Are we missing a simple treatment for most adult sleep apnea patients? The avoidance of the supine sleep position

Abstract

Summary Obstructive sleep apnea (OSA) is a sleep disorder which has been gradually accepted as an important cause of increased morbidity and mortality. The treatment of moderate–severe OSA has improved dramatically since the introduction of continuous positive airway pressure (CPAP) devices; however, the adherence of patients to CPAP treatment is relatively low. Adherence appears to be even worse in patients with mild or asymptomatic OSA. The failure to identify and treat mildly symptomatic or asymptomatic OSA patients may be costly, as such patients comprise about 20% of the general adult population. OSA patients could be divided into positional and non‐positional patients. Positional patients show most of their breathing abnormalities while sleeping in the supine position. Simply, by sleeping in the lateral postures, they eliminate or reduce significantly the number of apneas and hypopneas. On the contrary, non‐positional patients suffer from breathing abnormalities in the supine and lateral postures, and as a consequence those are the most severe OSA patients for whom CPAP is the treatment of choice. In this paper we intend to argue that positional therapy, i.e. avoidance of the supine posture during sleep, could represent a valuable therapy mainly for mild–moderate OSA. Considering the fact that the vast majority of mild–moderate OSA patients are positional patients (between 65 and 87%), positional therapy may be a simple, cheap and effective solution for them. High‐quality research regarding this issue is needed to evaluate the real effectiveness of this mode of therapy.

Usage of Positional Therapy in Adults with Obstructive Sleep Apnea

“…1,4 ; Johannes H. van der Hoeven, MD, PhD 5 ; Peter J. Wijkstra, MD, PhD an alarm system, 13 a backpack with ball, 14 behavioral therapy, 15 a pillow with straps, 16 the so-called tennis ball technique, 17,18 a recently developed neck-worn vibrating device, 19,20 and a chestworn vibrating device. 21,22 Oksenberg and Gadoth 23 argue that PT might be a simple solution for patients with mild to moderate positional OSA. While most devices appear effective in the beginning and compliance on a short-term (< 3 months) seems satisfactory, long-term (> 6 months) efficacy is unknown and compliance is poor.…”

Principles of practice parameters for the treatment of sleep disordered breathing in the elderly and frail elderly: the consensus of the International Geriatric Sleep Medicine Task Force

“…The severity of sleep-related breathing disorders may vary considerably from night to night depending on body position [112,113], although some data have suggested night-to-night variability in elderly persons occurs independently of position [114]. In particular, the supine body position is associated with a two-fold or greater increase in the number of respiratory events in those patients with position-dependent sleep apnoea.…”

“…Positional therapy includes a wide range of methods aimed at preventing the patient from sleeping in the supine position, including pillows, vests, tennis balls and positional alarms. Case reports have documented the potential utility of positional therapy [112].…”

Efficacy of the New Generation of Devices for Positional Therapy for Patients With Positional Obstructive Sleep Apnea: A Systematic Review of the Literature and Meta-Analysis

“…3,4,7 In PP, desaturations, cyclic variations in heart rate, loud snoring, and apneas and hypopneas appear almost exclusively in the supine position. 8 Cartwright first described the arbitrary cutoff point of a difference of 50% or more in apnea index between supine and nonsupine positions. In the medical literature many have applied modified versions of Cartwright's criteria.…”