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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?
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.
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.
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.
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.
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.
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.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
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 (email@example.com).
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.
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.
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