Therapeutic Positive Airway Pressure Level Predicts Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

Abstract

Study Objectives: To determine whether therapeutic positive airway pressure (PAP) level predicts response to hypoglossal nerve stimulation (HGNS) for obstructive sleep apnea using the coprimary outcomes of apnea-hypopnea index (AHI) and 4% oxygen desaturation index. Methods: Combined cohort study from two US sleep otolaryngology training programs. Subjects were adults with AHI > 15 events/h who underwent HGNS. Eligible subjects had diagnostic preoperative sleep studies, full-night efficacy postoperative studies and therapeutic PAP levels available for analysis. Low and high PAP groups were compared using the t test for continuous variables and chi-square test for categorical variables. Results: Fifty-six patients met all inclusion criteria. On average, patients were male, Caucasian, middle-aged, and overweight. Thirteen patients were in the low PAP group (< 8 cm H 2 O) and 43 patients in the high PAP group (≥ 8 cm H 2 O). Although both groups experienced improvement of polysomnographic measures with HGNS, the low PAP group achieved a significantly larger mean AHI reduction (36.7 ± 22.7 versus 18.4 ± 23.4, P = .02). Additionally, the low PAP group had a greater response rate (defined as AHI < 20 events/h and > 50% reduction of AHI) than the high PAP group (92% versus 44%, P < .01).Conclusions: Therapeutic PAP level may aid in the discernment of candidacy for HGNS, with a strong positive predictive value for PAP levels < 8 cm H 2 O. A larger prospective study is needed to confirm these findings.

No changes in nocturnal respiration with hypoglossal neurostimulation therapy for obstructive sleep apnoea

“…Only one of our patients had an efficient CPAP pressure level <8 cmH 2 O, which is consistent with the findings of Lee et al 16 This may explain our poor outcomes with HGNS. We downloaded the 95th percentile pressure from the CPAP device smart card as performed by Lee et.al 16 …”

“…Recently, it has been reported that CPAP therapy levels ≥8 cmH 2 O are associated with a greater probability of lower HGNS responsiveness 16 . Only one of our patients had an efficient CPAP pressure level <8 cmH 2 O, which is consistent with the findings of Lee et al 16 This may explain our poor outcomes with HGNS. We downloaded the 95th percentile pressure from the CPAP device smart card as performed by Lee et.al 16 …”

Success of Hypoglossal Nerve Stimulation Using Mandibular Advancement During Sleep Endoscopy

“…13,14 Recently, our group has shown that akin to MAD patients, HGNS patients with low therapeutic PAP levels are more likely to succeed compared to patients with higher pressure requirements. 15 At present, it is unclear if response to MA during DISE can similarly aid in the selection of HGNS candidates. Here we sought to answer the following research question: What is the value of mandibular advancement simulation during DISE in predicting success for HGNS, namely the response at the soft palate and lateral walls to MA?…”

“…Both therapeutic PAP level and airway opening response to mandibular advancement (MA) on DISE have been shown to predict successful treatment of OSA with a MAD 13–14 . Recently, our group has shown that akin to MAD patients, HGNS patients with low therapeutic PAP levels are more likely to succeed compared to patients with higher pressure requirements 15 . At present, it is unclear if response to MA during DISE can similarly aid in the selection of HGNS candidates.…”

Transoral Versus Endoscopic Examination in Predicting Outcomes of Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

“…Recent 5‐year data from the Stimulation Therapy for Apnea Reduction trial demonstrated long‐term reductions of apnea‐hypopnea index (AHI) and improvement of sleep symptoms. Yet, the overall response rate (defined as AHI < 20 events/hr and >50% reduction of AHI) remains around 60%, leaving room for optimization 9,10 …”