Upper-Airway Collapsibility and Loop Gain Predict the Response to Oral Appliance Therapy in Patients with Obstructive Sleep Apnea

Edwards, Bradley A.; Andara, Christopher; Landry, Shane A.; Sands, Scott A.; Joosten, Simon A.; Owens, Robert L.; White, David P.; Hamilton, Garun S.; Wellman, Andrew

doi:10.1164/rccm.201601-0099oc

Cited by 191 publications

(177 citation statements)

References 41 publications

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“…In these patients, it is the presence of an elevated LG and/or low arousal threshold that is the primary effect modifier predisposing them to OSA. 12 Previous work has demonstrated that other CPAP alternative treatments such as mandibular advancement devices (MADs) and lateral positioning during sleep improve upper airway collapsibility without improving ventilatory control instability or arousal threshold, 13,14 such that these residual causes of OSA can persist despite intervention. While previous evidence suggests that upper airway surgery can improve the anatomy/collapsibility, [15][16][17] it also remains unclear whether upper airway surgery alters the nonanatomical factors that contribute to OSA.…”

Section: Introductionmentioning

confidence: 99%

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea

Joosten

Leong

Landry

et al. 2017

Sleep

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Study Objectives: Upper airway surgery is often recommended to treat patients with obstructive sleep apnea (OSA) who cannot tolerate continuous positive airways pressure. However, the response to surgery is variable, potentially because it does not improve the nonanatomical factors (ie, loop gain [LG] and arousal threshold) causing OSA. Measuring these traits clinically might predict responses to surgery. Our primary objective was to test the value of LG and arousal threshold to predict surgical success defined as 50% reduction in apnea-hypopnea index (AHI) and AHI <10 events/hour post surgery. LG remained a significant predictor of surgical success after controlling for covariates (logistic regression p = .018; receiver operating characteristic area under curve = 0.80). Conclusions: Our study provides proof-of-principle that upper airway surgery most effectively resolves OSA in patients with lower LG. Predicting the failure of surgical treatment, consequent to less stable ventilatory control (elevated LG), can be achieved in the clinic and may facilitate avoidance of surgical failures.

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Section: Introductionmentioning

confidence: 99%

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea

Joosten

Leong

Landry

et al. 2017

Sleep

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“…Importantly, however, the choice of personalized treatment other than nCPAP for Patient A would be different than for Patient B. Patient A would likely benefit most from oral appliance therapy whereas Patient B may be better served by a pharmacologic intervention to lower loop gain and arousal threshold 10, 16, 17 . Also importantly, swapping therapy between patients would be particularly ineffective (e.g., Patient A instead receiving a pharmacologic intervention to lower loop gain and arousal threshold, and Patient B receiving oral appliance therapy), as the interventions would not target the primary causative factor in those individuals.…”

Section: Phenotyping Osa Patients Is Critical To Targeted Therapymentioning

confidence: 99%

A resource of potential drug targets and strategic decision‐making for obstructive sleep apnoea pharmacotherapy

2017

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There is currently no pharmacotherapy for OSA, but there is no principled a-priori reason why there shouldn’t be one. This review identifies a rational decision-making strategy with the necessary logical underpinnings that any reasonable approach would be expected to navigate to develop a viable pharmacotherapy for OSA. The process first involves phenotyping an individual to quantify and characterize the critical predisposing factor(s) to their OSA pathogenesis and identify, a-priori, if the patient is likely to benefit from a pharmacotherapy that targets those factors. We then identify rational strategies to manipulate those critical predisposing factor(s), and the barriers that have to be overcome for success of any OSA pharmacotherapy. A new analysis then identifies candidate drug targets to manipulate the upper airway motor circuitry for OSA pharmacotherapy. The first conclusion is that there are two general pharmacological approaches for OSA treatment that are of most potential benefit and are practically realistic, one being fairly intuitive but the second perhaps less so. The second conclusion is that after identifying the critical physiological obstacles to OSA pharmacotherapy, there are current therapeutic targets of high interest for future development. The final analysis provides a tabulated resource of “druggable” targets that are relatively restricted to the circuitry controlling the upper airway musculature, with these candidate targets being of high priority for screening and further study. We also emphasize that a pharmacotherapy may not cure OSA per se, but may still be a useful adjunct to improve the effectiveness of, and adherence to, other treatment mainstays.

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“…The findings of that study indicate that non-anatomic factors are important and may be even more important than anatomic features in some patients, although a prime predisposing factor in most patients with OSA is a highly collapsible airway. A study based on this concept recently showed that OA improved upper airway collapsibility without affecting muscle function, loop gain, or the arousal threshold (Edwards et al 2016). This suggests that patients with better passive upper airway anatomy/collapsibility and low loop gain will obtain the greatest benefit from OA therapy (Edwards et al 2016).…”

Section: Predictors Of Treatment Successmentioning

confidence: 99%

“…A study based on this concept recently showed that OA improved upper airway collapsibility without affecting muscle function, loop gain, or the arousal threshold (Edwards et al 2016). This suggests that patients with better passive upper airway anatomy/collapsibility and low loop gain will obtain the greatest benefit from OA therapy (Edwards et al 2016). Gray et al (2016) reported that non-obese patients with OSA were more likely to have a low respiratory arousal threshold and that these patients were difficult to treat with CPAP.…”

Section: Predictors Of Treatment Successmentioning

confidence: 99%

Practical considerations for effective oral appliance use in the treatment of obstructive sleep apnea: a clinical review

Tsuda

Wada

Ando

2017

Sleep Science Practice

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Oral appliance (OA) therapy is a promising alternative to continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA). By holding the mandible in a forward position, an OA keeps the airway open and prevents collapse. The recently revised practice parameters of the American Academy of Sleep Medicine extend the indications for OA therapy, recommending that "sleep physicians consider prescription of an OA for adult patients with OSA who are intolerant of CPAP therapy or prefer alternative therapy." This manuscript reviews the practical considerations for effective OA therapy with a discussion of three factors: patient eligibility for OA therapy, device features, and requirements for OA providers. Identification of patients who are eligible for OA therapy is a key factor because the overall success rate of OA therapy is lower than that of CPAP. Conventional predictive variables have low sensitivity and specificity; however, new tools such as drug-induced sleep endoscopy and single-night polysomnographic OA titration have been developed. Other factors to consider when determining the indications for OA include the patient's oral health, evidence of inadequate treatment for older populations, and the risk of long-term dentofacial side effects. For the second factor, customization of OA features is a key component of treatment success, and no single OA design most effectively improves every situation. Although adjustment of the mandibular position is much more important than device selection, the adjustment procedure has not been standardized. Additionally, a pitfall that tends to be forgotten is the relationship between application of the mandibular position and device selection. Promising new technology has become commercially available in the clinical setting to provide objective adherence monitoring. Finally, the third factor is the availability of enough qualified dentists because sleep medicine is a relatively new and highly multidisciplinary field. Because OSA treatments such as CPAP and OA therapy are generally considered for continuous use, treatments should be carefully planned with attention to multiple aspects. Additionally, because OA therapy requires the cooperation of professionals with different areas of expertise, such as dentists and physicians with various specialties, everyone involved in OA therapy must understand it well.

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Upper-Airway Collapsibility and Loop Gain Predict the Response to Oral Appliance Therapy in Patients with Obstructive Sleep Apnea

Abstract: Our findings suggest that OA therapy improves the upper-airway collapsibility under passive and active conditions. Importantly, a greater response to therapy occurred in those patients with a mild anatomic compromise and a lower loop gain.

Cited by 191 publications

References 41 publications

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea

A resource of potential drug targets and strategic decision‐making for obstructive sleep apnoea pharmacotherapy

Practical considerations for effective oral appliance use in the treatment of obstructive sleep apnea: a clinical review

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