Optimal positive airway pressure predicts oral appliance response to sleep apnoea

Abstract

Patients with less severe obstructive sleep apnoea (OSA) are usually prescribed oral appliances and/or smaller optimal nasal continuous positive airway pressure (PnCPAP) in nCPAP therapy. We hypothesised that OSA patients with greater PnCPAP would not respond favourably to oral appliances.Oral appliances were inserted in nCPAP users after washing-out the nCPAP effect. Follow-up polysomnography was undertaken with the adjusted oral appliance in place. The predictability of PnCPAP was evaluated with receiver-operating characteristic (ROC) curves.The median baseline apnoea/hypopnoea index (AHI) was reduced with the oral appliance from 36 to 12 events?h -1 in 35 patients. When responders were defined as patients showing a follow-up AHI of ,5 events?h -1 with .50% reduction in baseline AHI, the area under the ROC curve for PnCPAP was 0.76. The best cut-off value of PnCPAP turned out to be 10.5 cmH 2 O with a high negative predictive value (0.93) and a low negative likelihood ratio (0.18). OSA patients with a PnCPAP of .10.5 cmH 2 O are unlikely to respond to oral appliance therapy. This prediction is clinically helpful to both OSA patients and medical personnel in discussing oral appliances as a temporary substitute and/or alternative for nCPAP.

CPAP Pressure for Prediction of Oral Appliance Treatment Response in Obstructive Sleep Apnea

“…Our findings lend support to the previously reported relationship between CPAP pressure and MAS treatment response, 9 and extend these findings by identifying a much higher CPAP pressure cutoff for negative prediction of MAS response in this population. The implication is that there may be populationspecific characteristics that influence the cutoff pressure values for which CPAP is best predictive of MAS response.…”

“…Differences in the relationship between CPAP pressure and MAS response may relate to these different hard and soft tissue proportions. BMI was lower in MAS responders in our study and was a predictor of response in univariate analyses (data not shown); however, no such relationship was evident in the Japanese study, 9 suggesting obesity was less of a factor in MAS treatment response. BMI and neck circumference also relate to CPAP pressure in Caucasian populations.…”

“…In the Japanese study, a CPAP pressure cutoff value of 10.5 cm H 2 O most reliably classified patients in terms of MAS response, with pressures higher than this generally indicating a negative response to MAS. 9 This value was inadequate for use in our patient sample and correctly classified only 47% of patients as non-responders, due to a large overlap of MAS treatment responders and non-responders with therapeutic CPAP pressures in the < 12 cm H 2 O range. Our results indicate that application of this method of prediction to an Australian population requires a higher cutoff value of 13 cm H 2 O for best discrimination, with 100% of patients above this level correctly classified as non-responders and 75% of the patients below this level as responders.…”

“…A recent Japanese study has identifi ed pressure requirement in CPAP users as a predictor of MAS response. 9 In established CPAP users, a prescribed pressure of above 10.5 cm H 2 O indicated poor response to subsequent MAS therapy. This prediction method is, of course, restricted to patients who have used CPAP and wish to try MAS.…”

Mandibular Repositioning Appliance in the Treatment of Obstructive Sleep Apnea Syndrome-Mini Review

“…The same author in 2009 showed that it is possible to optimize MRA results by increasing mandibular advancement during a polysomnographic titration in patients with an incomplete response to treatment [33]. Tsuiki et al [34] observed better results with MRA in patients who had required CPAP pressure below 10.5 cmH2034. Despite these several possible predictors of success for MRA in the treatment of OSA already described in the literature, they are still not definitive, since the studies present differences in the criteria of success adopted, in the design of the employed MRA, in the configuration of the samples (age, BMI, cervical circumference, pre-treatment AHI, gender) and in the final mandibular position reached thus affecting the results obtained [35].…”