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

Abstract

bstructive sleep apnea (OSA) is a disorder that involves complete or partial blockage in airflow during sleep. The resulting hypoxia and sympathetic activation place patients at an increased risk for metabolic syndrome, neurocognitive decline, hypertension, stroke, and other cardiovascular sequelae. 1,2 The primary therapy for OSA is positive airway pressure (PAP); however, although PAP treatment is beneficial, recommended adherence to therapy ranges from 17% to 54%. 3 Consequently, there exists a need for treatment alternatives to PAP therapy.One class of alternatives to PAP therapy is upper airway surgery, which includes soft tissue surgery, skeletal surgery, tracheostomy, and hypoglossal nerve stimulation (HGNS). Hypoglossal nerve stimulation, the most recent develop-ment in OSA surgery, involves stimulation of select branches of the hypoglossal nerve resulting in tongue protrusion and upper airway dilation during sleep. The HGNS device used consists of 3 implantable components: a respiratory sensor, pulse generator (battery), and an electrode cuff (Inspire; Inspire Medical Systems). Upon inspiration, the respiratory sensor detects changes in the intrathoracic space and signals the pulse generator to stimulate the hypoglossal nerve. Stimulation persists through the end of expiration and then briefly deactivates to avoid overstimulation.Although studies have cited significant improvements in both objective and subjective outcomes following HGNS, [4][5][6] there exists a need to determine factors predictive of surgical outcomes. A previous study showed that a therapeutic PAP 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 PARTICIPANTSThis 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.

Association of hypoglossal nerve stimulator response with machine learning identified negative effort dependence patterns

“…Additionally, neck circumference, age, and sex are also unreliable predictors of response [ 6 ]. A more consistent finding is that lower pre-operative and intra-operative PAP required for airway opening [ 11 , 12 ] is associated with a greater reduction in the AHI with HGNS. The association of lower airway opening pressures with HGNS efficacy suggests that responders have more compliant airways, particularly at the level of the soft palate, which may be more amenable to airway opening with HGNS.…”

Beyond VOTE: The New Frontier of Drug-Induced Sleep Endoscopy

“…As our preliminary data using quantification of physiology during DISE have shown predictive capacity in HGNS-related outcomes [23], we continue to expand our resources into the physiologic assessment during DISE.…”

“…In order to do so, we identified a DISE outcome measure (PhOP) analogous to the minimally effective therapeutic PAP level obtained from natural sleep. In 2019, we conducted a DISE study which demonstrated the ability of a single, objective measurement – POP (DISE-POP) – to predict outcomes for HGNS beyond that of both the VOTE score and commonly used anthropometric measures [23]. Subsequently, our group formally launched a specialized protocol: Drug-Induced Sleep Endoscopy-Characterization of Airway Dynamics (DISE-CAD).…”

A Missing Voice: The Lingual Complex and Osteopathic Manual Medicine in the Context of Five Osteopathic Models

“…Patients with CHF often present with obstructive sleep apnea syndrome (OSAS) [54]. We know that one of the main causes of OSAS is morphological and functional alterations of the tongue, in particular, an increase in posterior volume and an alteration of the intervention of the autonomic nervous system [55,56]. Lingual dysfunction in CHF and OSAS raises the likelihood of systemic metabolic disorders, with the risk of further cardiovascular sequelae, the onset of metabolic syndrome, and cognitive impairment [56].…”