Positional vs nonpositional obstructive sleep apnea patients - Anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data

Tel Aviv Sourasky Medical Center, Tell Afif, Tel Aviv, Israel
Chest (Impact Factor: 7.48). 09/1997; 112(3):629-39. DOI: 10.1378/chest.112.3.629
Source: PubMed

ABSTRACT To compare anthropomorphic, nocturnal polysomnographic (PSG), and multiple sleep latency test (MSLT) data between positional (PP) and nonpositional (NPP) obstructive sleep apnea (OSA) patients.
This is a retrospective analysis of anthropomorphic, PSG, and MSLT data of a large group of OSA patients who underwent a complete PSG evaluation in our sleep disorders unit. The patients were divided in two groups: the PP group, those patients who had a supine respiratory disturbance index (RDI) that was at least two times higher than the lateral RDI, and the NPP group, those patients in whom the RDI in the supine position was less than twice that in the lateral position.
From a group of 666 consecutive OSA patients whose conditions were diagnosed in our unit from September 1990 to February 1995, 574 patients met the following criteria and were included in the study: RDI > 10; age > 20 years, and body mass index (BMI) > 20.
Of all 574 patients, 55.9% were found to be positional. No differences in height were observed but weight and BMI were significantly higher in the NPP group, these patients being on the average 6.5 kg heavier than those in the PP group. The PP group was, on average, 2 years younger than the NPP group. Nocturnal sleep quality was better preserved in the PP group. In this group, sleep efficiency and the percentages of deep sleep (stages 3 and 4) were significantly higher while the percentages of light sleep (stages 1 and 2) were significantly lower than in the NPP group. No differences for rapid eye movement (REM) sleep were found. In addition, wakefulness after sleep onset and the number of short arousals (< 15 s) were significantly lower in the PP group. Apnea index and total RDI were significantly higher and the minimal arterial oxygen saturation in REM and non-REM sleep was significantly lower in the NPP. No differences in periodic limb movements data were found between the two groups. The average MSLT was significantly shorter in the NPP group. Univariate and multivariate stepwise logistic regression analysis showed that the most dominant variable that correlates with positional dependency in OSA patients is RDI, followed by BMI which also adds a significant contribution to the prediction of positional dependency. Age, although significant, adds only a minor improvement to the prediction of this positional dependency phenomenon. A severe, obese, and older OSA patient is significantly less likely to be positional than a mild-moderate, thin, and young OSA patient. In four obese OSA patients who lost weight, a much more pronounced reduction was seen in the lateral RDI than in the supine RDI, and three of these cases who were previously NPP became PP.
In a large population of OSA patients, most were found to have at least twice as many apneas/hypopneas in the supine than in the lateral position. These so-called "positional patients" are on the average thinner and younger than "nonpositional patients." They had fewer and less severe breathing abnormalities than the NPP group. Consequently their nocturnal sleep quality was better preserved and, according to MSLT data, they were less sleepy during daytime hours. RDI was the most dominant factor that could predict the positional dependency followed by BMI and age. RDI showed a threshold effect, the prevalence of PP in those with severe RDI (RDI > or = 40) was significantly lower than in those OSA patients with mild-moderate RDI. BMI showed a major significant inverse relationship with positional dependency, while age had only a minor although significant inverse relationship with it. Body position during sleep has a profound effect on the frequency and severity of breathing abnormalities in OSA patients.

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    • "The effect of gravity on tissues anterior to the pharynx, particularly the tongue, has been suggested as the principle cause. With more than half of OSA patients demonstrating a substantial effect of body posture on OSA (Oksenberg et al., 1997), positional treatment has been recommended consistently as a treatment option since the 1980s (Cartwright et al., 1985). This treatment aims at avoiding the supine horizontal posture, allowing the patient to sleep in horizontal non-supine body positions. "
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    ABSTRACT: Sleep-disordered breathing covers a broad range of central, obstructive or mixed respiratory disturbances occurring or aggravating during sleep. Treatment recommendations depend upon the underlying path-ophysiology and severity of the disorder, and therapy should be tailored to the individual patient's needs. • Before starting specific medical therapy, applicability of general measures such as dietary interventions or abstinence of drugs should be considered. • Continuous positive airway pressure (CPAP) is the mainstay for treatment of moderate to severe obstruc-tive sleep apnoea, whereas the use of oral appliances has been proved beneficial for mild to moderate disease. • Surgical treatment of pharyngeal anomalies, retrogna-thia or obesity may be applied in selected cases with obstructive sleep apnoea. • Central sleep apnoea is a heterogeneous condition that first requires identification and treatment of any underlying disease processes. Symptomatic treat-ment comprises CPAP, bi-level PAP or adaptive servo-ventilation and oxygen supplementation. SUMMARY This chapter deals with different therapeutic approaches to sleep disturbances characterized by sleep-disordered breathing. General recommendations and conservative measures are crucial first steps in the management of sleep-disordered breathing. Pharma-cological agents have no major role in the treatment of obstructive sleep apnoea, but have certain indications in patients with central sleep apnoea, especially in those suffering from heart failure. Treatment with oral devices has become a cornerstone in the management of patients with mild to moderate obstructive sleep apnoea, and may also be helpful in selected patients with severe disease. Positive airway pressure contin-ues to be the mainstay of treatment of obstructive sleep apnoea patients with moderate to severe disease. Bi-level positive airway pressure is indicated as a therapy for respiratory failure (alveolar hypoventilation with hypercapnia). Adaptive servo-ventilation has been introduced as a specific treatment of cardiac patients with central sleep apnoea and Cheyne–Stokes respi-ration, but may also be used in other conditions associated with central sleep apnoea. Surgery of the upper airways or of the maxillomandibular skeleton is performed in selected obstructive sleep apnoea patients. Bariatric surgery is a therapy indicated in morbidly obese patients with obstructive sleep apnoea who fail to lose weight with conservative measures such as hypocaloric diet and exercise training.
    Sleep Medicine Textbook, first edition edited by Claudio Bassetti, Zoran Dogas, Philippe Peigneux, 01/2014: chapter D.5 Treatment of respiratory sleep disorders: pages 259-274; European Sleep Research Society., ISBN: 9781119038931
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    • "A reduction in the prevalence of positional patients was noted with an increase in BMI [42]. The same authors also found that nonpositional obese patients became positional on losing weight. "
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    ABSTRACT: Aim. The aim of this review is to determine the relationship between sleeping body posture and severity of obstructive sleep apnea. This relationship has been investigated in the past. However, the conclusions derived from some of these studies are conflicting with each other. This paper intends to summarize the reported relationships between sleep posture and various sleep indices in patients diagnosed with sleep apnea. Methods and Materials. A systematic review of the published English literature during a 25-year period from 1983 to 2008 was performed. Results. Published data concerning the sleep apnea severity and posture in adults are limited. Supine sleep posture is consistently associated with more severe obstructive sleep apnea indices in adults. However, relationship between sleep apnea severity indices and prone posture is inconsistent.
    10/2013; 2013:670381. DOI:10.1155/2013/670381
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    • "According to previous study [15], a severe, obese, and older OSAS patient is significantly less likely to be positional than a mild-moderate, thin, and young OSAS patient. And AHI was the most dominant factor that could predict the PD followed by BMI and age. "
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    ABSTRACT: The purpose of this study is to find out associations between positional dependency and obstructive levels based on sleep videofluoroscopy (SVF) in patients with obstructive sleep apnea syndrome (OSAS). Retrospective review was made of 91 OSAS patients who underwent polysomnography and SVF from August 2009 through June 2010. Polysomnography variables including apnea-hypopnea index (AHI), supine AHI, non-supine AHI, time spent in supine sleep position of the total sleep time and positional dependency (PD) were analyzed. Obstruction sites were evaluated as SVF variables. Of 91 patients, 65 (71.4%) were positional patients (PP) and 26 (28.6%) were non-positional patients (NPP). An analysis of polysomnography variables according to PD revealed that overall AHI, non-supine AHI and supine AHI in PP was significantly lower than that in NPP. The patients with soft palate obstruction (SP type) were more likely to have PD than the patients with tongue base obstruction (TB type; P=0.046). PD was inversely related to OSAS severity significantly (P=0.001). These results provide evidence that positional dependent patients may have higher success rate of soft palate OSA surgery alone than non-positional dependent patients. Although PD may be associated with obstruction site, PD only itself may not be useful in planning surgical treatment for OSAS.
    Clinical and Experimental Otorhinolaryngology 12/2012; 5(4):218-21. DOI:10.3342/ceo.2012.5.4.218 · 0.85 Impact Factor
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