Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity

Abstract

Study Objectives Mandibular advancement splint (MAS) therapy is a well-tolerated alternative to continuous positive airway pressure for obstructive sleep apnea (OSA). Other therapies, including nasal expiratory positive airway pressure (EPAP) valves, can also reduce OSA severity. However, >50% of patients have an incomplete or no therapeutic response with either therapy alone and thus remain at risk of adverse health outcomes. Combining these therapies may yield greater efficacy to provide a therapeutic solution for many incomplete/nonresponders to MAS therapy. Thus, this study evaluated the efficacy of combination therapy with MAS plus EPAP in incomplete/nonresponders to MAS alone. Methods Twenty-two people with OSA (apnea–hypopnea index [AHI] = 22 [13, 42] events/hr), who were incomplete/nonresponders (residual AHI > 5 events/hr) on an initial split-night polysomnography with a novel MAS device containing an oral airway, completed an additional split-night polysomnography with MAS + oral EPAP valve and MAS + oral and nasal EPAP valves (order randomized). Results Compared with MAS alone, MAS + oral EPAP significantly reduced the median total AHI, with further reductions with the MAS + oral/nasal EPAP combination (15 [10, 34] vs. 10 [7, 21] vs. 7 [3, 13] events/hr, p < 0.01). Larger reductions occurred in supine nonrapid eye movement AHI with MAS + oral/nasal EPAP combination therapy (ΔAHI = 23 events/hr, p < 0.01). OSA resolved (AHI < 5 events/hr) with MAS + oral/nasal EPAP in nine individuals and 13 had ≥50% reduction in AHI from no MAS. However, sleep efficiency was lower with MAS + oral/nasal EPAP versus MAS alone or MAS + oral EPAP (78 ± 19 vs. 87 ± 10 and 88 ± 10% respectively, p < 0.05). Conclusions Combination therapy with a novel MAS device and simple oral or oro-nasal EPAP valves reduces OSA severity to therapeutic levels for a substantial proportion of incomplete/nonresponders to MAS therapy alone. Clinical Trials Name: Targeted combination therapy: Physiological mechanistic studies to inform treatment for obstructive sleep apnea (OSA) URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372279 Registration: ACTRN12617000492358 (Part C)

Development and the Effectiveness of a Nasal Breathing Stimulator Combined with an Oral Appliance for Treating Obstructive Sleep Apnea

“…This study is considered a pilot study, as the number of subjects was small; therefore, in future research, a higher number of subjects should be included. The fact that wearing a combination of OA and NBS improved RDI, lowest SpO 2 , and ESS scores compared to wearing an OA alone, suggests that the NBS may be effective as a treatment for improving respiration during sleep in patients with OSA and clinical application is possible.Our findings are consistent with those of a previous study, which reported that a novel OA (O2Vent T, Oventus Medical Limited, Indooroopilly, Australia) could be combined with oral expiratory positive airway pressure (oral EPAP) and nasal EPAP ventilation during sleep to decrease apneahypopnea index scores and improve OSA severity(21) .…”

Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review

“…A positive airway pressure device combined with OA provided higher treatment efficiency in reducing the severity of OSA compared with OA alone. Among 22 individuals with OSA, nine patients resolved the symptom in the AHI index (AHI <5) with a positive airway pressure device combined with OA management [75]. A oneyear follow-up showed that mandibular advancement therapy was less cost-effective and clinically effective in terms of AHI than CPAP in moderate patients [76].…”

Indications for Dental Specialists for Treating Obstructive Sleep Apnea with Mandibular Advancement Devices: A Narrative Review

“…Since different treatments exhibit different mechanisms of action and the collapse of the upper airway occurs at multiple levels in most subjects with OSA [70,71], combined treatments could improve the overall therapeutic effectiveness. In this regard, MAD may be successfully combined with CPAP and nasal expiratory positive airway pressure (EPAP) with a further reduction of the AHI compared to the single therapy [72][73][74][75].…”