Sleep Apnea and MRD Treatment
Sleep apnea is recognized as a serious health problem
that impacts about 20% of adults; however, more
than 80% remain undiagnosed and untreated.1-2
Treatments for sleep apnea include continuous positive airway pressure (CPAP), mandibular repositioning devices (MRD) and uvulopalatopharyngoplasty
(UPPP). Clinical evidence has shown that MRDs
have proven to be equally efficacious with greater
patient adherence than the alternatives.3 Additionally,
no differences have been established between CPAP
and MRDs
on sleepiness, quality of life, systolic or diastolic
blood pressure and cognitive performance.
MRDs get superior results on AHI compared
to upper airway surgery.4
Due to the profound impact sleep apnea therapy can
have on patients , ResMed is working with primary
care physicians, dental clinicians and the sleep community to increase awareness of the need to screen
for sleep apnea and to provide simple and effective
treatment options.
Untreated
OSA patient
Patient treated
with Narval™CC
AASM Practice Parameters
Oral appliances (OA) are indicated for use in patients with mild to moderate OSA
who prefer them to CPAP therapy, patients who do not respond to CPAP and patients
who are not appropriate candidates for CPAP or fail CPAP treatment attempts.5
1st Line Treatment
•Mild to moderate OSAS (AHI 5-30) for patients who:
- Prefer MRDs over CPAP
- Do not respond to CPAP
- Are inappropriate candidates for or fail CPAP
- Fail behavioral measures treatment
•Primary snoring for patients who do not respond or are not
appropriate candidates for behavioral measures treatment
2nd Line Treatment
•Severe OSAS (AHI>30) in case of lack of compliance with CPAP
1 Young et al. Epidemiology of obstructive sleep apnea. Am J Respir Crit Care Med 2002;165:1217-1239
2 Young et al. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20(9):705-706
3 Aarab et al. Oral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial. Respiration 2011 81:411-419
4 Li et al. Oral appliances for OSA. Cochrane Database of Systematic Reviews 2009, Issue 3 Meta-analysis
5 American Academy of Sleep Medicine Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005
Sleep 2006;29(2):244-262
Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review
Kathleen A. Ferguson, MD1
Rosalind Cartwright, PhD2
Robert Rogers, DMD3
Wolfgang Schmidt-Nowara, MD4
1Division of Respirology, University of Western Ontario,
London, Ontario, Canada,
2Department of Behavioral Sciences, Rush University
Medical Center,Chicago, IL,
3Department of Dental Medicine, St. Barnabas Medical
Center, Gibsonia, PA,
4University of Texas Southwestern, Sleep
Medicine Associates of Texas, Dallas, TX
We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome
(OSA) from 1995 until the present. Our structured search revealed 141 articles
for systematic scrutiny, of which 87 were suitable for inclusion in the evidence
base; including 15 Level I to II randomized controlled trials and 5 of these trials
with placebo-controlled treatment.
The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour
of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other
neurocognitive outcomes were not consistent.
The mechanism of OA therapy is related to opening of the upper airway as
demonstrated by imaging and physiologic monitoring. Treatment adherence is
variable with patients reporting using the appliance a median of 77% of nights
at 1 year.
Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed
in some patients after prolonged use, but the long-term dental significance of
this is uncertain.
In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used
more (at least by self-report), and in many studies were preferred over CPAP
when the treatments were compared. OAs have also been compared favorably
to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP).
Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the
efficacy of this treatment modality and considerable guidance regarding the
frequency of adverse effects and the indications for use in comparison to
CPAP and UPPP.
766
M.F. Vecchierini et al. / Sleep Medicine 9 (2008) 762–769
SleepAMed
2008;9(7):762-9
signiﬁcant
reduction in patients’ snoring was
2
recorded, with the average number of snoring episodes
per hour falling from 24 ± 31 to 6 ± 11 (p < 0.01).
***
There was a signiﬁcant reduction in subjective day*
***
time sleepiness; the average patient ESS fell from
11.1 ± 3.9 at baseline to 7.7 ± 4.6 (p < 0.001). There
was a signiﬁcant reduction of the number of patients
1
with an ESS score P10 from baseline condition (65%)
to treated condition (35%) (p < 0.05).
Objective:
To assess
the efficacy and compliance of a traction-based mandibuVecchierini
MF, arterial
Léger D,blood
Laaban
JP,
Weight,
pressure
and
percentage
of
Putterman
G,
Figueredo
M,
Levy
J,
repositioning
obstructive versus central apneas werelarnot
aﬀected bydevice (MRD) for treatment of moderate to severe obstructive
Vacher
Monteyrol
PJ, Philip P.
sleep apnea syndrome (OSAS) under a patient-driven protocol in a routine outpathe C,
MRD
treatment.
tient care setting.
Source: C HU Bichat-Claude Bernard,
0
3.5. Quality of life and sleep assessment
APHP, Paris, France.
Methods: Forty patients, 10 severe and 30 moderate OSAS sufferers (apneaThe mental component score of the hypopnea
SF-36 was index
signif-[AHI] >30 and between 15 and 30, respectively), were enrolled
by
four
sleep
Nocturnal polygraphy, quality of life, and quality of sleep
icantly improved from a score of 39 ± 12 at baselinecenters.
to
questionnaires
were
used
to measure the effect of treatment after 45 days.
46 ± 10 at study end (p < 0.01). Improvement relied on
three speciﬁc individual items: mental health, role emoBaseline
With Device
*** p < 0.001; * p < 0.05
Results:
tionals and social functioning (Fig. 3).
There Thirty-five
was no patients completed the study. Frequency of respiratory
events,
daytime sleepiness, snoring, patient
improvement in the standardized physical
component
Fig.assessment
4. PSQI scores.of sleep quality,
rini et al. / Sleep Medicine 9 (2008) 762–769
765
specific
short-form
multipurpose
health
survey
(SF-36) and the Pittsburgh Sleep
score of SF-36 in the overall population.
Index
(PSQI) improved significantly with the MRD. Sixty percent of paPatients reported improvement onQuality
VAS for
items
ing wakefulness,’’ ‘‘Quality of sleep’’ and ‘‘Awakening
tients
were
(>50% decrease in AHI); 46% of patients were “full
‘‘Sleep quality’’ (slept poorly/slept well)
from
44 “responders”
± 27
from sleep’’ showed respective improvements of
toResponders
66 ± 24 (p < 0.001) and
‘‘Vitality atresponders”
wake up time’’
Non-responders
(>50% decrease and AHI <10). Observance of treatment was high;
17 ± 14, 12 ± 16 and 9 ± 14.
(felt
at patients
wake upwore the MRD every night. Side effects and patient complaints
21 sleepy at wake up 14time/felt refreshed
80% of
19(M)/2(F)
11(M)/3(F)
time) from 39 ± 26 to 57 ± 29 (p < 0.001).
However,
were minor
and transitory.
No serious side
effects or cases of pathology aggra3.6. Observance
and tolerance
54 ± 9
58 ± 7
NS
no
change
was
reported
on
the
items
‘‘Time
toNS
go
to
vation were
reported.
83 ± 11
85 ± 13
sleep’’
27 ± 3 and ‘‘Perceived sleep
29 ± 5 duration’’.
NS
Observance of treatment was high (Fig. 5) with 80%
40PSQI
±2
±4
NS Efficacy
results (Fig. 4) 42
showed
a signiﬁcant
decrease
in
Conclusion:
on respiratory and somnolence parameters of this innoof patients wearing their MRD every night and 63% of
96 ± 7
101 ± 11
NS
the
speciﬁc items:
daytime dysfunction,
vative traction-based
MRD was validated under a simple protocol of care with
25.3following
± 11.9
39.6 ± 25.9
NS subpatients wearing it all night. Only two patients had an
jective
sleep quality impairment
disturbances
11.4 ± 11.4
24.9 ± 26.7 and sleep
NS
response rates
similar observance
to those published
in unsatisfactory
the literature. This
that was
(lessstudy
thanshows
4 h per
± 18 as in the overall
33 PSQI
± 25
as21well
score from
7.1 ±NS
3.8
to
consistent
significant
improvement
by
the
MRD
in
quality
of
life
and
quality of
26 ± 37
18 ± 17
NS
night and less than 4 days per week).
5.1
in subjec10.9±±2.7
3.5 (p < 0.001). Overall
11.3 ± 4.6improvements
NS
sleep parameters
across Patient
several complaints
tests. Treatment
with the
MRDand
under
a simple,
were mostly
minor
transitory,
tive
by
the
Leeds
93.9 sleep
± 2.1 parameters were
92.7 ±corroborated
3.4
NS
patient-driven
protocolwith
of care
control
of efficacy
by nocturnal
polygraphy
thewith
most
common
morning
complaints
being is
78.1 ±Questionnaire
8.3
78.4 the
± 7.2items ‘‘Behaviour followNS
Sleep
where
appropriate
in
routine
outpatient
practice
for
moderate
OSAS
patients.
mouth
pain
in
43%
of
patients
and
TMJ
pain
(14%).
ation; BMI, body mass index.
After removal of the MRD in the morning, mouth
100
pain ceased within 30 min in 75% of cases and TMJ pain
r customceased within 30 min in 100% of recorded cases. Other
40
**
**
*
sted mod80
70
Pain
Vitality
Social
%
%
***
8.3
0
Role Physical
0
14.3
9.6***
functioning
5
Sleep
Medication
Sleep latency
Sleep
Efficiency
Sleep
duration
Sleep
disturbances
Excellent:
Patient wore MRD every
night of the week, all night
50
16.8
20
Role
10
***
Health
17.7
General
40
20
15
63
60
Emotional
25
Subj Sleep
Quality
Daytime
Dysfunction
31.1
30 60
Mental Health
adjust the
ceived an
reduction
ustments,
presented
ients were
graphy on
35
Average Score
ment but it
ments for
Average Score
Efficacy and compliance of mandibular repositioning device in obstructive sleep apnea
syndrome under a patient-driven protocol of care
AHI
AI
HI
ere classi** p < 0.01; * p < 0.05
Baseline
With Device
moderate),
Baseline
With Device
*** p < 0.001
ers. When
Fig.
3. Apnea
SF-36Hypopnea
scores on
individual
items.
AI: Apnea
Index
AHI:
Index
atient was
HI: Hypopnea Index
d a signifFig. 2. Respiratory events.
est).
d as nonmoderate.
with permission from Elsevier: 82603
signiﬁcantReprintedIn
the overall population, the average duration of
as no case
apnea and hypopnea events was reduced signiﬁcantly
Good:
Patient wore MRD for at
least 4 nights per week and
for at least 4 hrs per night
40
31
30
20
10
0
6
Excellent
Good
Unsatisfactory:
Patient wore the MRD for
less than 4 nights per week
for at least 4 hrs per night
Unsatisfactory
Fig. 5. Treatment observance.
Respiration 2011;81:411–419
Oral Appliance Therapy versus Nasal Continuous Positive Airway Pressure in
Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial
Ghizlane Aarab1
Frank Lobbezoo1
Hans L. Hamburger2
Machiel Naeije1
1Department of Oral Kinesiology, Academic Center for
Dentistry Amsterdam, Research Institute MOVE, University of Amsterdam and VU University Amsterdam
2Department of Clinical Neurophysiology and Center
for Sleep-Wake Disorders, Slotervaart Medical Center,
Amsterdam, The Netherlands
Background: Previous randomized controlled trials have addressed the efficacy
of mandibular advancement devices (MADs) in the treatment of obstructive
sleep apnea (OSA). Their common control condition, nasal continuous positive
airway pressure (nCPAP), was frequently found to be superior to MAD therapy.
However, in most of these studies, only nCPAP was titrated objectively but not
MAD. To enable an unbiased comparison between both treatment modalities,
the MAD should be titrated objectively as well.
Objective: The aim of the present study was to compare the treatment effects
of a titrated MAD with those of nCPAP and an intraoral placebo device.
40
AHI
AHI
30
20
10
0
Baseline
MAD in situ
AHI
50
50
Methods:
Sixty-four mild/moderate patients
with obstructive sleep apnea (OSA;
52.0 8 9.6 years) were randomly assigned to three parallel groups: MAD, nCPAP
40
and
placebo device. From all patients,40two polysomnographic recordings were
obtained at the hospital: one before treatment and one after approximately
30
630months of treatment.
50
Results:
The change in the apnea-hypopnea
index (AHI) between baseline
20
20
and therapy evaluation differed significantly between the three therapy groups
(ANCOVA;
p = 0.000). No differences10in the change AHI were found between
10
the MAD and nCPAP therapy (p = 0.092), whereas the changes in AHI in
these
groups were significantly larger 0than those in the placebo group
0
Baseline
nCPAP
Baseline
Placebo in situ
(p = 0.000
and 0.002, respectively).
Conclusion: There is no clinically relevant difference between MAD and
nCPAP
in (n
the
treatment
of mild/moderate
ings with the MAD (n = 20),
nCPAP
= 18)
and placebo
appliance (n = 19) OSA
in situ.when both treatment
modalities are titrated objectively.
Fig. 2. Individual AHI values of 57 patients completing the trial: baseline and therapy evaluation PSG record-
Table 3. The mean (8SD) baseline and delta (i.e. difference between baseline and therapy evaluation) values of the respiratory and
sleep outcome variables of the three groups (MAD, nCPAP and placebo)
MAD (n = 20)
Respiration, events/h
AHI
AHI_REM_supine
AHI_NREM_supine
AHI_REM_non-supine
AHI_NREM_non-supine
Sleep
Total sleep time, min
Stage 1 and 2, %
Stage 3 and 4, %
Stage REM, %
Sleep in supine position, %
Respiratory arousal index,
events/h
nCPAP (n = 18)
Placebo (n =19)
p
baseline
value
baseline
value
baseline
22.1810.8
24.6831.5
33.0823.9
15.1814.9
11.3811.9
16.3810.3
12.5834.8
25.1821.4
7.5813.0
8.6810.8
20.989.8
31.2830.5
39.2825.9
16.4816.5
10.289.8
19.588.7
26.7830.4
34.0824.4
14.1821.3
8.989.4
20.188.7
32.2828.1
22.1816.4
15.1815.7
12.6812.1
5.2810.5
5.6831.1
–2.6823.1
4.4821.5
5.989.0
0.000a
0.002b
0.000b
0.064
0.081
425.08128.6
68.8810.8
14.5810.9
18.386.4
47.4826.3
–11.88143.2
8.2814.7
–3.189.6
–1.986.4
7.7832.9
444.2882.9
66.2811.9
14.187.9
19.786.7
39.5825.3
–7.88113.4
0.8811.8
–0.189.4
–0.786.1
5.8838.7
0.229
0.293
0.788
0.752
0.161
17.089.6
13.089.0
13.886.6
3.588.2
0.008b
473.8883.2 58.88101.2
67.088.5
0.889.1
12.988.4
–1.488.7
20.086.4
0.688.2
38.5822.2 –10.1830.3
16.488.9
13.9811.8
value
ANCOVA was applied to compare differences among the three groups, controlled for the effect of the baseline value and BMI.
Statistically significant at the 0.05 probability level.
b
Statistically significant after Bonferroni-Holm correction.
a
© S. Karger AG
e maximum
studies, the
ded.
Table 3—Improvements With aOA
Chest 2011;140;1511-1516
Improvement
Mean AHI reduction
at final turn
Overall
Mild
Moderate
Severe
Change in O2 saturation nadir
Overall
% Time Spo2 , 90%
to establish
the efficacy of
Overall
95% CI
P Value
19.4-23.8 , .001
221.6
Efficacy of an Adjustable Oral Appliance and Comparison to Continuous
3.3-5.6 Airway
24.46 Positive
, .001
12.0-15.0 , .001
213.5
Pressure for the Treatment of Obstructive Sleep Apnea Syndrome 244.5 40.7-48.4 , .001
Table 1—Baseline Characteristics
Age
AaronBMI
B. Holley,
Men
Christopher
J. Lettieri, MD
HTN
ul unless anand Anita
A.
Shah
ESS
riterion for
Mallampati
OA studies
1
Author Affiliations:
Pulmonary,
01,3,4,7,12-16 to
2
Critical
Care,
and
Sleep
Medicine,
ard are also
3
Walter Reed Army Medical Center
4
Corresponding
author: Aaron B. Holley, Pulmonary,
Retrognathia/micrognathia
Critical
Care, and PSG
Sleepresults
Medicine, Walter Reed Army
Diagnostic
MedicalAHI
Center, 6900 Georgia Ave NW, Washington, DC
en categor20307, Phone:
Supine202-782-5720,
x2 analyses.
E-mail: [email protected]
Side
the paired Fax: 202-782-9032,
Positional
fy baseline
Spo2 nadir
nation preSpo2% TST , 90%
ression was
Mild OSA
y reached a
Moderate OSA
as assumed
Severe OSA
; SPSS Inc;
ere given
996 and
ause they
adjusted.
djustable
and 497
r analysis.
ble appliOA titray; P 5 .03)
ng to the
hen comre was no
r percent
the initial
f patients
between
PSG data
ation are
diagnos7 days.
titration.
OA titrants. Presing their
en studies
days, and
stic PSG
on (22.7;
th CPAP
and titra-
Measure
11.27
0.5-2.1
.001
41.3 9.0
28.7 4.4We sought
Objective:
an2adjustable
oral
0.8-3.0
.001
1.88
86.4
appliance
patient
population
studied
to
date,
28.7 (aOA) in the largest
O2 5 oxygen. See Table 1 and 2 legends for expansion of other
12.9 5.1 a comparisonabbreviations.
and provide
to CPAP.
7.3 Retrospective analysis of patients prescribed an aOA. Results
Methods:
17.4
improved the AHI by 23.43 (95% CI, 1.88-4.99;
of overnight,
PSG with aOA titration were evaluated and compared to CPAP.
50.0
P , .001). When adjusted for severity of disease,
25.3 of a successful aOA titration were determined using a multivariate
Predictors
the difference in AHI improvement between CPAP
logistic63.5
regression model.and an aOA was 21.9 (95% CI, 23.8 to 0.02;
30.0 24.8
P 5 .053), 21.7 (95% CI, 24.0 to 0.7; P 5 .17),
Results:
total of 497 patients were prescribed an aOA during the specified
23.7 A
17.9
and 25.88 (95% CI, 28.95 to 22.82; P , .001) for mild,
17.5 The aOA reduced the mean AHI to 8.4±11.4, and 70.3%, 47.6%,
time13.6
period.
moderate, and severe disease, respectively. On CPAP
37.4a
and 41.4%
of patients with
mild, moderate,
andof
severe
achieved
an
titration,
70.1% (268
378) disease
of patients
achieved
83.8 7.5
AHI<5,
respectively.
Patients
using
an
aOA
decreased
their
mean
Epworth
5.1 10.0
an AHI , 5 at final pressure, compared with 51.6%
33.4 Score (ESS) by
Sleepiness
2.71of(95%
p<0.001)
at follow-up.
CPAP
(195
378)CI:
at 2.3-3.2;
final turn
on their
aOA titration
30.8
improved
the
AHI
by
3.43
(95%
CI:
1.88-4.99;
p<0.001)
when
compared
to an
(
P
,
.001
for
difference).
When
the
same
comparison
35.8
aOA, but when adjusted for
severity
of disease,
this
difference
only
reached
was
done,
adjusting
for
disease
severity,
success
rates
Data are presented as mean SD or %. AHI 5 apnea-hypopnea
(AHIsevere
, 5) for
CPAP(-5.88
vs aOA
were
62.3%
significance
disease
(95%
CI: 76.2%
-8.95 - vs
-2.82;
index; ESS 5 Epworth Sleepiness Score; HTN 5 physician
diagnosis; for patients with
5
oxygen
OSA 5 obstructive sleep apnea; PSG 5 polysomnogram;
Sp
o
(
P
5
.15),
71.0%
vs
50.8%
(
P
5
.001),
and
63.4%
2
p<0.001)).
However, 70.1% of all patients achieved an AHI < 5using CPAP,
saturation by pulse oximetry; TST 5 total sleep time (in min).
vs aOA
39.9%
(P , .001)
mild, moderate,
and
severe
to
51.6% for the
(p<0.001).
Onfor
multivariate
analysis,
baseline
aAHI 50% less on side when compared with supine,compared
and AHI , 5 on
disease,
respectively.
AHI was a significant predictor of achieving an AHI < 5 on aOA titration,
side.
Results
for the univariate analysis are shown in
and age showed a trend toward
significance.
Table 5, and multivariate modeling in Table 6. Patients
tions with the aOA were completed an average of
whoto
achieved
an AHImore
, 5 on
their aOA
titration
Conclusions: In comparison
past reports,
patients
in our
study were
232 355 days after those with CPAP. Most patients
younger,
had
a
lower
BMI,
and
had
less
severe
OSA
achievedfian
aOA. The aOA is comparable to CPAP for patients
(98.7%) had their CPAP titrations performed
rst. AHI < 5 usingasanmeasured
by
the
AHI
and
degree
of
nocturnal
with
disease, while CPAP is superior for patients with moderate to severe
Results for the CPAP titration studies
aremild
shown
hypoxia. They were also more likely to be women.
A lower AHI was the only predictor of a successful aOA titration.
in Table 4. When compared with thedisease.
aOA, CPAP
On multivariate analysis, only baseline AHI retained
Table 2—aOA Titration Results
AHIa
AHI supine
AHI side
Spo2 nadir
Spo2% TST , 90%
REM at final turns
Time at final turns, min
AHI , 5a
AHI , 10a
Mild OSA (n 5 186)
AHIa
AHI , 5a
AHI , 10a
Moderate OSA (n 5 144)
AHIa
AHI , 5a
AHI , 10a
Severe OSA (n 5 167)
AHIa
AHI , 5a
AHI , 10a
Table 4—CPAP Titration Results
8.3 11.4
12.4 13.5
6.7 13.3
85.1 7.3
3.3 8.8
84.4
221.4 124.1
53.8
73.9
5.2 7.3
69.9
86.0
7.4 8.1
47.9
75.0
12.3 15.4
41.9
60.5
Data are presented as mean SD or %. aOA 5 adjustable oral appliance;
REM 5 rapid eye movement sleep. See Table 1 legend for expansion
of other abbreviations.
aData reflect AHI at final turn.
1513Physicians
140American
/ 6 / DECEMBER,
2011
Reproduced with permissionCHEST
from /the
College
of Chest
l.chestpubs.org by Ann Tisthammer on March 20, 2012
AHI at final pressure
Final CPAP pressure
AHI , 5 at final pressure
AHI , 10 at final pressure
Mild OSA (n 5 113)
AHI at final pressure
AHI , 5 at final pressure
AHI , 10 at final pressure
Moderate OSA (n 5 114)
AHI at final pressure
AHI , 5 at final pressure
AHI , 10 at final pressure
Severe OSA (n 5 151)
AHI at final pressure
AHI , 5 at final pressure
AHI , 10 at final pressure
5.6 10.9
8.7 2.9
69.1
84.3
3.8 7.4
76.2
85.7
5.7 11.0
70.7
87.7
6.8 12.8
62.9
80.1
Data are presented as mean SD or %. CPAP 5 continuous positive
airway pressure. See Table 1 legend for expansion of abbreviations.
signific
nifican
able, A
predict
0.97-0.
We f
achieve
ESS de
scribed
a signi
CPAP
the dif
and CP
and mo
In co
cess ra
lines1,2
success
just ov
the sam
formed
and 49
an AH
ably low
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Downloaded from chestjournal.chestpubs.org by Ann
© 2011 American College of Ches
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:605-610
Patients with positional versus nonpositional obstructive sleep apnea: A retrospective
study of risk factors associated with apnea-hypopnea severity
Jin Woo Chung, DDS, PhD
Reyes Enciso, PhD
Daniel J. Levendowski, MBA
Objective: The aim of this study was to investigate the differences in and risk
factors for positional and nonpositional obstructive sleep apnea (OSA).
Method: One hundred twenty-three nonpositional (supine apnea-hypopnea
index [AHI] _ 2 times the lateral AHI), 218 positional (supine AHI _ 2 times the
lateral AHI), and 109 age-, gender-, and BMI-matched patients with positional
OSA performed 2 nights of sleep study. Gender, age, BMI, and percentage of
time in supine position, and percentage of time snoring louder than 40 dB were
evaluated as risk factors.
Philip R. Westbrook, MD and
Glenn T. Clark, DDS, MS
Seoul, Korea, and Los Angeles
and Carlsbad, CA
Seoul National University, University of Southern
California, and Advanced Brain Monitoring, Inc.
608
Results: Both unmatched positional and matched positional patients had less
severe overall AHI values, higher mean SpO2, lower percentage time SpO2 less
than 90%, and lower percentage of time snoring when compared with the
nonpositional group. Overall AHI scores were associated with increasing age and
percentage of time snoring for positional and nonpositional groups. However,
BMIs were associated with the overall AHI only in the nonpositional group.
Conclusion: The influence of position on OSA severity may contribute to the
choice and prognosis of treatment and may represent 2 distinct groups with
probable anatomic differences.
OOOOE
November 2010
Chung et al.
Table III. Comparison of sleep study data across groups
Variables
A
Nonpositional
OSA (n 123)
B
All positional
OSA (n 218)
C
Matched positional
OSA (n 109)
A vs B
A vs C
% time in supine
Mean SpO2, %
% time SpO2 below 90%
% time of snoring 40 dB
AI (events/h)
AHI (events/h)
Supine AI (events/h)
Supine AHI (events/h)
Nonsupine AI (events/h)
Nonsupine AHI (events/h)
36.7 27.5
93.7 3.2
13.1 18.5
35.1 16.8
21.3 22.8
35.3 26.0
26.4 27.1
37.4 29.5
18.2 21.3
33.7 25.3
40.1 25.6
95.7 1.4
2.8 5.7
24.0 17.0
10.9 10.6
18.9 12.8
26.4 36.1
38.6 35.8
3.3 5.0
8.8 8.5
38.2 25.0
95.5 1.4
3.5 6.7
26.5 17.3
10.8 10.2
20.3 13.6
28.7 46.3
42.2 46.0
3.3 4.6
10.1 9.6
.168†
.001†‡
.001†‡
.001*
.001†‡
.001†‡
.342†
.345†
.001†‡
.001†‡
.657*
.001†‡
.001†‡
.001†‡
.006†
.001†‡
.381†
.237†
.001†‡
.001†‡
P value
OSA, obstructive sleep apnea; AI, apnea index; AHI, apnea-hypopnea index.
*P values were obtained from independent t-test.
†P values were obtained from Mann-Whitney test.
‡Signiﬁcant differences after Bonferroni correction.
Table IV. Multiple linear regression analysis of the
risk factors on the log overall AHI of the nonpositional
OSA group
Reprinted with permission from Elsevier: 82536
Risk factors
Coefﬁcient
95% CI
P value
Table VI. Multiple linear regression analysis of the
risk factors on the log overall AHI of the matched
positional OSA group
Risk factors
Coefﬁcient
95% CI
P value
Gender (male)
0.290
0.582
0.260, 0.903 .000
Gender, male
0.089
0.150
0.148, 0.449
.320
Age
0.180
0.012
0.001, 0.023
.033
Age
0.351
0.020
0.010, 0.030 .001
BMI
0.207
0.026
0.005, 0.046
.016
BMI
0.038
0.006
0.033, 0.022
.678
in supine
0.130
0.009Ltd Bella .126
% time
supine
0.253
0.002,
0.011
.004worldwide.
ResMed%
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CA, USA +1 858
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Specifications may0.007,
change without
1015505/1 2012-04% time of snoring
time ofofsnoring
0.299ResMed.0.016
0.024notice..001
0.447
0.017
0.010, 0.024 .001
40 dB
40 dB
in sleep
and respiratory
medicine analysis
www.resmed.com
Multivariate analysis of varianceGlobal
F-test leaders
P .001,
adjusted
R
Multivariate
of variance F-test P .001, adjusted R