CPAP combined with oral appliance therapy reduces CPAP requirements and pharyngeal pressure swings in obstructive sleep apnea

Abstract

Study objectives: Oral appliance (OA) therapy is the leading alternative to continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA). It is well tolerated compared to CPAP. However, ≥50% of patients using OA therapy have incomplete resolution of their OSA. Combination therapy with CPAP and oral appliance (CPAP+OA) is a potential alternative for incomplete responders to OA therapy. This study aimed to determine the extent to which combination therapy reduces therapeutic CPAP requirements using gold standard physiological methodology in those who have an incomplete response to OA therapy alone. Methods: 16 incomplete responders (residual AHI> 10events/h) to a novel OA with a built-in oral airway were recruited (3F:13M, aged 31-65 years, BMI: 22-38kg/m2, residual AHI range 13-63events/h). Participants were fitted with a nasal mask, pneumotachograph, epiglottic pressure catheter and standard polysomnography equipment. CPAP titrations were performed during NREM supine sleep in each participant during 3 conditions (order randomized): 1) CPAP only, 2) CPAP+OA(oral airway open), and 3) CPAP+OA(oral airway closed). Results: OSA was resolved at pressures of 4±2 and 5±2cmH2O during CPAP+OA (oral airway open) and CPAP+OA (oral airway closed) conditions versus 8±2cmH2O during CPAP only (P<0.01). Negative epiglottic pressure swings in oral airway open and closed conditions were normalized to CPAP only levels (-2.5[-3.7,-2.6] vs. -2.3[-3.2,-2.4]vs. -2.1[-2.7,-2.3]cmH2O). Conclusions: Combined CPAP and OA therapy reduces therapeutic CPAP requirements by 35-45% and minimizes epiglottic pressure swings. This combination may be a therapeutic alternative for patients with incomplete responses to OA therapy alone and those who cannot tolerate high CPAP levels.

European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea

“…Currently, the discussion on future options of alternative sleep apnoea treatment focuses on personalised selection or composition based on pathophysiological traits [95][96][97]. This may lead to multicomponent therapies, including various combinations of positive airway pressure, MADs or positional therapies [98][99][100] and may allow most effective and acceptable treatment for an individual patient to be found. New pharmaceutical agents may influence upper airway muscles [101], respiratory drive [102] or arousability.…”

Terapéutica del SAHOS (Síndrome de Apnea/Hipopnea Obstructiva del Sueño) desde el punto de vista Ortopédico y Ortodóntico: Una revisión de literatura

“…En la literatura existen numerosos estudios que se han publicado respecto al SAHOS en los últimos años, muchos de los cuales, han comparado los tratamientos tradicionales como la presión positiva continua en las vías aéreas superiores con otras terapias encaminadas hacia la ortodoncia y ortopedia, como el uso de dispositivos durante el sueño, indicando que ya sea por separado 14,15 , o combinadas 16 , presentan muy buenos resultados y es una alternativa adecuada.…”

Current and novel treatment options for obstructive sleep apnoea

“…Excess adipose tissue surrounding the upper airway can cause airway narrowing and increase the propensity for collapse during sleep [ 24 ]. Central obesity decreases lung volume and tracheal traction forces on the upper airway, and also increases upper airway collapsibility during sleep [ 25 , 26 ]. Moreover, an increased deposition of fat tissue within the genioglossus muscle has been shown.…”

“…T ong et al . [ 26 ] compared CPAP alone with CPAP combined with MAD either with open or closed oral airway for one night each. Both combination therapies reduced PAP pressure significantly as compared to CPAP alone.…”