Figure - available from: PLOS ONE
This content is subject to copyright.
Optimal therapeutic pressure of PAP (PPAP) and CT (PCT) in 14 patients The figure shows the individual pressure (black dots), the median (white dots), and the 25% and 75% quantiles (whiskers) on PAP and CT. PAP, continuous positive airway pressure; CT, combination therapy. Each solid line connects data of an individual patient. Dash line indicates 15 cm H2O.
Source publication
Introduction
This study aimed to determine the effect of combining positive airway pressure (PAP) therapy and mandibular advancement device (MAD) in patients with severe obstructive sleep apnea (OSA) who were pressure intolerant for PAP and were unresponsive to MAD.
Methods
This retrospective study reviewed the medical records of severe OSA patien...
Similar publications
Background:
The amount of mandibular protrusion is a key factor in optimizing the efficacy of mandibular advancement device (MAD) therapy in the individual patient diagnosed with obstructive sleep apnea (OSA). This process is called titration and is generally based on resolution of subjective symptoms like snoring and/or daytime sleepiness as a fun...
Purpose
To find out if a moderate protrusion with a mandibular advancement device (MAD) can significantly increase the upper airway volume and, further, what signs and symptoms of obstructive sleep apnea (OSA) can be improved by this maneuver.
Methods
There were 58 adults diagnosed with OSA who were referred for MAD therapy. The mean apnea-hypopne...
Background The amount of mandibular protrusion is a key factor in optimizing the efficacy of mandibular advancement device (MAD) therapy in the individual patient diagnosed with obstructive sleep apnea (OSA). This process is called titration and is generally based on resolution of subjective symptoms like snoring and/or daytime sleepiness as a func...
ABSTRACT – The contribution of orofacial myofunctional reeducation to the treatment of obstructive sleep apnoea syndrome (OSA): a systematic review of the literature. Introduction: Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem.
Orofacial myofunctional reeduc...
Purpose:
To comprehensively determine the effectiveness and safety of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA).
Patients and methods:
We designed and implemented a prospective multicenter cohort study to evaluate OSA patients who underwent MMA. The primary outcome measures and associated instruments...
Citations
... For example, the combination of positional therapy and OAT is more efficacious than either positional therapy or OAT alone [116]. The combination of CPAP therapy with oral appliances can treat OSA when OAT alone is ineffective, while reducing CPAP requirement (~9 cm H 2 O less with combined OAT and CPAP therapy than on CPAP therapy alone) [117]. Therefore, combination therapy may be a good option for those who are pressure intolerant. ...
People with obstructive sleep apnea (OSA) are a heterogeneous group. While many succeed in the treatment of their OSA, many others struggle with therapy. Herein, we discuss how anatomical and physiological factors that cause sleep apnea (OSA traits) impact treatment response and may offer an avenue for more precise care. These OSA traits, including anatomical (upper-airway collapsibility) and physiological (loop gain, airway muscle responsiveness, and arousal threshold) factors, may help determine who can succeed with continuous positive airway pressure, oral appliances, hypoglossal nerve stimulation, or pharmacotherapy. In the future, identifying OSA traits before initiating treatment may help guide the selection of the most effective and tolerable therapy modalities for each individual.
... Oral appliance therapy can be used in conjunction with other treatment modalities to improve adherence and patient outcomes. Using oral appliance therapy in conjunction with PAP can reduce the PAP pressure requirement [63,88]. When used in combination, PAP and OAT together have been shown to decrease both AHI and oxygen desaturation of the patient [88]. ...
... Using oral appliance therapy in conjunction with PAP can reduce the PAP pressure requirement [63,88]. When used in combination, PAP and OAT together have been shown to decrease both AHI and oxygen desaturation of the patient [88]. Furthermore, patients undergoing combination PAP and OAT had lowered therapeutic pressures, which helps with patient compliance in patients who are PAP intolerant [88]. ...
... When used in combination, PAP and OAT together have been shown to decrease both AHI and oxygen desaturation of the patient [88]. Furthermore, patients undergoing combination PAP and OAT had lowered therapeutic pressures, which helps with patient compliance in patients who are PAP intolerant [88]. OAT has also been shown to be beneficial and an increase in efficacy when used in combination with uvulopalatopharyngoplasty (UPPP) vs. UPPP alone [89]. ...
Obstructive sleep apnea (OSA) represents a significant health issue with numerous social and health ramifications caused by disturbed sleep. Additionally, it is well-known that OSA has an influence on cardiovascular diseases. OSA has a multifactorial etiology, and therefore requires a multidisciplinary approach for both diagnosis and treatment. Traditionally, dentists have treated OSA at the request of physicians and do not routinely contribute to diagnosis and treatment; however, the awareness of OSA is increasing within the healthcare profession and the potential role of dental practitioners in its treatment is an emerging field. The dental profession is in a unique position to work with their medical colleagues in providing treatment which can dramatically improve quality of life.
... For example, older and middle-aged patients with OSA were shown to have roughly double the healthcare costs of aged-matched controls [11] which were reduced considerably with effective treatment [12]. However, the limited utility of other treatments for more severe OSA means that patients who cannot tolerate CPAP often remain untreated, so new ways to modify CPAP pressure delivery are still needed [13]. ...
Background
Obstructive sleep apnoea (OSA) involves repeated breathing pauses during sleep due to upper airway obstruction. It causes excessive daytime sleepiness and has other health impacts. Continuous positive airway pressure (CPAP) therapy is effective first line treatment for moderate to severe OSA. Unfortunately, many patients have difficulty tolerating CPAP and pressure intolerance is probably an important contributing factor. Mandibular advancement devices (MAD) are an alternative to CPAP. They are worn in the mouth during sleep to reduce airway obstruction. There is some evidence that, when used in combination with CPAP, MADs improve airway anatomy enough to reduce the CPAP pressure required to treat OSA and that this combination therapy could improve CPAP adherence.
Methods
Consecutive patients starting on CPAP for moderate to severe OSA will be recruited at a regional NHS sleep service. Patients with high CPAP pressure requirements after initial titration, who satisfy all entry criteria and consent to participate, will undertake a 2-arm randomised crossover trial. The arms will be (i) standalone CPAP and (ii) CPAP + MAD therapy. Each arm will last 12 weeks, including 2 weeks acclimatisation. CPAP machines will be auto-titrating and with facility for data download, so the impact of MAD on CPAP pressure requirements and CPAP adherence can be easily measured. The primary outcome will be CPAP adherence. Secondary outcomes will include measures of OSA severity, patient-reported outcome measures including subjective daytime sleepiness, quality of life, and treatment preference at the trial exit and health service use. Cost-effectiveness analyses will be undertaken.
Discussion
If the intervention is shown to be effective and cost-effective in improving adherence in this standard CPAP-eligible OSA patient population it would be relatively straightforward to introduce into existing OSA treatment pathways, within the wider NHS and more widely. Both MAD and CPAP are already used by sleep services so their combination would require only minor adjustments to existing clinical pathways. It would be straightforward to disseminate the results of the study through regional, national, and international respiratory meetings. The health economics analysis would provide cost-effectiveness data to inform service planning and clinical guidelines through policy briefing papers, including those by NICE and SIGN.
Trial registration
PAPMAT was registered with ISRCTN prior to recruitment beginning (ISRCTN Registry 2021): https://www.isrctn.com/ISRCTN33966032. Registered on 17th November 2021.
... However, the limited utility of other treatments for more severe OSA means that patients who can't tolerate CPAP often remain untreated, so new ways to modify CPAP pressure delivery are still needed (13). ...
• Background: Obstructive Sleep Apnoea (OSA) involves repeated breathing pauses during sleep due to upper airway obstruction. It causes excessive daytime sleepiness and has other health impacts. Continuous Positive Airway Pressure(CPAP) therapy is effective first line treatment for moderate to severe OSA. Unfortunately, many patients have difficulty tolerating CPAP and pressure intolerance is probably an important contributing factor. Mandibular Advancement Devices (MAD) are an alternative to CPAP. They are worn in the mouth during sleep to reduce airway obstruction. There is some evidence that, when used in combination with CPAP, MADs improve airway anatomy enough to reduce the CPAP pressure required to treat OSA; and that this combination therapy could improve CPAP adherence.
• Methods: Consecutive patients starting on CPAP for moderate to severe OSA will be recruited at a regional NHS sleep service. Patients with high CPAP pressure requirements after initial titration, who satisfy all entry criteria and consent to participate, will undertake a 2-arm randomised crossover trial. The arms will be: i) standalone CPAP and ii) CPAP+MAD therapy. Each arm will last 12 weeks, including 2 weeks acclimatisation. CPAP machines will be auto-titrating and with facility for data download, so the impact of MAD on CPAP pressure requirements and CPAP adherence can be easily measured. The primary outcome will be CPAP adherence. Secondary outcomes will include measures of OSA severity, patient reported outcome measures including subjective daytime sleepiness, quality of life, and treatment preference at trial exit and health service use. Cost-effectiveness analyses will be undertaken.
• Discussion: If the intervention is shown to be effective and cost-effective in improving adherence in this standard CPAP-eligible OSA patient population it would be of immediate benefit to all patients with OSA, within the wider NHS and globally. Both MAD and CPAP are already used by sleep services so their combination would require only minor adjustments to existing clinical pathways. It would be straightforward to disseminate the results of the study through regional, national and international respiratory meetings. The health economics analysis would provide cost effectiveness data to inform service planning and clinical guidelines through policy briefing papers, including to NICE and SIGN.
• Trial registration: If your article reports the results of a health care intervention on human participants, it must be registered in an appropriate registry and the registration number and date of registration should be in stated in this section. If it was not registered prospectively (before enrollment of the first participant), you should include the words 'retrospectively registered'. See our editorial policies for more information on trial registration.
• PAPMAT wasregistered with ISRCTN prior to recruitment beginning (1).: https://www.isrctn.com/ISRCTN33966032
... Combination therapy, in which an OA is used in concert with PAP, may allow for lower pressure and improve PAP adherence. 21 Combination therapy may reduce upper airway resistance and allow a more comfortable and lower pressure required to maintain patency of the airway. The use of customized masks and interfaces can be fabricated by QDs to facilitate the use of combination therapy. ...
... [23][24][25][26] Our previous study identified that higher BMI and higher CPAP pressure were associated with AHI MAD ≥15/h. 27 Tsuiki et al reported that a fixed pressure ≥10.5 cmH 2 O could predict no response to MAD therapy across all three criteria in male Japanese patients adhering to CPAP treatment. 26 Sutherland et al reported that a fixed pressure ≥13 cmH 2 O was predictive of criterion 1 or 2 nonresponders in treatment-naïve Caucasian patients. ...
... Full-night PSG (Embla N7000, Medcare Flaga, Reykjavik, Iceland) was performed in the sleep lab following the protocol as previously described. 27 Apnea was defined as the absence of airflow for ≥ 10 sec, and hypopnea was defined as a 30% decrease in airflow for ≥ 10 sec associated with a ≥ 4% reduction in arterial oxygen saturation. The oxygen desaturation index was defined as the number of times that pulse oxygen saturation decreased by ≥ 4% per hour. ...
... The therapeutic pressure was determined by overnight manual titration using BiPAP Synchrony TM (Respironics Inc., Murrysville, PA, USA) following a published protocol. 27 The manual titration started with the CPAP mode at a pressure of 4 cmH 2 O. The pressure was then increased in 1 cmH 2 O increments over 10 min to eliminate obstructive events, including apnea, hypopnea, and snoring, and to minimize electroencephalography arousals until 30 min had elapsed without any obstructive events. ...
Objective
Both continuous positive airway pressure (CPAP) pressure and polysomnographic phenotypes have been associated with mandibular advancement device (MAD) treatment response, but the precise relationship has not been fully elucidated. We hypothesized that utilizing CPAP pressure would predict the MAD response in treatment-naïve patients with moderate-severe obstructive sleep apnea (OSA), and the MAD response would be associated with two polysomnographic phenotypes, including sleep stage dependency and positional dependency.
Methods
OSA treatment-naïve patients with an apnea-hypopnea index (AHI) ≥15/h who declined CPAP treatment and received MAD treatment for 3–6 months were enrolled. The MAD treatment response was defined as 1) residual AHI under MAD (AHIMAD) <5/h and 2) AHIMAD <10/h. Logistic regression was applied to identify the association between CPAP pressure and MAD treatment responders. The predictability of the MAD responder status utilizing CPAP pressure was assessed with the area under the receiver operating characteristic (AUROC).
Results
A total of 128 enrolled patients (AHI ≥30/h in 74.2%) were recruited, of whom 119 patients and 80 patients were included for analysis of sleep stage and positional dependency, respectively. REM-predominant OSA had lower AHI than stage-independent OSA, while the supine-predominant phenotype had lower anthropometrics than the nonpositional-dependent phenotype. The response rates for AHIMAD <5/h and AHIMAD <10/h were 25.8% and 48.4%, respectively. Lower anthropometrics, baseline AHI, and supine predominance were associated with the responder status, while CPAP pressure was an independent predictor. The AUROCs for the prediction of AHIMAD <5/h and AHIMAD <10/h responders were 0.635 and 0.664, respectively. Utilizing a CPAP level >14 cmH2O as the cutoff to predict criterion 1 and 2 nonresponders, the sensitivity was 93.9% and 95.2%, respectively.
Conclusion
In treatment-naïve patients with moderate-severe OSA, the supine-predominant phenotype and lower CPAP pressure were associated with the MAD response, while the sleep stage dependency phenotype was not. Utilization of a CPAP level >14 cmH2O could be a sensitive measure to identify nonresponders.
... 14 Liu and colleagues showed that the simultaneous use of OA and PAP for patients with severe OSA lowered AHI, oxygen desaturation index, and PAP pressure compared to the sole use of OA therapy or PAP. 15 The reduction of PAP pressure might contribute to improvement of adherence to PAP and therefore promote favorable health outcomes. However, Léotard and colleagues 16 showed no improvement in adherence to PAP and worse self-reported pain with the combination of nasal mask and OA, compared to PAP with oronasal mask. ...
... One possible factor is the severity of OSA. In the study by Liu et al, 15 all participants were patients with severe OSA (AHI≥30) and the therapeutic pressure during solo-PAP therapy was ≥15 cmH2O, and had lower pressure on CT than on solo PAP. The other possible factor is self-reported high pressure during solo-PAP therapy. ...
... The first is that reductions in pressure might improve adherence with continuous positive airway pressure . This premise is supported by work showing that individuals using both an oral compliance along with continuous positive airway pressure, results in reductions in continuous positive airway pressure coupled to improved treatment adherence (Liu et al., 2017). In addition, it was proposed that improvement in some comorbidities would exceed the response expected by the improved adherence . ...
This review explores forms of respiratory and autonomic plasticity, and associated outcome measures, that are initiated by exposure to intermittent hypoxia. The review focuses primarily on studies that have been completed in humans and primarily explores the impact of mild intermittent hypoxia on outcome measures. Studies that have explored two forms of respiratory plasticity, progressive augmentation of the hypoxic ventilatory response and long-term facilitation of ventilation and upper airway muscle activity, are initially reviewed. The role these forms of plasticity might have in sleep disordered breathing are also explored. Thereafter, the role of intermittent hypoxia in the initiation of autonomic plasticity is reviewed and the role this form of plasticity has in cardiovascular and hemodynamic responses during and following intermittent hypoxia is addressed. The role of these responses in individuals with sleep disordered breathing and spinal cord injury are subsequently addressed. Ultimately an integrated picture of the respiratory, autonomic and cardiovascular responses to intermittent hypoxia is presented. The goal of the integrated picture is to address the types of responses that one might expect in humans exposed to one-time and repeated daily exposure to mild intermittent hypoxia. This form of intermittent hypoxia is highlighted because of its potential therapeutic impact in promoting functional improvement and recovery in several physiological systems.
... Another potential role for MADs that is in need of further exploration is their use in combination therapy. There is limited evidence that combining a MAD simultaneously with CPAP may help improve adherence to treatment, possibly by reducing the CPAP pressure required to effectively treat OSA [68,69]. Another combination in need of further exploration in selected patients is the use of a MAD with positional therapy, for patients with breakthrough OSA when using one or other of these treatments [70]. ...
Obstructive sleep apnea (OSA) is a prevalent condition causing unrefreshing sleep and excessive daytime sleepiness. It has individual socioeconomic impacts and, through association with increased risk of road traffic accidents, diabetes, and cardiovascular disease, OSA is a public health issue. Continuous positive airway pressure (CPAP) is the first-line treatment for moderate-to-severe OSA. It is effective in improving excessive daytime sleepiness and quality of life. There is also evidence that CPAP therapy has cardiovascular benefits although nature and extent remain uncertain. Despite its benefits, a significant proportion of patients are unable to tolerate CPAP. There are also patients with mild but symptomatic disease, for whom CPAP is usually not available or appropriate, so there is a need for other treatment options. Mandibular advancement devices (MADs) offer an effective alternative to CPAP and can improve daytime symptoms and quality of life. There are many devices available, representing a range of complexity and cost. It is challenging to properly evaluate the effectiveness of this ever-evolving range. The more basic MADs are cheaper and more accessible but are less well tolerated. More complex devices are better tolerated and may be more effective. However, they are more expensive and often require dental expertise, so access is more limited. Efforts continue to try to improve accessibility to effective MAD therapy. Alongside increasing awareness, this may be facilitated by developing and refining devices that could be fitted by non-dental clinicians, and potentially by patients themselves. Research efforts need to focus on determining how to efficiently identify patients who are likely to respond to MAD therapy, so as to improve clinical and cost-effectiveness of OSA therapy overall.
... 27 Sürekli pozitif hava yolu basıncı (CPAP) cihazı, OUAS için "altın standart" olarak kabul edilen tedavi aracıdır ve uyku sırasında üst hava yolunun kollabe olmasını engeller. 28,29 Nitekim OUAS tedavisinin ağız sağlığını iyileştirebileceği belirtilmiştir. 30 OUAS hastaları CPAP cihazı ile tedavi edildiğinde periodontal durumlarının nasıl etkilendiğini araştırdığımız bu çalışma, 6 yıllık CPAP tedavisi sonunda hastalarda klinik periodontal bulgularda başlangıç verilerine göre istatistiksel olarak anlamlı bir fark oluşmadığını ortaya koymaktadır. ...
Amaç: Bu çalışmanın amacı, obstrüktif uyku apne sendromu (OUAS) hastalarında sürekli pozitif havayolu basıncı (CPAP) tedavisinin, klinik periodontal durum üzerine olası etkilerini değerlendirmektir.
Gereç ve Yöntem: OUAS tanısı konmuş olan ve düzenli CPAP cihazı kullanan toplam 11 hastada (3 hasta orta, 8 hasta ağır OUAS) tedavi başlandıktan 6 yıl sonra kapsamlı klinik periodontal muayene tekrarlandı. Tüm ağız ortalama sondalama derinliği (SD), klinik ataşman seviyesi (KAS), sondalamada kanama indeksi (SKİ) ve plak indeksi (Pİ) değerleri kaydedilerek başlangıç verileri ile karşılaştırıldı.
Bulgular: Orta ve ağır OUAS grupları arasında KAS, PI ölçümlerinde başlangıç ve tedavi sonrası 6. yıl verileri arasında anlamlı fark bulunmadı (p>0.05). Başlangıç, 6. yıl SD ve 6. yıl SKİ değerleri orta OUAS grubunda daha yüksek bulundu (sırasıyla p=0.024, p=0.030 ve p=0.014). Diş sayılarına bakıldığında her iki grupta ve tüm hastalarda başlangıç ve 6. yıl değerleri arasında anlamlı fark bulunmadı (p>0.05). Sigara içen ve içmeyen hastalarda başlangıç ve 6. yıl klinik periodontal ölçümleri karşılaştırdığımızda sonuçların benzer olduğu gözlendi (p>0.05).
Sonuç: Çalışmamızın sınırları içinde, CPAP cihazı ile yapılan uzun dönem OUAS tedavisinin klinik periodontal durum üzerine anlamlı etki göstermediği söylenebilir.
