Predicting epiglottic collapse in patients with obstructive sleep apnoea

Azarbarzin, Ali; Marques, Melania; Sands, Scott A.; Beeck, Sara Op de; Genta, Pedro Rodrigues; Taranto‐Montemurro, Luigi; Melo, Camila Maria de; Messineo, Ludovico; Vanderveken, Olivier M.; White, David P.; Wellman, Andrew

doi:10.1183/13993003.00345-2017

Cited by 64 publications

(70 citation statements)

References 30 publications

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“…However, methods to assess the pharyngeal structure causing collapse using non‐invasive airflow shape analysis have been developed (Azarbarzin et al . ; Genta et al . ; Azarbarzin et al .…”

Section: Discussionmentioning

confidence: 99%

Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea

Marques

Genta

Azarbarzin

et al. 2019

The Journal of Physiology

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Key points •Some patients with obstructive sleep apnoea (OSA) respond well to oral appliance therapy, whereas others do not for reasons that are unclear. •In the present study, we used gold‐standard measurements to demonstrate that patients with a posteriorly‐located tongue (natural sleep endoscopy) exhibit a preferential improvement in collapsibility (lowered critical closing pressure) with oral appliances. •We also show that patients with both posteriorly‐located tongue and less severe collapsibility (predicted responder phenotype) exhibit greater improvements in severity of obstructive sleep apnoea (i.e. reduction in event frequency by 83%, in contrast to 48% in predicted non‐responders). •The present study suggests that the structure and severity of pharyngeal obstruction determine the phenotype of sleep apnoea patients who benefit maximally from oral appliance efficacy. Abstract A major limitation to the administration of oral appliance therapy for obstructive sleep apnoea (OSA) is that therapeutic responses remain unpredictable. In the present study, we tested the hypotheses that oral appliance therapy (i) reduces pharyngeal collapsibility preferentially in patients with posteriorly‐located tongue and (ii) is most efficacious (reduction in apnoea‐hypopnea index; AHI) in patients with a posteriorly‐located tongue and less‐severe baseline pharyngeal collapsibility. Twenty‐five OSA patients underwent upper airway endoscopy during natural sleep to assess tongue position (type I: vallecula entirely visible; type II: vallecula obscured; type III: vallecula and glottis obscured), as well as obstruction as a result of other pharyngeal structures (e.g. epiglottis). Additional sleep studies with and without oral appliance were performed to measure collapsibility (critical closing pressure; Pcrit) and assess treatment efficacy. Overall, oral appliance therapy reduced Pcrit by 3.9 ± 2.4 cmH2O (mean ± SD) and AHI by 69 ± 19%. Therapy lowered Pcrit by an additional 2.7 ± 0.9 cmH2O in patients with posteriorly‐located tongue (types II and III) compared to those without (type I) (P < 0.008). Posteriorly‐located tongue (p = 0.03) and lower collapsibility (p = 0.04) at baseline were significant determinants of (greater‐than‐average) treatment efficacy. Predicted responders (type II and III and Pcrit < 1 cmH2O) exhibited a greater reduction in the AHI (83 ± 9 vs. 48 ± 8% baseline, P < 0.001) and a lower treatment AHI (9 ± 6 vs. 32 ± 15 events h–1, P < 0.001) than predicted non‐responders. The site and severity of pharyngeal collapse combine to determine oral appliance efficacy. Specifically, patients with a posteriorly‐located tongue plus less‐severe collapsibility are the strongest candidates for oral appliance therapy.

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Section: Discussionmentioning

confidence: 99%

Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea

Marques

Genta

Azarbarzin

et al. 2019

The Journal of Physiology

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“…The current results were obtained by additional analysis of data obtained in investigations of the association between structures causing upper airway collapse and airflow patterns(17, 18). Briefly, OSA patients with an apnea-hypopnea index (AHI) > 10 events/hr were invited to participate.…”

Section: Methodsmentioning

confidence: 99%

“…The lateral walls were considered the primary site of collapse if they narrowed the airway in the lateral dimension on both inspiration and expiration. Epiglottic collapse was defined as either anteroposterior or lateral (folding) collapse of the epiglottis(17, 18). Isolated palatal collapse was defined as collapse at the level of palate without any involvement of other airway structures.…”

Section: Methodsmentioning

confidence: 99%

“…Ten patients completed a prospective validation polysomnography(18, 21) to assess the validity of using nasal pressure as a clinical surrogate of ventilatory flow in our method. To simultaneously measure nasal pressure (nasal cannula) and ventilatory flow (pneumotachograph with oronasal mask), a modified cannula (Hudson RCI “over-the-ear”, cut to fit under the mask) provided a nasal pressure signal that was referenced to mask pressure to reflect the pressure signal available clinically.…”

Section: Methodsmentioning

confidence: 99%

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Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnoea

et al. 2018

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Objectives In some individuals with obstructive sleep apnea (OSA), the palate prolapses into the velopharynx during expiration, limiting airflow through the nose or shunting it out the mouth. We hypothesized that this phenomenon causes expiratory flow limitation (EFL) and is associated with inspiratory “isolated” palatal collapse. We also provide a robust non-invasive means to identify this mechanism of obstruction. Methods Using natural sleep endoscopy, 1211 breaths from 22 OSA patients were scored as having or not having palatal prolapse. The patient-level site of collapse (tongue-related, isolated palate, pharyngeal lateral walls, and epiglottis) was also characterized. EFL was quantified using expiratory resistance at maximal epiglottic pressure. A non-invasive expiratory flow limitation index (EFLI) was developed to detect the presence of palatal prolapse and EFL using the flow signal alone. In addition, the validity of using nasal pressure was assessed. Results A cutoff value of EFLI>0.8 detected the presence of palatal prolapse and EFL with an accuracy of >95% and 82%, respectively. The proportion of breaths with palatal prolapse predicted isolated inspiratory palatal collapse with 90% accuracy. Conclusions This study demonstrates that expiratory palatal prolapse can be quantified non-invasively, is associated with EFL, and predicts the presence of inspiratory isolated palatal collapse.

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“…An interesting finding of the present study is the persistence of epiglottis collapse in 43% (n = 6/ 14) of the patients after MMA surgery. Regarding the role of the epiglottis in adult OSA and snoring patients, knowledge is still limited . Although its prevalence in OSA seems to be greater than previously reported, more research is required to understand its role in OSA and, consequently, the best way to treat it .…”

Section: Discussionmentioning

confidence: 96%

Drug‐Induced Sleep Endoscopy Upper Airway Collapse Patterns and Maxillomandibular Advancement

et al. 2019

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Objectives/Hypothesis To evaluate upper airway (UA) collapse patterns during drug‐induced sleep endoscopy (DISE) and maxillomandibular advancement (MMA) surgery outcome, paying particular attention to the DISE phenotype complete concentric collapse at the level of the palate (CCCp). Study Design Prospective case series. Methods Nineteen patients diagnosed with obstructive sleep apnea (OSA) prospectively underwent mandibular advancement device (MAD) treatment followed by MMA surgery. UA collapse patterns were evaluated before and after MMA surgery. Baseline apnea‐hypopnea index (AHI) was compared with AHI during MAD treatment and after MMA surgery. UA collapse patterns and the presence of baseline CCCp were assessed. AHI differences between patients with and without CCCp after MMA surgery were compared. Results In 14 patients, a full dataset was obtained: 8/6 (male/female), mean age = 51 ± 7 years, body mass index (BMI) = 25.6 ± 3.7 kg/m2, and baseline AHI = 40.2 ± 25.6 per hour of sleep. MMA surgery reduced AHI to 9.9 ± 7.2 per hour of sleep (P = .0001). Eight patients benefited from additional AHI reduction compared to MAD treatment (P = .0113). Six out of 14 (43%) patients showed baseline CCCp. Baseline patient characteristics (age, BMI, and AHI) did not significantly differ between patients with and without CCCp. AHI was equally reduced after MMA, whether (P = .0145) or not (P = .0075) CCCp was present at baseline. All patients showed resolution of CCCp (P = .0159) during postoperative DISE. Conclusions CCCp seems not to be a negative predictor for MMA surgery outcome measured by AHI reduction. Furthermore, MMA is likely to eliminate CCCp. Therefore, MMA might be a solution for OSA patients showing CCCp and broadens the perspective for personalized medicine and combination therapy. However, a large sample is required for definitive results. Level of Evidence 4 Laryngoscope, 130:E268–E274, 2020

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Predicting epiglottic collapse in patients with obstructive sleep apnoea

Cited by 64 publications

References 30 publications

Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea

Structure and severity of pharyngeal obstruction determine oral appliance efficacy in sleep apnoea

Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnoea

Drug‐Induced Sleep Endoscopy Upper Airway Collapse Patterns and Maxillomandibular Advancement

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