syndrome. The variability of performance of some APAP devices with unintentional air leak should make clinicians evaluate their use in a home setting.

Performance Evaluation of a Low-Cost Non-Invasive Ventilator during the COVID-19 Pandemic. A Bench Study.

BACKGROUND: During the COVID-19 breakout, a global call for low-cost portable ventilators was made following the strong demand for ventilatory support techniques. Among a few development projects, COVIDair non-invasive ventilator was developed and produced in a record time during the critical period of spring 2020. OBJECTIVES: To evaluate COVIDair performance (i.e., inspiratory trigger delay time, TDT, pressurization time and inspiratory to expiratory time ratio, I:E) on a test bench simulating physiological characteristics of breathing. METHOD: Performance tests were conducted on a breathing simulator (ASL 5000, IngMar Medical™) in two different lung mechanics (i.e., normal and severe restrictive). RESULTS: Under normal pulmonary mechanics, the inspiratory TDT is on average between 89.0 (±2.1) and 135.0 (±9.7) ms. In a situation of severe restrictive pulmonary mechanics, the inspiratory TDT is on average between 80 (±3.1) and 99.2 (±5.5) ms. Pressurization time to pre-set inspiratory pressure was on average from 234.6 (±5.5) to 318.6 (±1.9) ms. The absolute difference between the actual I:E cycling measure and the pre-set I:E cycling value ranged from 0.1 to 10.7% on average. CONCLUSION: In normal and severe restrictive pulmonary mechanics scenarios, the performance of COVIDair meets the expected standards for non-invasive ventilators.

The effect of tongue elevation muscle training in patients with obstructive sleep apnea: A randomised controlled trial.

BACKGROUND: Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy. OBJECTIVE: To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA. METHODS: We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use <4 h per night). The intervention group completed a 6 weeks tongue elevation training protocol that consisted in anterior tongue elevation strength and endurance tasks with the Iowa Oral Performance Instrument. The control group completed a 6 weeks sham training protocol that involved expiratory muscle training at very low intensity. Polygraphy data, tongue force and endurance, and OSA symptoms were evaluated pre- and post-intervention. The primary outcome was apneoa-hypopnea index (AHI). RESULTS: Twenty-seven patients (55 ± 11 years) were recruited. According to modified intention-to-treat analysis (n = 25), changes in AHI and c did not significantly differ between groups. Daytime sleepiness (Epworth Sleepiness Scale) and tongue endurance significantly improved in the intervention group compared to the control group (p = .015 and .022, respectively). In the intervention group, 75% of participants had a decrease in daytime sleepiness that exceeded the minimal clinically important difference. CONCLUSION: Six weeks of tongue elevation muscle training had no effect on OSA severity.

Impact of additional HEPA filter on APAP performance and CPAP pressure level in simulated sleep apnea events.

Background: CPAP is the first line treatment of obstructive sleep apnea. Recently, the use of added filters has been debated following the field safety notice of Philips Respironics™ on potential health risks due to foam degradation used in their ventilators. However, the added resistance of filters has never been analyzed. Objectives: The primary aim was to investigate the impact of four different filters on APAP mode performance with and without added unintentional air leaks (UIAL) with two simulated respiratory events. The secondary aim was to assess the pressure drop due to the increased filter resistance at different fixed CPAP pressure levels. Method: This is a bench study. Performance tests were performed on a breathing simulator (ASL 5000™) with a DreamStation™ device. To assess the combined effect of UIAL, a controlled valve was added to the setup. Results: Without UIAL, the algorithm was able to detect respiratory events and increase pressure level consequently. In the presence of UIAL, the device's response to simulated events was affected. In fixed CPAP mode, the median measured end-expiratory pressure was 6.2 to 10.0% (p < 0.001) below the set pressure with the additional filters. Additional UIAL severely impacted the delivered pressure with a median reduction up to 28.3% (p < 0.001) to the set pressure. Conclusion: Despite a slight pressure drop, the APAP algorithm still performed with additional filters when UIAL were avoided. However, the combined effect of added filter resistance and UIAL severely impacted APAP performance and effectively delivered set pressure.

Role of Non-Invasive Respiratory Supports in COVID-19 Acute Respiratory Failure Patients with Do Not Intubate Orders.

The current gold-standard treatment for COVID-19-related hypoxemic respiratory failure is invasive mechanical ventilation. However, do not intubate orders (DNI), prevent the use of this treatment in some cases. The aim of this study was to evaluate if non-invasive ventilatory supports can provide a good therapeutic alternative to invasive ventilation in patients with severe COVID-19 infection and a DNI. Data were collected from four centres in three European countries. Patients with severe COVID-19 infection were included. We emulated a hypothetical target trial in which outcomes were compared in patients with a DNI order treated exclusively by non-invasive respiratory support with patients who could be intubated if necessary. We set up a propensity score and an inverse probability of treatment weighting to remove confounding by indication. Four-hundred patients were included: 270 were eligible for intubation and 130 had a DNI order. The adjusted risk ratio for death among patients eligible for intubation was 0.81 (95% CI 0.46 to 1.42). The median length of stay in acute care for survivors was similar between groups (18 (10-31) vs. (19 (13-23.5); p = 0.76). The use of non-invasive respiratory support is a good compromise for patients with severe COVID-19 and a do not intubate order.

One-Year Adherence to Continuous Positive Airway Pressure With Telemonitoring in Sleep Apnea Hypopnea Syndrome: A Randomized Controlled Trial.

Study Objective: Telemedicine (TM) for continuous positive airway pressure (CPAP) treated patients may save health-care resources without compromising treatment effectiveness. We assessed the effect of TM (AirView Online System, ResMed) during the CPAP habituation phase on 3-month and 1-year treatment adherence and efficacy in patients with moderate-to-severe obstructive sleep apnea (OSA). Methods: At CPAP initiation, 120 patients diagnosed with OSA were randomized to either usual care (UC) or TM during the habituation phase (clinical registration: ISRCTN12865936). Both groups received a first face-to-face appointment with a sleep care giver at CPAP initiation. Within the following month, 2 other physical visits were scheduled in the UC group whereas two phone consultations were planned in the TM group, in which CPAP parameters were remotely adapted. Additional physical visits were programmed at the patient's request. Face-to-face consultations were scheduled at 3 and 12 months after CPAP initiation. The primary outcome was the mean CPAP daily use over the course of 12 months. Results: Twenty of 60 patients stopped CPAP therapy in the UC group vs. 14 of 60 in the TM group (p = 0.24). In per protocol analysis, mean [95% CI] daily CPAP use among 86 patients still using CPAP at 12 months was 279 [237; 321] min in the 38 patients on UC and 279 [247; 311] min in the 43 patients on TM, mean difference [95% CI]: 0 [-52; 52] min, P = 0.99. Total consultation time per patient was not different between groups, TM: 163 [147; 178] min, UC: 178 [159; 197] min, difference: -15 [-39; 9] min, p = 0.22. Conclusions: Telemedicine during the CPAP habituation phase did not alter daily CPAP use or treatment adherence and did not require more healthcare time. Telemedicine may support clinic attendance for CPAP titration. Clinical Trial Registration: [ISRCTN], identifier [ISRCTN12865936].

The relationship between maximal expiratory pressure values and critical outcomes in mechanically ventilated patients: a post hoc analysis of an observational study.

BACKGROUND: Little interest has been paid to expiratory muscle strength, and the impact of expiratory muscle weakness on critical outcomes is not known. Very few studies assessed the relationship between maximal expiratory pressure (MEP) and critical outcomes. The aim of this study was to investigate the relationship between MEP and critical outcomes. METHODS: This work was a secondary analysis of a prospective, observational study of adult patients who required mechanical ventilation for ≥ 24 h in an 18-bed ICU. MEP was assessed before extubation after a successful, spontaneous breathing trial. The relationships between MEP and extubation failure, and short-term (30 days) mortality, were investigated. Univariate logistic regressions were computed to investigate the relationship between MEP values and critical outcomes. Two multivariate analyses, with and without maximal inspiratory pressure (MIP), both adjusted using principal component analysis, were undertaken. Unadjusted and adjusted ROC curves were computed to compare the respective ability of MEP, MIP and the combination of both measures to discriminate patients with and without extubation failure or premature death. RESULTS: One hundred and twenty-four patients were included. Median age was 66 years (IQR 18) and median mechanical ventilation duration was 7 days (IQR 6). Extubation failure rate was 15% (18/124 patients) and the rate for 30-day mortality was 11% (14/124 patient). Higher MEP values were significantly associated with a lower risk of extubation failure in the univariate analysis [OR 0.96 95% CI (0.93-0.98)], but not with short-term mortality. MEP was independently linked with extubation failure when MIP was not included in the multivariate model, but not when it was included, despite limited collinearity between these variables. This study was not able to differentiate the respective abilities of MEP, MIP, and their combination to discriminate patients with extubation failure or premature death (adjusted AUC for the combination of MEP and MIP: 0.825 and 0.650 for extubation failure and premature death, respectively). CONCLUSIONS: MEP is related to extubation failure. But, the results did not support its use as a substitute for MIP, since the relationship between MEP and critical outcomes was no longer significant when MIP was included. The use of MIP and MEP measurements combined did not reach higher discriminative capacities for critical outcomes that MEP or MIP alone. Trial Registration This study was retrospectively registered at https://clinicaltrials.gov/ct2/show/NCT02363231?cond=NCT02363231&draw=2&rank=1 (NCT02363231) in 13 February 2015.

ICU outcomes can be predicted by noninvasive muscle evaluation: a meta-analysis.

BACKGROUND: The relationship between muscle function in critically ill patients assessed using bedside techniques and clinical outcomes has not been systematically described. We aimed to evaluate the association between muscle weakness assessed by bedside evaluation and mortality or weaning from mechanical ventilation, and the capacity of each evaluation tool to predict outcomes. METHODS: Five databases (PubMed, Embase, CINAHL, Cochrane Library, Science Direct) were searched from January 2000 to December 2018. Data were extracted and random effects meta-analyses were performed. RESULTS: 60 studies were analysed, including 4382 patients. Intensive care unit (ICU)-related muscle weakness was associated with an increase in overall mortality with odds ratios ranging from 1.2 (95% CI 0.60-2.40) to 4.48 (95% CI 1.49-13.42). Transdiaphragmatic twitch pressure had the highest predictive capacity for overall mortality, with a sensitivity of 0.87 (95% CI 0.76-0.93) and a specificity of 0.36 (95% CI 0.27-0.43). The area under the curve (AUC) was 0.74 (95% CI 0.70-0.78). Muscle weakness was associated with an increase in mechanical ventilation weaning failure rate with an odds ratio ranging from 2.64 (95% CI 0.72-9.64) to 19.07 (95% CI 9.35-38.9). Diaphragm thickening fraction had the highest predictive capacity for weaning failure with a sensitivity of 0.76 (95% CI 0.67-0.83) and a specificity of 0.86 (95% CI 0.78-0.92). The AUC was 0.86 (95% CI 0.83-0.89). CONCLUSION: ICU-related muscle weakness detected by bedside techniques is a serious issue associated with a high risk of death or prolonged mechanical ventilation. Evaluating diaphragm function should be a clinical priority in the ICU.

Intrapulmonary Percussive Ventilation as an Airway Clearance Technique in Subjects With Chronic Obstructive Airway Diseases.

BACKGROUND: Airway clearance techniques are regularly proposed as a part of the treatment in chronic obstructive airway diseases. Intrapulmonary percussive ventilation (IPV) is used as an airway clearance technique in patients affected by excessive lung secretions. The aim of this systematic review is to summarize the physiological and clinical effects related to the use of IPV as an airway clearance technique in chronic obstructive airway diseases. METHODS: This systematic review followed the PRISMA guidelines. Randomized, controlled, comparative, and cohort studies investigating IPV as an airway clearance technique were identified and reviewed from 3 databases. Two reviewers independently assessed study quality and reviewed the selected studies. RESULTS: 278 subjects from 12 studies were included in the final analysis, with 3 diseases studied. Only one of the included studies had a sample size > 50 subjects. The main findings showed that IPV improves gas exchange during exacerbation and could reduce the hospital length of stay for patients with COPD. In subjects with cystic fibrosis, neither lung function nor other parameters were improved. CONCLUSIONS: The systematic use of IPV as an airway clearance technique in chronic obstructive airway diseases is not supported by sufficiently strong evidence to recommend routine use in this patient population.