Evaluation of PAP as an Outcomes Predictor of Hypoglossal Nerve Stimulation Surgery in Patients With OSA | Otolaryngology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Evaluation of Therapeutic Positive Airway Pressure as a Hypoglossal Nerve Stimulation Predictor in Patients With Obstructive Sleep Apnea

Educational Objective
To evaluate the use of therapeutic nasal positive airway pressure response during drug-induced sleep endoscopy as a predictor of the success of subsequent hypoglossal nerve stimulation.
1 Credit CME
Key Points

Question  Is therapeutic nasal positive airway pressure at the soft palate during drug-induced sleep endoscopy associated with response to hypoglossal nerve stimulation in patients with obstructive sleep apnea?

Findings  In this cohort study of 27 consecutive patients with obstructive sleep apnea undergoing therapeutic nasal positive airway pressure during drug-induced sleep endoscopy, those who responded to hypoglossal nerve stimulation had significantly lower palatal opening pressures than nonresponders (5.0 vs 9.2 cm H2O, respectively). A palatal opening pressure cutoff level less than 8 cm H2O was associated with a positive predictive value.

Meaning  Airway distensibility, as measured by the palatal opening pressure in administration of therapeutic nasal positive airway pressure during drug-induced sleep endoscopy, may be a physiologic predictor of hypoglossal nerve stimulation success.

Abstract

Importance  Recent retrospective hypoglossal nerve stimulation (HGNS) outcomes data suggest that patients with low therapeutic positive airway pressure (PAP) levels achieve greater success than patients with high therapeutic PAP levels.

Objective  To examine the use of therapeutic nasal PAP levels at the soft palate in predicting the outcomes of HGNS for patients with obstructive sleep apnea.

Design, Setting, and Participants  This prospective cohort study used drug-induced sleep endoscopy (DISE) to evaluate the predictive capacity of therapeutic PAP levels in HGNS outcomes. In an academic sleep surgery center, 27 consecutive patients with obstructive sleep apnea who underwent DISE before implantation of an HGNS device were evaluated. The study was conducted from May 1, 2018, to June 26, 2019.

Exposures  Positive airway pressure delivered through a nasal mask during DISE.

Main Outcomes and Measures  Improvement in apnea-hypopnea index as measured from full-night preoperative and postoperative efficacy studies.

Results  Twenty-seven patients met all inclusion criteria. The mean (SD) age was 62.0 (14.4) years, 14 participants were men (51.9%), and mean body mass index was 28.1 (4.0). Responders to HGNS therapy (n = 18) had significantly lower mean (SD) palatal opening pressure compared with nonresponders (n = 9) (5.0 [2.8] vs 9.2 [3.7] cm H2O, respectively; mean difference, −4.2; 95% CI, −6.8 to −1.6 cm H2O). After adjusting for age, sex, and body mass index, the mean palatal opening pressure value for the responders remained 3.5 cm H2O lower (95% CI, −6.7 to −0.4 cm H2O) than that of nonresponders. A palatal opening pressure cutoff level less than 8 cm H2O demonstrated a positive predictive value of 82.4%; sensitivity, 77.8%; and specificity, 66.7%.

Conclusions and Relevance  In this small prospective cohort study, therapeutic nasal PAP levels during DISE differed significantly between responder and nonresponders to HGNS. Because DISE represents a mandatory, relatively standardized diagnostic tool for HGNS candidacy, the use of therapeutic nasal PAP through DISE can be broadly implemented and studied across multiple centers to possibly improve patient selection for HGNS.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: April 13, 2020.

Corresponding Author: Raj C. Dedhia, MD, MSCR, Perelman School of Medicine, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, 3400 Spruce St, Ravdin 5, Philadelphia, PA 19104 (raj.dedhia@pennmedicine.upenn.edu).

Published Online: June 4, 2020. doi:10.1001/jamaoto.2020.1018

Author Contributions: Mr Seay and Dr Dedhia had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Seay, Dedhia.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Seay, Keenan, Dedhia.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Seay, Keenan.

Obtained funding: Schwartz, Dedhia.

Administrative, technical, or material support: Seay, Dedhia.

Supervision: Schwartz.

Conflict of Interest Disclosures: Mr Seay reported having a patent to a positive airway pressure drug-induced sleep endoscopy mask pending. Dr Schwartz reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Dedhia reported having a patent to a positive airway pressure drug-induced sleep endoscopy mask pending. No other disclosures were reported.

Funding/Support: Funding for the study was provided by grant 1R01HL144859-01 from the NIH.

Role of the Funder/Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: Mr Seay and Dr Dedhia were affiliated with Emory University at the time of the study.

References
1.
Javaheri  S , Barbe  F , Campos-Rodriguez  F ,  et al.  Sleep apnea: types, mechanisms, and clinical cardiovascular consequences.   J Am Coll Cardiol. 2017;69(7):841-858. doi:10.1016/j.jacc.2016.11.069 PubMedGoogle Scholar
2.
Gagnon  K , Baril  A-A , Gagnon  J-F ,  et al.  Cognitive impairment in obstructive sleep apnea.   Pathol Biol (Paris). 2014;62(5):233-240. doi:10.1016/j.patbio.2014.05.015 PubMedGoogle Scholar
3.
Weaver  TE , Grunstein  RR .  Adherence to continuous positive airway pressure therapy: the challenge to effective treatment.   Proc Am Thorac Soc. 2008;5(2):173-178. doi:10.1513/pats.200708-119MG PubMedGoogle Scholar
4.
Strollo  PJ  Jr , Soose  RJ , Maurer  JT ,  et al; STAR Trial Group.  Upper-airway stimulation for obstructive sleep apnea.   N Engl J Med. 2014;370(2):139-149. doi:10.1056/NEJMoa1308659 PubMedGoogle Scholar
5.
Gillespie  MB , Soose  RJ , Woodson  BT ,  et al; STAR Trial Investigators.  Upper airway stimulation for obstructive sleep apnea: patient-reported outcomes after 48 months of follow-up.   Otolaryngol Head Neck Surg. 2017;156(4):765-771. doi:10.1177/0194599817691491 PubMedGoogle Scholar
6.
Woodson  BT , Strohl  KP , Soose  RJ ,  et al.  Upper airway stimulation for obstructive sleep apnea: 5-year outcomes.   Otolaryngol Head Neck Surg. 2018;159(1):194-202. doi:10.1177/0194599818762383 PubMedGoogle Scholar
7.
Lee  CH , Seay  EG , Walters  BK , Scalzitti  NJ , Dedhia  RC .  Therapeutic positive airway pressure level predicts response to hypoglossal nerve stimulation for obstructive sleep apnea.   J Clin Sleep Med. 2019;15(8):1165-1172. doi:10.5664/jcsm.7814 PubMedGoogle Scholar
8.
Huntley  C , Cooper  J , Stiles  M , Grewal  R , Boon  M .  Predicting success of oral appliance therapy in treating obstructive sleep apnea using drug-induced sleep endoscopy.   J Clin Sleep Med. 2018;14(8):1333-1337. doi:10.5664/jcsm.7266 PubMedGoogle Scholar
9.
De Corso  E , Bastanza  G , Della Marca  G ,  et al.  Drug-induced sleep endoscopy as a selection tool for mandibular advancement therapy by oral device in patients with mild to moderate obstructive sleep apnoea.   Acta Otorhinolaryngol Ital. 2015;35(6):426-432. doi:10.14639/0392-100X-959PubMedGoogle Scholar
10.
Jung  SH , Koo  SK , Choi  JW , Moon  JS , Lee  SH .  Upper airway structural changes induced by CPAP in OSAS patients: a study using drug-induced sleep endoscopy.   Eur Arch Otorhinolaryngol. 2017;274(1):247-252. doi:10.1007/s00405-016-4233-9 PubMedGoogle Scholar
11.
Civelek  S , Emre  IE , Dizdar  D ,  et al.  Comparison of conventional continuous positive airway pressure to continuous positive airway pressure titration performed with sleep endoscopy.   Laryngoscope. 2012;122(3):691-695. doi:10.1002/lary.22494 PubMedGoogle Scholar
12.
Lan  M-C , Hsu  Y-B , Lan  M-Y ,  et al.  The predictive value of drug-induced sleep endoscopy for CPAP titration in OSA patients.   Sleep Breath. 2018;22(4):949-954. doi:10.1007/s11325-017-1600-8 PubMedGoogle Scholar
13.
Safiruddin  F , Vanderveken  OM , de Vries  N ,  et al.  Effect of upper-airway stimulation for obstructive sleep apnoea on airway dimensions.   Eur Respir J. 2015;45(1):129-138. doi:10.1183/09031936.00059414 PubMedGoogle Scholar
14.
Lee  CH , Seay  EG , Dedhia  RC .  IMAGES: drug-induced sleep endoscopy: an investigative tool for mechanisms of PAP failure.   J Clin Sleep Med. 2019;15(1):171-172. doi:10.5664/jcsm.7604 PubMedGoogle Scholar
15.
Deng  X , Gu  W , Li  Y , Liu  M , Li  Y , Gao  X .  Age-group–specific associations between the severity of obstructive sleep apnea and relevant risk factors in male and female patients.   PLoS One. 2014;9(9):e107380. doi:10.1371/journal.pone.0107380 PubMedGoogle Scholar
16.
Cohen  J .  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Lawrence Erlbaum Associates; 1998.
17.
Thaler  E , Schwab  R , Maurer  J ,  et al.  Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy.   Laryngoscope. 2020;130(5):1333-1338. doi:10.1002/lary.28286 PubMedGoogle Scholar
18.
Vanderveken  OM , Maurer  JT , Hohenhorst  W ,  et al.  Evaluation of drug-induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea.   J Clin Sleep Med. 2013;9(5):433-438. doi:10.5664/jcsm.2658 PubMedGoogle Scholar
19.
Schwab  RJ , Wang  SH , Verbraecken  J ,  et al.  Anatomic predictors of response and mechanism of action of upper airway stimulation therapy in patients with obstructive sleep apnea.   Sleep. 2018;41(4). doi:10.1093/sleep/zsy021 PubMedGoogle Scholar
20.
Steffen  A , Hartmann  JT , König  IR , Ravesloot  MJL , Hofauer  B , Heiser  C .  Evaluation of body position in upper airway stimulation for obstructive sleep apnea: is continuous voltage sufficient enough?   Sleep Breath. 2018;22(4):1207-1212. doi:10.1007/s11325-018-1716-5 PubMedGoogle Scholar
21.
Ayers  CM , Lohia  S , Nguyen  SA , Gillespie  MB .  The effect of upper airway surgery on continuous positive airway pressure levels and adherence: a systematic review and meta-analysis.   ORL J Otorhinolaryngol Relat Spec. 2016;78(3):119-125. doi:10.1159/000442023 PubMedGoogle Scholar
22.
Farré  R , Rotger  M , Montserrat  JM , Calero  G , Navajas  D .  Collapsible upper airway segment to study the obstructive sleep apnea/hypopnea syndrome in rats.   Respir Physiol Neurobiol. 2003;136(2-3):199-209. doi:10.1016/S1569-9048(03)00082-X PubMedGoogle Scholar
23.
Rigau  J , Montserrat  JM , Wöhrle  H ,  et al.  Bench model to simulate upper airway obstruction for analyzing automatic continuous positive airway pressure devices.   Chest. 2006;130(2):350-361. doi:10.1378/chest.130.2.350 PubMedGoogle Scholar
24.
Gold  AR , Schwartz  AR .  The pharyngeal critical pressure: the whys and hows of using nasal continuous positive airway pressure diagnostically.   Chest. 1996;110(4):1077-1088. doi:10.1378/chest.110.4.1077 PubMedGoogle Scholar
25.
Ayers  CM , Lohia  S , Nguyen  SA , Gillespie  MB .  The effect of upper airway surgery on continuous positive airway pressure levels and adherence: a systematic review and meta-analysis.   ORL J Otorhinolaryngol Relat Spec. 2016;78(3):119-125. doi:10.1159/000442023PubMedGoogle Scholar
26.
Rabelo  FAW , Braga  A , Küpper  DS ,  et al.  Propofol-induced sleep: polysomnographic evaluation of patients with obstructive sleep apnea and controls.   Otolaryngol Head Neck Surg. 2010;142(2):218-224. doi:10.1016/j.otohns.2009.11.002 PubMedGoogle Scholar
27.
Rabelo  FAW , Küpper  DS , Sander  HH , Fernandes  RMF , Valera  FCP .  Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep disorders and controls.   Laryngoscope. 2013;123(9):2300-2305. doi:10.1002/lary.23664 PubMedGoogle Scholar
28.
Dedhia  RC , Woodson  BT .  Standardized reporting for hypoglossal nerve stimulation outcomes.   J Clin Sleep Med. 2018;14(11):1835-1836. doi:10.5664/jcsm.7470 PubMedGoogle Scholar
29.
Dijemeni  E , D’Amone  G , Gbati  I .  Drug-induced sedation endoscopy (DISE) classification systems: a systematic review and meta-analysis.   Sleep Breath. 2017;21(4):983-994. doi:10.1007/s11325-017-1521-6 PubMedGoogle Scholar
30.
Andrade  RGS , Viana  FM , Nascimento  JA ,  et al.  Nasal vs oronasal CPAP for OSA treatment: a meta-analysis.   Chest. 2018;153(3):665-674. doi:10.1016/j.chest.2017.10.044 PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close