Effect of genioglossus contraction on pharyngeal lumen and airflow in sleep apnoea patients

Oliven, Arie; Tov, Nave; Geitini, Louis; Steinfeld, Uri; Oliven, Ron; Schwartz, Alan R.; Odeh, Majed

doi:10.1183/09031936.00131106

Cited by 73 publications

(93 citation statements)

References 35 publications

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“…In these prior studies, investigators scrutinized EEG and ECG signals to exclude responses associated with cortical or autonomic activation (13,18,19). Additional studies with implantable nerve cuff (13) and fine-wire electrodes have demonstrated responses to selective lingual muscle stimulation during sleep and anesthesia (13)(14)(15)(16)(17). The present study also screened for evidence of cortical and autonomic activation, and further required strict temporal synchrony between the stimulus burst and airflow response to exclude arousal responses from the analysis.…”

Section: Arousalsmentioning

confidence: 99%

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Acute Upper Airway Responses to Hypoglossal Nerve Stimulation during Sleep in Obstructive Sleep Apnea

Schwartz

Barnes

Hillman

et al. 2012

Am J Respir Crit Care Med

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Rationale: Hypoglossal nerve stimulation (HGNS) recruits lingual muscles, reduces pharyngeal collapsibility, and treats sleep apnea. Objectives: We hypothesized that graded increases in HGNS relieve pharyngeal obstruction progressively during sleep. Methods: Responses were examined in 30 patients with sleep apnea who were implanted with an HGNS system. Current (milliampere) was increased stepwise during non-REM sleep. Frequency and pulse width were fixed. At each current level, stimulation was applied on alternating breaths, and responses in maximal inspiratory airflow (V I max) and inspiratory airflow limitation (IFL) were assessed. Pharyngeal responses to HGNS were characterized by the current levels at which V I max first increased and peaked (flow capture and peak flow thresholds), and by the V I max increase from flow capture to peak (DV I max). Measurements and Main Results: HGNS produced linear increases in V I max from unstimulated levels at flow capture to peak flow thresholds (215 6 21 to 509 6 37 ml/s; mean 6 SE; P , 0.001) with increasing current from 1.05 6 0.09 to 1.46 6 0.11 mA. V I max increased in all patients and IFL was abolished in 57% of patients (non-IFL subgroup). In the non-IFL compared with IFL subgroup, the flow response slope was greater (1241 6 199 vs. 674 6 166 ml/s/mA; P , 0.05) and the stimulation amplitude at peak flow was lower (1.23 6 0.10 vs. 1.80 6 0.20 mA; P , 0.05) without differences in peak flow. Conclusions: HGNS produced marked dose-related increases in airflow without arousing patients from sleep. Increases in airflow were of sufficient magnitude to eliminate IFL in most patients and IFL and non-IFL subgroups achieved normal or near-normal levels of flow, suggesting potential HGNS efficacy across a broad range of sleep apnea severity.Keywords: obstructive sleep apnea; electrical hypoglossal nerve stimulation; pharynx; upper airway; titration Obstructive sleep apnea is characterized by recurrent episodes of upper airway obstruction during sleep (1). Airflow obstruction is thought to result from decreases in pharyngeal neuromuscular activity at sleep onset (2). These episodes lead to intermittent hypoxemia and recurrent arousals from sleep, accounting for the long-term neurocognitive (3, 4), metabolic (5), and cardiovascular (6) sequelae of this disorder. Nasal continuous positive airway pressure remains the mainstay of treatment for moderate to severe obstructive sleep apnea (7). Difficulties adhering to therapy can limit its effectiveness in the home setting (8, 9), and alternatives have been generally less effective in relieving upper airway obstruction during sleep (10-12).Hypoglossal nerve stimulation (HGNS) has been piloted as treatment for obstructive sleep apnea (13). Implantable HGNS systems have been developed to stimulate the hypoglossal nerve during inspiration, and recruit the lingual musculature, leading to decreases in pharyngeal collapsibility during sleep (14-17). Motor activity protrudes the tongue, and mitigates airflow obstruction during sleep (18,19)....

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Section: Arousalsmentioning

confidence: 99%

“…Implantable HGNS systems have been developed to stimulate the hypoglossal nerve during inspiration, and recruit the lingual musculature, leading to decreases in pharyngeal collapsibility during sleep (14)(15)(16)(17). Motor activity protrudes the tongue, and mitigates airflow obstruction during sleep (18,19).…”

mentioning

confidence: 99%

Acute Upper Airway Responses to Hypoglossal Nerve Stimulation during Sleep in Obstructive Sleep Apnea

Schwartz

Barnes

Hillman

et al. 2012

Am J Respir Crit Care Med

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“…Activation of the GG, the main tongue protrusor, has been shown in animal studies to reduce pharyngeal resistance and collapsibility by far more than all other upper airway dilators (15,16). Electrically induced tongue protrusion has been shown to reduce pharyngeal resistance during wakefulness (24), lower the critical pressure (Pcrit) during sleep and anesthesia (18,19), and enlarge the pharynx (19). However, despite its central role, electrically induced GG contraction resulted in rather modest effects on upper airway mechanics (i.e., collapsibility), with wide variations in response between subjects (18,19).…”

mentioning

confidence: 99%

“…Electrically induced tongue protrusion has been shown to reduce pharyngeal resistance during wakefulness (24), lower the critical pressure (Pcrit) during sleep and anesthesia (18,19), and enlarge the pharynx (19). However, despite its central role, electrically induced GG contraction resulted in rather modest effects on upper airway mechanics (i.e., collapsibility), with wide variations in response between subjects (18,19). Failure to stimulate adequate areas of the GG and hypotonia of the nonstimulated upper airway muscles were considered as possible explanations for the lack of response in some of the patients.…”

mentioning

confidence: 99%

“…The combined effect of MA and GG electrical stimulation (GG-ES) is difficult to predict: both MA and GG contraction are thought to ameliorate pharyngeal patency by displacing the tongue anteriorly, thereby preventing its collapse into the pharynx, reducing external pressure at the level of the velopharynx, and possibly stretching the soft palate indirectly by pulling lateral pharyngeal structures (11,19). Due to the similar mode of action, their combination may be less than additive.…”

mentioning

confidence: 99%

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Interacting effects of genioglossus stimulation and mandibular advancement in sleep apnea

Oliven¹,

Tov²,

Odeh³

et al. 2009

Journal of Applied Physiology

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Oliven A. Interacting effects of genioglossus stimulation and mandibular advancement in sleep apnea. J Appl Physiol 106: 1668-1673, 2009. First published February 19, 2009 doi:10.1152/japplphysiol.91501.2008 and stimulation of the genioglossus (GG) have been shown to improve upper airway patency, but neither one achieves the effect of continuous positive airway pressure (CPAP) treatment. In the present study we assessed the combined effect of MA and GG stimulation on the relaxed pharynx in patients with obstructive sleep apnea (OSA). We evaluated responses of upper airway pressure-flow relationships and endoscopically determined pharyngeal cross-sectional area to MA and electrical stimulation of the GG in 14 propofol-anesthetized OSA patients. Measurements were undertaken at multiple levels of CPAP, enabling calculation of the critical closing pressure (Pcrit), upstream resistance (Rus), and pharyngeal compliance. GG stimulation, MA, and the combination of both shifted the pressure:flow relationships toward higher flow levels, resulting in progressively lower Pcrit (from baseline of 2.9 Ϯ 2.2 to 0.9 Ϯ 2.5, Ϫ1.4 Ϯ 2.9, and Ϫ4.2 Ϯ 3.3 cmH2O, respectively), without significant change in Rus. ⌬Pcrit during GG stimulation was significantly larger during MA than under baseline conditions (Ϫ2.8 Ϯ 1.4 vs. Ϫ2.0 Ϯ 1.4 cmH 2O, P ϭ 0.011). Combining the effect of GG stimulation with MA lowered Pcrit below 0 in all patients and restored pharyngeal patency to a level that enabled flow above the hypopnea level in 10/14 of the patients. Velopharyngeal compliance was not affected by either manipulation. We conclude that the combined effect of MA and GG stimulation is additive and may act in synergy, preventing substantial flow limitation of the relaxed pharynx in most OSA patients.

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International Consensus Statement on Obstructive Sleep Apnea

Chang

Goldberg

Alt

et al. 2023

Int Forum Allergy Rhinol

100

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Background: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). Methods: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidencebased review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. Results: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. Conclusion:This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

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Effect of genioglossus contraction on pharyngeal lumen and airflow in sleep apnoea patients

Cited by 73 publications

References 35 publications

Acute Upper Airway Responses to Hypoglossal Nerve Stimulation during Sleep in Obstructive Sleep Apnea

Acute Upper Airway Responses to Hypoglossal Nerve Stimulation during Sleep in Obstructive Sleep Apnea

Interacting effects of genioglossus stimulation and mandibular advancement in sleep apnea

International Consensus Statement on Obstructive Sleep Apnea

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