Clinical Review

Treatments for Obstructive Sleep Apnea

Journal of Clinical Outcomes Management. 2016 April;23(4)

 

References

Positional Therapy

It has been known for some time that sleeping in a supine position doubles a patient’s AHI compared to sleeping in the lateral position [39]. A more recent analysis showed that 60% of patients were “supine predominant OSA;” these patients had supine AHI that was twice that of non-supine AHI [40]. Moreover, a drug-induced sleep endoscopy study showed that the upper airway collapses at multiple levels sleeping in the supine position as opposed to at a single level sleeping in the lateral position [41]. Another study showed that lateral sleeping position improved passive airway anatomy and decreased collapsibility [42]. Many studies have shown that patients who wear a device that alerts the sleeper that he or she is in a supine position (referred to as positional therapy) significantly decreases AHI, but long-term compliance is still an issue, and new and improved devices are needed [43]. Three new studies bolster the effectiveness of positional therapy [44–46]. In all 3 studies, sleeping in the supine position went down to 0% (no change in sleep efficiency [the ratio of total time spent sleeping to the total time spent in bed]), AHI decreased to less than 6, and sleep quality and daytime sleepiness increased and decreased, respectively [44–46]. Compliance was as low as 76% [44] and as high as 93% [46]. For those who cannot tolerate CPAP, positional therapy could be a substitute for decreasing severity of OSA. However, “phenotyping” OSA patients as “supine predominant OSA” would need to be implemented to guarantee efficacy of positional therapy.

Nasal Expiratory Positive Airway Pressure

Nasal expiratory positive airway pressure (nEPAP), sold under the commercial name Provent (Provent Sleep Therapy, Manchester, NH), consists of a single-use device that attaches to the nostrils using an adhesive to create an airtight seal ( Figure 1 ). The device contains a mechanical valve that creates high resistance during expiration but not during inspiration [12]. The greatest risk of upper airway collapse occurs at the end of the expiratory phase of the respiratory cycle because of a lack of positive pressure or phasic activation of the upper airways [47]. nEPAP increases positive pressure at the expiratory phase, thus preventing upper airway collapse [12]. A recent review detailed the positive benefits (eg, decreased AHI, improved oxygen saturation, increased quality of life, decreased snoring) and very few negative effects (eg, dry mouth, nasal discomfort) of nEPAP; adherence was still a problem, but better compared to CPAP [12]. A recent meta-analysis of 18 studies was published about nEPAP [48]. The authors concluded that there was a 53.2% decrease in AHI and an improvement in the quality of life; however, nEPAP did not entirely eliminate OSA (residual AHI was still elevated), and similar to CPAP, adherence was still an issue. But for those patients who are intolerant of CPAP or are traveling, as well as the ease of application and low cost, makes nEPAP a decent alternative [48].

Oral Pressure Therapy

Retro-palatal collapse occurs in OSA and can be prevented by applying negative pressure to the upper airway [49]. The oral pressure therapy (OPT) device applies gentle suction anteriorly and superiorly to displace the tongue and soft palate and breathing occurs via nasopharyngeal airway [12]. A recent systematic review [49] of OPT revealed that successful OPT treatment rate was 25% to 37% if using standard and stringent definitions of treatment success. Although OPT decreased AHI, residual AHI still remained high due to positional apneas and collapse of upper airway at other levels besides retro-palatal. The authors of this systematic review recommend more rigorous and controlled studies with defined “treatment success” [49]. The advantage of OPT is that adherence was good; patients used the device on average 6 hours a night. There were no severe or serious adverse events with OPT, however oral tissue discomfort or irritation, dental discomfort, and dry mouth were reported [50].

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