Treatment of Obstructive Sleep Apnea. Prospects for Personalized Combined Modality Therapy

Abstract

Obstructive sleep apnea (OSA) is a common sleep disorder with serious associated morbidities. Although several treatment options are currently available, variable efficacy and adherence result in many patients either not being treated or receiving inadequate treatment long term. Personalized treatment based on relevant patient characteristics may improve adherence to treatment and long-term clinical outcomes. Four key traits of upper airway anatomy and neuromuscular control interact to varying degrees within individuals to cause OSA. These are: (1) the pharyngeal critical closing pressure, (2) the stability of ventilator chemoreflex feedback control (loop gain), (3) the negative intraesophageal pressure that triggers arousal (arousal threshold), and (4) the level of stimulus required to activated upper airway dilator muscles (upper airway recruitment threshold). Simplified diagnostic methods are being developed to assess these pathophysiological traits, potentially allowing prediction of which treatment would best suit each patient. In contrast to current practice of using various treatment modes alone, model predictions and pilot clinical trials show improved outcomes by combining several treatments targeted to each patient's pathophysiology profile. These developments could theoretically improve efficacy and adherence to treatment and in turn reduce the social and economic health burden of OSA and the associated life-threatening morbidities. This article reviews OSA pathophysiology and identifies currently available and investigational treatments that may be combined in the future to optimize therapy based on individual profiles of key patient pathophysiological traits.

Decrease of respiratory events in patients with obstructive sleep apnea-hypopnea syndrome using a mandibular advancement device assessed with split night polysomnography

“…Recent assessments have shown, first in obesity, there is an increasing the prevalence of this pathology, this has attracted the attention of physicians [4], with the recognizing of the need of a multidisciplinary management of sleep breathing disorders such as snoring and OSAHS [5], [6], [7], [8].…”

Stimulating therapy for obstructive sleep apnoea

“…Considerable work is ongoing suggesting only a subset of patients with OSA have a major issue with upper airway dilator muscle function. 1415 Thus, one might predict that efforts to augment hypoglossal motor output may be more effective for some patients than for others with OSA depending on underlying mechanism. 15 (3) Is bilateral stimulation and opposition to unilateral stimulation the better approach?…”

“…On the other hand, patients with OSA with an issue primarily of unstable ventilatory control or low arousal threshold may be predicted to fail treatment targeted just at upper airway dilator muscles. 1420 …”

Kinesthetic stimulation for obstructive sleep apnea syndrome: An “on-off” proof of concept trial

“…Patients with OSA have varying degrees of symptomatology and OSA-related co-morbid conditions 2,3 . The two leading current treatments for OSA are continuous positive airway pressure (CPAP) and mandibular advancement devices (MAD) 4 .…”